Representation, affiliation and compassion in selected fiction by Michael Ondaatje

Magister Artium - M

How innovation can be defined, evaluated and rewarded in health technology assessment

This study has received support from researchproject PID2019.105597RA.I00 financed by the Spanish Ministry of Science and Innovation/National Research Agency MCIN/AEI/10.13039/501100011033. The funders had no role in the study.Background: What constitutes innovation in health technologies can be defined and measured in a number of ways and it has been widely researched and published about. However, while many countries mention it as a criterion for pricing or reimbursement of health technologies, countries differ widely in how they define and operationalise it. Methods: We performed a literature review, using a snowballing search. In this paper, we explore how innovation has been defined in the literature in relation to health technology assessment. We also describe how a selection of countries (England, France, Italy, Spain and Japan) take account of innovation in their health technology assessment frameworks and explore the key methodologies that can capture it as a dimension of value in a new health technology. We propose a way of coming to, and incorporating into health technology assessment systems, a definition of innovation for health technologies that is independent of other dimensions of value that they already account for in their systems, such as clinical benefit. We use Spain as an illustrative example of how innovation might be operationalised as a criterion for decision making in health technology assessment. Results: The countries analysed here can be divided into 2 groups with respect to how they define innovation. France, Japan and Italy use features such as severity, unmet need and therapeutic added value as indicators of the degree of innovation of a health technology, while England, Spain consider the degree of innovation as a separate and additional criterion from others. In the case of Spain, a notion of innovation might be constructed around concepts of `step-change’, `convenience’, `strength of evidence base’ and `impact on future research & development’. Conclusions: If innovation is to be used as operational criteria for adoption, pricing and reimbursement of health technologies, the concept must be clearly defined, and it ought to be independent from other value dimensions already captured in their health technology assessment systems.Spanish Ministry of Science and Innovation/National Research Agency PID2019.105597RA.I00MCIN/AEI/10.13039/50110001103

Multiple criteria decision analysis for HTA across four EU member states: piloting the Advance Value Framework

Multiple Criteria Decision Analysis (MCDA) has emerged as a methodology for Health Technology Assessment (HTA). However, limited empirical evidence is available on its use by decision-makers; where available, it only comes from single-setting exercises, while cross-country comparative studies are unavailable. This study applies the Advance Value Framework (AVF), an MCDA methodology for HTA based on multi-attribute value theory, through a series of case studies with decision-makers in four countries, to explore its feasibility and compare decision-makers' value preferences and results. The AVF was applied in the evaluation of three drugs for metastatic, castrate resistant, prostate cancer (abiraterone, cabazitaxel and enzalutamide) in the post-chemotherapy indication. Decision conferences were organised in four European countries in collaboration with their HTA or health insurance organisations by involving relevant assessors and experts: Sweden (TLV), Andalusia/Spain (AETSA), Poland (AOTMiT) and Belgium (INAMI-RIZIV). Participants' value preferences, including performance scoring and criteria weighting, were elicited through a facilitated decision-analysis modelling approach using the MACBETH technique. Between 6 and 11 criteria were included in each jurisdiction's value model, allocated across four criteria domains; Therapeutic Benefit criteria consistently ranked first in relative importance across all countries. Consistent drug rankings were observed in all settings, with enzalutamide generating the highest overall weighted preference value (WPV) score, followed by abiraterone and cabazitaxel. Dividing drugs' overall WPV scores by their costs produced the lowest “cost per unit of value” for enzalutamide, followed by abiraterone and cabazitaxel. These results come in contrast with the actual country HTA recommendations and pricing decisions. Overall, although some differences in value preferences were observed between countries, drug rankings remained the same. The MCDA methodology employed could act as a decision support tool in HTA, due to the transparency in the construction of value preferences in a collaborative manner

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Conference of Microelectronic Research 1990

https://scholarworks.rit.edu/meec_archive/1003/thumbnail.jp

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Profiling the Responses of Soccer Substitutes: A Review of Current Literature.

Depending upon competition regulations, the laws of soccer allow between three and an unlimited number of substitutions that can be made on either a permanent or rolling basis. Substitutes are typically introduced to minimise/offset the effects of fatigue, alter tactics, replace players deemed as underperforming or injured, and/or give playing time to youth players or to squad members returning from injury. While the match-day practices of substitutes include participation in the pre-match warm-up, and sporadic periods of rewarm-up activity, it is currently unclear as to whether these pre-entry preparations facilitate optimal match performance thereafter. Acknowledging the contextual factors that possibly influence substitutes' performance, this review summarises the presently available literature on soccer substitutes, and makes recommendations for future research. Literature searching and screening yielded 13 studies, which have typically focused on characterising: (1) the patterns, including timing, of substitutes' introduction; (2) indices of match-performance; and (3) the emotional experiences of soccer substitutes. The majority of substitutions occur after the first-half has ended (i.e. at half-time or during the second-half), with introduced players exceeding the second-half physical performances of those who started the match. Observations of progressive improvements in running performance as playing time increases, and findings that substitutes mostly experience negative emotions, highlight the potential inadequacies of pre-match preparations, and present future research opportunities. Additional work is therefore needed to confirm these findings and to determine the efficacy of current preparation strategies, thereby providing opportunities to assess then address substitutes' pre-pitch entry preparations, on-field performance and emotional responses

The ‘Staffrider’ figure and the Reading of South African Poetry

This article revisits the figure of the ‘staffrider’ which inspired the title of the literary journal more than forty years ago. It considers how the disruptive, radical nature of this figure regains a measure of relevance in the aftermath of developments in literary theory, in particular, what is understood as the ‘linguistic turn’ with regard to language and meaning. The discussion here follows the premise that if a white aesthetic practice as a discursive construction is susceptible to a process of dismantling, then it must follow that the same can be applied to the constructed nature of a black aesthetic. These critiques must, simultaneously, trouble the claims that what has been circumscribed as a black aesthetics in poetry constitutes a homogenous counter aesthetic and, thus, a poetic tradition inspired almost exclusively by the terms of a fixed subjectivity. As a consequence, a revision of the antithesis between a black and white aesthetic is required, one which must explode the conventional schematic of South African poetry which has remained prevalent in critical scholarship up to this point. In doing so, I suggest it may be valuable to evoke the figure of the ‘staffrider’ as a productive symbol of the troubling yet always equally dynamic nature of the literary text. Keywords: Aesthetics, deconstruction, South African poetry, Staffrider, subjectivit

The Volume and Tone of Twitter Posts About Cannabis Use During Pregnancy: Protocol for a Scoping Review

BackgroundCannabis use has increased in Canada since its legalization in 2018, including among pregnant women who may be motivated to use cannabis to reduce symptoms of nausea and vomiting. However, a growing body of research suggests that cannabis use during pregnancy may harm the developing fetus. As a result, patients increasingly seek medical advice from online sources, but these platforms may also spread anecdotal descriptions or misinformation. Given the possible disconnect between online messaging and evidence-based research about the effects of cannabis use during pregnancy, there is a potential for advice taken from social media to affect the health of mothers and their babies. ObjectiveThis study aims to quantify the volume and tone of English language posts related to cannabis use in pregnancy from January 2012 to December 2021. MethodsModeling published frameworks for scoping reviews, we will collect publicly available posts from Twitter that mention cannabis use during pregnancy and use the Twitter Application Programming Interface for Academic Research to extract data from tweets, including public metrics such as the number of likes, retweets, and quotes, as well as health effect mentions, sentiment, location, and users’ interests. These data will be used to quantify how cannabis use during pregnancy is discussed on Twitter and to build a qualitative profile of supportive and opposing posters. ResultsThe CHEO Research Ethics Board reviewed our project and granted an exemption in May 2021. As of December 2021, we have gained approval to use the Twitter Application Programming Interface for Academic Research and have developed a preliminary search strategy that returns over 3 million unique tweets posted between 2012 and 2021. ConclusionsUnderstanding how Twitter is being used to discuss cannabis use during pregnancy will help public health agencies and health care providers assess the messaging patients may be receiving and develop communication strategies to counter misinformation, especially in geographical regions where legalization is recent or imminent. Most importantly, we foresee that our findings will assist expecting families in making informed choices about where they choose to access advice about using cannabis during pregnancy. Trial RegistrationOpen Science Framework 10.17605/OSF.IO/BW8DA; www.osf.io/6fb2e International Registered Report Identifier (IRRID)PRR1-10.2196/3442