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This paper explores the characteristics of health technology assessment (HTA) systems and practices in Asia. Representatives from nine countries were surveyed to understand each step of the HTA pathway. The analysis finds that although there are similarities in the processes of HTA and its application to inform decision making, there is variation in the number of topics assessed and the stakeholders involved in each step of the process. There is limited availability of resources and technical capacity and countries adopt different means to overcome these challenges by accepting industry submissions or adapting findings from other regions. Inclusion of stakeholders in the process of selecting topics, generating evidence, and making funding recommendations is critical to ensure relevance of HTA to country priorities. Lessons from this analysis may be instructive to other countries implementing HTA processes and inform future research on the feasibility of implementing a harmonized HTA system in the region.
Anecdotal evidence suggests the use of bolus tube feeding is increasing in long term home enteral tube feed (HETF) patients. A cross-sectional survey to assess the prevalence of bolus tube feeding and to characterise these patients was undertaken. Dietitians from 10 centres across the UK collected data on all adult HETF patients on the dietetic caseload receiving bolus tube feeding, (n=604, 60% male, age 58years). Demographic data, reasons for tube and bolus feeding, tube and equipment types, feeding method and patients’ complete tube feeding regimens were recorded. Over a third of patients receiving HETF used bolus feeding (37%). Patients were long-term tube fed (4.1years tube feeding, 3.5years bolus tube feeding), living at home (71%) and sedentary (70%). The majority were head and neck cancer patients (22%) who were significantly more active (79%) and lived at home (97%), while those with cerebral palsy (12%) were typically younger (age 31years) but sedentary (94%). Most patients used bolus feeding as their sole feeding method (46%), because it was quick and easy to use, as a top up to oral diet or to mimic meal times. Importantly, oral nutritional supplements (ONS) were used for bolus feeding in 85% of patients, with 51% of these being compact-style ONS (2.4kcal/ml, 125ml). This survey shows that bolus tube feeding is common amongst UK HETF patients, is used by a wide variety of patient groups and can be adapted to meet the needs of a variety of patients, clinical conditions, nutritional requirements and lifestyles.
A common feature in Answer Set Programming is the use of a second negation, stronger than default negation and sometimes called explicit, strong or classical negation. This explicit negation is normally used in front of atoms, rather than allowing its use as a regular operator. In this paper we consider the arbitrary combination of explicit negation with nested expressions, as those defined by Lifschitz, Tang and Turner. We extend the concept of reduct for this new syntax and then prove that it can be captured by an extension of Equilibrium Logic with this second negation. We study some properties of this variant and compare to the already known combination of Equilibrium Logic with Nelson’s strong negation.
The topology and unsteady behaviour of ventilated and natural cavity flows over a two-dimensional (2-D) wall-mounted fence are investigated for fixed length cavities with varying free-stream velocity using high-speed and still imaging, X-ray densitometry and dynamic surface pressure measurement in two experimental facilities. Cavities in both ventilated and natural flows were found to have a re-entrant jet closure, but not to exhibit large-scale oscillations, yet the irregular small-scale shedding at the cavity closure. Small-scale cavity break-up was associated with a high-frequency broadband peak in the wall pressure spectra, found to be governed by the overlying turbulent boundary layer characteristics, similar to observations from single-phase flow over a forward-facing step. A low-frequency peak reflecting the oscillations in size of the re-entrant jet region, analogous to ‘flapping’ motion in single-phase flow, was found to be modulated by gravity effects (i.e. a Froude number dependence). Likewise, a significant change in cavity behaviour was observed as the flow underwent transition analogous to the transition from sub- to super-critical regime in open-channel flow. Differences in wake topology were examined using shadowgraphy and proper orthogonal decomposition, from which it was found that the size and number of shed structures increased with an increase in free-stream velocity for the ventilated case, while remaining nominally constant in naturally cavitating flow due to condensation of vaporous structures.
Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.
The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time.
A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time.
A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively.
This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study’s results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.
A fragment of Roman monumental bronze sculpture was discovered near Lincoln in 2015 and reported to the Portable Antiquities Scheme. This note offers identification of the piece as an over-life-size finger, describes comparable examples and similar pieces from the local area, and makes suggestions as to the original form of the sculpture from which it may have derived. The statue's metallurgical characteristics and making, the possible context of display and the circumstances of deposition are also considered.
Introduction: We examined our local sepsis patient population, and specifically our most vulnerable patients - those presenting to the emergency department (ED) in septic shock - for variables predictive of survival to hospital discharge. We applied the familiar ED paradigm of, “Door to,” to calculate the impact of time to antibiotics against patient survival to hospital discharge. Methods: Retrospective chart review of patients aged > = 18 years, presenting to tertiary care ED between 01 Nov 2014 and 31 Oct 2015. Patients determined to have sepsis if A) > = 2 SIRS criteria and ED suspicion of infection (ED acquisition of blood/urine cultures or antibiotic administration) and/or B) received ED or Hospital discharge diagnosis of sepsis (ICD-10 diagnostic codes A4xx and R65). Patients sub-classified with septic shock if A) triage SBP < = 90mmHg, B) triage MAP < = 65mmHg or C) serum lactate > = 4mmol/L. “Door Time” was defined as the earliest time recorded for the patient encounter, either the time the patient registered in the Emergency Department, or the triage time. A generalized linear model was performed with a binomial distribution using survival to discharge as the response variable. Age, sex, ED arrival method, time to antibiotics, ED serum lactate and ED serum glucose level were the predictor variables. Results: 13506 patient encounters met inclusion criteria (10980 unique patients). Linear regression of time to antibiotics against survival to hospital discharge failed to achieve statistical significance. Linear regression of the secondary outcome variables achieved statistical significance for age and serum lactate level. Per the model, as age increased by 1 year, the odds of dying prior to hospital discharge increased by 3.8% and as serum lactate increased by 1 mmol/L, odds of dying prior to hospital discharge increased by 11.1%. Conclusion: We found no association between time to antibiotic treatment and mortality. Causal relationships require randomized controlled trials, and this analysis contributes to clinical equipoise.
This article provides a new defence against the logical problem of evil, based on the naturalistic functional/teleological theory of mind (NFT). I argue that if the NFT is self-consistent then it is consistent with theism. Further, the NFT entails that it is not possible for created minds to exist in the absence of evil. It follows that if the NFT is self-consistent then the existence of God is consistent with the existence of evil.
This study was conducted to evaluate the cost-effectiveness of sunitinib versus interferon-alfa for the treatment of advanced and/or metastatic renal cell carcinoma (RCC) in Singapore.
A partitioned survival model with three health states (progression-free, progressive disease, and death) was developed from a healthcare payer perspective over a 10-year time horizon. Survival curves from the pivotal trial of sunitinib versus interferon-alfa were extrapolated beyond the trial period to estimate the underlying progression-free survival and overall survival parametric distributions. Health state utilities were derived from the literature and direct costs were sourced from local public healthcare institutions. The sunitinib dose in the model reflected local prescribing practices whereby a combination of 50 mg (28 percent) and 37.5 mg (72 percent) strengths are used.
The base-case analysis comparing sunitinib versus interferon-alfa resulted in an incremental cost effectiveness ratio (ICER) of SGD191,061 (USD139,757) per quality-adjusted life-year gained. Sensitivity analysis demonstrated that the ICER was most sensitive to variations in the utility value assumed for the progression-free health state and the price of sunitinib.
In the absence of any price reduction, sunitinib had an exceedingly high ICER and was not considered a cost-effective use of healthcare resources in Singapore's context for the first-line treatment of advanced RCC. The findings from our evaluation will be useful to inform local healthcare decision making and resource allocations for tyrosine kinase inhibitors when appraised alongside comparative clinical effectiveness data and payer affordability considerations.
Birth weight and early growth have been associated with later blood pressure. However, not all studies consistently find a significant reduction in blood pressure with an increase in birth weight. In addition, the relative importance of birth weight and of other lifestyle and environmental factors is often overlooked and the association is rarely studied in adolescents. We investigated early life predictors, including birth weight, of adolescent blood pressure in the Gateshead Millennium Study (GMS). The GMS is a cohort of 1029 individuals born in 1999–2000 in Gateshead in Northern England. Throughout infancy and early childhood, detailed information were collected, including birth weight and measures of height and weight. Assessments of 491 returning participants at age 12 years included measures of body mass and blood pressure. Linear regression and path analysis were used to determine predictors and their relative importance on blood pressure. Birth weight was not directly associated with blood pressure at the age of 12. However, after adjustment for contemporaneous body mass index (BMI), an inverse association of standardized birth weight on systolic blood pressure was significant. The relative importance of birth weight on later systolic blood pressure was smaller than other contemporaneous body measures (height and BMI). There was no independent association of birth weight on blood pressure seen in this adolescent population. Contemporaneous body measures have an important role to play. Lifestyle factors that influence body mass or size, such as diet and physical activity, where interventions are directed at early prevention of hypertension should be targeted.
Weed management in tobacco (Nicotiana tabacum L.) is accomplished primarily with soil-residual herbicides, cultivation, and hand removal. Management practices that reduce weed emergence, like reduced tillage and cover crop mulches, may improve weed management efficacy. Depending on cover-cropping goals, growers face trade-offs in species selection and management priorities—producing weed-suppressive mulches may lead to transplanting difficulties and soil-residual herbicide interception. Managing more complex cover crop mixtures may result in different challenges. We established on-farm trials across 4 site-years to study impacts of cover crop composition [wheat (Triticum aestivum L.) monoculture or mixture], termination treatment (early or late chemical termination or removing aboveground biomass), and soil-residual herbicides on weed density and biomass. The cover crop mixture contained cereal rye (Secale cereale L.), crimson clover (Trifolium incarnatum L.), and hairy vetch (Vicia villosa Roth.), with canola (Brassica napus L.) at 1 site-year. The mixture typically produced more biomass than monoculture wheat, although composition had few impacts on weed density or biomass. With residual herbicides, termination treatment had few impacts on weed density, suggesting that residues did not adversely affect herbicide efficacy. Without residual herbicides, early-season weed density was often higher following the late-terminated cover crop compared with other termination treatments, though midseason weed density was typically lower. When termination treatment affected final weed biomass, it was lower following late termination, with one exception—crop establishment was reduced at 1 site-year, leading to reduced weed–crop competition and greater weed biomass. Our results suggest that growers can use mixtures and, if well-timed to a rainfall event for incorporation, still effectively use soil-residual herbicides to maintain adequate weed control in tobacco regardless of how the cover crop is managed. Later termination, resulting in more residue, may lead to less weed biomass accumulation in the absence of herbicide use.
A fine-grained, up to 3-m-thick tephra bed in southwestern Saskatchewan, herein named Duncairn tephra (Dt), is derived from an early Pleistocene eruption in the Jemez Mountains volcanic field of New Mexico, requiring a trajectory of northward tephra dispersal of ~1500 km. An unusually low CaO content in its glass shards denies a source in the closer Yellowstone and Heise volcanic fields, whereas a Pleistocene tephra bed (LSMt) in the La Sal Mountains of Utah has a very similar glass chemistry to that of the Dt, supporting a more southerly source. Comprehensive characterization of these two distal tephra beds along with samples collected near the Valles caldera in New Mexico, including grain size, mineral assemblage, major- and trace-element composition of glass and minerals, paleomagnetism, and fission-track dating, justify this correlation. Two glass populations each exist in the Dt and LSMt. The proximal correlative of Dt1 is the plinian Tsankawi Pumice and co-ignimbritic ash of the first ignimbrite (Qbt1g) of the 1.24 Ma Tshirege Member of the Bandelier Tuff. The correlative of Dt2 and LSMt is the co-ignimbritic ash of Qbt2. Mixing of Dt1 and Dt2 probably occurred during northward transport in a jet stream.
Proglacial environments are ideal for studying the development of soils through the changes of rocks exposed by glacier retreat to weathering and microbial processes. Carbon (C) and nitrogen (N) contents as well as soil pH and soil elemental compositions are thought to be dominant factors structuring the bacterial, archaeal and fungal communities in the early stages of soil ecosystem formation. However, the functional linkages between C and N contents, soil composition and microbial community structures remain poorly understood. Here, we describe a multivariate analysis of geochemical properties and associated microbial community structures between a moraine and a glaciofluvial outwash in the proglacial area of a High Arctic glacier (Longyearbreen, Svalbard). Our results reveal distinct differences in developmental stages and heterogeneity between the moraine and the glaciofluvial outwash. We observed significant relationships between C and N contents, δ13Corg and δ15N isotopic ratios, weathering and microbial abundance and community structures. We suggest that the observed differences in microbial and geochemical parameters between the moraine and the glaciofluvial outwash are primarily a result of geomorphological variations of the proglacial terrain.