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High-cost gene therapies strain the sustainability of healthcare budgets. Despite the potential long-term savings promised by certain gene therapies, realizing these savings faces challenges due to uncertainties regarding the treatment’s durability and a lesser-discussed factor: the true potential for cost offset. Our study aims to assess the cost-offset uncertainty for US Medicaid regarding recently approved gene therapies in hemophilia A and B.
Methods
The analysis used 2018 to 2022 Colorado Department of Health Care Policy & Financing data to determine direct costs of standard of care (factor replacement therapy or emicizumab). Cost-simulation models over five- and ten-year time horizons estimated Colorado Medicaid costs if patients switched to gene therapy (valoctocogene roxaparvovec or etranacogene dezaparvovec) versus maintaining standard of care. Patients were included if aged 18 and over with ICD-10-CM codes D66 (hemophilia A) and D67 (hemophilia B). In the base case, severe hemophilia A was defined as requiring greater than or equal to six yearly factor VIII or emicizumab claims and moderate/severe hemophilia B requiring greater than or equal to four factor IX replacement therapy claims annually.
Results
Annual standard-of-care costs were USD426,000 (SD USD353,000) for hemophilia A and USD546,000 (SD USD542,000) for hemophilia B. Valoctocogene roxaparvovec (hemophilia A) had incremental costs of USD880,000 at five years and −USD481,000 at 10 years. Sensitivity analysis revealed a 23 percent chance of break-even within five years and 48 percent within 10 years. Etranacogene dezaparvovec (hemophilia B) showed incremental costs of USD429,000 at five years and −USD2,490,000 at 10 years. Simulation indicated a 32 percent chance of break-even within five years and 59 percent within 10 years. Varying eligibility (≥4 to ≥15 standard-of-care claims) notably affected break-even; for example, valoctocogene roxaparvovec: 40 percent to 77 percent chance of break-even in 10 years.
Conclusions
Our study highlights significant cost variation in the standard of care of patients eligible for gene therapies, adding to the uncertainty surrounding cost estimation and highlighting the importance of addressing this factor in risk-sharing agreements. The impact of varying eligibility criteria on cost offsets emphasizes the importance of carefully defining eligibility when using real-world data in the context of health technology assessment.
This article focuses on the Nechung kang-so (bskang gso), a ritual performed at Nechung monastery in exile, and deemed secret (gsang ba) by the monks. In my interactions with the monks, this secret presented itself as an unremitting series of contradictions and conundrums. I attempt here to portray and understand them. I posit that the secret invoked an implicit “cultural concept” (Silverstein 2004), namely, the kang-so’s transmissibility. For the kang-so’s transmission within the monastery involved a specific semiotics of authorization, rooted in a karmic ethic. To reveal the secret to me was to extricate the esoteric ritual from that traditional “social organization of interdiscursivity,” and the ethic shaping it (Gal 2018). The monks’ citations of the esoteric ritual, whereby they spoke to me of the secret, thus performed an alteration in the kang-so’s transmissibility, a reorganization of the esoteric ritual’s interdiscursivities, toward enabling its “circulation” among academic publics.
The Agenda for Social Justice 3 provides accessible insights into some of the most pressing social problems in the United States and proposes public policy responses to those problems. Chapters include discussion of social problems related to criminal justice, the economy, food insecurity, education, healthcare, housing and immigration.
We report direct numerical simulations results of the rough-wall channel, focusing on roughness with high $k_{rms}/k_a$ statistics but small to negative $Sk$ statistics, and we study the implications of this new dataset on rough-wall modelling. Here, $k_{rms}$ is the root mean square, $k_a$ is the first-order moment of roughness height, and $Sk$ is the skewness. The effects of packing density, skewness and arrangement of roughness elements on mean streamwise velocity, equivalent roughness height ($z_0$) and Reynolds and dispersive stresses have been studied. We demonstrate that two-point correlation lengths of roughness height statistics play an important role in characterizing rough surfaces with identical moments of roughness height but different arrangements of roughness elements. Analysis of the present as well as historical data suggests that the task of rough-wall modelling is to identify geometric parameters that distinguish the rough surfaces within the calibration dataset. We demonstrate a novel feature selection procedure to determine these parameters. Further, since there is no finite set of roughness statistics that distinguish between all rough surfaces, we argue that obtaining a universal rough-wall model for making equivalent sand-grain roughness ($k_s$) predictions would be challenging, and that each rough-wall model would have its applicable range. This motivates the development of group-based rough-wall models. The applicability of multi-variate polynomial regression and feedforward neural networks for building such group-based rough-wall models using the selected features has been shown.
Pteridophytes are excellent ecological indicators of habitat quality. In this study, we built a model that predicts the habitat suitability of Elaphoglossum beddomei Sledge, an epiphytic or lithophytic and endemic pteridophyte in Southern Western Ghats, by using the technique of species distribution modelling. The occurrence data of E. beddomei from field explorations as well as from various herbaria were collected during 2018–2022. These occurrence data along with climatic data were processed by R packages. The processed data were further analysed using MaxEnt software to project the distribution of E. beddomei in future climatic scenarios. After correlation analysis, five bioclimatic variables – Mean Temperature of Wettest Quarter (bio8), Precipitation of Driest Quarter (bio17), Precipitation of Warmest Quarter (bio18), Precipitation of Wettest Quarter (bio16) and Temperature Annual Range (BIO5-BIO6) (bio7) – were selected from 19 bioclimatic variables with less correlation. Precipitation of Warmest Quarter (bio18) had the most influence in determining the distribution of E. beddomei, with a permutation importance of 83%. Conversely, Temperature Annual Range (BIO5-BIO6) (bio7) and Precipitation of Driest Quarter (bio17) showed least influence in determining the distribution of E. beddomei, and hence, the models created without these variables are considered for prediction. The habitat suitability predictions of the model indicate that the potential habitats of the species may get reduced in Southern Western Ghats in future climatic scenarios. It is in tune with the predicted expansion of drier climatic zones in Southern Western Ghats, which may reduce the suitable habitats for the E. beddomei in near future. So, it demands formulating suitable strategies for reducing the emission of greenhouse gases, regenerating forests and conserving forests by implementing more stringent policies on the environment to protect such highly habitat-specific evergreen elements.
This study investigates the impact of environmental factors and genotype-by-environment interactions (GEI) on the expression of maydis leaf blight (MLB) resistance in a diverse maize germplasm comprising 359 genotypes. Extensive field trials were conducted, involving artificial inoculations and disease scoring across two locations over two years. Using genotype and genotype–environment (GGE) biplot analysis based on the site regression model (SREG), we identified stable MLB-resistant 10 donors with consistent genotypic responses. These inbred lines, which consistently exhibited disease scores of ⩽3 across locations, are recommended as potential parents for breeding MLB-resistant varieties. Furthermore, the identification of a non-crossover interaction and high correlations among testing locations allowed us to define a single mega-environment for the initial screening of MLB resistance in a large set of maize germplasm. This study suggests that initial screenings can be efficiently conducted in one representative location, with validation of resistant lines at multiple sites during advanced breeding stages. This approach optimizes the use of land, labour and resources in MLB resistance testing.
Rastelli surgery is used for the correction of several CHDs. Although late-onset cardiac arrhythmias have emerged as a major complication after corrective surgeries, there is a paucity of data on arrhythmias after Rastelli surgery.
Methods:
This retrospective cohort study was conducted on patients who had undergone Rastelli surgery and have been followed at the adult CHD clinic at our hospital.
Results:
A total of 55 patients (36.4% female, age 22.2 ± 6.4 years) were followed for a median period of 24.2 (20.6–31.0) years. Tachyarrhythmias occurred in 21 (38.4 %) patients (n = 15 for atrial tachycardia, 5 for ventricular tachycardia, and 1 for both atrial and ventricular tachycardia). Older age at surgery was significantly associated with the risk of tachyarrhythmias (P = 0.022). Bradyarrhythmia occurred in 12 (21.8%) patients and consisted of perioperative AV block (n = 5), late AV block (n = 1), and sinus node dysfunction (n = 6). Nine (16.4%) patients underwent catheter ablation. The mechanisms of atrial arrhythmias include cavotricuspid isthmus-dependent and surgical scar-dependent intra-atrial reentrant tachycardias. Among the three patients who underwent ablation for ventricular tachycardia, all circuits were dependent on the scar at the base of the right ventricle to pulmonary artery conduit. Median survival free from any event (arrhythmia, death, or heart failure) was 31.6 (28.1–35.1) years after Rastelli surgery.
Conclusions:
The prevalence of arrhythmias late after Rastelli surgery is substantial and increases in the second decade after surgery. Older age at surgery is associated with a higher prevalence of arrhythmias.
Hedonic analysis of Wisconsin Beef Improvement Association Bull Sale and Development Program data revealed buyer preferences for calving ease, growth, production weight, and carcass merit traits. Attributes like calving ease direct Expected Progeny Differences (EPD), average daily gain, birth to yearling gain EPD, and rib-eye area consistently ranked higher and significantly influenced the bull’s sale price. Further analysis using a 2-Class Finite Mixture Model indicated distinct groups of buyers in the region who prioritized measured bull attributes and others who did not, confirming heterogeneity in buyer preferences.
Background: Patients undergoing hemodialysis are at high risk for healthcare-associated infections; they are at 100 times the risk of Staphylococcus aureus bloodstream infections (BSI) compared with U.S. adults not on hemodialysis. Prior studies found that nasal decolonization with mupirocin prevented S. aureus BSI among hemodialysis patients. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess: 1) hemodialysis patients’ knowledge of their infection risk and their willingness to take an active role in infection prevention; 2) the acceptability of the PVI nasal decolonization intervention. Methods: We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis centers. Patients were surveyed: before starting PVI, 1 month after their center started using PVI, and ~6 months after starting PVI. We used a chi-square test to compare results. Results: 469 patients completed at least 1 survey: 400 pre-intervention, 237 at 1 month and 201 at 6 months. Overall, 56% of patients thought that their risk of infection was average or below average compared with an average person in the U.S. (Figure). Over 98% agreed with the statement “One of the most important things I can do for my health is to take an active role in my health care." In the pre-intervention survey, 73% were willing to do “a lot of effort” to prevent an infection. This proportion was similar (73%) in the 2nd survey, but decreased to 63% in the final survey (p < 0 .01). Among 106 patients who reported starting PVI, 85% reported that PVI felt neutral or pleasant, 9.4% reported a side effect, and 79% reported using it during the past 3 dialysis sessions. Among 102 patients who reported using PVI at 6 months, 87% said it felt neutral/pleasant, 3.9% reported a side effect and 75% reported using it during the past 3 dialysis sessions. Side effects included nasal dripping, congestion or burning/stinging, unpleasant smell, headache, yellow tears, and minor nose bleeding. Conclusions: Hemodialysis patients are not aware of their high risk of infection. Although many were willing to expend a lot of effort to prevent an infection, this willingness decreased during an infection prevention intervention. There were few PVI side effects and most patients stated that PVI felt neutral/pleasant, yet many patients chose to not use PVI. Future research should aim to improve patient education on their risk of infection and assess barriers to adherence with infection prevention interventions.