One year cost effectiveness of sirolimus eluting stents compared with bare metal stents in the treatment of single native de novo coronary lesions: an analysis from the RAVEL trial

OBJECTIVE: To assess the balance between costs and effects of the sirolimus eluting stent in the treatment of single native de novo coronary lesions in the RAVEL (randomised study with the sirolimus eluting Bx Velocity balloon expandable stent in the treatment of patients with de novo native coronary artery lesions) study. DESIGN: Multicentre, double blind, randomised trial. SETTING: Percutaneous coronary intervention for single de novo coronary lesions. PATIENTS: 238 patients with stable or unstable angina. INTERVENTIONS: Randomisation to sirolimus eluting stent or bare stent implantation. MAIN OUTCOME MEASURES: Patients were followed up to one year and the treatment effects were expressed as one year survival free of major adverse cardiac events (MACE). Costs were estimated as the product of resource utilisation and Dutch unit costs. RESULTS: At one year, the absolute difference in MACE-free survival was 23% in favour of the sirolimus eluting stent group. At the index procedure, sirolimus eluting stent implantation had an estimated additional procedural cost of 1286. At one year, however, the estimated additional cost difference had decreased to 54 because of the reduction in the need for repeat revascularisations in the sirolimus group (0.8% v 23.6%; p < 0.01). After adjustment of actual results for the consequences of angiographic follow up (correction based on data from the BENESTENT (Belgium Netherlands stent) II study), the difference in MACE-free survival was estimated at 11.1% and the addit

Randomized clinical trial: Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition

Background & aims: Staphylococcus aureus decolonization has proven successful in prevention of S. aureus infections and is a key strategy to maintain venous access and avoid hospitalization in patients receiving home parenteral nutrition (HPN). We aimed to determine the most effective and safe long-term S. aureus decolonization regimen. Methods: A randomized, open-label, multicenter clinical trial was conducted. Adult intestinal failure patients with HPN support and carrying S. aureus were randomly assigned to a ‘continuous suppression’ (CS) strategy, a repeated chronic topical antibiotic treatment or a ‘search and destroy’ (SD) strategy, a short and systemic antibiotic treatment. Primary outcome was the proportion of patients in whom S. aureus was totally eradicated during a 1-year period. Secondary outcomes included risk factors for decolonization failure and S. aureus infections, antimicrobial resistance, adverse events, patient compliance and cost-effectivity. Results: 63 participants were included (CS 31; SD 32). The mean 1-year S. aureus decolonization rate was 61% (95% CI 44, 75) for the CS group and 39% (95% CI 25, 56) for the SD group with an OR of 2.38 (95% CI 0.92, 6.11, P = 0.07). More adverse effects occurred in the SD group (P = 0.01). Predictors for eradication failure were a S. aureus positive caregiver and presence of a (gastro)enterostomy. Conclusion: We did not demonstrate an increased efficacy of a short and systemic S. aureus decolonization strategy over a continuous topical suppression treatment. The latter may be the best option for HPN patients as it achieved a higher long-term decolonization rate and was well-tolerated (NCT03173053)

Physical activity assessment by accelerometry in people with heart failure

Background: International guidelines for physical activity recommend at least 150 min per week of moderate-to-vigorous physical activity (MVPA) for adults, including those with cardiac disease. There is yet to be consensus on the most appropriate way to categorise raw accelerometer data into behaviourally relevant metrics such as intensity, especially in chronic disease populations. Therefore the aim of this study was to estimate acceleration values corresponding to inactivity and MVPA during daily living activities of patients with heart failure (HF), via calibration with oxygen consumption (VO2) and to compare these values to previously published, commonly applied PA intensity thresholds which are based on healthy adults. Methods: Twenty-two adults with HF (mean age 71 ± 14 years) undertook a range of daily living activities (including laying down, sitting, standing and walking) whilst measuring PA via wrist- and hip-worn accelerometers and VO2 via indirect calorimetry. Raw accelerometer output was used to compute PA in units of milligravity (mg). Energy expenditure across each of the activities was converted into measured METs (VO2/resting metabolic rate) and standard METs (VO2/3.5 ml/kg/min). PA energy costs were also compared with predicted METs in the compendium of physical activities. Location specific activity intensity thresholds were established via multilevel mixed effects linear regression and receiver operator characteristic curve analysis. A leave-one-out method was used to cross-validate the thresholds. Results: Accelerometer values corresponding with intensity thresholds for inactivity ( 50% lower than previously published intensity thresholds for both wrists and waist accelerometers (inactivity: 16.7 to 18.6 mg versus 45.8 mg; MVPA: 43.1 to 49.0 mg versus 93.2 to 100 mg). Measured METs were higher than both standard METs (34-35%) and predicted METs (45-105%) across all standing and walking activities. Conclusion: HF specific accelerometer intensity thresholds for inactivity and MVPA are lower than previously published thresholds based on healthy adults, due to lower resting metabolic rate and greater energy expenditure during daily living activities for HF patients. Trial registration: Clinical trials.gov NCT03659877, retrospectively registered on September 6th 2018.This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.This study was undertaken as part of a PhD, which was funded by a University of Exeter Postgraduate Studentship Grant. The funders were not involved in design of the study, data collection, analysis, and interpretation of data, and in writing the manuscript.published version, accepted versio

Internalisation Theory and outward direct investment by emerging market multinationals

The rise of multinational enterprises from emerging countries (EMNEs) poses an important test for theories of the multinational enterprise such as internalisation theory. It has been contended that new phenomena need new theory. This paper proposes that internalisation theory is appropriate to analyse EMNEs. This paper examines four approaches to EMNEs—international investment strategies, domestic market imperfections, international corporate networks and domestic institutions—and three case studies—Chinese outward FDI, Indian foreign acquisitions and investment in tax havens—to show the enduring relevance and predictive power of internalisation theory. This analysis encompasses many other approaches as special cases of internalisation theory. The use of internalisation theory to analyse EMNEs is to be commended, not only because of its theoretical inclusivity, but also because it has the ability to connect and to explain seemingly desperate phenomena

Geometry and field theory in multi-fractional spacetime

We construct a theory of fields living on continuous geometries with fractional Hausdorff and spectral dimensions, focussing on a flat background analogous to Minkowski spacetime. After reviewing the properties of fractional spaces with fixed dimension, presented in a companion paper, we generalize to a multi-fractional scenario inspired by multi-fractal geometry, where the dimension changes with the scale. This is related to the renormalization group properties of fractional field theories, illustrated by the example of a scalar field. Depending on the symmetries of the Lagrangian, one can define two models. In one of them, the effective dimension flows from 2 in the ultraviolet (UV) and geometry constrains the infrared limit to be four-dimensional. At the UV critical value, the model is rendered power-counting renormalizable. However, this is not the most fundamental regime. Compelling arguments of fractal geometry require an extension of the fractional action measure to complex order. In doing so, we obtain a hierarchy of scales characterizing different geometric regimes. At very small scales, discrete symmetries emerge and the notion of a continuous spacetime begins to blur, until one reaches a fundamental scale and an ultra-microscopic fractal structure. This fine hierarchy of geometries has implications for non-commutative theories and discrete quantum gravity. In the latter case, the present model can be viewed as a top-down realization of a quantum-discrete to classical-continuum transition.Comment: 1+82 pages, 1 figure, 2 tables. v2-3: discussions clarified and improved (especially section 4.5), typos corrected, references added; v4: further typos correcte

The impact of work-related values and work control on the career satisfaction of female freelancers

Using the job demands-resources theory incorporating a job-crafting perspective to develop a set of hypotheses, this study contributes to the self-employment and freelancing literature by examining whether female freelancers use their agency to mobilize their personal resources (i.e. work-related values) to craft their work resources (i.e. work–control indicators: work autonomy and time-spatial flexibility) to achieve more career satisfaction. Our structural partial least squares model (N = 203) shows that the work-related value ‘intrinsically rewarding work’ prompts two motivational processes that affect career satisfaction: one running directly to ‘career satisfaction’ and one through ‘work autonomy’. Although the value ‘work–life balance’ is positively associated with greater ‘time-spatial flexibility’, this does not affect career satisfaction. Moreover, we find negative associations between the value ‘financial security’, on the one hand, and the two work resources, on the other hand. Hence, the value financial security is negatively related to work autonomy towards career satisfaction. We conclude that female freelancers’ multiple, oftentimes blended values compete with one another, implying that achieving meaningful work, work–life balance and financial independence simultaneously is difficult in female freelancers’ careers. We discuss the study’s implications for future research and advocate labour–market stakeholders (e.g. freelancers, freelancers’ networks, career coaches, temporary work agencies, unions, local and national governments, educational institutions and public and private organizations) to partner in developing value-based career strategies and policies that account for less linear career paths in increasingly flexible and individualized markets and truly support (female) workers developing portfolios that better match with their multiple work-related values on a long-term basis

Sono-electroanalysis: Application to the detection of lead in petrol

The quantitative detection of lead in petrol is shown to be possible by anodic stripping voltammetry in aqueous media under conditions of insonation-induced emulsification. An immersion horn probe is introduced into a thermostatted conventional three-electrode cell opposite a mercury plated platinum disk working electrode. Under ultrasonic emulsification of the sample, lead is preconcentrated as an amalgam on the Hg/Pt electrode surface via reduction at -1.0 V (vs. SCE). The large mass transport associated with power ultrasound makes this step highly efficient. Subsequently the lead is quantified by applying an anodic linear sweep of the potential from -1.0 V to -0.15 V (vs. SCE) so as to oxidize the Pb(0) to Pb(II). The area under the stripping peak gives a measure of the lead formed during the initial step. By use of standard microaddition of lead to the solution the system can be calibrated to give the total amount of lead present in the petrol sample. Experiments using samples of 4 star leaded petrol gave a total lead content of 380 ± 40 mgL-1. This value was in quantitative agreement with that obtained by an independent laboratory using atomic absorption spectroscopy (AAS). In addition to the high mass transport and emulsification insonation offers the crucial benefits of first surface activation and cleaning, helping to prevent electrode fouling by the organic components of petrol and second the complete extraction of lead from the water-insoluble target phase

A comparison between pulsed sonovoltammetry and low power laser activated voltammetry for the electroanalysis of ascorbic acid in a commercial fruit drink

A comparison is made between two 'dual activation' electroanalytical techniques for the detection and measurement of vitamin C (L-ascorbic acid) in a commercially available fruit drink via its two electron oxidation at platinum electrodes. Glucose is found not to interfere with the analytical response. First in sonovoltammetry pulses of 25 Wcm-2 are applied and the current response characterized in the 'pulse off' period where a current plateau is attained. Second in laser activated voltammetry a 10 Hz pulsed laser (532 nm, ca. 240 Wcm-2 average intensity) is used to 'burn' surface adsorbed passivating species off the electrode. Both methods cause agitation of the solution in the bulk phase or at the electrode-solution interface and lead to regular renewal of the diffusion layer. The mass transport limited oxidation currents so obtained are found to scale with ascorbic acid concentration in media where electroanalysis without simultaneous ultrasonic or laser stimulation may be precluded due to electrode passivation. Application to the quantitative electroanalysis of ascorbic acid in the fruit drinks Ribena and 'No added sugar' Ribena is reported. The results obtained are in excellent agreement with those yielded by independent chemical and electrochemical methods