The Cost Effectiveness of Single-Patient-Use Electrocardiograph Cable and Lead Systems in Monitoring for Coronary Artery Bypass Graft Surgery

Background: During admission for coronary artery bypass graft (CABG) surgery patients receive electrocardiograph (ECG) monitoring; for which reusable ECG cable and leads (rECG) are standard.Objective: Evaluate the cost effectiveness of a single-patient-use ECG cable and lead system (spECG).Methods: Review of the Medicare 2011–2014 database followed by a cost-effectiveness model considering a Medicare facility transitioning from rECG ($9 per patient) to spECG ($15). In-hospital ECG monitoring was for ≤8 days. In the model, patients underwent CABG and recovered in the intensive care unit, before transfer to the general ward and discharge. Surgical site infection (SSI) resulted in increased length of stay, readmission, or outpatient care. Health outcomes impacted EQ-5D-measured quality adjusted life years (QALYs). Health and cost outcomes were discounted at 3.5% annually. All costs in 2016 USD. Significance (95% level) was assessed via 2,000 simulations.Results: In 2014, 5.49% of patients had an SSI by 90-days post-surgery, with spECG reducing the odds of an SSI (odds ratio: 0.74, 0.62–0.89). Mean 40-year, per-patient costs to Medicare were $65,497 with rECG and$65,048 with spECG. The $450 saving was significant, with a median (95$466 ($174 to$989). Cost drivers were days required to treat inpatient SSIs. QALYs increases with spECG were significant but minor (median increase 0.008). Medicare savings may total $40 million per year with use of spECG.Conclusions: Post-operative SSI is a concern for Medicare patients undergoing CABG, and use of spECG is likely to provide cost and patient benefits

Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis

OBJECTIVE: To evaluate the effect of capnography monitoring on sedation-related adverse events during procedural sedation and analgesia (PSA) administered for ambulatory surgery relative to visual assessment and pulse oximetry alone. DESIGN AND SETTING: Systematic literature review and random effects meta-analysis of randomised controlled trials (RCTs) reporting sedation-related adverse event incidence when adding capnography to visual assessment and pulse oximetry in patients undergoing PSA during ambulatory surgery in the hospital setting. Searches for eligible studies published between 1 January 1995 and 31 December 2016 (inclusive) were conducted in PubMed, the Cochrane Library and EMBASE without any language constraints. Searches were conducted in January 2017, screening and data extraction were conducted by two independent reviewers, and study quality was assessed using a modified Jadad scale. INTERVENTIONS: Capnography monitoring relative to visual assessment and pulse oximetry alone. PRIMARY AND SECONDARY OUTCOME MEASURES: Predefined endpoints of interest were desaturation/hypoxaemia (the primary endpoint), apnoea, aspiration, bradycardia, hypotension, premature procedure termination, respiratory failure, use of assisted/bag-mask ventilation and death during PSA. RESULTS: The literature search identified 1006 unique articles, of which 13 were ultimately included in the meta-analysis. Addition of capnography to visual assessment and pulse oximetry was associated with a significant reduction in mild (risk ratio (RR) 0.77, 95% CI 0.67 to 0.89) and severe (RR 0.59, 95% CI 0.43 to 0.81) desaturation, as well as in the use of assisted ventilation (OR 0.47, 95% CI 0.23 to 0.95). No significant differences in other endpoints were identified. CONCLUSIONS: Meta-analysis of 13 RCTs published between 2006 and 2016 showed a reduction in respiratory compromise (from respiratory insufficiency to failure) during PSA with the inclusion of capnography monitoring. In particular, use of capnography was associated with less mild and severe oxygen desaturation, which may have helped to avoid the need for assisted ventilation

Computational analyses of the surface properties of protein–protein interfaces

This paper presents a survey of techniques that explore the surface properties of protein:protein interfaces so as to inform the prediction of probable sites of protein:protein interaction on newly determined protein structures

Clinical and economic burden of procedural sedation-related adverse events and their outcomes: analysis from five countries

Background: Studies have reported on the incidence of sedation-related adverse events (AEs), but little is known about their impact on health care costs and resource use. Methods: Health care providers and payers in five countries were recruited for an online survey by independent administrators to ensure that investigators and respondents were blinded to each other. Surveys were conducted in the local language and began with a screener to ensure that respondents had relevant expertise and experience. Responses were analyzed using Excel and R, with the Dixon\u27s Q statistic used to identify and remove outliers. Global and country-specific average treatment patterns were calculated via bootstrapping; costs were mean values. The sum product of costs and intervention probability gave a cost per AE. Results: Responses were received from 101 providers and 26 payers, the majority having \u3e 5 years of experience. At a minimum, the respondents performed a total of 3,430 procedural sedations per month. All AEs detailed occurred in clinical practice in the last year and were reported to cause procedural delays and cancellations in some patients. Standard procedural sedation costs ranged from euro74 (Germany) to $2,300 (US). Respondents estimated that AEs would increase costs by between 16$43 ($27-$68). Other frequent AEs, including mild hypotension, bradycardia, tachycardia, mild oxygen desaturation, hypertension, and brief apnea, were estimated to increase health care spending on procedural sedation by $2.2 billion annually in the US. Conclusion: All sedation-related AEs can increase health care costs and result in substantial delays or cancellations of subsequent procedures. The prevention of even minor AEs during procedural sedation may be crucial to ensuring its value as a health care service

Fast In-House Next-Generation Sequencing in the Diagnosis of Metastatic Non-small Cell Lung Cancer: A Hospital Budget Impact Analysis

**Background:** Targeted therapy for cancer is becoming more frequent as the understanding of the molecular pathogenesis increases. Molecular testing must be done to use targeted therapy. Unfortunately, the testing turnaround time can delay the initiation of targeted therapy. **Objective:** To investigate the impact of a next-generation sequencing (NGS) machine in the hospital that would allow for in-house NGS testing of metastatic non-small cell lung cancer (mNSCLC) in a US setting. **Methods:** The differences between 2 hospital pathways were established with a cohort-level decision tree that feeds into a Markov model. A pathway that used in-house NGS (75%) and the use of external laboratories (so-called send-out NGS) (25%), was compared with the standard of exclusively send-out NGS. The model was from the perspective of a US hospital over a 5-year time horizon. All cost input data were in or inflated to 2021 USD. Scenario analysis was done on key variables. **Results:** In a hospital with 500 mNSCLC patients, the implementation of in-house NGS was estimated to increase the testing costs and the revenue of the hospital. The model predicted a 710 060 increase in testing costs, a 1 732 506 increase in revenue, and a $1 022 446 return on investment over 5 years. The payback period was 15 months with in-house NGS. The number of patients on targeted therapy increased by 3.38%, and the average turnaround time decreased by 10 days when in-house NGS was used. **Discussion:** Reducing testing turnaround time is a benefit of in-house NGS. It could contribute to fewer mNSCLC patients lost to second opinion and an increased number of patients on targeted therapy. The model outcomes predicted that, over a 5-year period, there would be a positive return on investment for a US hospital. The model reflects a proposed scenario. The heterogeneity of hospital inputs and the cost of send-out NGS means context-specific inputs are needed. **Conclusion:** Using in-house NGS testing could reduce the testing turnaround time and increase the number of patients on targeted therapy. Additional benefits for the hospital are that fewer patients will be lost to second opinion and that in-house NGS could generate additional revenue

Through a Glass, Darkly:The CIA and Oral History

This article broaches the thorny issue of how we may study the history of the CIA by utilizing oral history interviews. This article argues that while oral history interviews impose particular demands upon the researcher, they are particularly pronounced in relation to studying the history of intelligence services. This article, nevertheless, also argues that while intelligence history and oral history each harbour their own epistemological perils and biases, pitfalls which may in fact be pronounced when they are conjoined, the relationship between them may nevertheless be a productive one. Indeed, each field may enrich the other provided we have thought carefully about the linkages between them: this article's point of departure. The first part of this article outlines some of the problems encountered in studying the CIA by relating them to the author's own work. This involved researching the CIA's role in US foreign policy towards Afghanistan since a landmark year in the history of the late Cold War, 1979 (i.e. the year the Soviet Union invaded that country). The second part of this article then considers some of the issues historians must confront when applying oral history to the study of the CIA. To bring this within the sphere of cognition of the reader the author recounts some of his own experiences interviewing CIA officers in and around Washington DC. The third part then looks at some of the contributions oral history in particular can make towards a better understanding of the history of intelligence services and the CIA

Synonymous codon usage influences the local protein structure observed

Translation of mRNA into protein is a unidirectional information flow process. Analysing the input (mRNA) and output (protein) of translation, we find that local protein structure information is encoded in the mRNA nucleotide sequence. The Coding Sequence and Structure (CSandS) database developed in this work provides a detailed mapping between over 4000 solved protein structures and their mRNA. CSandS facilitates a comprehensive analysis of codon usage over many organisms. In assigning translation speed, we find that relative codon usage is less informative than tRNA concentration. For all speed measures, no evidence was found that domain boundaries are enriched with slow codons. In fact, genes seemingly avoid slow codons around structurally defined domain boundaries. Translation speed, however, does decrease at the transition into secondary structure. Codons are identified that have structural preferences significantly different from the amino acid they encode. However, each organism has its own set of ‘significant codons’. Our results support the premise that codons encode more information than merely amino acids and give insight into the role of translation in protein folding

Co-translational protein folding

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Evaluating the Cost-Effectiveness of Proportional-Assist Ventilation Plus vs. Pressure Support Ventilation in the Intensive Care Unit in Two Countries

Background: Mechanical ventilation is an integral, but expensive, part of the intensive care unit (ICU). Optimal use of mechanical ventilation could save costs and improve patient outcomes. Here, the cost effectiveness of proportional assist ventilation (PAV™ ventilation by Medtronic) is estimated relative to pressure support ventilation (PSV).Methods: A cohort-level, clinical model was built using data from clinical trials. The model estimates patient-ventilator asynchrony >10%, tracheostomy, ventilator-associated pneumonia, other nosocomial infections, spontaneous breathing trial success, hypoxemia, and death. Cost and quality of life are associated with all events, with cost effectiveness defined as the cost per quality-adjusted life year (QALY) gained in the US and UK.Results: The mean cost of ICU care was lower with PAV™ than with PSV in the US and UK, but the total cost of care over 40 years was higher due to more patients surviving and incurring future care costs. Reduced time on mechanical ventilation, fewer nosocomial infections, and extended life expectancy with PAV™ drove QALY improvement. The cost per QALY gained with PAV™ was $8,628 and £2,985.Conclusion: PAV™ improves quality of life and reduces short-term costs. PAV™ is likely to be considered cost-effective over 40-years in the US and UK