The social value of a QALY : raising the bar or barring the raise?

Background: Since the inception of the National Institute for Health and Clinical Excellence (NICE) in England, there have been questions about the empirical basis for the cost-per-QALY threshold used by NICE and whether QALYs gained by different beneficiaries of health care should be weighted equally. The Social Value of a QALY (SVQ) project, reported in this paper, was commissioned to address these two questions. The results of SVQ were released during a time of considerable debate about the NICE threshold, and authors with differing perspectives have drawn on the SVQ results to support their cases. As these discussions continue, and given the selective use of results by those involved, it is important, therefore, not only to present a summary overview of SVQ, but also for those who conducted the research to contribute to the debate as to its implications for NICE. Discussion: The issue of the threshold was addressed in two ways: first, by combining, via a set of models, the current UK Value of a Prevented Fatality (used in transport policy) with data on fatality age, life expectancy and age-related quality of life; and, second, via a survey designed to test the feasibility of combining respondents’ answers to willingness to pay and health state utility questions to arrive at values of a QALY. Modelling resulted in values of £10,000-£70,000 per QALY. Via survey research, most methods of aggregating the data resulted in values of a QALY of £18,000-£40,000, although others resulted in implausibly high values. An additional survey, addressing the issue of weighting QALYs, used two methods, one indicating that QALYs should not be weighted and the other that greater weight could be given to QALYs gained by some groups. Summary: Although we conducted only a feasibility study and a modelling exercise, neither present compelling evidence for moving the NICE threshold up or down. Some preliminary evidence would indicate it could be moved up for some types of QALY and down for others. While many members of the public appear to be open to the possibility of using somewhat different QALY weights for different groups of beneficiaries, we do not yet have any secure evidence base for introducing such a system

Same Exposure but Two Radically Different Responses to Antibiotics: Resilience of the Salivary Microbiome versus Long-Term Microbial Shifts in Feces

Due to the spread of resistance, antibiotic exposure receives increasing attention. Ecological consequences for the different niches of individual microbiomes are, however, largely ignored. Here, we report the effects of widely used antibiotics (clindamycin, ciprofloxacin, amoxicillin, and minocycline) with different modes of action on the ecology of both the gut and the oral microbiomes in 66 healthy adults from the United Kingdom and Sweden in a two-center randomized placebo-controlled clinical trial. Feces and saliva were collected at baseline, immediately after exposure, and 1, 2, 4, and 12 months after administration of antibiotics or placebo. Sequences of 16S rRNA gene amplicons from all samples and metagenomic shotgun sequences from selected baseline and post-antibiotic-treatment sample pairs were analyzed. Additionally, metagenomic predictions based on 16S rRNA gene amplicon data were performed using PICRUSt. The salivary microbiome was found to be significantly more robust, whereas the antibiotics negatively affected the fecal microbiome: in particular, health-associated butyrate-producing species became strongly underrepresented. Additionally, exposure to different antibiotics enriched genes associated with antibiotic resistance. In conclusion, healthy individuals, exposed to a single antibiotic treatment, undergo considerable microbial shifts and enrichment in antibiotic resistance in their feces, while their salivary microbiome composition remains unexpectedly stable. The health-related consequences for the gut microbiome should increase the awareness of the individual risks involved with antibiotic use, especially in a (diseased) population with an already dysregulated microbiome. On the other hand, understanding the mechanisms behind the resilience of the oral microbiome toward ecological collapse might prove useful in combating microbial dysbiosis elsewhere in the body. IMPORTANCE Many health care professionals use antibiotic prophylaxis strategies to prevent infection after surgery. This practice is under debate since it enhances the spread of antibiotic resistance. Another important reason to avoid nonessential use of antibiotics, the impact on our microbiome, has hardly received attention. In this study, we assessed the impact of antibiotics on the human microbial ecology at two niches. We followed the oral and gut microbiomes in 66 individuals from before, immediately after, and up to 12 months after exposure to different antibiotic classes. The salivary microbiome recovered quickly and was surprisingly robust toward antibiotic-induced disturbance. The fecal microbiome was severely affected by most antibiotics: for months, health-associated butyrate-producing species became strongly underrepresented. Additionally, there was an enrichment of genes associated with antibiotic resistance. Clearly, even a single antibiotic treatment in healthy individuals contributes to the risk of resistance development and leads to long-lasting detrimental shifts in the gut microbiome

Health, Health-Related Quality of Life, and Quality of Life: What is the Difference?

The terms health, health-related quality of life (HRQoL), and quality of life (QoL) are used interchangeably. Given that these are three key terms in the literature, their appropriate and clear use is important. This paper reviews the history and definitions of the terms and considers how they have been used. It is argued that the definitions of HRQoL in the literature are problematic because some definitions fail to distinguish between HRQoL and health or between HRQoL and QoL. Many so-called HRQoL questionnaires actually measure self-perceived health status and the use of the phrase QoL is unjustified. It is concluded that the concept of HRQoL as used now is confusing. A potential solution is to define HRQoL as the way health is empirically estimated to affect QoL or use the term to only signify the utility associated with a health state

How does one become spiritual? The Spiritual Modeling Inventory of Life Environments (SMILE)

We report psychometric properties, correlates and underlying theory of the Spiritual Modeling Index of Life Environments (SMILE), a measure of perceptions of spiritual models, defined as everyday and prominent people who have functioned for respondents as exemplars of spiritual qualities, such as compassion, self-control, or faith. Demographic, spiritual, and personality correlates were examined in an ethnically diverse sample of college students from California, Connecticut, and Tennessee (N=1010). A summary measure of model influence was constructed from perceived models within family, school, religious organization, and among prominent individuals from both tradition and media. The SMILE, based on concepts from Bandura\u27s (1986) Social Cognitive Theory, was well-received by respondents. The summary measure demonstrated good 7-week test/retest reliability (r=.83); patterns of correlation supporting convergent, divergent, and criterion-related validity; demographic differences in expected directions; and substantial individual heterogeneity. Implications are discussed for further research and for pastoral, educational, and health-focused interventions

Gonadal function in male patients after treatment for malignant lymphomas, with emphasis on chemotherapy

Gonadal function was assessed in male lymphoma survivors based on serum hormone levels (LH, FSH, testosterone, SHBG), and was related to treatment, age and observation time. Male patients ⩽50 years at diagnosis treated for Hodgkin's (HL) and/or non-Hodgkin's lymphoma (NHL) at the Norwegian Radium Hospital from 1 January 1980 to 31 December 2002 were included. Five treatment groups were defined: 1: radiotherapy only and/or low gonadotoxic chemotherapy (both HL and NHL)(‘No/low'), 2: medium gonadotoxicity chemotherapy for NHL (‘med-NHL'), 3: medium gonadotoxicity chemotherapy for HL (‘med-HL'), 4: highly gonadotoxic chemotherapy for NHL (‘high-NHL'), 5: highly gonadotoxic chemotherapy for HL (‘high-HL'). Gonadal hormone levels were categorised into three groups: 1: All gonadal hormones within normal range (normal), 2: Isolated elevated FSH, with LH, SHBG and testosterone within normal range (exocrine hypogonadism), 3: Testosterone below and/or LH above normal range (endocrine hypogonadism). One hundred and forty-four (49%) of the patients had normal gonadal hormones, 60 (20%) displayed exocrine hypogonadism and almost one-third (n=90, 30%) had endocrine hypogonadism. Compared to those treated with no/low gonadotoxic chemotherapy patients from all other treatment groups had significantly elevated risk for exocrine hypogonadism. Patients from the other treatment groups, except those in the med-NHL group, also had significantly elevated risk for endocrine hypogonadism compared with the group treated with no/low gonadotoxic chemotherapy. Men aged above 50 years at survey were about five times more likely to have endocrine hypogonadism compared with those less than 40 years. Because of the adverse health effects following long-lasting endocrine hypogonadism, gonadal hormones should be assessed regularly in male lymphoma survivors, especially after treatment with alkylating agents and high-dose chemotherapy with autologous stem cell support and in male patients who are 50 years and older

UV-luminous, star-forming hosts of z similar to 2 reddened quasars in the Dark Energy Survey

We present the first rest-frame UV population study of 17 heavily reddened, high-luminosity [E(B − V)QSO ≳ 0.5; Lbol > 1046 erg s−1] broad-line quasars at 1.5 < z < 2.7. We combine the first year of deep, optical, ground-based observations from the Dark Energy Survey (DES) with the near-infrared VISTA Hemisphere Survey and UKIDSS Large Area Survey data, from which the reddened quasars were initially identified. We demonstrate that the significant dust reddening towards the quasar in our sample allows host galaxy emission to be detected at the rest-frame UV wavelengths probed by the DES photometry. By exploiting this reddening effect, we disentangle the quasar emission from that of the host galaxy via spectral energy distribution fitting. We find evidence for a relatively unobscured, star-forming host galaxy in at least 10 quasars, with a further three quasars exhibiting emission consistent with either star formation or scattered light. From the rest-frame UV emission, we derive instantaneous, dust-corrected star formation rates (SFRs) in the range 25 < SFRUV < 365 M⊙ yr−1, with an average SFRUV = 130 ± 95 M⊙ yr−1. We find a broad correlation between SFRUV and the bolometric quasar luminosity. Overall, our results show evidence for coeval star formation and black hole accretion occurring in luminous, reddened quasars at the peak epoch of galaxy formation

UV-luminous, star-forming hosts of z ~ 2 reddened quasars in the Dark Energy Survey

We present the first rest-frame UV population study of 17 heavily reddened, high-luminosity (E(B-V)$_{\rm{QSO}}\gtrsim$ 0.5; L$_{\rm{bol}}>$ 10$^{46}$ergs$^{-1}$) broad-line quasars at $1.5 < z < 2.7$. We combine the first year of deep, optical, ground-based observations from the Dark Energy Survey (DES) with the near infrared VISTA Hemisphere Survey (VHS) and UKIDSS Large Area Survey (ULAS) data, from which the reddened quasars were initially identified. We demonstrate that the significant dust reddening towards the quasar in our sample allows host galaxy emission to be detected at the rest-frame UV wavelengths probed by the DES photometry. By exploiting this reddening effect, we disentangle the quasar emission from that of the host galaxy via spectral energy distribution (SED) fitting. We find evidence for a relatively unobscured, star-forming host galaxy in at least ten quasars, with a further three quasars exhibiting emission consistent with either star formation or scattered light. From the rest-frame UV emission, we derive instantaneous, dust-corrected star formation rates (SFRs) in the range 25 < SFR$_{\rm{UV}}$ < 365 M$_{\odot}$yr$^{-1}$, with an average SFR$_{\rm{UV}}$ = 130 $\pm$ 95 M$_{\odot}$yr$^{-1}$. We find a broad correlation between SFR$_{\rm{UV}}$ and the bolometric quasar luminosity. Overall, our results show evidence for coeval star formation and black hole accretion occurring in luminous, reddened quasars at the peak epoch of galaxy formation

Imprint of DES super-structures on the Cosmic Microwave Background

Small temperature anisotropies in the Cosmic Microwave Background can be sourced by density perturbations via the late-time integrated Sachs-Wolfe effect. Large voids and superclusters are excellent environments to make a localized measurement of this tiny imprint. In some cases excess signals have been reported. We probed these claims with an independent data set, using the first year data of the Dark Energy Survey in a different footprint, and using a different super-structure finding strategy. We identified 52 large voids and 102 superclusters at redshifts $0.2 < z < 0.65$. We used the Jubilee simulation to a priori evaluate the optimal ISW measurement configuration for our compensated top-hat filtering technique, and then performed a stacking measurement of the CMB temperature field based on the DES data. For optimal configurations, we detected a cumulative cold imprint of voids with $\Delta T_{f} \approx -5.0\pm3.7~\mu K$ and a hot imprint of superclusters $\Delta T_{f} \approx 5.1\pm3.2~\mu K$ ; this is $\sim1.2\sigma$ higher than the expected $|\Delta T_{f}| \approx 0.6~\mu K$ imprint of such super-structures in $\Lambda$CDM. If we instead use an a posteriori selected filter size ($R/R_{v}=0.6$), we can find a temperature decrement as large as $\Delta T_{f} \approx -9.8\pm4.7~\mu K$ for voids, which is $\sim2\sigma$ above $\Lambda$CDM expectations and is comparable to previous measurements made using SDSS super-structure data

Testing the lognormality of the galaxy and weak lensing convergence distributions from Dark Energy Survey maps

It is well known that the probability distribution function (PDF) of galaxy density contrast is approximately lognormal; whether the PDF of mass fluctuations derived from weak lensing convergence (kappa_WL) is lognormal is less well established. We derive PDFs of the galaxy and projected matter density distributions via the Counts in Cells (CiC) method. We use maps of galaxies and weak lensing convergence produced from the Dark Energy Survey (DES) Science Verification data over 139 deg^2. We test whether the underlying density contrast is well described by a lognormal distribution for the galaxies, the convergence and their joint PDF. We confirm that the galaxy density contrast distribution is well modeled by a lognormal PDF convolved with Poisson noise at angular scales from 10-40 arcmin (corresponding to physical scales of 3-10 Mpc). We note that as kappa_WL is a weighted sum of the mass fluctuations along the line of sight, its PDF is expected to be only approximately lognormal. We find that the kappa_WL distribution is well modeled by a lognormal PDF convolved with Gaussian shape noise at scales between 10 and 20 arcmin, with a best-fit chi^2/DOF of 1.11 compared to 1.84 for a Gaussian model, corresponding to p-values 0.35 and 0.07 respectively, at a scale of 10 arcmin. Above 20 arcmin a simple Gaussian model is sufficient. The joint PDF is also reasonably fitted by a bivariate lognormal. As a consistency check we compare the variances derived from the lognormal modelling with those directly measured via CiC. Our methods are validated against maps from the MICE Grand Challenge N-body simulation

Discovery of the lensed quasar system DES J0408-5354

We report the discovery and spectroscopic confirmation of the quad-like lensed quasar system DES J0408-5354 found in the Dark Energy Survey (DES) Year 1 (Y1) data. This system was discovered during a search for DES Y1 strong lensing systems using a method that identified candidates as red galaxies with multiple blue neighbors. DES J0408-5354 consists of a central red galaxy surrounded by three bright (i<20) blue objects and a fourth red object. Subsequent spectroscopic observations using the Gemini South telescope confirmed that the three blue objects are indeed the lensed images of a quasar with redshift z = 2.375, and that the central red object is an early-type lensing galaxy with redshift z = 0.597. DES J0408-5354 is the first quad lensed quasar system to be found in DES and begins to demonstrate the potential of DES to discover and dramatically increase the sample size of these very rare objects