Pre-operative optimisation employing dopexamine or adrenaline for patients undergoing major elective surgery: a cost-effectiveness analysis

<b>Objective</b>: To compare the cost and cost-effectiveness of a policy of pre-operative optimisation of oxygen delivery (using either adrenaline or dopexamine) to reduce the risk associated with major elective surgery, in high-risk patients. <b>Methods</b>: A cost-effectiveness analysis using data from a randomised controlled trial (RCT). In the RCT 138 patients undergoing major elective surgery were allocated to receive pre-operative optimisation employing either adrenaline or dopexamine (assigned randomly), or to receive routine peri-operative care. Differential health service costs were based on trial data on the number and cause of hospital in-patient days and the utilisation of health care resources. These were costed using unit costs from a UK hospital. The cost-effectiveness analysis related differential costs to differential life-years during a 2 year trial follow-up. <b>Results</b>: The mean number of in-patient days was 16 in the pre-optimised groups (19 adrenaline; 13 dopexamine) and 22 in the standard care group. The number (%) of deaths, over a 2 year follow-up, was 24 (26%) in the pre-optimised groups and 15 (33%) in the standard care group. The mean total costs were EUR 11,310 in the pre-optimised groups and EUR 16,965 in the standard care group. Life-years were 1.68 in the pre-optimised groups and 1.46 in the standard care group. The probability that pre-operative optimisation is less costly than standard care is 98%. The probability that it dominates standard care is 93%. Conclusions: Based on resource use and effectiveness data collected in the trial, pre-operative optimisation of high-risk surgical patients undergoing major elective surgery is cost-effective compared with standard treatment

Double trouble: the impact of multimorbidity and deprivation on preference-weighted health related quality of life - a cross sectional analysis of the Scottish Health Survey

<b>Objective</b> To investigate the association between multimorbidity and Preference_Weighted Health Related Quality of Life (PW_HRQoL), a score that combines physical and mental functioning, and how this varies by socioeconomic deprivation and age.<p></p> <b>Design</b> The Scottish Health Survey (SHeS) is a cross-sectional representative survey of the general population which included the SF-12, a survey of HRQoL, for individuals 20 years and over.<p></p> <b>Methods</b> For 7,054 participants we generated PW_HRQoL scores by running SF-12 responses through the SF-6D algorithm. The resulting scores ranged from 0.29 (worst health) to 1 (perfect health). Using ordinary least squares, we first investigated associations between scores and increasing counts of longstanding conditions, and then repeated for multimorbidity (2+ conditions). Estimates were made for the general population and quintiles of socioeconomic deprivation. For multimorbidity, the analyses were repeated stratifying the population by age group (20--44, 45--64, 65+).<p></p> <b>Results</b> 45% of participants reported a longstanding condition and 18% reported multimorbidity. The presence of 1, 2, or 3+ longstanding conditions were associated with average reductions in PW_HRQoL scores of 0.081, 0.151 and 0.212 respectively. Reduction in scores associated with multimorbidity was 33% greater in the most deprived quintile compared to the least deprived quintile, with the biggest difference (80%) in the 20--44 age groups. There were no significant gender differences.<p></p> <b>Conclusions</b> PW_HRQoL decreases markedly with multimorbidity, and is exacerbated by higher deprivation and younger age. There is a need to prioritise interventions to improve the HRQoL for (especially younger) adults with multimorbidity in deprived areas

Toward Enriched Conceptions of Work Learning: Participation, Expansion, and Translation Among Individuals With/In Activity

Despite the long recognition in HRD theory that learning is socially and materially situated in activity and relations, HRD literature indicates a continuing strong emphasis on individualistic theories representing learning as knowledge acquisition or individual development. It is argued here that understandings of work learning within HRD theory can be fruitfully enriched by more fully incorporating practice-based perspectives. Three contemporary theories that analyse learning as a relation of individuals with/in activity have been selected for discussion here: the participational perspective of situated cognition, the notion of expansion from cultural-historical activity theory, and the constructs of translation and mobilization presented by actor-network theory. While these are not particularly new to HRD, the contribution of this discussion is to bring together these theories, along with published empirical workplace research based on them, to highlight selected dynamics that may be useful tools for HRD theory development. One element in particular is read across the three theories: the dialectic of ‘flying’ and ‘grounding’, or lines of discontinuity and continuity characterising work learning. The argument is theory-driven, drawing from HRD literature of work learning and practice-based theories of social activity and knowledge production

A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial.

BACKGROUND: The prevalence of male obesity is increasing but few men take part in weight loss programmes. We assessed the effect of a weight loss and healthy living programme on weight loss in football (soccer) fans. METHODS: We did a two-group, pragmatic, randomised controlled trial of 747 male football fans aged 35-65 years with a body-mass index (BMI) of 28 kg/m(2) or higher from 13 Scottish professional football clubs. Participants were randomly assigned with SAS (version 9·2, block size 2-9) in a 1:1 ratio, stratified by club, to a weight loss programme delivered by community coaching staff in 12 sessions held every week. The intervention group started a weight loss programme within 3 weeks, and the comparison group were put on a 12 month waiting list. All participants received a weight management booklet. Primary outcome was mean difference in weight loss between groups at 12 months, expressed as absolute weight and a percentage of their baseline weight. Primary outcome assessment was masked. Analyses were based on intention to treat. The trial is registered with Current Controlled Trials, number ISRCTN32677491. FINDINGS: 374 men were allocated to the intervention group and 374 to the comparison group. 333 (89%) of the intervention group and 355 (95%) of the comparison group completed 12 month assessments. At 12 months the mean difference in weight loss between groups, adjusted for baseline weight and club, was 4·94 kg (95% CI 3·95-5·94) and percentage weight loss, similarly adjusted, was 4·36% (3·64-5·08), both in favour of the intervention (p<0·0001). Eight serious adverse events were reported, five in the intervention group (lost consciousness due to drugs for pre-existing angina, gallbladder removal, hospital admission with suspected heart attack, ruptured gut, and ruptured Achilles tendon) and three in the comparison group (transient ischaemic attack, and two deaths). Of these, two adverse events were reported as related to participation in the programme (gallbladder removal and ruptured Achilles tendon). INTERPRETATION: The FFIT programme can help a large proportion of men to lose a clinically important amount of weight; it offers one effective strategy to challenge male obesity. FUNDING: Scottish Government and The UK Football Pools funded delivery of the programme through a grant to the Scottish Premier League Trust. The National Institute for Health Research Public Health Research Programme funded the assessment (09/3010/06)

The Impact of Diabetic Retinopathy and Diabetic Macular Edema on Health-Related Quality of Life in Type 1 and Type 2 Diabetes

This article is made available with the permission of the publisher, Association for Research in Vision and OphthalmologyPurpose.: To assess the impact of diabetic retinopathy (DR) and diabetic macular edema (DME) on health-related quality of life (HRQoL) in type 1 and type 2 diabetes using the EuroQoL EQ-5D generic multi-attribute utility instrument (MAUI). Methods.: In this cross-sectional study, 577 patients with diabetes were recruited from specialized eye clinics in Melbourne, Australia. Each patient underwent clinical, biochemical, and anthropometric assessments. The severity of combined DR and DME (no DR/DME; mild NPDR [nonproliferative DR (NPDR)] and/or mild DME; moderate NPDR and/or moderate DME; and vision-threatening DR (VTDR) (severe NPDR or PDR and/or severe DME) in the worse eye was calculated. EQ-5D utility measures were the main outcome. Because the distribution of the utility measures was skewed, independent associations were explored using multivariate quantile regression models (five quintiles, namely 15th, 30th, 45th, 60th, 75th) ranging from poorest to highest HRQoL. Results.: Median age of the participants was 66 years (range, 26–90 years). Of the 577 participants, 223 (38.7%) had no DR/DME, 35 (6.1%) had mild NPDR/DME, 127 (22.0%) had moderate NPDR/DME, and 192 (33.3%) had VTDR. In adjusted models, neither presence nor severity of DR/DME was significantly associated with any quantile of the EQ-5D. In contrast, the presence of diabetic complications (other than DR) (β = −0.153; SE = 0.052; P < 0.001), other nonocular comorbidities (β = −0.115; SE = 0.038; P < 0.01), and higher body mass index (β = −0.007; SE = 0.002; P < 0.001) were all associated with worse HRQoL. Conclusions.: Using a generic MAUI, the EQ-5D, the authors found that the presence or severity of DR/DME and concomitant vision loss were not associated with any quantile of HRQoL. These findings suggest that the EQ-5D lacks sensitivity in assessing the impact of the severity of DR/DME on HRQoL parameters and that condition-specific instruments may better capture the full impact of the association

Identifying Content for the Glaucoma-specific Item Bank to Measure Quality-of-life Parameters

"This is a non-final version of an article published in final form in Khadka J, McAlinden C, Craig JE, Fenwick EK, Lamoureux EL, Pesudovs K. Identifying content for the glaucoma-specific item bank to measure quality-of-life parameters. Journal of Glaucoma . 2015 Jan;24(1):12-9. doi: 10.1097/IJG.0b013e318287ac11.". Author manuscript version made available in accordance with publisher copyright policy.PURPOSE: Patient-reported outcomes (PROs) have become essential clinical trial end points. However, a comprehensive, multidimensional, patient-relevant, and precise glaucoma-specific PRO instrument is not available. Therefore, the purpose of this study was to identify content for a new, glaucoma-specific, quality-of-life (QOL) item bank. METHODS: Content identification was undertaken in 5 phases: (1) identification of extant items in glaucoma-specific instruments and the qualitative literature; (2) focus groups and interviews with glaucoma patients; (3) item classification and selection; (4) expert review and revision of items; and (5) cognitive interviews with patients. RESULTS: A total of 737 unique items (extant items from PRO instruments, 247; qualitative articles, 14 items; focus groups and semistructured interviews, 476 items) were identified. These items were classified into 10 QOL domains. Four criteria (item redundancy, item inconsistent with domain definition, item content too narrow to have wider applicability, and item clarity) were used to remove and refine the items. After the cognitive interviews, the final minimally representative item set had a total of 342 unique items belonging to 10 domains: activity limitation (88), mobility (20), visual symptoms (19), ocular surface symptoms (22), general symptoms (15), convenience (39), health concerns (45), emotional well-being (49), social issues (23), and economic issues (22). CONCLUSIONS: The systematic content identification process identified 10 QOL domains, which were important to patients with glaucoma. The majority of the items were identified from the patient-specific focus groups and semistructured interviews suggesting that the existing PRO instruments do not adequately address QOL issues relevant to individuals with glaucoma

Kirigami-Inspired Organic and Inorganic Film-Based Flexible Thermoelectric Devices with Built-In Heat Sink

Thermoelectric (TE) devices can convert heat to electricity directly, which offers a unique opportunity to realize waste heat recovery. However, conventional TE devices inevitably use heat sinks, which are bulky, rigid and heavy, limiting practical applications. Herein, we propose a fully integrated film-based TE device with intrinsically built-in fins as heat sink in a hexagonal honeycomb device structure, that simultaneously achieves high TE performance and conformability, as confirmed by experiments and modelling. A flexible Kapton substrate with copper electrodes, integrating either carbon nanotube (CNT) veils or bismuth telluride (Bi2Te3) TE ‘legs’, both of n- and p-type, achieved a remarkable specific power of 185.4 nW K−2 for a Bi2Te3-based device and 53.1 nW K−2 for a CNT-based device, thanks to the heat dissipation effect granted by the built-in fins. Besides, the addition of oriented polymer films interconnects, contracting when above their glass transition temperature, allowed a single substrate two-dimensional (2D) TE device to self-fold into a three-dimensional (3D) hexagonal honeycomb structure, with built-in fins, contactlessly and autonomously. The demonstrated shape-programmed kirigami-inspired scalable TE device paves the way for realising self-powered applications comprising hundreds of TE legs with both inorganic (e.g., Bi2Te3) and organic (e.g. CNT veils) TE materials and integrated heat sinks

A systematic review of the effectiveness of docetaxel and mitoxantrone for the treatment of metastatic hormone-refractory prostate cancer

A systematic review was performed to evaluate the clinical effectiveness of docetaxel in combination with prednisolone (docetaxel is licensed in the UK for use in combination with prednisone or prednisolone for the treatment of patients with metastatic hormone-refractory prostate cancer. Prednisone is not used in the UK, but it is reasonable to use docetaxel plus prednisone data in this review of docetaxel plus prednisolone) for the treatment of metastatic hormone-refractory prostate cancer. A scoping search identified a trial of docetaxel plus prednisone vs mitoxantrone plus prednisone, but did not identify any trials comparing docetaxel plus prednisolone/prednisone with any other treatments. Therefore, we considered additional indirect evidence that would enable a comparison of docetaxel plus prednisolone/prednisone with other chemotherapy regimens and active supportive care. Systematic searching (upto April 2005) identified seven randomised controlled trials. One large well-conducted trial assessed docetaxel plus prednisone vs mitoxantrone plus prednisone; this showed statistically significant improvements with 3-weekly docetaxel in terms of overall survival, quality of life, pain response and PSA decline. Two other chemotherapy regimens that included docetaxel with estramustine also showed improved outcomes in comparison with mitoxantrone plus prednisone. Three trials that compared mitoxantrone plus corticosteroids with corticosteroids alone were identified and their results for overall survival combined, which showed very little difference between the two groups. The addition of clodronate to mitoxantrone plus prednisone showed no significant differences in comparison with mitoxantrone plus prednisone alone. The evidence suggests that chemotherapy regimens containing 3-weekly docetaxel are superior to mitoxantrone or corticosteroids alone