Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis C

The cost-effectiveness of noninvasive tests (NITs) as alternatives to liver biopsy is unknown. We compared the cost-effectiveness of using NITs to inform treatment decisions in adult patients with chronic hepatitis C (CHC). We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes (quality-adjusted life-years; QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four treatment strategies: testing with NITs and treating patients with fibrosis stage ≥F2; testing with liver biopsy and treating patients with ≥F2; treat none; and treat all irrespective of fibrosis. We compared all NITs and tested the cost-effectiveness using current triple therapy with boceprevir or telaprevir, but also modeled new, more-potent antivirals. Treating all patients without any previous NIT was the most effective strategy and had an incremental cost-effectiveness ratio (ICER) of £9,204 per additional QALY gained. The exploratory analysis of currently licensed sofosbuvir treatment regimens found that treat all was cost-effective, compared to using an NIT to decide on treatment, with an ICER of £16,028 per QALY gained. The exploratory analysis to assess the possible effect on results of new treatments, found that if SVR rates increased to >90% for genotypes 1-4, the incremental treatment cost threshold for the "treat all" strategy to remain the most cost-effective strategy would be £37,500. Above this threshold, the most cost-effective option would be noninvasive testing with magnetic resonance elastography (ICER=£9,189). Conclusions: Treating all adult patients with CHC, irrespective of fibrosis stage, is the most cost-effective strategy with currently available drugs in developed countries. © 2014 The Authors

Potential Environmental Impacts of Hydrogen-based Transportation and Power Systems

Hydrogen (H2) offers advantages as an energy carrier: minimal discharge of pollutants, production from multiple sources, increased thermodynamic efficiencies compared to fossil fuels, and reduced dependence on foreign oil. However, potential impacts from the H2 generation processes, transport and distribution of H2, and releases of H2 into the atmosphere have been proposed. The goal of this project was to analyze the effects of emissions of hydrogen, the six criteria pollutants and greenhouse gases on climate, human health, materials and structures. This project was part of a larger effort by DOE to assess the life-cycle costs and benefits and environmental impacts to inform decisions regarding future hydrogen research. Technical Approach: A modeling approach was developed and used to evaluate the potential environmental effects associated with the conversion of the on-road vehicle fleet from fossil-fuel vehicles to hydrogen fuel cell vehicles. GATOR-GCMOM was the primary tool used to predict atmospheric concentrations of gases and aerosols for selected scenarios. This model accounts for all feedbacks among major atmospheric processes based on first principles. The future scenarios and the emission rates selected for this analysis of hydrogen environmental effects are based on the scenarios developed by IPCC. The scenarios selected for the model simulations are a 2000 and 2050 A1B base cases, and a 2050 A1B case with hydrogen fuel cell vehicles (HFCVs). The hydrogen fuel cell scenario assumed conversion of 90% of fossil-fuel on-road vehicles (FFOV) in developed countries and 45% of FFOVs vehicles in other countries to HFCVs, with the H2 produced by steam-reforming of natural gas (SHFCVs). Simulations were conducted to examine the effect of converting the worldâÂÂs FFOVs to HFCVs, where the H2 is produced by wind-powered electrolysis (WHFCVs). In all scenarios a 3% leakage of H2 consumed was assumed. Two new models were developed that provide the ability to evaluate a wider range of conditions and address some of the uncertainties that exist in the evaluation of hydrogen emissions. A simplified global hydrogen cycle model that simulates hydrogen dynamics in the troposphere and stratosphere was developed. A Monte Carlo framework was developed to address hydrogen uptake variability for different types of ecosystems. Findings 1.Converting vehicles worldwide in 2050 to SHFCVs at 90% penetration in developed countries and 45% penetration in other countries is expected to reduce NOx, CO, CO2, CH4, some other organic gases, ozone, PAN, black carbon, and other particle components in the troposphere, but may increase some other organic gases, depending on emissions. Conversion to SHFCVs is also expected to cool the troposphere and warm the stratosphere, but to a lesser extent than WHFCVs. Finally, SHFCVs are expected to increase UTLS ozone while decreasing upper stratospheric ozone, but to a lesser extent than WHFCVs. 2.The predicted criteria pollutant concentrations from the GATOR-GCMOM simulations indicated that near-surface annual mean concentrations in the US are likely to increase from the 2000 base case to the 2050 A1B base case for CO2 and ozone due to the increased economic activity, but to decrease for CO, NO2, SO2, and PM10 due to improved pollution control equipment and energy efficiencies. The shift to SHFCVs in 2050 was predicted to result in decreased concentrations for all the criteria pollutants, except for SO2 and PM10. The higher predicted concentrations for SO2 and PM10 were attributed to increased emissions using the steam-reforming method to generate H2. If renewable methods such as wind-based electrolysis were used to generate H2, the emissions of SO2 and PM10 would be lower. 3.The effects on air quality, human health, ecosystem, and building structures were quantified by comparing the GATOR-GCMOM model output and accepted health and ecosystem effects levels and ambient air quality criteria. Shifting to HFCVs is expected to result in improved air quality and benefits to human health. Shifting to HFCVs is unlikely to result in damage to buildings. 4.Results are thought to be robust for larger leakage rates of H2 and for greater penetrations of HFCVs, since the controlling factor for stratospheric ozone impacts is the reduction in fossil-fuel greenhouse gases and the resulting surface cooling, which reduces water vapor emissions and stratospheric warming, which increases tropopause stability reducing water vapor transport to the stratosphere. 5.The supplemental modeling results were generally supportive of the results from the GATOR-GCMOM simulations, and recommendations for additional analyses were made. Extending the duration of the simulation to coincide with the time required for hydrogen mixing ratios to attain a steady state condition was recommended. Further evaluation of algorithms to describe hydrogen uptake in the model was also recommended

Organizational learning and emotion: constructing collective meaning in support of strategic themes

Missing in the organizational learning literature is an integrative framework that reflects the emotional as well as the cognitive dynamics involved. Here, we take a step in this direction by focusing in depth over time (five years) on a selected organization which manufactures electronic equipment for the office industry. Drawing on personal construct theory, we define organizational learning as the collective re-construal of meaning in the direction of strategically significant themes. We suggest that emotions arise as members reflect on progress or lack of progress in achieving organizational learning. Our evidence suggests that invalidation – where organizational learning fails to correspond with expectations – gives rise to anxiety and frustration, while validation – where organizational learning is aligned with or exceeds expectations – evokes comfort or excitement. Our work aims to capture the key emotions involved as organizational learning proceeds

Can majority support save an endangered language? A case study of language attitudes in Guernsey

Many studies of minority language revitalisation focus on the attitudes and perceptions of minorities, but not on those of majority group members. This paper discusses the implications of these issues, and presents research into majority andf minority attitudes towards the endangered indigenous vernacular of Guernsey, Channel Islands. The research used a multi-method approach (questionnaire and interview) to obtain attitudinal data from a representative sample of the population that included politicians and civil servants (209 participants). The findings suggested a shift in language ideology away from the post-second world war ‘culture of modernisation’ and monolingual ideal, towards recognition of the value of a bi/trilingual linguistic heritage. Public opinion in Guernsey now seems to support the maintenance of the indigenous language variety, which has led to a degree of official support. The paper then discusses to what extent this ‘attitude shift’ is reflected in linguistic behaviour and in concrete language planning measures

Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis B in the UK: systematic review and economic evaluation

The copyright line for this article was changed on 18 November 2016 after original online publication. Abbreviations: CEAF cost-effectiveness frontier. CHB chronic hepatitis B. CI confidence intervals. FN false negative. FP false positive. HBV hepatitis B virus. HCC hepatocellular carcinoma. ICER incremental cost-effectiveness ratio. NITs noninvasive tests. QUADAS Quality Assessment of Diagnostic Accuracy Studies. QUALYs quality-adjusted-life-years. TN true negative. TP true positive.Copyright © 2015 The Authors. We compared the cost-effectiveness of various noninvasive tests (NITs) in patients with chronic hepatitis B and elevated transaminases and/or viral load who would normally undergo liver biopsy to inform treatment decisions. We searched various databases until April 2012. We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes quality-adjusted-life-years (QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four decision-making strategies: testing with NITs and treating patients with fibrosis stage ≥F2, testing with liver biopsy and treating patients with ≥F2, treat none (watchful waiting) and treat all irrespective of fibrosis. Treating all patients without prior fibrosis assessment had an incremental cost-effectiveness ratio (ICER) of £28 137 per additional QALY gained for HBeAg-negative patients. For HBeAg-positive patients, using Fibroscan was the most cost-effective option with an ICER of £23 345. The base case results remained robust in the majority of sensitivity analyses, but were sensitive to changes in the ≥F2 prevalence and the benefit of treatment in patients with F0–F1. For HBeAg-negative patients, strategies excluding NITs were the most cost-effective: treating all patients regardless of fibrosis level if the high cost-effectiveness threshold of £30 000 is accepted; watchful waiting if not. For HBeAg-positive patients, using Fibroscan to identify and treat those with ≥F2 was the most cost-effective option.The analysis for Hepatitis B was part of a larger project funded by The National Institute for Health Research Health Technology Assessment (HTA project 09/114/02) and will be published in full in the Health Technology Assessment journal series. Visit the HTA programme website for more details www.hta.ac.uk/link to project page

Potential Environmental Impacts of Hydrogen-based Transportation and Power Systems

Hydrogen (H2) offers advantages as an energy carrier: minimal discharge of pollutants, production from multiple sources, increased thermodynamic efficiencies compared to fossil fuels, and reduced dependence on foreign oil. However, potential impacts from the H2 generation processes, transport and distribution of H2, and releases of H2 into the atmosphere have been proposed. The goal of this project was to analyze the effects of emissions of hydrogen, the six criteria pollutants and greenhouse gases on climate, human health, materials and structures. This project was part of a larger effort by DOE to assess the life-cycle costs and benefits and environmental impacts to inform decisions regarding future hydrogen research. Technical Approach: A modeling approach was developed and used to evaluate the potential environmental effects associated with the conversion of the on-road vehicle fleet from fossil-fuel vehicles to hydrogen fuel cell vehicles. GATOR-GCMOM was the primary tool used to predict atmospheric concentrations of gases and aerosols for selected scenarios. This model accounts for all feedbacks among major atmospheric processes based on first principles. The future scenarios and the emission rates selected for this analysis of hydrogen environmental effects are based on the scenarios developed by IPCC. The scenarios selected for the model simulations are a 2000 and 2050 A1B base cases, and a 2050 A1B case with hydrogen fuel cell vehicles (HFCVs). The hydrogen fuel cell scenario assumed conversion of 90% of fossil-fuel on-road vehicles (FFOV) in developed countries and 45% of FFOVs vehicles in other countries to HFCVs, with the H2 produced by steam-reforming of natural gas (SHFCVs). Simulations were conducted to examine the effect of converting the worldâÂÂs FFOVs to HFCVs, where the H2 is produced by wind-powered electrolysis (WHFCVs). In all scenarios a 3% leakage of H2 consumed was assumed. Two new models were developed that provide the ability to evaluate a wider range of conditions and address some of the uncertainties that exist in the evaluation of hydrogen emissions. A simplified global hydrogen cycle model that simulates hydrogen dynamics in the troposphere and stratosphere was developed. A Monte Carlo framework was developed to address hydrogen uptake variability for different types of ecosystems. Findings 1.Converting vehicles worldwide in 2050 to SHFCVs at 90% penetration in developed countries and 45% penetration in other countries is expected to reduce NOx, CO, CO2, CH4, some other organic gases, ozone, PAN, black carbon, and other particle components in the troposphere, but may increase some other organic gases, depending on emissions. Conversion to SHFCVs is also expected to cool the troposphere and warm the stratosphere, but to a lesser extent than WHFCVs. Finally, SHFCVs are expected to increase UTLS ozone while decreasing upper stratospheric ozone, but to a lesser extent than WHFCVs. 2.The predicted criteria pollutant concentrations from the GATOR-GCMOM simulations indicated that near-surface annual mean concentrations in the US are likely to increase from the 2000 base case to the 2050 A1B base case for CO2 and ozone due to the increased economic activity, but to decrease for CO, NO2, SO2, and PM10 due to improved pollution control equipment and energy efficiencies. The shift to SHFCVs in 2050 was predicted to result in decreased concentrations for all the criteria pollutants, except for SO2 and PM10. The higher predicted concentrations for SO2 and PM10 were attributed to increased emissions using the steam-reforming method to generate H2. If renewable methods such as wind-based electrolysis were used to generate H2, the emissions of SO2 and PM10 would be lower. 3.The effects on air quality, human health, ecosystem, and building structures were quantified by comparing the GATOR-GCMOM model output and accepted health and ecosystem effects levels and ambient air quality criteria. Shifting to HFCVs is expected to result in improved air quality and benefits to human health. Shifting to HFCVs is unlikely to result in damage to buildings. 4.Results are thought to be robust for larger leakage rates of H2 and for greater penetrations of HFCVs, since the controlling factor for stratospheric ozone impacts is the reduction in fossil-fuel greenhouse gases and the resulting surface cooling, which reduces water vapor emissions and stratospheric warming, which increases tropopause stability reducing water vapor transport to the stratosphere. 5.The supplemental modeling results were generally supportive of the results from the GATOR-GCMOM simulations, and recommendations for additional analyses were made. Extending the duration of the simulation to coincide with the time required for hydrogen mixing ratios to attain a steady state condition was recommended. Further evaluation of algorithms to describe hydrogen uptake in the model was also recommended

Nurses Alumni Association Bulletin, Fall 1991

Annual Meeting Calendar Annual Luncheon - Meeting Notice Meeting Notice Dates Officers and Committee Chairmen President\u27s Message Treasurer\u27s Report Proposed Budget- 1991 News About Our Graduates History of the School of Nursing The Future of Nursing School Health - 20 Years Ago - Today Happy Birthday Resume of Minutes of Alumni Association Meetings Alumni Office News Committee Reports By-Laws Bulletin Nominating Relief Fund Satellite Scholarship Social Finance Nursing Education at Jefferson - A Century of Excellence The Decade Fund Fiftieth Anniversary In Memoriam, Names of Deceased Graduates Luncheon Photos My Dear Son Weather Lore Class News Scholarship Application Non-Graduate Scholarship Fund Application Relief Fund Application Centennial Tile Order Form Membership Application Pins, Transcripts, Class Address Lists, Change of Address Form Ma

Understanding Interorganizational Learning Based on Social Spaces and Learning Episodes

Different organizational settings have been gaining ground in the world economy, resulting in a proliferation of different forms of strategic alliances that translate into a growth in the number of organizations that have started to deal with interorganizational relationships with different actors. These circumstances reinforce Crossan, Lane, White and Djurfeldt (1995) and Crossan, Mauer and White (2011) in exploring what authors refer to as the fourth, interorganizational, level of learning. These authors, amongst others, suggest that the process of interorganizational learning (IOL) warrants investigation, as its scope of analysis needs widening and deepening. Therefore, this theoretical essay is an attempt to understand IOL as a dynamic process found in interorganizational cooperative relationships that can take place in different structured and unstructured social spaces and that can generate learning episodes. According to this view, IOL is understood as part of an organizational learning continuum and is analyzed within the framework of practical rationality in an approach that is less cognitive and more social-behavioral