Economic evaluation of the routine use of echocardiography versus natriuretic peptide and ECG-targeted echocardiography in the diagnosis of heart failure

Objectives: To investigate the most efficient use of echocardiography and natriuretic peptide testing in the diagnosis of heart failure. Design: An economic model comparing two strategies: (A) provide echocardiography and electrocardiogram (ECG) for all individuals who present to a GP with symptoms that may be due to heart failure; (B) carry out B-type natriuretic peptide (BNP) blood test and ECG on all such individuals and provide echocardiography only where an abnormality is detected in one of more of these tests. Setting: Primary care in the UK NHS. Subjects: Individuals who present to a GP with new symptoms of heart failure. Main outcome measures: Cost per life year gained. Results: Baseline cost per life year gained by strategy A compared with strategy B is £3,987. Conclusions: Immediate echocardiography is the most cost-effective option. Where echocardiography is a scarce resource, efficient use can be obtained by using BNP and ECG tests to identify patients most likely to have heart failure

Cost-effectiveness of eplerenone in patients with systolic heart failure and mild symptoms

Aim In the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF), aldosterone blockade with eplerenone decreased mortality and hospitalisation in patients with mild symptoms (New York Heart Association class II) and chronic systolic heart failure (HF). The present study evaluated the cost-effectiveness of eplerenone in the treatment of these patients in the UK and Spain.<p></p> Methods and results Results from the EMPHASIS-HF trial were used to develop a discrete-event simulation model estimating lifetime direct costs and effects (life years and quality-adjusted life years (QALYs) gained) of the addition of eplerenone to standard care among patients with chronic systolic HF and mild symptoms. Eplerenone plus standard care compared with standard care alone increased lifetime direct costs per patient by £4284 for the UK and €7358 for Spain, with additional quality-adjusted life expectancy of 1.22 QALYs for the UK and 1.33 QALYs for Spain. Mean lifetime costs were £3520 per QALY in the UK and €5532 per QALY in Spain. Probabilistic sensitivity analysis suggested a 100% likelihood of eplerenone being regarded as cost-effective at a willingness-to-pay threshold of £20 000 per QALY (UK) or €30 000 per QALY (Spain).<p></p> Conclusions By currently accepted standards of value for money, the addition of eplerenone to optimal medical therapy for patients with chronic systolic HF and mild symptoms is likely to be cost-effective.<p></p&gt

Clinical applications of B-type natriuretic peptide (BNP) testing

Many claims have been made in recent years regarding the utility of plasma B-type natriuretic peptide (BNP) concentration measurements in the diagnosis, risk stratification and monitoring of patients with heart failure. This paper summarizes the current evidence and provides guidance for practising clinicians. Overall, plasma BNP testing appears to be of most value in the diagnostic arena, where it is likely to improve the performance of non-specialist physicians in diagnosing heart failure. In clinical practice, BNP testing is best used as a ‘rule out' test for suspected cases of new heart failure in breathless patients presenting to either the outpatient or emergency care settings; it is not a replacement for echocardiography and full cardiological assessment, which will be required for patients with an elevated BNP concentration. Although work is ongoing in establishing the ‘normal' values of BNP, heart failure appears to be highly unlikely below a plasma concentration of 100pg/ml. However, as BNP levels rise with age and are affected by gender, comorbidity and drug therapy, the plasma BNP measurement should not be used in isolation from the clinical contex

Implications of structural inheritance in oblique rift zones for basin compartmentalization: Nkhata Basin, Malawi Rift (EARS)

The Cenozoic East African Rift System (EARS) is an exceptional example of active continental extension, providing opportunities for furthering our understanding of hydrocarbon plays within rifts. It is divided into structurally distinct western and eastern branches. The western branch comprises deep rift basins separated by transfer zones, commonly localised onto pre-existing structures, offering good regional scale hydrocarbon traps. At a basin-scale, local discrete inherited structures might also play an important role on fault localisation and hydrocarbon distribution. Here, we consider the evolution of the Central basin of the Malawi Rift, in particular the influence of pre-existing structural fabrics.Integrating basin-scale multichannel 2D, and high resolution seismic datasets we constrain the border, Mlowe-Nkhata, fault system (MNF) to the west of the basin and smaller Mbamba fault (MF) to the east and document their evolution. Intra basin structures define a series of horsts, which initiated as convergent transfers, along the basin axis. The horsts are offset along a NE-SW striking transfer fault parallel to and along strike of the onshore Karoo (Permo-Triassic) Ruhuhu graben. Discrete pre-existing structures probably determined its location and, oriented obliquely to the extension orientation it accommodated predominantly strike-slip deformation, with more slowly accrued dip-slip.To the north of this transfer fault, the overall basin architecture is asymmetric, thickening to the west throughout; while to the south, an initially symmetric graben architecture became increasingly asymmetric in sediment distribution as strain localised onto the western MNF. The presence of the axial horst increasingly focussed sediment supply to the west. As the transfer fault increased its displacement, so this axial supply was interrupted, effectively starving the south-east while ponding sediments between the western horst margin and the transfer fault. This asymmetric bathymetry and partitioned sedimentation continues to the present-day, overprinting the early basin symmetry and configuration. Sediments deposited earlier become increasingly dissected and fault juxtapositions changed at a small (10-100 m) scale. The observed influence of basin-scale transfer faults on sediment dispersal and fault compartmentalization due to pre-existing structures oblique to the extension orientation is relevant to analogous exploration settings

Menus for Feeding Black Holes

Black holes are the ultimate prisons of the Universe, regions of spacetime where the enormous gravity prohibits matter or even light to escape to infinity. Yet, matter falling toward the black holes may shine spectacularly, generating the strongest source of radiation. These sources provide us with astrophysical laboratories of extreme physical conditions that cannot be realized on Earth. This chapter offers a review of the basic menus for feeding matter onto black holes and discusses their observational implications.Comment: 27 pages. Accepted for publication in Space Science Reviews. Also to appear in hard cover in the Space Sciences Series of ISSI "The Physics of Accretion onto Black Holes" (Springer Publisher

Orbital Observations of Dust Lofted by Daytime Convective Turbulence

Over the past several decades, orbital observations of lofted dust have revealed the importance of mineral aerosols as a climate forcing mechanism on both Earth and Mars. Increasingly detailed and diverse data sets have provided an ever-improving understanding of dust sources, transport pathways, and sinks on both planets, but the role of dust in modulating atmospheric processes is complex and not always well understood. We present a review of orbital observations of entrained dust on Earth and Mars, particularly that produced by the dust-laden structures produced by daytime convective turbulence called “dust devils”. On Earth, dust devils are thought to contribute only a small fraction of the atmospheric dust budget; accordingly, there are not yet any published accounts of their occurrence from orbit. In contrast, dust devils on Mars are thought to account for several tens of percent of the planet’s atmospheric dust budget; the literature regarding martian dust devils is quite rich. Because terrestrial dust devils may temporarily contribute significantly to local dust loading and lowered air quality, we suggest that martian dust devil studies may inform future studies of convectively-lofted dust on Earth

Dust Devil Sediment Transport: From Lab to Field to Global Impact

The impact of dust aerosols on the climate and environment of Earth and Mars is complex and forms a major area of research. A difficulty arises in estimating the contribution of small-scale dust devils to the total dust aerosol. This difficulty is due to uncertainties in the amount of dust lifted by individual dust devils, the frequency of dust devil occurrence, and the lack of statistical generality of individual experiments and observations. In this paper, we review results of observational, laboratory, and modeling studies and provide an overview of dust devil dust transport on various spatio-temporal scales as obtained with the different research approaches. Methods used for the investigation of dust devils on Earth and Mars vary. For example, while the use of imagery for the investigation of dust devil occurrence frequency is common practice for Mars, this is less so the case for Earth. Modeling approaches for Earth and Mars are similar in that they are based on the same underlying theory, but they are applied in different ways. Insights into the benefits and limitations of each approach suggest potential future research focuses, which can further reduce the uncertainty associated with dust devil dust entrainment. The potential impacts of dust devils on the climates of Earth and Mars are discussed on the basis of the presented research results

Observations of the High Redshift Universe

(Abridged) In these lectures aimed for non-specialists, I review progress in understanding how galaxies form and evolve. Both the star formation history and assembly of stellar mass can be empirically traced from redshifts z~6 to the present, but how the various distant populations inter-relate and how stellar assembly is regulated by feedback and environmental processes remains unclear. I also discuss how these studies are being extended to locate and characterize the earlier sources beyond z~6. Did early star-forming galaxies contribute significantly to the reionization process and over what period did this occur? Neither theory nor observations are well-developed in this frontier topic but the first results presented here provide important guidance on how we will use more powerful future facilities.Comment: To appear in `First Light in Universe', Saas-Fee Advanced Course 36, Swiss Soc. Astrophys. Astron. in press. 115 pages, 64 figures (see http://www.astro.caltech.edu/~rse/saas-fee.pdf for hi-res figs.) For lecture ppt files see http://obswww.unige.ch/saas-fee/preannouncement/course_pres/overview_f.htm