How do diabetes models measure up? A review of diabetes economic models and ADA guidelines

Introduction: Economic models and computer simulation models have been used for assessing short-term cost-effectiveness of interventions and modelling long-term outcomes and costs. Several guidelines and checklists have been published to improve the methods and reporting. This article presents an overview of published diabetes models with a focus on how well the models are described in relation to the considerations described by the American Diabetes Association (ADA) guidelines. Methods: Relevant electronic databases and National Institute for Health and Care Excellence (NICE) guidelines were searched in December 2012. Studies were included in the review if they estimated lifetime outcomes for patients with type 1 or type 2 diabetes. Only unique models, and only the original papers were included in the review. If additional information was reported in subsequent or paired articles, then additional citations were included. References and forward citations of relevant articles, including the previous systematic reviews were searched using a similar method to pearl growing. Four principal areas were included in the ADA guidance reporting for models: transparency, validation, uncertainty, and diabetes specific criteria. Results: A total 19 models were included. Twelve models investigated type 2 diabetes, two developed type 1 models, two created separate models for type 1 and type 2, and three developed joint type 1 and type 2 models. Most models were developed in the United States, United Kingdom, Europe or Canada. Later models use data or methods from earlier models for development or validation. There are four main types of models: Markov-based cohort, Markov-based microsimulations, discrete-time microsimulations, and continuous time differential equations. All models were long-term diabetes models incorporating a wide range of compilations from various organ systems. In early diabetes modelling, before the ADA guidelines were published, most models did not include descriptions of all the diabetes specific components of the ADA guidelines but this improved significantly by 2004. Conclusion: A clear, descriptive short summary of the model was often lacking. Descriptions of model validation and uncertainty were the most poorly reported of the four main areas, but there exist conferences focussing specifically on the issue of validation. Interdependence between the complications was the least well incorporated or reported of the diabetes-specific criterion

Optimising service organisation for stroke patients

Background Stroke is the leading cause of long-term neurological disability in adults and the third most common cause of death in Britain. It is well known that in addition to the patient characteristics of age and severity, the treatment a stroke patient receives in hospital signifcantly affects outcome. The effectiveness of complex service interventions, how the benefits of these interventions are achieved and the economic impact of different types of service delivery were explored. Methods The Stroke Unit Trialists' Collaboration systematic review was updated and currently contains 31 clinical trials (6936 subjects). The aims were explored using various basic frequentist and Bayesian meta-analysis techniques as well as more complex meta-analysis ideas. These more complex ideas include: meta-regression where covariate information is incorporated into the model; and network meta-analysis where direct and indirect information is used in a mixed treatment comparisons model while also incorporating covariate information. Results Organised inpatient (stroke unit) care showed reductions in death, death or dependency and death or institutional care compared to general medical wards. Stroke unit care appears to reduce the risk of adverse outcomes through prevention and treatment of complications. Acute, comprehensive and rehabilitation stroke unit care appeared to be most effective and acute stroke unit care appeared to be the most cost-effective. However, acute followed by rehabilitation stroke unit care, if required, appears to be the most cost-effective pathway of care compared to the other pathways analysed. Discussion Future research should focus on rehabilitation, acute and comprehensive systems of inpatient care, and explore the best ways of preventing and managing specific complications. Effort should be made to make individual patient data and information on the care pathway of a stroke patient available for meta-analysis

How do diabetes models measure up? A review of diabetes economic models and ADA guidelines

Introduction: Economic models and computer simulation models have been used for assessing short-term cost-effectiveness of interventions and modelling long-term outcomes and costs. Several guidelines and checklists have been published to improve the methods and reporting. This article presents an overview of published diabetes models with a focus on how well the models are described in relation to the considerations described by the American Diabetes Association (ADA) guidelines. Methods: Relevant electronic databases and National Institute for Health and Care Excellence (NICE) guidelines were searched in December 2012. Studies were included in the review if they estimated lifetime outcomes for patients with type 1 or type 2 diabetes. Only unique models, and only the original papers were included in the review. If additional information was reported in subsequent or paired articles, then additional citations were included. References and forward citations of relevant articles, including the previous systematic reviews were searched using a similar method to pearl growing. Four principal areas were included in the ADA guidance reporting for models: transparency, validation, uncertainty, and diabetes specific criteria. Results: A total 19 models were included. Twelve models investigated type 2 diabetes, two developed type 1 models, two created separate models for type 1 and type 2, and three developed joint type 1 and type 2 models. Most models were developed in the United States, United Kingdom, Europe or Canada. Later models use data or methods from earlier models for development or validation. There are four main types of models: Markov-based cohort, Markov-based microsimulations, discrete-time microsimulations, and continuous time differential equations. All models were long-term diabetes models incorporating a wide range of compilations from various organ systems. In early diabetes modelling, before the ADA guidelines were published, most models did not include descriptions of all the diabetes specific components of the ADA guidelines but this improved significantly by 2004. Conclusion: A clear, descriptive short summary of the model was often lacking. Descriptions of model validation and uncertainty were the most poorly reported of the four main areas, but there exist conferences focussing specifically on the issue of validation. Interdependence between the complications was the least well incorporated or reported of the diabetes-specific criterion

Multimodal Secondary Prevention Behavioral Interventions for TIA and Stroke: A Systematic Review and Meta-Analysis

BackgroundGuidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions.StrategySearches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines.ResultsTwenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (?6.24 to ?2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (?3.19 to ?0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (?6.69 cm, ?11.44 to ?1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (?1.20, ?1.77 to ?0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I2 = 0%, 4,053 participants).ConclusionsThere are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required

Comparative effectiveness of antiviral treatment for hepatitis B:a systematic review and Bayesian network meta-analysis

Objective A wide variety of competing drugs are available to patients for the treatment of chronic hepatitis B. We update a recent meta-analysis to include additional trial evidence with the aim of determining which treatment is the most effective. Methods Twelve monotherapy or combination therapy were evaluated in treatment-naive individuals with hepatitis B e antigen (HBeAg) positive or negative patients. Databases were searched for randomized controlled trials in the first year of therapy. Bayesian random effects network meta-analysis was used to calculate the pairwise odds ratios, 95% credible intervals and ranking of six surrogate outcomes. Results In total, 22 studies were identified (7508 patients): 12 studies analysed HBeAg-positive patients, six analysed HBeAgnegative patients, and four evaluated both. Tenofovir was most effective at increasing efficacy in HBeAg-positive patients, ranking first for three outcomes and increased odds of undetectable levels of hepatitis B virus (HBV) DNA compared with seven other therapies (such as lamivudine: odds ratio 33.0; 95% credible interval 7.0–292.7). For HBeAg-negative patients, the large network (seven therapies) ranked entecavir alone or in combination with tenofovir highly for reduction in HBV DNA and histologic improvement. In the smaller network (three therapies), tenofovir ranked first for undetectable HBV DNA and histologic improvement. No data existed to directly or indirectly compare these treatments. Conclusion For HBeAg-positive patients tenofovir is the most effective at increasing efficacy, whereas for HBeAg-negative patients, either tenofovir or entecavir is most effective. Further research should focus on strengthening the network connections, in particular comparing tenofovir and entecavir in HBeAg-negative patients

Offering views in both directions A survey of member agencies and complainants on their views of the Ombudsman for Corporate Estate Agents scheme

SIGLEAvailable from British Library Document Supply Centre-DSC:q96/33187 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Yoga for stroke rehabilitation

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effectiveness of yoga on recovery and quality of life (QoL) during stroke rehabilitation

Chemical stability of heparin, isopropanol, and ethanol line lock solutions

Background: Ethanol line locks are used in the US to prevent catheter associated bloodstream infections. Heparin precipitates in solution with ethanol. However, isopropanol may reduce precipitate formation. We aimed to determine the chemical stability of heparin, isopropanol, and ethanol line lock for a 10 day period at 2–8 °C and 25 °C.&lt;br&gt;&lt;/br&gt; Methods: Forty samples were prepared for analysis. Each sample was prepared identically using a 5 ml syringe capped with a Combi-stopper: 1 ml 70% isopropanol, 1 ml 70% ethanol, and 1 ml heparin sodium 10 IU/ml. Twenty syringes were stored at 2–8 °C and 20 at 25 °C. Analysis was carried out on days 1, 3, 6, 8, and 10 with a single syringe from each condition being tested in duplicate. Samples were assessed visually. Sub-visible particle count analysis was carried out using a CLIMET particle counting system. Heparin concentration was analysed using an anti-Xa assay. Ethanol and isopropanol concentrations were analysed by gas chromatography.&lt;br&gt;&lt;/br&gt; Results: Samples remained clear and colourless throughout the study. Sub-visible particle counts remained within limits specified in British Pharmacopoeia 2013 when stored at 2–8 °C and 25 °C, 60% humidity for up to 10 days. There was no significant change in ethanol or isopropanol concentration during the study. However, heparin activity fell by &gt; 10% after 1 day storage and to 65% of original activity after 10 days.&lt;br&gt;&lt;/br&gt; Conclusions: This study shows that addition of isopropanol to heparin and ethanol prevents precipitation. However, this solution shows a progressive decline in heparin activity over time making it unsuitable for extended shelf life

Remarks on Dilworth partially ordered sets

This paper is a part of the talk presented at the 11th Workshop on Graph Theoretic Concepts in Computer Science, June 18-21, 1985 at Castle Schwanberg (near Wuerzburg), GermanySIGLETIB: RN 4052 (85381-OR) / FIZ - Fachinformationszzentrum Karlsruhe / TIB - Technische InformationsbibliothekDEGerman