Costs and Outcomes of Increasing Access to Bariatric Surgery: Cohort Study and Cost-Effectiveness Analysis Using Electronic Health Records

Objectives: To estimate costs and outcomes of increasing access to bariatric surgery in obese adults and in population subgroups of age, sex, deprivation, comorbidity, and obesity category. Methods: A cohort study was conducted using primary care electronic health records, with linked hospital utilization data, for 3,045 participants who underwent bariatric surgery and 247,537 participants who did not undergo bariatric surgery. Epidemiological analyses informed a probabilistic Markov model to compare bariatric surgery, including equal proportions with adjustable gastric banding, gastric bypass, and sleeve gastrectomy, with standard nonsurgical management of obesity. Outcomes were quality-adjusted life-years (QALYs) and net monetary benefits at a threshold of £30,000 per QALY. Results: In a UK population of 250,000 adults, there may be 7,163 people with morbid obesity including 1,406 with diabetes. The immediate cost of 1,000 bariatric surgical procedures is £9.16 million, with incremental discounted lifetime health care costs of £15.26 million (95% confidence interval £15.18–£15.36 million). Patient-years with diabetes mellitus will decrease by 8,320 (range 8,123–8,502). Incremental QALYs will increase by 2,142 (range 2,032–2,256). The estimated cost per QALY gained is £7,129 (range £6,775–£7,506). Net monetary benefits will be £49.02 million (range £45.72–£52.41 million). Estimates are similar for subgroups of age, sex, and deprivation. Bariatric surgery remains cost-effective if the procedure is twice as costly, or if intervention effect declines over time. Conclusions: Diverse obese individuals may benefit from bariatric surgery at acceptable cost. Bariatric surgery is not cost-saving, but increased health care costs are exceeded by health benefits to obese individuals

Vitamin D and Risk of Neuroimaging Abnormalities.

Vitamin D deficiency has been linked with an increased risk of incident all-cause dementia and Alzheimer's disease. The aim of the current study was to explore the potential mechanisms underlying these associations by determining whether low vitamin D concentrations are associated with the development of incident cerebrovascular and neurodegenerative neuroimaging abnormalities. The population consisted of 1,658 participants aged ≥65 years from the US-based Cardiovascular Health Study who were free from prevalent cardiovascular disease, stroke and dementia at baseline in 1992-93. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were determined by liquid chromatography-tandem mass spectrometry from blood samples collected at baseline. The first MRI scan was conducted between 1991-1994 and the second MRI scan was conducted between 1997-1999. Change in white matter grade, ventricular grade and presence of infarcts between MRI scan one and two were used to define neuroimaging abnormalities. During a mean follow-up of 5.0 years, serum 25(OH)D status was not significantly associated with the development of any neuroimaging abnormalities. Using logistic regression models, the multivariate adjusted odds ratios (95% confidence interval) for worsening white matter grade in participants who were severely 25(OH)D deficient (<25 nmol/L) and deficient (≥25-50 nmol/L) were 0.76 (0.35-1.66) and 1.09 (0.76-1.55) compared to participants with sufficient concentrations (≥50 nmol/L). The multivariate adjusted odds ratios for ventricular grade in participants who were severely 25(OH)D deficient and deficient were 0.49 (0.20-1.19) and 1.12 (0.79-1.59) compared to those sufficient. The multivariate adjusted odds ratios for incident infarcts in participants who were severely 25(OH)D deficient and deficient were 1.95 (0.84-4.54) and 0.73 (0.47-1.95) compared to those sufficient. Overall, serum vitamin D concentrations could not be shown to be associated with the development of cerebrovascular or neurodegenerative neuroimaging abnormalities in Cardiovascular Health Study participants.The Cardiovascular Health Study was supported by contracts HHSN268201200036C, HHSN268200800007C, N01 HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, and grant HL080295 from the National Heart, Lung, and Blood Institute (NHLBI), with additional contribution from the National Institute of Neurological Disorders and Stroke (NINDS). Additional support was provided by AG023629, AG20098, AG15928 and HL084443 from the National Institute on Aging (NIA). A full list of principal CHS investigators and institutions can be found at chs-nhlbi.org. Additional support was also provided by NIRG-11-200737 from the Alzheimer’s Association, the Mary Kinross Charitable Trust, the James Tudor Foundation, the Halpin Trust, the Age Related Diseases and Health Trust, and the Norman Family Charitable Trust (to D.J.L.). This research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The National Institutes of Health was involved in the original design and conduct of the Cardiovascular Health Study and in the data collection methods

\u27Vitamin D and cognition in older adults\u27: updated international recommendations.

BACKGROUND: Hypovitaminosis D, a condition that is highly prevalent in older adults aged 65 years and above, is associated with brain changes and dementia. Given the rapidly accumulating and complex contribution of the literature in the field of vitamin D and cognition, clear guidance is needed for researchers and clinicians. METHODS: International experts met at an invitational summit on \u27Vitamin D and Cognition in Older Adults\u27. Based on previous reports and expert opinion, the task force focused on key questions relating to the role of vitamin D in Alzheimer\u27s disease and related disorders. Each question was discussed and voted using a Delphi-like approach. RESULTS: The experts reached an agreement that hypovitaminosis D increases the risk of cognitive decline and dementia in older adults and may alter the clinical presentation as a consequence of related comorbidities; however, at present, vitamin D level should not be used as a diagnostic or prognostic biomarker of Alzheimer\u27s disease due to lack of specificity and insufficient evidence. This population should be screened for hypovitaminosis D because of its high prevalence and should receive supplementation, if necessary; but this advice was not specific to cognition. During the debate, the possibility of \u27critical periods\u27 during which vitamin D may have its greatest impact on the brain was addressed; whether hypovitaminosis D influences cognition actively through deleterious effects and/or passively by loss of neuroprotection was also considered. CONCLUSIONS: The international task force agreed on five overarching principles related to vitamin D and cognition in older adults. Several areas of uncertainty remain, and it will be necessary to revise the proposed recommendations as new findings become available

The central engine of GRB 130831A and the energy breakdown of a relativistic explosion

Gamma-ray bursts (GRBs) are the most luminous explosions in the universe, yet the nature and physical properties of their energy sources are far from understood. Very important clues, however, can be inferred by studying the afterglows of these events. We present optical and X-ray observations of GRB 130831A obtained by Swift, Chandra, Skynet, RATIR, Maidanak, ISON, NOT, LT and GTC. This burst shows a steep drop in the X-ray light-curve at $\simeq 10^5$ s after the trigger, with a power-law decay index of $\alpha \sim 6$. Such a rare behaviour cannot be explained by the standard forward shock (FS) model and indicates that the emission, up to the fast decay at $10^5$ s, must be of "internal origin", produced by a dissipation process within an ultrarelativistic outflow. We propose that the source of such an outflow, which must produce the X-ray flux for $\simeq 1$ day in the cosmological rest frame, is a newly born magnetar or black hole. After the drop, the faint X-ray afterglow continues with a much shallower decay. The optical emission, on the other hand, shows no break across the X-ray steep decrease, and the late-time decays of both the X-ray and optical are consistent. Using both the X-ray and optical data, we show that the emission after $\simeq 10^5$ s can be explained well by the FS model. We model our data to derive the kinetic energy of the ejecta and thus measure the efficiency of the central engine of a GRB with emission of internal origin visible for a long time. Furthermore, we break down the energy budget of this GRB into the prompt emission, the late internal dissipation, the kinetic energy of the relativistic ejecta, and compare it with the energy of the associated supernova, SN 2013fu.Comment: Accepted for publication by MNRAS. 21 pages, 3 figures, 8 tables. Extra table with magnitudes in the sourc

The origin of the early time optical emission of Swift GRB 080310

We present broadband multi-wavelength observations of GRB 080310 at redshift z = 2.43. This burst was bright and long-lived, and unusual in having extensive optical and near IR follow-up during the prompt phase. Using these data we attempt to simultaneously model the gamma-ray, X-ray, optical and IR emission using a series of prompt pulses and an afterglow component. Initial attempts to extrapolate the high energy model directly to lower energies for each pulse reveal that a spectral break is required between the optical regime and 0.3 keV to avoid over predicting the optical flux. We demonstrate that afterglow emission alone is insufficient to describe all morphology seen in the optical and IR data. Allowing the prompt component to dominate the early-time optical and IR and permitting each pulse to have an independent low energy spectral indices we produce an alternative scenario which better describes the optical light curve. This, however, does not describe the spectral shape of GRB 080310 at early times. The fit statistics for the prompt and afterglow dominated models are nearly identical making it difficult to favour either. However one enduring result is that both models require a low energy spectral index consistent with self absorption for at least some of the pulses identified in the high energy emission model.Comment: 24 pages, 12 figures, 12 tables. Accepted to MNRA

Evidence-informed capacity building for setting health priorities in low- and middle-income countries: : A framework and recommendations for further research

Priority-setting in health is risky and challenging, particularly in resource-constrained settings. It is not simply a narrow technical exercise, and involves the mobilisation of a wide range of capacities among stakeholders – not only the technical capacity to “do” research in economic evaluations. Using the Individuals, Nodes, Networks and Environment (INNE) framework, we identify those stakeholders, whose capacity needs will vary along the evidence-to-policy continuum. Policymakers and healthcare managers require the capacity to commission and use relevant evidence (including evidence of clinical and cost-effectiveness, and of social values); academics need to understand and respond to decision-makers’ needs to produce relevant research. The health system at all levels will need institutional capacity building to incentivise routine generation and use of evidence. Knowledge brokers, including priority-setting agencies (such as England’s National Institute for Health and Care Excellence, and Health Interventions and Technology Assessment Program, Thailand) and the media can play an important role in facilitating engagement and knowledge transfer between the various actors. Especially at the outset but at every step, it is critical that patients and the public understand that trade-offs are inherent in priority-setting, and careful efforts should be made to engage them, and to hear their views throughout the process. There is thus no single approach to capacity building; rather a spectrum of activities that recognises the roles and skills of all stakeholders. A range of methods, including formal and informal training, networking and engagement, and support through collaboration on projects, should be flexibly employed (and tailored to specific needs of each country) to support institutionalisation of evidence-informed priority-setting. Finally, capacity building should be a two-way process; those who build capacity should also attend to their own capacity development in order to sustain and improve impact

GRB 130831a: Rise and demise of a magnetar at z = 0.5

Gamma-ray bursts (GRBs) are the brightest explosions in the universe, yet the properties of their energy sources are far from understood. Very important clues, however, can be deduced by studying the afterglows of these events. We present observations of GRB 130831A and its afterglow obtained with Swift, Chandra, and multiple ground-based observatories. This burst shows an uncommon drop in the X-ray light curve at about 100 ks after the trigger, with a decay slope of α 7. The standard Forward Shock (FS) model offers no explanation for such a behaviour. Instead, a model in which a newly born magnetar outflow powers the early X-ray emission is found to be viable. After the drop, the X-ray afterglow resumes its decay with a slope typical of FS emission. The optical emission, on the other hand, displays no clear break across the X-ray drop and its decay is consistent with that of the late X-rays. Using both the X-ray and optical data, we show that the FS model can explain the emission after 100 ks. We model our data to infer the kinetic energy of the ejecta and thus estimate the efficiency of a magnetar “central engine” of a GRB. Furthermore, we break down the energy budget of this GRB into prompt emission, late internal dissipation, kinetic energy of the relativistic ejecta, and compare it with the energy of the accompanying supernova, SN 2013fu