Evaluation of the Economic Burden of Psoriatic Arthritis and the Relationship Between Functional Status and Healthcare Costs

Doce imágenes de un liposarcoma metastatizado situado en el cerebro de un paciente de 44 años.Twelve pictures of a metastasized liposarcoma located in the brain of a 44-year-old male patient

Planar SIW leaky wave antenna with electronically reconfigurable E-and H-plane scanning

This paper reports on a novel technique of switching radiation characteristics electronically between E-and H-planes of planar Substrate Integrated Waveguide Leaky Wave Antennas (SIW-LWAs). The leaky wave mode is achieved through increasing the pitch of bounding metallic via posts on one side of SIW transmission section. The radiation switching is achieved by extending the top and bottom metallic planes to a distance of 1 mm along the leakage side. The extended section acts as a parallel plate section which is conveniently connected or disconnected from the leaking side of SIW through PIN diodes. The ‘ON’ state of PIN diodes extends the metal guides and results in the H-plane leakage whereas ‘OFF’ state of PIN diodes truncates the extended metal earlier and alter the leakage line boundary condition towards E-plane. The whole concept is validated by series of simulations followed by the realization and testing of the SIW-LWA. The measured radiation pattern scans about 54° in the E-plane between 10.0 GHz to 11.7 GHz, and 58° in the H-plane from 9 GHz to 10.6 GHz. The proposed topology is a suitable candidate for remote sensing and airborne applications

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Cost-effectiveness of apremilast in moderate to severe psoriasis in the United Kingdom

Purpose: Apremilast, an oral phosphodiesterase-4 inhibitor, is effective and well tolerated in the treatment of moderate-to-severe psoriasis. The cost-effectiveness of introducing apremilast before biologics was assessed from a UK payer perspective. Materials and methods: A 10-year Markov cohort model was developed to compare alternative treatment sequences: (1) apremilast followed by adalimumab and etanercept and (2) adalimumab followed by etanercept. Non-responders moved to the next treatment line, and patients for whom etanercept therapy failed continued on best supportive care (BSC) in both sequences. Response was defined as a ≥ 75% reduction in Psoriasis Area and Severity Index score (PASI-75) at the end of the trial periods (12‒16 weeks). A network meta-analysis provided efficacy inputs. Results: As a treatment-extension strategy, apremilast had an incremental cost-effectiveness ratio of £20,593 per quality-adjusted life-year gained versus the comparator sequence. PASI-75 was sustained for 0.73 additional years, and the total time on biologics and BSC was reduced by 0.44 and 1.01 years, respectively. These results were consistent with findings from sensitivity and scenario analyses. Conclusions: Apremilast, an oral treatment option for the treatment of moderate-to-severe plaque psoriasis, is cost-effective from a UK payer perspective when administered before biologics based on assumptions detailed within this analysis

Challenges for decision-makers when assessing within-class comparative effectiveness: the case of anticoagulation therapy for atrial fibrillation

In September 2020, the UK National Institute of HealthCare Excellence (NICE) published a draft report for consultation on anticoagulation therapy for stroke prevention in people with atrial fibrillation (AF) [1]. This intervention evidence review is part of the process of updating the NICE clinical guideline on management of AF [2] and addressed the question of which nonvitamin K oral anticoagulation (NOAC) therapy is most clinically and cost-effective for stroke prevention in people with AF. Four NOACs were included in the evidence review, each with a low and high dose formulation: apixaban, dabigatran, rivaroxaban and edoxaban, and all of which had been previously evaluated and recommended in NICE single technology appraisals [3–6]. On the basis of a systematic literature review to identify relevant evidence, network meta-analysis (NMA) to address comparative effectiveness, and subsequent cost–effectiveness analysis (CEA), the committee concluded that apixaban and dabigatran had the most favorable cost–effectiveness (CE) results of the four NOACs, at the NHS list prices and this led to a draft recommendation in the report that apixaban and dabigatran should be used as first-line options [1]. A further recommendation was made that patients who are stable on one of the other anticoagulants (rivaroxaban, edoxaban or warfarin) should discuss switching with their physician [1]. This draft decision by the committee, to recommend two NOACs within a class of four, represents an unusually strong recommendation to differentiate drugs within a particular class. This is especially so, given that the committee themselves state that the acquisition costs based on NHS list prices of the four NOACs are similar (page 74, line 28) [1]. This suggests that the opinion reached by the committee was grounded in the results of the NMA produced comparative effectiveness estimates that then formed the basis of the CEA. This manuscript reports on the process of examining the committee’s draft decision to differentiate drugs within the NOAC class on the basis of clinical and CE in light of the evidence considered by the committee. This manuscript was sponsored by the manufacturer of one of the NOACs that was not recommended as a first-line option by the committee (edoxaban, Daiichi Sankyo) in order to help them respond to the consultation process NICE initiated and which closed in November 2020. The aim of this manuscript is to elucidate the methodological challenges involved in any decision made by a reimbursement authority, such as NICE in the UK, and ask an open question regarding the strength of evidence of comparative effectiveness be required in order to differentiate similarly-priced drugs within a single drug class. The manuscript is structured around three further sections. The next section looks at the evidence on comparative effectiveness of seven key clinical outcomes, the need for NMA to generate those estimates of comparative effectiveness and the representation of uncertainty in the results of NMAs. The third section looks specifically at how the results of the NMA are then turned into a CEA that uses quality-adjusted life-years (QALYs) as the metric to synthesize the seven clinical outcomes into a QALY comparison, before considering the inclusion of costs and the representation of uncertainty in the CE results. A final section then discusses the challenges of making recommendations in the context of the uncertainty in clinical and CE both between the NOAC and vitamin-K antagonist (VKA) drug classes and within the NOAC class

A Multilayer Notch Band Printed Duplex Dipole Antenna for Ku-band Applications

A band reject broadband antenna with bandwidthof 8.82 GHz operating in the Ku-band realized in multilayerconfiguration is proposed in this paper. The band rejection hasbeen achieved by introducing Split Ring Resonators (SRRs).The multilayer topology adopted in this paper has resulted inan overall antenna size of 22 x 12 x 2:285 mm^3. Such topology allows an additional benefit of loading the middle layer with SRRs to reject a specific frequency

C-Band and X-Band Switchable Frequency-Selective Surface

This paper presents a highly compact frequency-selective surface (FSS) that has the potential to switch between the X-band (8 GHz–12 GHz) and C-band (4 GHz–8 GHz) for RF shielding applications. The proposed FSS is composed of a square conducting loop with inward-extended arms loaded with curved extensions. The symmetric geometry allows the RF shield to perform equally for transverse electric (TE), transverse magnetic (TM), and 45° polarizations. The unit cell has a dimension of 0.176 λ0 and has excellent angular stability up to 60°. The resonance mechanism was investigated using equivalent circuit models of the shield. The design of the unit element allowed incorporation of PIN diodes between adjacent elements for switching to a lower C-band spectrum at 6.6 GHz. The biasing network is on the bottom layer of the substrate to avoid effects on the shielding performance. A PIN diode configuration for the switching operation was also proposed. In simulations, the PIN diode model was incorporated to observe the switchable operation. Two prototypes were fabricated, and the switchable operation was demonstrated by etching copper strips on one fabricated prototype between adjacent unit cells (in lieu of PIN diodes) as a proof of the design prototypes. Comparisons among the results confirmed that the design offers high angular stability and excellent performance in both bands

Evaluation of the Economic Burden of Psoriatic Arthritis and the Relationship Between Functional Status and Healthcare Costs

OBJECTIVE: This analysis aimed to evaluate the economic burden of patients with psoriatic arthritis (PsA) on the UK healthcare system and estimate the relationship between functional status and direct healthcare costs.METHODS: Functional status (measured using the Health Assessment Questionnaire- Disability Index [HAQ-DI]), demographics, disease history and healthcare resource use data were extracted from a cohort of patients at the Royal National Hospital for Rheumatic Diseases, Bath, UK. Each resource use item per patient was then allocated a unit cost. Linear regression models were used to predict costs as a function of HAQ-DI. Medication costs were not included in the primary analysis, which was carried out from the UK National Health Service perspective.RESULTS: Data were available for 101 patients. Mean HAQ-DI score was 0.84 (SD 0.75) and mean age at HAQ-DI measurement was 57.8 (SD 10.7). Total annual healthcare costs per patient, excluding medication costs, ranged between £174 and £8,854, with a mean of £1,586 (SD £1,639). A 1-point increase in HAQ-DI score was associated with an increase in total costs of £547.49 (SE £224), with secondary care consultations appearing to be the primary factor. Subgroup analyses suggested higher cost increases in patients with HAQ-DI scores 2-3 and with a disease duration &gt;10 years.CONCLUSION: Patients with PsA have a significant economic burden on the healthcare system. Functional status is highly correlated with costs and appears to be driven mainly by the cost of secondary care consultations. Results were similar to previous studies in rheumatoid arthritis populations.</p