Comparative Review on the Cost-Effectiveness Analysis of Relief Teams' Deployment to Sudden-Onset Disasters

When a disaster exceeds the capacity of the affected country to cope with its own resources, the provision of external rescue and health services is required, and the deployment of relief units requested. Recently, the cost of international relief and the belief that such deployment is cost-effective has been questioned by the international community; unfortunately, there is still little informed debate and few detailed data are available. This paper presents the results of a comparative review on the cost-effectiveness analysis (CEA) of search and rescue (SAR) and Emergency Medical Team (EMT) deployment. The aim of this work is to provide an overview of the topic, highlight the criteria used to assess the effectiveness, and identify gaps in existing literature. The results show that both deployments are highly expensive, and their success is strongly related to the time they need to be operational; SAR deployments are characterized by limited outcomes in terms of lives saved, and EMTs by insufficient data and lack of detailed assessment. This research highlights that the criteria used to assess the effectiveness need to be explored further, considering different purposes, lengths of stay, and different activities performed, especially for any comparison. This study concludes that data reporting should be mandatory for humanitarian response agencies.</p

Clinical review: Mass casualty triage – pandemic influenza and critical care

Worst case scenarios for pandemic influenza planning in the US involve over 700,000 patients requiring mechanical ventilation. UK planning predicts a 231% occupancy of current level 3 (intensive care unit) bed capacity. Critical care planners need to recognise that mortality is likely to be high and the risk to healthcare workers significant. Contingency planning should, therefore, be multi-faceted, involving a robust health command structure, the facility to expand critical care provision in terms of space, equipment and staff and cohorting of affected patients in the early stages. It should also be recognised that despite this expansion of critical care, demand will exceed supply and a process for triage needs to be developed that is valid, reproducible, transparent and consistent with distributive justice. We advocate the development and validation of physiological scores for use as a triage tool, coupled with candid public discussion of the process

FAD Mutations in Amyloid Precursor Protein Do Not Directly Perturb Intracellular Calcium Homeostasis

Disturbances in intracellular calcium homeostasis are likely prominent and causative factors leading to neuronal cell death in Alzheimer's disease (AD). Familial AD (FAD) is early-onset and exhibits autosomal dominant inheritance. FAD-linked mutations have been found in the genes encoding the presenilins and amyloid precursor protein (APP). Several studies have shown that mutated presenilin proteins can directly affect calcium release from intracellular stores independently of Aβ production. Although less well established, there is also evidence that APP may directly modulate intracellular calcium homeostasis. Here, we directly examined whether overexpression of FAD-linked APP mutants alters intracellular calcium dynamics. In contrast to previous studies, we found that overexpression of mutant APP has no effects on basal cytosolic calcium, ER calcium store size or agonist-induced calcium release and subsequent entry. Thus, we conclude that mutated APP associated with FAD has no direct effect on intracellular calcium homeostasis independently of Aβ production

EEG responses to standardised noxious stimulation during clinical anaesthesia: a pilot study.

BACKGROUND During clinical anaesthesia, the administration of analgesics mostly relies on empirical knowledge and observation of the patient's reactions to noxious stimuli. Previous studies in healthy volunteers under controlled conditions revealed EEG activity in response to standardised nociceptive stimuli even at high doses of remifentanil and propofol. This pilot study aims to investigate the feasibility of using these standardised nociceptive stimuli in routine clinical practice. METHODS We studied 17 patients undergoing orthopaedic trauma surgery under general anaesthesia. We evaluated if the EEG could track standardised noxious phase-locked electrical stimulation and tetanic stimulation, a time-locked surrogate for incisional pain, before, during, and after the induction of general anaesthesia. Subsequently, we analysed the effect of tetanic stimulation on the surgical pleth index as a peripheral, vegetative, nociceptive marker. RESULTS We found that the phase-locked evoked potentials after noxious electrical stimulation vanished after the administration of propofol, but not at low concentrations of remifentanil. After noxious tetanic stimulation under general anaesthesia, there were no consistent spectral changes in the EEG, but the vegetative response in the surgical pleth index was statistically significant (Hedges' g effect size 0.32 [95% confidence interval 0.12-0.77], P=0.035). CONCLUSION Our standardised nociceptive stimuli are not optimised for obtaining consistent EEG responses in patients during clinical anaesthesia. To validate and sufficiently reproduce EEG-based standardised stimulation as a marker for nociception in clinical anaesthesia, other pain models or stimulation settings might be required to transfer preclinical studies into clinical practice. CLINICAL TRIAL REGISTRATION DRKS00017829

Evolution in the black hole mass-bulge mass relation: a theoretical perspective

We explore the growth of super-massive black holes and host galaxy bulges in the galaxy population using the Millennium Run LCDM simulation coupled with a model of galaxy formation. We find that, if galaxy mergers are the primary drivers for both bulge and black hole growth, then in the simplest picture one should expect the mBH-mbulge relation to evolve with redshift, with a larger black hole mass associated with a given bulge mass at earlier times relative to the present day. This result is independent of an evolving cold gas fraction in the galaxy population. The evolution arises from the disruption of galactic disks during mergers that make a larger fractional mass contribution to bulges at low redshift than at earlier epochs. There is no comparable growth mode for the black hole population. Thus, this effect produces evolution in the mBH-mbulge relation that is driven by bulge mass growth and not by black holes.Comment: 6 pages, 3 figures, minor revisions, replaced with accepted MNRAS versio

Psychosocial care for persons affected by emergencies and major incidents: a Delphi study to determine the needs of professional first responders for education, training and support

Background The role of ambulance clinicians in providing psychosocial care in major incidents and emergencies is recognised in recent Department of Health guidance. The study described in this paper identified NHS professional first responders’ needs for education about survivors’ psychosocial responses, training in psychosocial skills, and continuing support. Method Ambulance staff participated in an online Delphi questionnaire, comprising 74 items (Round 1) on 7-point Likert scales. Second-round and third-round participants each received feedback based on the previous round, and responded to modified versions of the original items and to new items for clarification. Results One hundred and two participants took part in Round 1; 47 statements (64%) achieved consensus. In Round 2, 72 people from Round 1 participated; 15 out of 39 statements (38%) achieved consensus. In Round 3, 49 people from Round 2 participated; 15 out of 27 statements (59%) achieved consensus. Overall, there was consensus in the following areas: ‘psychosocial needs of patients’ (consensus in 34/37 items); ‘possible sources of stress in your work’ (8/9); ‘impacts of distress in your work’ (7/10); ‘meeting your own emotional needs’ (4/5); ‘support within your organisation’ (2/5); ‘needs for training in psychosocial skills for patients’ (15/15); ‘my needs for psychosocial training and support’ (5/6). Conclusions Ambulance clinicians recognise their own education needs and the importance of their being offered psychosocial training and support. The authors recommend that, in order to meet patients’ psychosocial needs effectively, ambulance clinicians are provided with education and training in a number of skills and their own psychosocial support should be enhanced

Philosophy with children : facilitating children's voices on childhood

Increasingly there is a search for participatory research methods that work to ensure children’s authentic voices are heard. In this presentation we will propose that Philosophy with Children might be employed as a research method that facilitates children’s participation and voice in research. Further, it may also impact positively in children’s wider participation and engagement in recognising children’s agency and conceptual autonomy. We will discuss the advantages of using philosophical dialogue as a method for collecting data and will also consider challenges that arise from using Philosophy with Children as a research tool. In discussing the challenges and opportunities afforded by such a method, the presentation will draw on two studies to exemplify the approach. One study explored what kind of society children want to live in, and the second is an on-going international study that aims to explore children’s conceptions of child/childhood. We will also suggest that using Philosophy with Children might be considered as addressing the need for rights-based approaches to research as in affording children ownership of the dialogue it does not assume children as deficient in their capacities and it recognises children’s particular perspectives on the world. In addition, we will suggest that using a philosophical approach to gathering children’s views might offer a deeper insight into their thinking of and understanding about the world. Elements of the approaches used in the study will be discussed in order to gauge the strengths and limitations of using practical philosophy as a means of gathering data in subsequent analysis. In juxtaposition to the Philosophy with Children approach discussed, we will comment briefly on the use of an alternative research method, Nominal Group Technique, which was also used in the first project. In comparing the two approaches we aim to show where Philosophy with Children may provide richer and deeper evidence when seeking children’s views. While the presentation will not share the findings of either of the projects mentioned above, the approach taken in using Philosophy with Children as a research method, relates strongly to the findings of the initial project and the goals of the Children’s Voices on Childhood project. In using Philosophy with Children, it will be proposed that, while there may be some limitations in using the approach, it takes account of children’s voices in research; it affords opportunities to explore children’s conceptual thinking and the application to ‘real life’; it allows children to have ownership of the topic under consideration; and it potentially leads to addressing children’s status in wider society

Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia.

BACKGROUND &amp; AIMS: Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. METHODS: We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. RESULTS: From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and &lt;0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. CONCLUSIONS: Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts

Accelerated discharge of patients in the event of a major incident: observational study of a teaching hospital

BACKGROUND: Since October 2002 in the UK Primary Care Trusts (PCTs) have had statutory responsibility for having and maintaining a Major Incident plan and since 2005 they have been obliged to co-operate with other responders to an incident. We aimed to establish the number of beds in our Trust which could be freed up over set periods of time in the event of a major incident and the nature and quantity of support which might be required from PCTs in order to achieve this. METHODS: Repeated survey over 12 days in 3 months of hospital bed occupancy by type of condition and discharge capacity in an 855-bed UK tertiary teaching hospital also providing secondary care services. Outcome measures were bed spaces which could be generated, timescale over which this could happen and level and type of PCT support which would be required to achieve this. RESULTS: Mean beds available were 78 immediately, a further 69 in 1–4 hours and a further 155 in 4–12 hours, generating a total of 302 beds (36% of hospital capacity) within 12 hours of an incident. This would require support from a PCT of 150,000 population of 10 nursing care beds, 20 therapy-supported intermediate care beds, and 25 care packages in patients' own homes. CONCLUSION: In order to fulfill the requirements of the Civil Contingencies Act 2004, PCTs should plan to have surge capacity in the order of 30 residential placements and 25 community support packages per 150,000 population to support Acute Trusts in the event of a major incident

Antibody production in micro-organisms

Global demand for monoclonal antibody-based therapeutics (Mab’s) far exceeds current production capacity, and is expected to continue to grow based on current development pipelines. Despite their proven efficacy in a large number of indications, equitable use of these drugs is limited by the high cost of CHO-cell based production and purification. Micro-organisms such as yeasts and filamentous fungi present an attractive alternative for antibody production, but will require extensive genetic modification to achieve both high titers and mammalian-like glycosylation patterns in a secreted product that is easily purified. Towards this end, we developed state-of-the-art genetic engineering tools for eight micro-organisms to enable the highly efficient, targeted multiplexed integrations necessary for antibody production in these hosts. We demonstrated successful antibody production in several of these micro-organisms, paving the way to low-cost microbial fermentation to replace CHO fermentation