Estimating the cost-effectiveness of fluticasone propionate for treating chronic obstructive pulmonary disease in the presence of missing data

Objectives: To explore the cost-effectiveness of fluticasone propionate (FP) for the treatment of chronic obstructive pulmonary disease (COPD), we estimated costs and qualityadjusted life-years (QALYs) over 3 years, based on an economic appraisal of a previously reported clinical trial (Inhaled Steroids in Obstructive Lung Disease in Europe [ISOLDE]). Methods: Seven hundred forty-two patients enrolled in the ISOLDE trial who received either FP or placebo had data available on health-care costs and quality of life over the period of the study. The SF-36-based utility scores for quality of life were used to calculate QALYs. A combined imputation and bootstrapping procedure was employed to handle missing data and to estimate statistical uncertainty in the estimated cumulative costs and QALYs over the study period. The imputation approach was based on propensity scoring and nesting this approach within the bootstrap ensured that multiple imputations were performed such that statistical estimates included imputation uncertainty. Results: Complete data were available on mortality within the follow-up period of the study and a nonsignificant trend toward improved survival of 0.06 (95% confidence interval [CI] –0.01 to 0.15) life-years was observed. In an analysis based on a propensity scoring approach to missing data we estimated the incremental costs of FP versus placebo to be £1021 (95% CI £619–1338) with an additional effect of 0.11 QALYs (CI 0.04–0.20). Cost-effectiveness estimates for the within-trial period of £17,700 per life-year gained (£6900 to ∞) and £9500 per QALY gained (CI £4300–26,500) were generated that include uncertainty due to the imputation process. An alternative imputation approach did not materially affect these estimates. Conclusions: Previous analyses of the ISOLDE study showed significant improvement on disease-specific health status measures and a trend toward a survival advantage for treatment with FP. This analysis shows that joint considerations of quality of life and survival result in a substantial increase in QALYs favoring treatment with FP. Based on these data, the inhaled corticosteroid FP appears costeffective for the treatment of COPD. Confirmation or refutation of this result may be achieved once the Towards a Revolution in COPD Health (TORCH) study reports, a large randomized controlled trial powered to detect mortality changes associated with the use of FP alone, or in combination with salmeterol, which is also collecting resource use and utility data suitable for estimating cost-effectiveness

More Social Needs Endorsed by Caregivers of Young Children Experiencing Everyday Discrimination

Background: Both discrimination and social needs are underlying risk factors for poor health outcomes; however, there are no studies looking at how feelings of discrimination impact reporting of social needs in the pediatric health care setting. Objective: To compare caregiver report of social needs and desire for help addressing social needs in the pediatric primary care setting based on respondents’ experiences with discrimination. Methods: We conducted a cross-sectional study of caregivers of children aged 2-5 in an urban primary care setting. Caregivers completed a tool to screen for 15 social needs and desire for help to address these needs, with in-person assistance available. The tool was adapted based on qualitative data with this same population and included items from the PHQ-2, 2-item food insecurity screener, and WE CARE survey. The short version of the “Everyday Discrimination Scale” was also completed, and caregivers were categorized as experiencing everyday discrimination if they responded “rarely”, “sometimes”, or “often” on any of 5 types of discrimination. If caregivers experienced everyday discrimination, they were also asked about perceived basis for discrimination. T-tests were conducted to compare the number of reported social needs and number of needs for which a caregiver desired help between groups based on experience of everyday discrimination and type of discrimination. Results: One hundred seventy-eight caregivers (94% mothers, mean age 32) of diverse racial and ethnic backgrounds (29% white, 61% black; 10% Hispanic) completed the screening tool. Sixty-seven percent had public insurance, and 35% were from households with an annual income below $20,000. Fifty-three percent of caregivers reported everyday discrimination, especially in regards to being treated with less respect and receiving poorer service in stores and restaurants (Figure 1) and most commonly on the basis of race (48%), gender (38%), and age (31%). Both caregivers who endorsed everyday discrimination in general, and those endorsing discrimination specifically by gender and age, reported a significantly higher number of social needs and number of social needs for which they wanted help (Table 1). Conclusions: In an urban population of mostly young Black mothers, the majority endorsed feeling some degree of everyday discrimination. Despite this, caregivers who endorsed feelings of discrimination, especially because of their gender and age, reported more social needs and a greater desire for help addressing these needs. This suggests that caregivers feel comfortable reporting sensitive social needs in the context of a child’s healthcare setting even though they may experience everyday discrimination. These findings may also suggest an association between experienced discrimination and social needs, with both potentially influenced by similar sociodemographic factors

Management of Peritonsillar Abscess Within a Local Emergency Department: A Quality Analysis Study.

OBJECTIVE: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck, affecting thousands of people annually with high treatment costs. The purpose of this project was to determine how in-network emergency departments (EDs) adhere to generally accepted guidelines regarding diagnosis and management of potential PTAs. METHODS: The authors performed a retrospective chart review to identify patients with PTA in five EDs in one year. Information pertaining to diagnostic tests, treatment, and airway status was also collected. Descriptive analysis was used to assess if EDs were consistent with generally accepted guidelines. RESULTS: Six hundred twenty-one patient records were identified and 140 were included in final analysis. Out of 140 patients, 71 were admitted for inpatient management and 23 were admitted for observation. Of the 46 patients diagnosed and discharged from the ED, 61% received a computerized tomography (CT) scan and only 39% had PTA drainage performed. Four (3%) patients received a point of care ultrasound and a CT scan and no patient received only an ultrasound. Out of all patients, 116/140 received a CT scan and 22 received drainage in the ED. The remainder of these patients either had drainage performed by an otolaryngologist or had no drainage performed. Of the 94 patients admitted for inpatient or observation, 84 received a CT scan and six received drainage by an ED physician. Only 62% of patients were given a penicillin derivative and 29% were given clindamycin, which has no Gram-negative coverage. CONCLUSION: One-third of PTA patients were managed within the ED, far less than similar studies. Of these, over 50% received a CT scan and less than 50% had PTA drainage. PTA drainage can improve patients\u27 symptoms and antibiotic effectiveness. The majority of patients were prescribed a penicillin derivative with or without another antibiotic

Evaluation of the SPOT™ Photoscreener’s Efficacy for Detecting Amblyopia Risk Factors Compared to Optometrists’ Examinations in 305 South Dakota Children

Purpose: This study sought to further validate the efficacy of the SPOTTM photoscreener version (v) 3.0.0500 as a screening device for amblyopia risk factors (ARF). Methods: This was a cross-sectional study from five different western South Dakota outpatient clinics. Data from 610 eyes of 305 children aged 6 months to 13.5 years collected between July 2018 to September 2018 were analyzed, using both the out-of-box referral criteria and the 2013 American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria. Optometrist (eye care provider or ECP) cycloplegia practice patterns were deferred to each clinics’ specific protocols. Power vector and Bland-Altman plot analyses were performed. Results: The average age of the 305 children in the study population is 99.6 months (~8.3 years), with a total of 42% of these subjects receiving no dilating drops prior to testing. From these cases, the SPOTTM v3.0.0500 photoscreener evaluation parameters for detecting ARFs using the out-of-box referral criteria yielded an overall sensitivity (SN) of 95.2%, specificity (SP) of 91.9%, positive predictive value (PPV) of 81.6%, and negative predictive value (NPV) of 98.1%; the SPOTTM v3.0.0500 photoscreener evaluation parameters for detecting ARFs using the 2013 AAPOS referral criteria yielded an overall SN of 96.3%, SP of 92.4%, PPV of 82.1%, and NPV of 98.6%. Conclusions: With SN and NPV values exceeding 95%, this study supports the efficacy of the SPOTTM v3.0.0500 photoscreener as a pediatric screening device to detect ARFs. Power vector analyses help to provide further objective comparisons of refractive measurements between photoscreening devices and refractive examinations

Machine Learning Approaches for Principle Prediction in Naturally Occurring Stories

Value alignment is the task of creating autonomous systems whose values align with those of humans. Past work has shown that stories are a potentially rich source of information on human values; however, past work has been limited to considering values in a binary sense. In this work, we explore the use of machine learning models for the task of normative principle prediction on naturally occurring story data. To do this, we extend a dataset that has been previously used to train a binary normative classifier with annotations of moral principles. We then use this dataset to train a variety of machine learning models, evaluate these models and compare their results against humans who were asked to perform the same task. We show that while individual principles can be classified, the ambiguity of what "moral principles" represent, poses a challenge for both human participants and autonomous systems which are faced with the same task.Comment: Nahian and Frazier contributed equally to this wor

Maximally mixing active nematics

Active nematics are an important new paradigm in soft condensed matter systems. They consist of rod-like components with an internal driving force pushing them out of equilibrium. The resulting fluid motion exhibits chaotic advection, in which a small patch of fluid is stretched exponentially in length. Using simulation, this Letter shows that this system can exhibit stable periodic motion when sufficiently confined to a square with periodic boundary conditions. Moreover, employing tools from braid theory, we show that this motion is maximally mixing, in that it optimizes the (dimensionless) ``topological entropy'' -- the exponential stretching rate of a material line advected by the fluid. That is, this periodic motion of the defects, counterintuitively, produces more chaotic mixing than chaotic motion of the defects. We also explore the stability of the periodic state. Importantly, we show how to stabilize this orbit into a larger periodic tiling, a critical necessity for it to be seen in future experiments

Developmental white matter microstructure in autism phenotype and corresponding endophenotype during adolescence.

During adolescence, white matter microstructure undergoes an important stage of development. It is hypothesized that the alterations of brain connectivity that have a key role in autism spectrum conditions (ASCs) may interact with the development of white matter microstructure. This interaction may be present beyond the phenotype of autism in siblings of individuals with ASC, who are 10 to 20 times more likely to develop certain forms of ASC. We use diffusion tensor imaging to examine how white matter microstructure measurements correlate with age in typically developing individuals, and how this correlation differs in n=43 adolescents with ASC and their n=38 siblings. Correlations observed in n=40 typically developing individuals match developmental changes noted in previous longitudinal studies. In comparison, individuals with ASC display weaker negative correlation between age and mean diffusivity in a broad area centred in the right superior longitudinal fasciculus. These differences may be caused either by increased heterogeneity in ASC or by temporal alterations in the group's developmental pattern. Siblings of individuals with ASC also show diminished negative correlation between age and one component of mean diffusivity-second diffusion eigenvalue-in the right superior longitudinal fasciculus. As the observed differences match for location and correlation directionality in our comparison of typically developing individuals to those with ASC and their siblings, we propose that these alterations constitute a part of the endophenotype of autism.This research was funded by an MRC Clinician Scientist Fellowship to MDS from the UK Medical Research Council (G0701919). LRC was supported by the Gates Cambridge Scholarship Trust. SB-C was supported by the Wellcome Trust, the MRC and the Autism Research Trust, during the period of this work.This is the final published version. It first appeared at http://www.nature.com/tp/journal/v5/n3/full/tp201523a.html