Decision-analytic cost-effectiveness model to compare prostate cryotherapy to androgen deprivation therapy for treatment of radiation recurrent prostate cancer

Objective: To determine the cost-effectiveness of salvage cryotherapy (SC) in men with radiation recurrent prostate cancer (RRPC). Design: Cost-utility analysis using decision analytic modelling by a Markov model. Setting and methods: Compared SC and androgen deprivation therapy (ADT) in a cohort of patients with RRPC (biopsy proven local recurrence, no evidence of metastatic disease). A literature review captured published data to inform the decision model, and resource use data were from the Scottish Prostate Cryotherapy Service. The model was run in monthly cycles for RRPC men, mean age of 70 years. The model was run over the patient lifetime, to assess changes in patient health states and the associated quality of life, survival and cost impacts. Results are reported in terms of the discounted incremental costs and discounted incremental quality-adjusted life years (QALYs) gained between the 2 alternative interventions. Probabilistic sensitivity analysis used a 10 000 iteration Monte Carlo simulation. Results: SC has a high upfront treatment cost, but delays the ongoing monthly cost of ADT. SC is the dominant strategy over the patient lifetime; it is more effective with an incremental 0.56 QALY gain (95% CI 0.28 to 0.87), and less costly with a reduced lifetime cost of £29 719 (€37 619) (95% CI −51 985 to −9243). For a ceiling ratio of £30 000, SC has a 100% probability to be cost-effective. The cost neutral point was at 3.5 years, when the upfront cost of SC (plus any subsequent cumulative cost of side effects and ADT) equates the cumulative cost in the ADT arm. Limitations of our model may arise from its insensitivity to parameter or structural uncertainty. Conclusions: The platform for SC versus ADT cost-effective analysis can be employed to evaluate other treatment modalities or strategies in RRPC. SC is the dominant strategy, costing less over a patient's lifetime with improvements in QALYs

Stress Tensor from the Trace Anomaly in Reissner-Nordstrom Spacetimes

The effective action associated with the trace anomaly provides a general algorithm for approximating the expectation value of the stress tensor of conformal matter fields in arbitrary curved spacetimes. In static, spherically symmetric spacetimes, the algorithm involves solving a fourth order linear differential equation in the radial coordinate r for the two scalar auxiliary fields appearing in the anomaly action, and its corresponding stress tensor. By appropriate choice of the homogeneous solutions of the auxiliary field equations, we show that it is possible to obtain finite stress tensors on all Reissner-Nordstrom event horizons, including the extreme Q=M case. We compare these finite results to previous analytic approximation methods, which yield invariably an infinite stress-energy on charged black hole horizons, as well as with detailed numerical calculations that indicate the contrary. The approximation scheme based on the auxiliary field effective action reproduces all physically allowed behaviors of the quantum stress tensor, in a variety of quantum states, for fields of any spin, in the vicinity of the entire family (0 le Q le M) of RN horizons.Comment: 43 pages, 12 figure

Haemodynamic changes with paracetamol in critically-ill children.

PURPOSE: Paracetamol has been associated with a reduction in blood pressure, especially in febrile, critically-ill adults. We hypothesised that blood pressure would fall following administration of paracetamol in critically-ill children and this effect would be greater during fever and among children with a high body surface area to weight ratio. METHODS: A 12-month prospective observational study of children (0-16years) admitted to paediatric intensive care, who underwent pulse contour analysis and received paracetamol concurrently. RESULTS: Mean arterial blood pressure decreased significantly by 4.7% from baseline (95% CI 1.75-8.07%) in 31 children following 148 doses of paracetamol. The nadir was 2-hour post-dose. The effect was pronounced in children with fever at baseline (6.4%, 95% CI 2.8-10%), although this was not statistically significant. There was no simple relationship between this effect and body surface area to weight ratio. The association between a change in blood pressure and changes in heart rate or measured stroke volume was poor; therefore it was likely that a change in the systemic vascular resistance contributes most to this effect. CONCLUSION: There is a significant but modest reduction in blood pressure post-paracetamol in critically-ill children. This is likely related to a change in systemic vascular resistance

Joint modelling of serological and hospitalization data reveals that high levels of pre-existing immunity and school holidays shaped the influenza A pandemic of 2009 in the Netherlands.

Obtaining a quantitative understanding of the transmission dynamics of influenza A is important for predicting healthcare demand and assessing the likely impact of intervention measures. The pandemic of 2009 provides an ideal platform for developing integrative analyses as it has been studied intensively, and a wealth of data sources is available. Here, we analyse two complementary datasets in a disease transmission framework: cross-sectional serological surveys providing data on infection attack rates, and hospitalization data that convey information on the timing and duration of the pandemic. We estimate key epidemic determinants such as infection and hospitalization rates, and the impact of a school holiday. In contrast to previous approaches, our novel modelling of serological data with mixture distributions provides a probabilistic classification of individual samples (susceptible, immune and infected), propagating classification uncertainties to the transmission model and enabling serological classifications to be informed by hospitalization data. The analyses show that high levels of immunity among persons 20 years and older provide a consistent explanation of the skewed attack rates observed during the pandemic and yield precise estimates of the probability of hospitalization per infection (1-4 years: 0.00096 (95%CrI: 0.00078-0.0012); 5-19 years: 0.00036 (0.00031-0.0044); 20-64 years: 0.0015 (0.00091-0.0020); 65+ years: 0.0084 (0.0028-0.016)). The analyses suggest that in The Netherlands, the school holiday period reduced the number of infectious contacts between 5- and 9-year-old children substantially (estimated reduction: 54%; 95%CrI: 29-82%), thereby delaying the unfolding of the pandemic in The Netherlands by approximately a week

Penrose Diagram for a Transient Black Hole

A Penrose diagram is constructed for a spatially coherent black hole that smoothly begins an accretion, then excretes symmetrically as measured by a distant observer, with the initial and final states described by a metric of Minkowski form. Coordinate curves on the diagram are computationally derived. Causal relationships between space-time regions are briefly discussed. The life cycle of the black hole demonstrably leaves asymptotic observers in an unaltered Minkowski space-time of uniform conformal scale.Comment: 14 pages, 9 figures, spelling correction

Evidence Synthesis for Stochastic Epidemic Models.

In recent years, the role of epidemic models in informing public health policies has progressively grown. Models have become increasingly realistic and more complex, requiring the use of multiple data sources to estimate all quantities of interest. This review summarises the different types of stochastic epidemic models that use evidence synthesis and highlights current challenges

Ion trap simulations of quantum fields in an expanding universe

We propose an experiment in which the phonon excitation of ion(s) in a trap, with a trap frequency exponentially modulated at rate kappa, exhibits a thermal spectrum with an Unruh temperature given by k(B)T=h kappa. We discuss the similarities of this experiment to the response of detectors in a de Sitter universe and the usual Unruh effect for uniformly accelerated detectors. We demonstrate a new Unruh effect for detectors that respond to antinormally ordered moments using the ion's first blue sideband transition

Efficient real-time monitoring of an emerging influenza epidemic: how feasible?

A prompt public health response to a new epidemic relies on the ability to monitor and predict its evolution in real time as data accumulate. The 2009 A/H1N1 outbreak in the UK revealed pandemic data as noisy, contaminated, potentially biased, and originating from multiple sources. This seriously challenges the capacity for real-time monitoring. Here we assess the feasibility of real-time inference based on such data by constructing an analytic tool combining an age-stratified SEIR transmission model with various observation models describing the data generation mechanisms. As batches of data become available, a sequential Monte Carlo (SMC) algorithm is developed to synthesise multiple imperfect data streams, iterate epidemic inferences and assess model adequacy amidst a rapidly evolving epidemic environment, substantially reducing computation time in comparison to standard MCMC, to ensure timely delivery of real-time epidemic assessments. In application to simulated data designed to mimic the 2009 A/H1N1 epidemic, SMC is shown to have additional benefits in terms of assessing predictive performance and coping with parameter non-identifiability.MRC, NIH