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Fecal microbiota transplantation (FMT) is an effective therapy in recurrent Clostridium difficile infection (rCDI). It is only recommended for this indication by European and American guidelines. Other indications of FMT are being studied, such as inflammatory bowel disease (IBD), and they have shown promising results.
To identify and review published FMT-related economic evaluations (EEs) to assess their quality and the economic impact of FMT in the treatment of these diseases.
The systematic literature research was conducted in both PubMed and Cochrane to identify EEs published before July 1, 2019.
Study eligibility criteria:
Articles were included if they concerned FMT (whatever the disease and its line of treatment), if they reported full or partial EEs, and if they were written in English. Articles were excluded if they did not concern FMT; if they did not report an EE; or if they were a systematic review, editorial, comment, letter to the editor, practice point, or poster.
A measurement tool, AMSTAR, was used to optimize the quality of this systematic review. Based on the CHEERS checklist, data were identified and extracted from articles. The quality of each EE was assessed using the Drummond checklist.
Overall, 9 EEs were included: all EEs were full evaluations and 8 were cost-utility analyses (CUAs). All EEs had a Drummond score ≥ 7, which indicated high quality. All CUAs related to rCDI and IBD concluded that FMT was cost-effective compared with other reference treatments, at a threshold ≤$50,000/QALY. One EE about initial CDI showed that FMT was dominated by metronidazole.
Despite a limited number of EEs, FMT seems to be a promising and cost-effective treatment for rCDI. More EE studies on other diseases like IBD are necessary to address FMT efficiency for new indications. Therefore, our systematic review provides a framework for healthcare decision making.
Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.
To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).
We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.
The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.
In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.
Declaration of interest
R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
Virtual patient software allows health professionals to practise their skills by interacting with tools simulating clinical scenarios. A natural language dialogue system can provide natural interaction for medical history-taking. However, the large number of concepts and terms in the medical domain makes the creation of such a system a demanding task. We designed a dialogue system that stands out from current research by its ability to handle a wide variety of medical specialties and clinical cases. To address the task, we designed a patient record model, a knowledge model for the task and a termino-ontological model that hosts structured thesauri with linguistic, terminological and ontological knowledge. We used a frame- and rule-based approach and terminology-rich resources to handle the medical dialogue. This work focuses on the termino-ontological model, the challenges involved and how the system manages resources for the French language. We adopted a comprehensive approach to collect terms and ontological knowledge, and dictionaries of affixes, synonyms and derivational variants. Resources include domain lists containing over 161,000 terms, and dictionaries with over 959,000 word/concept entries. We assessed our approach by having 71 participants (39 medical doctors and 32 non-medical evaluators) interact with the system and use 35 cases from 18 specialities. We conducted a quantitative evaluation of all components by analysing interaction logs (11,834 turns). Natural language understanding achieved an F-measure of 95.8%. Dialogue management provided on average 74.3 (±9.5)% of correct answers. We performed a qualitative evaluation by collecting 171 five-point Likert scale questionnaires. All evaluated aspects obtained mean scores above the Likert mid-scale point. We analysed the vocabulary coverage with regard to unseen cases: the system covered 97.8% of their terms. Evaluations showed that the system achieved high vocabulary coverage on unseen cases and was assessed as relevant for the task.
Oases are subject to decreasing resources and changing human activities. Fully aware of their rich heritage, the United Arab Emirates (UAE) have undertaken work to preserve and revitalize these oases. However, there is a clear lack of understanding of the dynamic links between climate change, hydraulic and agricultural management, and socioeconomic activities. To clarify these links, our team conducted a systematic geoarchaeological, geophysical, spatial, and chronological study of the Masafi oasis, UAE. Results indicate the existence of a natural humid area as early as the late Pleistocene (~18 cal ka BP). These conditions persist during the early-mid Holocene with drainage activation and soil development (~12–6.3 ka). During the late Holocene, after the emergence of the “artificial” oasis around ~3250 cal yr BP, cycles of intense management suggesting water availability (~3250–2380 cal yr BP; 550 cal yr BP) alternate with episodes of fluvial detritism (~2380–1870 cal yr BP; >550 cal yr BP) and scattered evidence of farming activities with complex hydroclimatic signatures (~2300–550 cal yr BP). These results, together with regional environmental data, indicate that water and soil resources were available and exploited strategically throughout the Holocene despite adverse climatic conditions, and the oasis of Masafi could have acted as a desert refugium.
Little is known about terrestrial climate dynamics in the Levant during the penultimate interglacial-glacial period. To decipher the palaeoclimatic history of the Marine Oxygen Isotope Stage (MIS) 6 glacial period, a well-dated stalagmite (~194 to ~154 ka) from Kanaan Cave on the Mediterranean coast in Lebanon was analyzed for its petrography, growth history, and stable isotope geochemistry. A resolved climate record has been recovered from this precisely U–Th dated speleothem, spanning the late MIS 7 and early MIS 6 at low resolution and the mid–MIS 6 at higher resolution. The stalagmite grew discontinuously from ~194 to ~163 ka. More consistent growth and higher growth rates between ~163 and ~154 ka are most probably linked to increased water recharge and thus more humid conditions. More distinct layering in the upper part of the speleothem suggests strong seasonality from ~163 ka to ~154 ka. Short-term oxygen and carbon isotope excursions were found between ~155 and ~163 ka. The inferred Kanaan Cave humid intervals during the mid–MIS 6 follow variations of pollen records in the Mediterranean basins and correlate well with the synthetic Greenland record and East Asian summer monsoon interstadial periods, indicating short warm/wet periods similar to the Dansgaard-Oeschger events during MIS 4–3 in the eastern Mediterranean region.
This study aims to develop an expedited radiotherapy (RT) process and evaluate its time savings in women requiring whole breast RT.
Material and methods
An inter-professional RT team streamlined the computed tomography (CT) simulation and treatment pathway for a ‘QuickStart’ process. Target delineation was performed by an advanced practice radiation therapist and approved by the radiation oncologist (RO) for planning. Automated breast planning software was used for treatment planning and standard quality checks were performed. To assess time savings, the initial 25 QuickStart patients were matched with women who underwent whole breast simulation on the same day (±3 days), treated using the conventional process.
A total of 73 post-lumpectomy women were treated through the QuickStart process; the median consent-to-RT was 2 days (range: 0–13) and the mean CT simulation-to-RT treatment was 2 hours and 42 minutes (SD 0:30). In the subgroup analysis, QuickStart patients saved an average of 11 days from CT simulation-to-RT and had shorter median wait-times for both surgery/chemotherapy-to-RT (60 versus 38 days; p=0·002) and consultation-to-RT (7 versus 20 days; p<0·001).
Through inter-professional team efforts and the application of automated planning software, we have achieved a process that significantly decreases patient wait-times while maintaining the quality of whole breast RT.
Since 1991, in France, studies on the conditioning of iodine were carried out to assess the potential of several specific inorganic host matrices. The apatite family has been mainly studied because of its good chemical durability and its ability to confine iodine over geological time scales. A lead-bearing apatite, Pb10(VO4)4.8(PO4)1.2I2, and a calcium-bearing apatite, Ca10(PO4)6(OH)2-x(IO3)x, were selected on the basis of their incorporation rate (between 7 and 10 wt.%) and a satisfactory resistance to leaching (V0(50 °C, pure water) ∼ 10-2 g.m-2.d-1; Vr(50 °C, pure water) < 10-4 g.m-2.d-1). However, with such materials, the removal of open porosity requires non conventional sintering techniques like spark plasma sintering to decrease the surface exposed to water. This is why, in parallel, other matrices, like silver phosphate glasses, have also been investigated. To improve the chemical durability and thermal properties of these glasses, cross-linking reagents were added to their formulation.
Rome is but one vast museum: Pompeii is a living antiquity.
This paper investigates the way particular locations in the Romantic period can operate as nodal points for the convergence of questions about materiality, representation, and presence. A location can be, in certain instances, a place of dislocation, or of emptiness, and scenes and sites of ruin, particularly, may evoke ideas of vacancy and oblivion even through their material presentness. Visitors to the entombed city of Pompeii, which was effectively frozen in time by the volcanic eruption of Vesuvius in AD79, have always been struck by the sense of walking back into the past, while at the same time experiencing, in the present, the overwhelming presence of death. Time has been, on the one hand, suspended – and history held in abeyance – while on the other, the very transience or vacancy of time is captured. What famously attracted Freud to Wilhelm Jensen's 1903 novella Gradiva, set in the city of Pompeii, was this very idea of the past locked into and embedded in the present, which provided suggestive spatial and archaeological analogies for the aims and procedures of psychoanalysis. For the Romantic traveller, encountering the site in the early decades after its ‘rediscovery’ in the middle of the eighteenth century, the most striking feature of this ‘city of the dead’ was precisely the perception of the past co-mingling with the present.
Within the context of Jordan, the term ‘heritage’ is verbally and mentally more approachable for lay people than the term ‘archaeology’. Thus, in this chapter, community heritage is used interchangeably with community archaeology to describe a discipline that explores people's engagement with material of the past. Basically, community archaeology ‘create[s] an open, participatory and rational-critical debate, which is presumably the only way to integrate public opinions into decisions about archaeology’ (Matsuda 2004, 66). This critical engagement with contemporary issues, using a participatory approach, enhances archaeological theories and practices related to heritage management, given that ‘archaeological theory falls short in addressing heritage management and how archaeological knowledge is used within the management process’ (Smith 1994, 300).
This chapter is about establishing engagement with people in Jordan regarding archaeological sites. The respondents in the study supplied data through in-depth interviews about certain archaeological sites that exist within their living or working environments. The interviews focused on the respondents’ opinions of the interventions carried out within the sites in question. Their accounts are then incorporated with community archaeology literature that is, basically, produced in Western academic contexts. Thus, the study places the theoretical framework provided by the literature within a practical perspective influenced by the Jordanian setting. This should support the respondents’ accounts and make them eligible to be part of the archaeological knowledge that can be used in the management process, as Smith (1994, 300) observes.