A reassessment of the cost-effectiveness of hormone replacement therapy in Sweden – results based on the Women’s Health Initiative randomised controlled trial

The cost-effectiveness of hormone replacement therapy (HRT) based on a societal perspective is reassessed based on new medical evidence found in the Women’s Health Initiative (WHI). Within a model framework using an individual state transition model the cost-effectiveness of 50-60 year old women with menopausal symptoms is assessed in Sweden. The Markov model has a 50 year time horizon divided into a cycle length of 1 year. The model consists of the following disease states: Coronary Heart Disease (CHD), Stroke, Venous thromboembolic events, breast cancer, colorectal cancer, hip fracture, vertebral fracture and wrist fracture. An intervention is modelled by its impact on the disease risks during and after the cessation of therapy. The model calculates costs and quality adjusted life years (QALYs) with and without intervention. The resulting cost per gained QALY is compared to the value of a gained QALY, which is set to SEK 600 000. The model requires data on clinical effects, risks, mortality rates, quality of life weights and costs valid for Sweden. The cost-effectiveness ratios are estimated at about SEK 10 000, which is far below the value of a gained QALY. Conditional on that HRT increases the quality of life weight more than 0.013 the therapy is cost-effective. In conclusion, given the new evidence in WHI, there is still a high probability that HRT is a cost-effective strategy for women with menopausal symptoms.cost-effectiveness analysis; hormone replacement therapy; Markov model

Costs and quality of life associated with osteoporosis related fractures - Results from a Swedish survey

There are few studies investigating the consequences of osteoporotic (low bone density) fractures in terms of costs and health outcomes. The purpose of this Swedish pilot study is to assess the costs and quality of life related to fractures of the hip, spine, wrist and shoulder and further to identify important cost items that should be included in future studies in this area. Data were collected using a questionnaire administered by a nurse at Malmö University Hospital. The costs are collected based on a societal perspective and include both direct and indirect costs. Health effects were measured by the EuroQol questionnaire, rating scale method and the SF-36. The total costs varied between SEK 23 000 for a wrist fracture and SEK 63 000 for a hip fracture. Although that the response rate is low the cost and quality of life related to hip fracture are close to the results presented in other studies. The major new finding is that spine fractures are associated with higher costs and lower quality of life than previously assumed. Future studies must include a sufficient number of patients in order to obtain reliable cost and health effect estimates after osteoporotic fractures in general and after spine fractures in particular. Such studies will provide important inputs for health economic evaluations assessing the cost-effectiveness of the treatment and prevention of osteoporosis.costs; fracture; osteoporosis; quality of life

Nutritional status and nutritional treatment are related to outcomes and mortality in older adults with hip fracture

Malnutrition is very prevalent in geriatric patients with hip fracture. Nevertheless, its importance is not fully recognized. The objective of this paper is to review the impact of malnutrition and of nutritional treatment upon outcomes and mortality in older people with hip fracture. We searched the PubMed database for studies evaluating nutritional aspects in people aged 70 years and over with hip fracture. The total number of studies included in the review was 44, which analyzed 26,281 subjects (73.5% women, 83.6 ± 7.2 years old). Older people with hip fracture presented an inadequate nutrient intake for their requirements, which caused deterioration in their already compromised nutritional status. The prevalence of malnutrition was approximately 18.7% using the Mini-Nutritional Assessment (MNA) (large or short form) as a diagnostic tool, but the prevalence was greater (45.7%) if different criteria were used (such as Body Mass Index (BMI), weight loss, or albumin concentration). Low scores in anthropometric indices were associated with a higher prevalence of complications during hospitalization and with a worse functional recovery. Despite improvements in the treatment of geriatric patients with hip fracture, mortality was still unacceptably high (30% within 1 year and up to 40% within 3 years). Malnutrition was associated with an increase in mortality. Nutritional intervention was cost effective and was associated with an improvement in nutritional status and a greater functional recovery. To conclude, in older people, the prevention of malnutrition and an early nutritional intervention can improve recovery following a hip fracture

Land Use among Rare Species

This project focused on a site in Lancaster, Massachusetts with potential for development that contains possible habitat for rare species. The practices of low-impact and sustainable development were investigated and to applied to the site, keeping in mind the welfare of the possible rare inhabitants. Three example developments were designed: a typical high-impact development, low-impact, and low-impact with increased sustainability. Using the results from our studies and drawings, conclusions were drawn regarding the different designs, and recommendations were made to potential developers and townships looking to embrace low-impact options

Reducing Stigma toward the Transgender Community: An Evaluation of a Humanizing and Perspective-Taking Intervention

Transgender (TG) individuals, or those whose gender identities, expressions and/or behaviors differ from their biological sex (Kirk & Kulkarni, 2006) feel there is a pervasive pattern of discrimination and prejudice directed toward them (Lombardi et al., 2001). In comparison to their heterosexual peers, LGBT youth and emerging adults are at increased risk for a host of adverse outcomes including: suicide, depression, harassment, and victimization (IOM, 2011). Stigma has been characterized as encompassing several components: labeling, making an association between the label and a negative stereotype, separating those who are different as an “out-group” and discriminating. In a recent analysis of the transgender experience, Hill (2002) described three key constructs that can be used to understand negative emotions and behaviors toward transgender individuals: transphobia – an emotional disgust toward gender non-conforming individuals; genderism – a belief that gender non-conforming individuals are pathological or disordered; gender bashing – assault or harassment of gender non-conforming individuals. Recent work on minority stress posits a distal-proximal model of stress in which a person identifies with and makes proximal, distal social attitudes that can have negative effects on their psychological well-being (Meyer, 2003). Thus, stigmatized attitudes and behaviors not only have the potential to contribute to violence or discriminatory behavior but also have a direct impact on the psychological health of the target individual. Thus, the question of how to change negative attitudes and behaviors toward TG individuals is paramount. Researchers have sought to develop interventions aimed at reducing stigma with three basic strategies identified: protest, education and contact (Corrigan & Penn, 1999). However, to date only two such strategies have garnered empirical support: contact and education. In relation to mental illness, education strategies have received limited support (Holmes et al., 1999; see Luty et al., 2007 for an exception). In contrast, contact-based interventions yield the most dramatic changes in attitudes and behaviors; contact involving media depictions have also been demonstrated to yield positive attitude change. Comparing traditional diagnosis-centered teaching about mental illness to a humanizing approach that required students to write a first-person narrative about suffering from a mental illness, Mann and Himelein (2008) found that attitudes changed only when students were required to adopt the perspective of a mentally ill individual. In their recent meta-analysis, Pettigrew and Tropp (2006) demonstrated that contact reduces prejudice and is particularly effective when it occurs under favorable conditions (e.g., conditions of equality, cooperation, and institutional support). While a wealth of research has supported the contact hypothesis related to changing negative attitudes toward ethnic minorities, the mentally ill, the homeless, gays/lesbians and other stigmatized groups, there have been a limited number of studies evaluating associations between contact and attitudes toward the TG community (Harvey, 2002; Hill & Willoughby, 2005) and no controlled studies to evaluate the efficacy of such methods. The current study extends work evaluating anti-stigma interventions to the TG community and seeks to evaluate whether attitude change will differ between participants receiving basic education about the transgender community and those who are educated about TG through media depictions of TG families and are asked to engage in a perspective-taking task. We hypothesize that participants in the humanizing condition who view a documentary and write a first-person narrative of transgender experiences will show a more significant change in transphobia, genderist attitudes and desire for social distance across time relative to participants in the education-only condition signaling less stigmatized and prejudicial attitudes at post-test. Hodson (2011) recently examined the existing contact literature and found that, consistent with Pettigrew’s (1998) focus on individual differences, intergroup contact was effective (and perhaps even more effective) among individuals who were intolerant and cognitively rigid. Religious fundamentalism has been associated with anti-homosexual sentiment (Fulton et al., 1999). Whether religiosity is similarly associated with negative attitudes toward TG individuals will be explored. Whether religiosity and prior contact with the LGBTQ community will moderate intervention outcomes will also be explored

Automated Bench-Scale Bioreactor

The objective of this project was to design and build an automated bench-scale sequencing batch reactor to demonstrate the treatment of wastewater using an activated sludge process. LabVIEW 8.0 development software was used to build a user interface to control timing sequence, pumping, aeration, and temperature of the physical reactor setup

Vitamin D supplementation in the prevention and management of major chronic diseases not related to mineral homeostasis in adults : research for evidence and a scientific statement from the European society for clinical and economic aspects of osteoporosis and osteoarthritis (ESCEO)

Introduction: Optimal vitamin D status promotes skeletal health and is recommended with specific treatment in individuals at high risk for fragility fractures. A growing body of literature has provided indirect and some direct evidence for possible extraskeletal vitamin D-related effects. Purpose and Methods: Members of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis have reviewed the main evidence for possible proven benefits of vitamin D supplementation in adults at risk of or with overt chronic extra-skeletal diseases, providing recommendations and guidelines for future studies in this field. Results and conclusions: Robust mechanistic evidence is available from in vitro studies and in vivo animal studies, usually employing cholecalciferol, calcidiol or calcitriol in pharmacologic rather than physiologic doses. Although many cross-sectional and prospective association studies in humans have shown that low 25-hydroxyvitamin D levels (i.e., 50 nmol/L, did not simultaneously assess multiple outcomes, and did not report overall safety (e.g., falls). Thus, no recommendations can be made to date for the use of vitamin D supplementation in general, parental compounds, or non-hypercalcemic vitamin D analogs in the prevention and treatment of extra-skeletal chronic diseases. Moreover, attainment of serum 25-hydroxyvitamin D levels well above the threshold desired for bone health cannot be recommended based on current evidence, since safety has yet to be confirmed. Finally, the promising findings from mechanistic studies, large cohort studies, and small clinical trials obtained for autoimmune diseases (including type 1 diabetes, multiple sclerosis, and systemic lupus erythematosus), cardiovascular disorders, and overall reduction in mortality require further confirmation

Epidemiology of fractures in Armenia: development of a country-specific FRAX model and comparison to its surrogate

Summary: Fracture probabilities derived from the surrogate FRAX model for Armenia were compared to those from the model based on regional estimates of the incidence of hip fracture. Disparities between the surrogate and authentic FRAX models indicate the importance of developing country-specific FRAX models. Despite large differences between models, differences in the rank order of fracture probabilities were minimal. Objective: Armenia has relied on a surrogate FRAX model based on the fracture epidemiology of Romania. This paper describes the epidemiology of fragility fractures in Armenia used to create an Armenia-specific FRAX model with an aim of comparing this new model with the surrogate model. Methods: We carried out a population-based study in two regions of Armenia (Ararat and Vayots Dzor representing approximately 11% of the country’s population). We aimed to identify all low-energy fractures: retrospectively from hospital registers in 2011–2012 and prospectively in 2013 with the inclusion of primary care sources. Results: The differences in incidence between the surveys with and without data from primary care suggested that 44% of patients sustaining a hip fracture did not receive specialized medical care. A similar proportion of forearm and humeral fractures did not come to hospital attention (48 and 49%, respectively). Only 57.7% of patients sustaining a hip fracture were hospitalized. In 2013, hip fracture incidence at the age of 50 years or more was 201/100,000 for women and 136/100,000 for men, and age- and sex-specific rates were incorporated into the new “authentic” FRAX model for Armenia. Compared to the surrogate model, the authentic model gave lower 10-year fracture probabilities in men and women aged less than 70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the surrogate and authentic models ( >  0.99) so that the revisions had little impact on the rank order of risk. Conclusion: A substantial proportion of major osteoporotic fractures in Armenia do not come to hospital attention. The disparities between surrogate and authentic FRAX models indicate the importance of developing country-specific FRAX models. Despite large differences between models, differences in the rank order of fracture probabilities were minimal

Extensive undertreatment of osteoporosis in older Swedish women

Summary In a population-based study of older Swedish women, we investigated the proportion of women treated with osteoporosis medication in relation to the proportion of women eligible for treatment according to national guidelines. We found that only a minority (22%) of those eligible for treatment were prescribed osteoporosis medication. Introduction Fracture rates increase markedly in old age and the incidence of hip fracture in Swedish women is among the highest in the world. Although effective pharmacological treatment is available, treatment rates remain low. Limited data are available regarding treatment rates in relation to fracture risk in a population-based setting in older women. Therefore, we aimed to investigate the proportion of older women eligible for treatment according to Swedish Osteoporosis Society (SvOS) guidelines. Methods A population-based study was performed in Gothenburg in 3028 older women (77.8 ± 1.6 years [mean ± SD]). Bone mineral density of the spine and hip was measured with dual-energy X-ray absorptiometry. Clinical risk factors for fracture and data regarding osteoporosis medication was collected with self-administered questionnaires. Logistic regression was used to evaluate whether the 10-year probability of sustaining a major osteoporotic fracture (FRAX-score) or its components predicted treatment with osteoporosis medication. Results For the 2983 women with complete data, 1107 (37%) women were eligible for treatment using SvOS criteria. The proportion of these women receiving treatment was 21.8%. For women eligible for treatment according to SvOS guidelines, strong predictors for receiving osteoporosis medication were glucocorticoid treatment (odds ratio (95% CI) 2.88 (1.80–4.59)) and prior fracture (2.58 (1.84–3.61)). Conclusion This study demonstrates that a substantial proportion of older Swedish women should be considered for osteoporosis medication given their high fracture risk, but that only a minority receives treatment

The application of FRAX in Ecuador

Introduction Intervention thresholds for the treatment of osteoporosis have been based historically on the measurement of bone mineral density. The development of FRAX® has permitted more accurate assessment of fracture risk. Objective The aim of the present study was to explore treatment paths and characteristics of women eligible for treatment in Ecuador based on FRAX. Methodology and methods A total of 2367 women aged 60–94 years were selected from the National Health, Welfare and Aging Survey (SABE) conducted in Ecuador. Probabilities of major osteoporotic and hip fracture were computed using the Ecuadorian FRAX model. The proportion of women eligible for treatment and bone mineral density assessment was determined based on age-specific intervention thresholds and a hybrid threshold was fixed from age 75 years. Results A total of 87 women (3.7%) had a prior fragility fracture and would be eligible for treatment for this reason. An additional 49 women were eligible for treatment in that MOF probabilities lay above the upper assessment threshold using age-specific thresholds. An BMD test would be recommended in 1131 women (48%) so that FRAX could be recalculated with the inclusion of femoral neck BMD. With the hybrid threshold, an additional 170 women were eligible for treatment and an BMD test recommended in 1218 women. Conclusions The hybrid threshold identifies more women eligible for treatment than age-specific thresholds. Although age-specific thresholds identify women at higher risk of fracture, the lower number of women identified results in fewer identified fracture cases. Resumen Introducción Los umbrales de intervención para el tratamiento de osteoporosis se han basado históricamente en la medición de la densidad ósea. El desarrollo del FRAX® ha permitido una evaluación más precisa del riesgo de fractura. Objetivo El objetivo del estudio fue explorar las rutas de tratamiento y las características de las mujeres elegibles para tratamiento en Ecuador con base en FRAX. Materiales y métodos Se seleccionó a 2.367 mujeres de 60 a 94 años de la encuesta SABE. Se calcularon las probabilidades de fracturas osteoporóticas principales y de cadera utilizando el modelo FRAX ecuatoriano. Se calculó la proporción de mujeres elegibles para tratamiento y evaluación de la densidad ósea, con base en umbrales de intervención específicos de la edad y de un umbral fijo a partir de los 75 años. Resultados Ochenta y siete mujeres (3,7%) tenían una fractura previa y eran elegibles para tratamiento. Utilizando umbrales específicos de edad, otras 49 mujeres eran elegibles para recibir tratamiento debido a que las probabilidades de fractura osteoporótica principal estaban por encima del umbral de evaluación superior. Se recomienda medir la densidad ósea en 1.131 mujeres para que el FRAX pueda ser recalculado con la inclusión de la densidad ósea del cuello femoral. Con el umbral híbrido, otras 170 mujeres fueron elegibles para tratamiento y la medición de la densidad ósea se recomendó a 1.218 mujeres. Conclusiones El umbral híbrido identifica a más mujeres elegibles para tratamiento que los umbrales específicos de la edad. Aunque estos últimos identifican a las mujeres con mayor riesgo de fractura, el menor número de mujeres identificadas resulta en menos casos de fractura identificados