NICEly does it: economic analysis within evidence-based clinical practice guidelines

There is increasing professional and policy interest in the role of clinical guidelines for promoting effective and efficient health care. The NHS Health Technology Assessment Programme identified an urgent need, when such guidelines are produced, to develop a framework and methods for incorporating the best evidence of effectiveness, taking into account information on cost-effectiveness. This paper describes the development of recent evidence-based guidelines, for use in primary care, which were the result of recent work by the North of England Guidelines Development Group. Their specific aim was to incorporate economic analysis into the guideline process and treatment recommendations. The introduction of economic data raised some methodological issues, specifically: in providing valid and generalisable cost estimates; in the grading of cost ‘evidence’; in finding a presentation helpful to clinicians. The approach used was to help clinicians aggregate the various attributes of treatment to make good treatment recommendations, rather than interpret cost-effectiveness ratios. In none of the guideline areas was there adequate information to estimate a cost per quality-adjusted-life-year. In the light of this research, future areas of work are identified and some recommendations are made for the forthcoming National Institute for Clinical Excellence.evidence-based medicine, economic evaluation, clinical guidelines, NICE

BSC Football: The Swenson Era

A recollection of Bridgewater State College Coach Edward Swenson’s efforts to bring varsity-level football back into a Massachusetts state college and the stories of the trials and tribulations of his first eight years as head coach. The book is a Bridgewater State University Football Alumni project inspired by many of Coach Swenson’s former players, commemorating the coach and several of their former teammates

Conventional versus highly cross-linked polyethylene in primary total knee replacement : a comparison of revision rates using data from the National Joint Registry for England, Wales, and Northern Ireland

There is evidence to support the use of highly cross-linked polyethylene (HXLPE) in patients undergoing total hip arthroplasty. However, the benefits for those undergoing total knee arthroplasty are uncertain, with conflicting reports based on previous cohort analyses. The purpose of the present study was to compare the revision rates following primary total knee arthroplasty with use of HXLPE as compared with conventional polyethylene (CPE) using data from the National Joint Registry (NJR) for England, Wales and Northern Ireland. We performed a retrospective analysis of primary total knee arthroplasties recorded in the NJR from 2003 to 2014. Cobalt-chromium (CoCr)-CPE and CoCr-HXLPE bearing surfaces were compared using all-cause revision, aseptic revision, and septic revision as end points. Survival analyses were conducted using rates per 100 years observed, Kaplan-Meier survival estimates, and Cox regression hazard ratios (HRs) adjusted for age, sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), lead surgeon grade, and implant constraint. Secondary analyses compared the most commonly used HXLPEs (Zimmer Prolong, DePuy XLK, and Stryker X3) against CPE for the 3 most common total knee arthroplasty systems (NexGen, PFC Sigma, and Triathlon). In the present study of 550,658 total knee arthroplasties, the unadjusted aseptic revision rates were significantly lower following procedures performed with CPE (n = 513,744) as compared with those performed with HXLPE total knee replacements (n = 36,914) (0.29 [95% confidence interval (CI), 0.28 to 0.30] compared to 0.38 [95% CI, 0.35 to 0.42], p 35 kg/m, the "second-generation" Stryker X3 HXLPE demonstrated significantly better survival than its respective CPE, with CPE having an HR of 2.6 (95% CI, 1.2 to 5.9) (p = 0.02). Alternative bearings are marketed as having improved wear properties over traditional CoCr-CPE. This registry-based analysis demonstrated no overall survival benefit of HXLPE after a maximum duration of follow-up of 12 years. Because of their increased cost, the routine use of HXLPE bearings may not be justified. However, they may have a role in specific "higher demand" groups such as patients 35 kg/m. Therapeutic Level III. See Instructions for Authors for a complete list of levels of evidence

Global warming and geothermal profiles: the surface rock-temperature response in South Africa

Southern hemisphere and South African regional air temperature anomalies for the period 1860–1996 are compared to borehole‐derived surface rock‐temperature anomalies to assess the extent to which surface rock temperatures reflect possible global warming in South Africa. The warming of the southern hemisphere since the mid‐nineteenth century is evident in the regional air temperatures for South Africa. Following a temperature increase to a maximum in the 1920s, the climate cooled until strong warming recommenced in the mid 1970s. Highest temperatures have been experienced in the 1990s. Borehole‐derived surface rock temperatures followed a similar pattern, but with a lag of a few decades in the case of the 1920s maximum. The overall warming trend is clearly evident in the rock temperatures. Despite uncertainties in the different data sets, an encouraging degree of agreement exists between the increase in rock temperatures during the twentieth century, the corresponding regional South African air temperature increase and the southern hemisphere counterpart

Introduction

Humanity recognised millennia ago the importance of climate variability to the sustenance of life, whether that variability was expressed in the form of droughts, floods, heat, cold, or wind. Coping strategies, developed to handle the consequences of climate variability, helped ensure mankind’s survival, although the historic record indicates that not all societies successfully overcame past challenges imposed by long-term droughts, extensive flooding, and the like. Early coping strategies included migration, invasion, appropriation and storage. In addition many, probably most, perhaps all, societies developed indigenous knowledge or belief systems that they felt enabled them to foresee or control those elements of the climate that are so critical for maintaining water and food supplies

Water, health and early warnings

Water management is the focus in the first section, in which a number of projects are described whereby historical and forecast information is used directly in planning specific actions; in this case the forecaster-user chain is short and manageable at a personal level. Next is a detailed account of the steps required to establish climate services in the health area. Finally, Early Warning Systems are described. Early Warning Systems have not tended to use predictions until recently, traditionally having been built around historical observations. In that context Early Warning Systems provide an example of an application mainly designed for humanitarian benefit built solely using climate data alongside other information, but with growing use of predictions. A worked example is included establishing the impact of climate variability on disease incidence, the results of which provide a basis for incorporating seasonal climate forecasts into a Malaria Early Warning System in southern Africa

Signed weighted gene co-expression network analysis of transcriptional regulation in murine embryonic stem cells

<p>Abstract</p> <p>Background</p> <p>Recent work has revealed that a core group of transcription factors (TFs) regulates the key characteristics of embryonic stem (ES) cells: pluripotency and self-renewal. Current efforts focus on identifying genes that play important roles in maintaining pluripotency and self-renewal in ES cells and aim to understand the interactions among these genes. To that end, we investigated the use of unsigned and signed network analysis to identify pluripotency and differentiation related genes.</p> <p>Results</p> <p>We show that signed networks provide a better systems level understanding of the regulatory mechanisms of ES cells than unsigned networks, using two independent murine ES cell expression data sets. Specifically, using signed weighted gene co-expression network analysis (WGCNA), we found a pluripotency module and a differentiation module, which are not identified in unsigned networks. We confirmed the importance of these modules by incorporating genome-wide TF binding data for key ES cell regulators. Interestingly, we find that the pluripotency module is enriched with genes related to DNA damage repair and mitochondrial function in addition to transcriptional regulation. Using a connectivity measure of module membership, we not only identify known regulators of ES cells but also show that Mrpl15, Msh6, Nrf1, Nup133, Ppif, Rbpj, Sh3gl2, and Zfp39, among other genes, have important roles in maintaining ES cell pluripotency and self-renewal. We also report highly significant relationships between module membership and epigenetic modifications (histone modifications and promoter CpG methylation status), which are known to play a role in controlling gene expression during ES cell self-renewal and differentiation.</p> <p>Conclusion</p> <p>Our systems biologic re-analysis of gene expression, transcription factor binding, epigenetic and gene ontology data provides a novel integrative view of ES cell biology.</p

Screening for diabetic retinopathy by optometrists: effectiveness and cost-effectiveness

This report examines the effectiveness and cost-effectiveness of screening for diabetic retinopathy by optometrists. There are strong arguments for screening. Diabetic retinopathy is an important public health problem, there is an effective treatment, the natural history of the disease is well understood, adequate and acceptable screening exists and the cost of case finding is small in relation to overall expenditure on the disease (Section 2). The major unresolved issue concerns the choice of screening modality i.e. who should perform screening, when and how. A literature search revealed 18 citations presenting data relating to screening by optometrists (Section 3). The only cost-effectiveness study of screening modalities directly relevant to the UK is the Special Medical Development Project (SMDP). Whilst an extensive study, the SMDP has a number of methodological weaknesses which made it inappropriate to conclude that one screening modality is more cost-effective than another (Section 3.2). Another British study, undertaken in Frenchay health district, provides starkly different evidence on the effectiveness of screening by optometrists (Section 3.4). The overall conclusion is that there are no ideal data for addressing the effectiveness and cost-effectiveness of optometrists in screening for diabetic retinopathy (Section 3.9). The selection of screening modalities for diabetic retinopathy needs to take account of the current environment for care. IN particular, the manner in which diabetics currently present to the health service would make a single modality of limited use (Section 4). Key features of the development of screening schemes include the role of training of practitioners, the development of protocols for care and sharing data, reimbursement and audit (Section 4). One way to resolve controversy would be to undertake a new prospective stuffy of optometrists in screening. However, a more pragmatic design, mirroring the current environment of care, may be important. Smaller trials investigating sub-issues and surveys of diabetics and potential screeners may produce a valuable backdrop in designing appropriate studies (Section 5).Special Medical Development Project, SMDP, screening

The DH register of cost-effectiveness studies: a review of study content and quality

The Department of Health has recently published a register of economic evaluations of health care treatments and programmes. The objective of the register is to assist health care decision makers in assessing the value for money from alternative ways of allocation scarce resources. If the register is to be useful, it is important that decision makers have an appreciation of the methodological quality of the studies contained in the register, and hence the confidence that can be placed in the results. This discussion paper gives details of an approach for assessing the methodological quality of economic evaluations. A worked example of a search in the register is presented and discussed. Some summary findings of the studies contained in the first published version of the register are presented together with a listing of the studies included. The interpretation of the existing register and the future reporting of economic evaluations are discussed.RCES, economic evaluation

A way forward for seasonal climate services

The enthusiasm for engaging the challenges of Seasonal to Interannual Prediction, both within the disciplines of physical and social sciences and at their interface, was well demonstrated through the energetic engagement of all during the May to June 2005 NATO ASI course, upon which this book is based. Several panel sessions were held during the course, which permitted everyone to offer views within an informal setting; some, not reflected in the main body of the book, are incorporated in this chapter. Little stays stationary in such a fast-developing field, and so, to provide the most advanced position at publication, this summarising chapter has included some of the latest development to supplement the material drawn from the course presentations and the panel discussions. Additionally, a view to the future is offered so as to provide further stimulation to those interested in the fascinating field of Seasonal to Interannual Climat