Cost-Effectiveness of a Community Pharmacist-Led Sleep Apnea Screening Program – A Markov Model

Background

Despite the high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. In many developed countries, because community pharmacists (CP) are easily accessible, they have been developing additional clinical services that integrate the services of and collaborate with other healthcare providers (general practitioners (GPs), nurses, etc.). Alternative strategies for primary care screening programs for OSAS involving the CP are discussed.

Objective

To estimate the quality of life, costs, and cost-effectiveness of three screening strategies among patients who are at risk of having moderate to severe OSAS in primary care.

Design

Markov decision model.

Data Sources

Published data.

Target Population

Hypothetical cohort of 50-year-old male patients with symptoms highly evocative of OSAS.

Time Horizon

The 5 years after initial evaluation for OSAS.

Perspective

Societal.

Interventions

Screening strategy with CP (CP-GP collaboration), screening strategy without CP (GP alone) and no screening.

Outcomes measures

Quality of life, survival and costs for each screening strategy.

Results of base-case analysis

Under almost all modeled conditions, the involvement of CPs in OSAS screening was cost effective. The maximal incremental cost for “screening strategy with CP” was about 455€ per QALY gained.

Results of sensitivity analysis

Our results were robust but primarily sensitive to the treatment costs by continuous positive airway pressure, and the costs of untreated OSAS. The probabilistic sensitivity analysis showed that the “screening strategy with CP” was dominant in 80% of cases. It was more effective and less costly in 47% of cases, and within the cost-effective range (maximum incremental cost effectiveness ratio at €6186.67/QALY) in 33% of cases.

Conclusions

CP involvement in OSAS screening is a cost-effective strategy. This proposal is consistent with the trend in Europe and the United States to extend the practices and responsibilities of the pharmacist in primary care.     

Multidisciplinary approach to diagnosis and management of osteosarcoma – a review of the St Vincent's Hospital experience

Background

Osteosarcoma is the most common primary malignant bone tumour in children and young adults. Despite advances in the diagnosis and management of osteosarcoma, there have been few recent studies describing the experiences of tertiary referral centres. This paper aims to describe and discuss the clinical features, pre-operative work-up, management and outcomes of these patients at St Vincent's Hospital (Melbourne, Australia).

Methods

Retrospective study of fifty-nine consecutive patients managed for osteosarcoma at St Vincent's Hospital between 1995 and 2005.

Results

Median age at diagnosis was 21 (range, 11–84) years. Gender distribution was similar, with thirty-one male and twenty-eight female patients.Twenty-five patients had osteosarcoma in the femur, eleven each were located in the humerus and tibia, six were identified in the pelvis, and one each in the clavicle, maxilla, fibula, sacrum, ulna and radius.Pre-operative tissue diagnosis of osteosarcoma was obtained through computed tomography-guided percutaneous biopsy in over ninety percent of patients.Following initial therapy, over fifty percent of patients remained relapse-free during the follow-up period, with twelve percent and twenty-seven percent of patients documented as having local and distant disease recurrence, respectively. Of patients with recurrent disease, sixty-two percent remained disease-free following subsequent surgical intervention (most commonly, pulmonary metastatectomy).

Conclusion

Patient outcomes can be optimised through a multidisciplinary approach in a tertiary referral centre. At St Vincent's Hospital, survival and relapse rates of patients managed for osteosarcoma compare favourably with the published literature.

     

Dispersion and Field Distribution of SPP Waves at the Interface of a Metal and Nonlinear Magnetic Material

We study the properties of surface plasmon polaritons at an interface between a metal and a strongly nonlinear magnetic cladding, characterized by permeability $\mu=\mu_\textrm{l}+\mu_{\textrm{nl}} H^2$ . It is observed that the dispersion of modes has a significant dependance on the incident power. The incident power can be adjusted to control the propagation length. In addition, the structure shows strong confinement of the modes at the interface.     

Seasonal Dynamics of the Airborne Bacterial Community and Selected Viruses in a Children’s Daycare Center

Children’s daycare centers appear to be hubs of respiratory infectious disease transmission, yet there is only limited information about the airborne microbial communities that are present in daycare centers. We have investigated the microbial community of the air in a daycare center, including seasonal dynamics in the bacterial community and the presence of specific viral pathogens. We collected filters from the heating, ventilation, and air conditioning (HVAC) system of a daycare center every two weeks over the course of a year. Amplifying and sequencing the 16S rRNA gene revealed that the air was dominated by Proteobacteria, Firmicutes, Actinobacteria, and Bacteroidetes that are commonly associated with the human skin flora. Clear seasonal differences in the microbial community were not evident; however, the community structure differed when the daycare center was closed and unoccupied for a 13-day period. These results suggest that human occupancy, rather than the environment, is the major driver in shaping the microbial community structure in the air of the daycare center. Using PCR for targeted viruses, we detected a seasonal pattern in the presence of respiratory syncytial virus that included the period of typical occurrence of the disease related to the virus; however, we did not detect the presence of adenovirus or rotavirus at any time.     

Yield and Economic Performance of Organic and Conventional Cotton-Based Farming Systems – Results from a Field Trial in India

The debate on the relative benefits of conventional and organic farming systems has in recent time gained significant interest. So far, global agricultural development has focused on increased productivity rather than on a holistic natural resource management for food security. Thus, developing more sustainable farming practices on a large scale is of utmost importance. However, information concerning the performance of farming systems under organic and conventional management in tropical and subtropical regions is scarce. This study presents agronomic and economic data from the conversion phase (2007–2010) of a farming systems comparison trial on a Vertisol soil in Madhya Pradesh, central India. A cotton-soybean-wheat crop rotation under biodynamic, organic and conventional (with and without Bt cotton) management was investigated. We observed a significant yield gap between organic and conventional farming systems in the 1^st crop cycle (cycle 1: 2007–2008) for cotton (−29%) and wheat (−27%), whereas in the 2^nd crop cycle (cycle 2: 2009–2010) cotton and wheat yields were similar in all farming systems due to lower yields in the conventional systems. In contrast, organic soybean (a nitrogen fixing leguminous plant) yields were marginally lower than conventional yields (−1% in cycle 1, −11% in cycle 2). Averaged across all crops, conventional farming systems achieved significantly higher gross margins in cycle 1 (+29%), whereas in cycle 2 gross margins in organic farming systems were significantly higher (+25%) due to lower variable production costs but similar yields. Soybean gross margin was significantly higher in the organic system (+11%) across the four harvest years compared to the conventional systems. Our results suggest that organic soybean production is a viable option for smallholder farmers under the prevailing semi-arid conditions in India. Future research needs to elucidate the long-term productivity and profitability, particularly of cotton and wheat, and the ecological impact of the different farming systems.     

Grassland Leafhoppers (Hemiptera: Auchenorrhyncha) as Indicators of Habitat Condition – A Comparison of between-site and between-year differences in Assemblage Composition

The Auchenorrhyncha (leafhoppers) show great potential as indicators of grassland habitat quality, which would make them useful as a conservation tool. However, they are known to have labile populations. The relative importance of site identity and the year of sampling in the composition of leafhopper assemblages on chalk grassland are assessed for two sets of sites sampled twice. The study included a total of 95 sites (one set of 54, the other of 41), and demonstrated that for both sets the vegetation community and geographical location had high explanatory value, while the influence of year was small. The conclusion is that, notwithstanding population fluctuations, the leafhopper assemblages are a good indicator of habitat quality, and represent a potentially valuable tool in grassland conservation and restoration.     

Microevolution and epidemic spread of serogroup A Neisseria meningitidis – a review

An extensive and representative strain collection of serogroup A Neisseria meningitidis was established. These bacteria were obtained from different endemic and epidemic/pandemic sources and include strains from diseased patients and healthy carriers. The genetic relationships of the bacteria were defined by multi-locus enzyme electrophoresis and sequence polymorphisms of genetically variable antigens have been analyzed in closely-related groupings. The results are interpreted as reflecting a balance of recombination events, which disrupt clonal relationships, and sequential bottlenecks, which purify the bacterial population of genetic variants during epidemic spread.     

Predictors of Recurrent Sickness Absence Due to Depressive Disorders – A Delphi Approach Involving Scientists and Physicians

Background

Depression is a common and highly recurrent mental disorder that is accompanied by poor functioning at home and at work. Not all depressed employees report sick and little is known about variables associated with sickness absence (SA) due to depression. Recurrent SA due to depression tends to marginalize employees from the workforce and exclude them from social participation. Therefore, this study sought group consensus on factors predicting recurrent SA due to depression.

Methodology/principal findings

23 scientists in the field of work and mental health and 23 physicians with expertise in assessing work disability were invited for a Delphi study. Sixty-seven factors retrieved from the literature were scored for their impact on the recurrence of SA due to depression, range 1 (no impact) to 10 (very high impact) in two Delphi rounds. The third Delphi round addressed the assessability and modifiability of elected predictors. Group consensus was defined as 75% agreement. In the first round (response 78%), group consensus was reached on a high impact of 13 factors on recurrent SA due to depression. The second round (response 79%) added another 8 factors with high impact on recurrent SA due to depression. The panelists were of the opinion that stressful life and work events, age at first diagnosis, duration of the last depressive episode, anxiety, lifetime number of depressive episodes, and psychological work demands were readily assessable in consultation with patients. Furthermore, work factors, particularly decision latitude, psychological job demands, and commitment to work, were recognized as modifiable.

Conclusions/significance

Although results have to be validated with further quantitative research, physicians may identify employees at risk of recurrent SA due to depression and may support them to adjust their work aimed at increasing commitment to work and preventing future SA due to depression.     

A Novel Method to Evaluate the Community Built Environment Using Photographs – Environmental Profile of a Community Health (EPOCH) Photo Neighbourhood Evaluation Tool

Background

Previous research has shown that environments with features that encourage walking are associated with increased physical activity. Existing methods to assess the built environment using geographical information systems (GIS) data, direct audit or large surveys of the residents face constraints, such as data availability and comparability, when used to study communities in countries in diverse parts of the world. The aim of this study was to develop a method to evaluate features of the built environment of communities using a standard set of photos. In this report we describe the method of photo collection, photo analysis instrument development and inter-rater reliability of the instrument.

Methods/Principal Findings

A minimum of 5 photos were taken per community in 86 communities in 5 countries according to a standard set of instructions from a designated central point of each community by researchers at each site. A standard pro forma derived from reviewing existing instruments to assess the built environment was developed and used to score the characteristics of each community. Photo sets from each community were assessed independently by three observers in the central research office according to the pro forma and the inter-rater reliability was compared by intra-class correlation (ICC). Overall 87% (53 of 60) items had an ICC of ≥0.70, 7% (4 of 60) had an ICC between 0.60 and 0.70 and 5% (3 of 60) items had an ICC ≤0.50.

Conclusions/Significance

Analysis of photos using a standardized protocol as described in this study offers a means to obtain reliable and reproducible information on the built environment in communities in very diverse locations around the world. The collection of the photographic data required minimal training and the analysis demonstrated high reliability for the majority of items of interest.     

Internal auditory canal metastasis mimicking a vestibular schwannoma at presentation – a case report and review of the literature

Metastasis to the internal auditory canal from breast carcinoma is extremely rare and difficult to diagnose. It radiologically mimics vestibular schwannoma and can occur as a first manifestation of systemic relapse after a long disease-free interval in patients previously treated for early breast cancer. The diagnosis is usually made retrospectively and the optimal management of such metastasis following complete resection remains undefined.     

Assessment and illustration of cultural ecosystem services at the local scale – A retrospective trend analysis

There is a need to develop non-monetary methods for the assessment of cultural ecosystem services, in order to integrate them into the ES framework in a more balanced way. With this in mind, an adequate and comprehensive indicator base and mapping methods are required to communicate and discuss cultural ecosystem services, for it to be understood holistically. Referring to land use changes as an important driver for ES changes, we demonstrate the analysis of cultural ecosystem services trends, in a retrospective, as a supporting tool to better understand social and natural interactions as drivers behind land use changes, which are reflected in the landscape scene. There are two main outcomes of this study: (1) first, we developed and tested a catalogue of indicators as an approach to evaluate cultural ecosystem services trends at the local scale and (2) we established a mapping method for cultural ecosystem services trends in parallel with land use changes. This we did following the example of the afforestation processes which had taken place since the 19th century in the suburban area of Göttingen (Lower Saxony/Germany), called Hainberg. Our main conclusion is that cultural ecosystem services trends can indicate the reasons and drivers for land use changes that can be beneficial to forest/landscape management issues by means of the restoration of lost services. The proposed assessment method can be integrated into the development of future landscape plans, e.g. by providing information on historical guiding principles.     

Dynamics of soil carbon,nitrogen, and phosphorus in calcareous soils after land-use abandonment – A chronosequence study

Aims

The objective of this study was to investigate changes in soil total organic C (TOC), total nitrogen (TN), phosphorus (P) fractions, and microbial community structure during secondary succession after abandonment of vineyards on calcareous soils.

Methods

Two chronosequences covering 200 years and differing in aspect and slope were established in Hungary, and the upper 10 cm of the mineral soils were studied.

Results

We found strong increases in TOC concentrations after land-use abandonment, especially at the south-exposed sites. The TOC/TN ratio increased by a factor of 1.3 in the south-west exposed chronosequence and by a factor of 1.6 in south exposed chronosequence. The concentration of labile P (NaHCO₃-extractable P) diminished during the first 50 years after land-use abandonment, leading to low P availability at the later stages of the succession. The total organic P (TOP) concentration increased during the first 40 years after abandonment. At the later stages of succession, TOP concentrations decreased again, while the ratio of TOC/TOP increased continuously over 200 years. The ratio of arbuscular-mycorrhizal-fungi-to-bacteria (AMF/bacteria) increased strongly during the first decade after abandonment of the vineyards.

Conclusions

Our study indicates that impacts of former cultivation on secondary ecosystems persisted for more than a century, and that especially P concentrations showed long lasting legacy effects.

     

A review of symbiotic fungal endophytes in lycophytes and ferns – a global phylogenetic and ecological perspective

We present a review of the documented fungal colonizations of presumably symbiotic nature in lycophytes and ferns (“pteridophytes”). The sampling covers ca. 11 % (1287 spp.) of the estimated global diversity of these taxa (ca. 12,000 spp.) and shows an average presence of fungal endophytes of 68 %, which is significantly lower than the average presence of mycorrhiza of 80–85 % for the remaining tracheophytes. Above-average colonization rates up to 100 % among ferns are mainly found in phylogenetically old lineages, whereas below-average mycorrhization characterizes the Polypod I clade and the Aspleniaceae of the derived leptosporangiate ferns. Arbuscular Mycorrhizal Fungi (AMF) are found in 54 % of the species, to which 6 % of unspecified records of mycorrhizae should probably be added. Dark Septate Endophytes (DSE) are found in 13 % of the species, in about half the cases (6 %) together with AMF. Ectomycorrhizae have not been confirmed for pteridophytes so far, and basidiomycetes are found very rarely in mycoheterotropic gametophytes. Fungal endophytes are unevenly distributed across the life forms and most frequent with 75 % in the terrestrial species, followed with 69 % in saxicolous and with 58 % in epiphytic species. Although AMF have a low dispersal potential and thus are considered unreliable symbiotic partners for epiphytes, they are still present in 27 % of the investigated epiphytic pteridophytes. The occurrence of mycorrhizae across the taxa of pteridophytes bears a phylogenetic signal, as the derived ferns show a notable trend towards a growing independence from AM, in epiphytes more pronouncedly so than in terrestrial taxa.     

Localization of Cholesterol and Fatty Acid in a Model Lipid Membrane: A?Neutron Diffraction Approach

The intercellular lipid matrix of the skin’s stratum corneum serves to protect the body against desiccation and simultaneously limits the passage of drugs and other xenobiotics into the body. The matrix is made up of ceramides, free fatty acids, and cholesterol, which are organized as two coexisting crystalline lamellar phases. In studies reported here, we sought to use the technique of neutron diffraction, together with the device of isotopic (H/D) substitution, to determine the molecular architecture of the lamellar phase having a repeat distance of 53.9 ± 0.3 Å. Using hydrogenous samples as well as samples incorporating perdeuterated (C24:0) fatty acids and selectively deuterated cholesterol, the diffraction data obtained were used to construct neutron scattering length density profiles. By this means, the locations within the unit cell were determined for the cholesterol and fatty acids. The cholesterol headgroup was found to lie slightly inward from the unit cell boundary and the tail of the molecule located 6.2 ± 0.2 Å from the unit cell center. The fatty acid headgroups were located at the unit cell boundary with their acyl chains straddling the unit cell center. Based on these results, a molecular model is proposed for the arrangement of the lipids within the unit cell.     

Structure of the 30 kDa HIV-1 RNA Dimerization Signal by a Hybrid Cryo-EM,NMR, and Molecular Dynamics Approach

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A History of Abuse and Operative Delivery – Results from a European Multi-Country Cohort Study

Objective

The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult.

Design

The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations.

Results

Among 3308 primiparous women, sexual abuse as an adult (≥18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28–3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24–11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46–11.3). Neither physical abuse (in adulthood or childhood <18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05–2.19).

Conclusion

Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS.