Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing telemedicine: a Health Economic Modeling Study.

OBJECTIVE: Depressive disorders are important causes of disease burden and are associated with substantial economic costs. Therefore, it is important to design a health care system that can effectively manage depression at sustainable costs. This paper computes the benefit-to-costs ratio of the current Dutch health care system for depression, and investigates whether offering more online preventive interventions improves the cost-effectiveness overall. METHODS: A health economic (Markov) model was used to synthesize clinical and economic evidence and to compute population-level costs and effects of interventions. The model compares a base-case scenario without preventive telemedicine and alternative scenarios with preventive telemedicine. The central outcome is the benefit-to-cost ratio, also known as return-on-investment (ROI). RESULTS: In terms of ROI, a health care system with preventive telemedicine for depressive disorders offers better value for money than a health care system without internet-based prevention. Overall, the ROI increases from €1.45 ($1.72) in the base-case scenario to €1.76 ($2.09) in the alternative scenario where preventive telemedicine is offered. In a scenario where the costs of offering preventive telemedicine are balanced by cutting back on the expenditure for curative interventions, ROI increases to €1.77 ($2.10), while keeping the health care budget constant. CONCLUSION: In order for a health care system for depressive disorders to remain economically sustainable, its cost-benefit ratio needs to be improved. Offering preventive telemedicine at a large scale is likely to introduce such an improvement

The WHAM Northern Sky Survey and the Nature of the Warm Ionized Medium in the Galaxy

The Wisconsin H-Alpha Mapper (WHAM) has completed a velocity-resolved map of diffuse H-alpha emission of the entire northern sky, providing the first comprehensive picture of both the distribution and kinematics of diffuse ionized gas in the Galaxy. WHAM continues to advance our understanding of the physical conditions of the warm ionized medium through observations of other optical emission lines throughout the Galactic disk and halo. We discuss some highlights from the survey, including an optical window into the inner Galaxy and the relationship between HI and HII in the diffuse ISM.Comment: 9 pages, 3 figures. To be published in "How does the Galaxy work?", eds. E.J. Alfaro, E. Perez & J. Franco, Kluwer, held 23-27 June 2003 in Granada, Spain. Higher resolution version available at http://www.astro.wisc.edu/~madsen/prof/pubs.htm

Multidimensional relativistic MHD simulations of Pulsar Wind Nebulae: dynamics and emission

Pulsar Wind Nebulae, and the Crab nebula in particular, are the best cosmic laboratories to investigate the dynamics of magnetized relativistic outflows and particle acceleration up to PeV energies. Multidimensional MHD modeling by means of numerical simulations has been very successful at reproducing, to the very finest details, the innermost structure of these synchrotron emitting nebulae, as observed in the X-rays. Therefore, the comparison between the simulated source and observations can be used as a powerful diagnostic tool to probe the physical conditions in pulsar winds, like their composition, magnetization, and degree of anisotropy. However, in spite of the wealth of observations and of the accuracy of current MHD models, the precise mechanisms for magnetic field dissipation and for the acceleration of the non-thermal emitting particles are mysteries still puzzling theorists to date. Here we review the methodologies of the computational approach to the modeling of Pulsar Wind Nebulae, discussing the most relevant results and the recent progresses achieved in this fascinating field of high-energy astrophysics.Comment: 29 pages review, preliminary version. To appear in the book "Modelling Nebulae" edited by D. Torres for Springer, based on the invited contributions to the workshop held in Sant Cugat (Barcelona), June 14-17, 201

HI Clouds Beyond the Galactic Disk

Recent observations in the 21cm line with the Green Bank Telescope have changed our view of the neutral interstellar medium (ISM) in several ways. The new data show that in the inner parts of the Milky Way the disk-halo interface is composed of many discrete HI clouds. The clouds lie in a layer more than one kpc thick and follow Galactic rotation. Their origin and evolution is unknown. In the outer Galaxy, the new data show that the high-velocity cloud Complex H is likely a satellite on a retrograde orbit interacting with some extended component of the Milky Way's ISM. These observations place new constraints on models of the ISM and are directly related to the work of Don Cox and Ron Reynolds.Comment: 8 pages includes 2 figures. To appear in "How Does the Galaxy Work?", eds. E.J. Alfaro, E. Perez, & J. Franco, Kluwer, Proceedings of a Conference held 23-27 June 2003 in Granada, Spai

Magnetic fields in supernova remnants and pulsar-wind nebulae

We review the observations of supernova remnants (SNRs) and pulsar-wind nebulae (PWNe) that give information on the strength and orientation of magnetic fields. Radio polarimetry gives the degree of order of magnetic fields, and the orientation of the ordered component. Many young shell supernova remnants show evidence for synchrotron X-ray emission. The spatial analysis of this emission suggests that magnetic fields are amplified by one to two orders of magnitude in strong shocks. Detection of several remnants in TeV gamma rays implies a lower limit on the magnetic-field strength (or a measurement, if the emission process is inverse-Compton upscattering of cosmic microwave background photons). Upper limits to GeV emission similarly provide lower limits on magnetic-field strengths. In the historical shell remnants, lower limits on B range from 25 to 1000 microGauss. Two remnants show variability of synchrotron X-ray emission with a timescale of years. If this timescale is the electron-acceleration or radiative loss timescale, magnetic fields of order 1 mG are also implied. In pulsar-wind nebulae, equipartition arguments and dynamical modeling can be used to infer magnetic-field strengths anywhere from about 5 microGauss to 1 mG. Polarized fractions are considerably higher than in SNRs, ranging to 50 or 60% in some cases; magnetic-field geometries often suggest a toroidal structure around the pulsar, but this is not universal. Viewing-angle effects undoubtedly play a role. MHD models of radio emission in shell SNRs show that different orientations of upstream magnetic field, and different assumptions about electron acceleration, predict different radio morphology. In the remnant of SN 1006, such comparisons imply a magnetic-field orientation connecting the bright limbs, with a non-negligible gradient of its strength across the remnant.Comment: 20 pages, 24 figures; to be published in SpSciRev. Minor wording change in Abstrac

Pulsar-wind nebulae and magnetar outflows: observations at radio, X-ray, and gamma-ray wavelengths

We review observations of several classes of neutron-star-powered outflows: pulsar-wind nebulae (PWNe) inside shell supernova remnants (SNRs), PWNe interacting directly with interstellar medium (ISM), and magnetar-powered outflows. We describe radio, X-ray, and gamma-ray observations of PWNe, focusing first on integrated spectral-energy distributions (SEDs) and global spectral properties. High-resolution X-ray imaging of PWNe shows a bewildering array of morphologies, with jets, trails, and other structures. Several of the 23 so far identified magnetars show evidence for continuous or sporadic emission of material, sometimes associated with giant flares, and a few possible "magnetar-wind nebulae" have been recently identified.Comment: 61 pages, 44 figures (reduced in quality for size reasons). Published in Space Science Reviews, "Jets and Winds in Pulsar Wind Nebulae, Gamma-ray Bursts and Blazars: Physics of Extreme Energy Release

Atomic X-ray Spectroscopy of Accreting Black Holes

Current astrophysical research suggests that the most persistently luminous objects in the Universe are powered by the flow of matter through accretion disks onto black holes. Accretion disk systems are observed to emit copious radiation across the electromagnetic spectrum, each energy band providing access to rather distinct regimes of physical conditions and geometric scale. X-ray emission probes the innermost regions of the accretion disk, where relativistic effects prevail. While this has been known for decades, it also has been acknowledged that inferring physical conditions in the relativistic regime from the behavior of the X-ray continuum is problematic and not satisfactorily constraining. With the discovery in the 1990s of iron X-ray lines bearing signatures of relativistic distortion came the hope that such emission would more firmly constrain models of disk accretion near black holes, as well as provide observational criteria by which to test general relativity in the strong field limit. Here we provide an introduction to this phenomenon. While the presentation is intended to be primarily tutorial in nature, we aim also to acquaint the reader with trends in current research. To achieve these ends, we present the basic applications of general relativity that pertain to X-ray spectroscopic observations of black hole accretion disk systems, focusing on the Schwarzschild and Kerr solutions to the Einstein field equations. To this we add treatments of the fundamental concepts associated with the theoretical and modeling aspects of accretion disks, as well as relevant topics from observational and theoretical X-ray spectroscopy.Comment: 63 pages, 21 figures, Einstein Centennial Review Article, Canadian Journal of Physics, in pres

Effect of D2R, NMDAR and CB1R genetic variants associated with cannabis use and childhood trauma in first-episode psychosis in a Brazilian population [abstract only]

Introduction Gene-environment interactions increase psychosis risk (Gayer-Anderson et al. Soc Psychiatry Psychiatr Epidemiol 2020; 55(5):645-657). However, identifying the genetic variants involved and how they interact with environmental risk factors underlying psychosis remains challenging. Objectives To investigate whether there are gene-environment interactions in the relationships of childhood trauma, lifetime cannabis use, and single nucleotide variants (SNVs) of dopamine D2 receptor (D2R: DRD2), N-methyl-d-aspartate receptor (NMDAR: GRIN1, GRIN2A and GRIN2B) and cannabinoid receptor type 1 (CB1R: CNR1) with psychosis. Methods In a population-based case-control study nested in an incident study (STREAM, Brazil) (Del-Ben et al. Br J of Psychiatry 2019; 215(6):726-729), part of the EU-GEI consortium (Gayer-Anderson et al. Soc Psychiatry Psychiatr Epidemiol 2020; 55(5):645-657), 143 first-episode psychosis patients and 286 community-based controls of both sexes aged between 16 and 64 years were included over a period of 3 years. Twenty-three SNVs of D2R (rs1799978, rs7131056, rs6275), NMDAR (GRIN1: rs4880213, rs11146020; GRIN2A: rs1420040, rs11866328; GRIN2B: rs890, rs2098469, rs7298664), and CB1R genes (CNR1: rs806380, rs806379, rs1049353, rs6454674, rs1535255, rs2023239, rs12720071, rs6928499, rs806374, rs7766029, rs806378, rs10485170, rs9450898), were genotyped from peripheral blood DNA using a custom Illumina HumanCoreExome-24 BeadChip. Environmental adversities were evaluated using the Cannabis Experience Questionnaire (Di Forti et al. The Lancet Psychiatry 2009; 6(5):427–436) and the Childhood Trauma Questionnaire (Grassi-Oliveira et al. Rev Saude Publica 2006; 40(2):249-55). Associations between SNVs and environmental risk factors were performed using the nonparametric multifactor dimensionality reduction software (version 3.0.2). Results Single locus analysis showed no association among the 23 SNVs with psychosis; however, gene-environment analysis was significant for the polymorphic loci rs12720071 and rs7766029 in CNR1. The best association models were the two-factor representing by the combination of CNR1 rs12720071 with lifetime cannabis use (p<0.001), and CNR1 rs12720071 with childhood trauma (p<0.05), both suggesting an increased risk of psychosis. Additionally, when considering the interaction of both environmental factors in the same model, we found CNR1 rs7766029 to be associated with psychosis (p<0.001). Conclusions Our study supports the hypothesis of gene-environment interactions for psychosis involving the T allele carriers of CNR1 SNVs (rs12720071 and rs7766029), childhood trauma and lifetime cannabis use in psychosis

Implications of H.E.S.S. observations of pulsar wind nebulae

In this review paper on pulsar wind nebulae (PWN) we discuss the properties of such nebulae within the context of containment against cross-field diffusion (versus normal advection), the effect of reverse shocks on the evolution of offset ``Vela-like'' PWN, constraints on maximum particle energetics, magnetic field strength estimates based on spectral and spatial properties, and the implication of such field estimates on the composition of the wind. A significant part of the discussion is based on the High Energy Stereoscopic System ({\it H.E.S.S.} or {\it HESS}) detection of the two evolved pulsar wind nebulae Vela X (cocoon) and HESS J1825-137. In the case of Vela X (cocoon) we also review evidence of a hadronic versus a leptonic interpretation, showing that a leptonic interpretation is favored for the {\it HESS} signal. The constraints discussed in this review paper sets a general framework for the interpretation of a number of offset, filled-center nebulae seen by {\it HESS}. These sources are found along the galactic plane with galactic latitudes $|b|\sim 0$, where significant amounts of molecular gas is found. In these regions, we find that the interstellar medium is inhomogeneous, which has an effect on the morphology of supernova shock expansion. One consequence of this effect is the formation of offset pulsar wind nebulae as observed.Comment: to appear in Springer Lecture Notes on Neutron Stars and Pulsars: 40 years after their discovery, eds. W. Becke