Mapping marine benthic biological traits to facilitate future sustainable development.

Escalating societal demands placed on the seabed mean there has never been such a pressing need to align our understanding of the relationship between the physical impact of anthropogenic activities (e.g., installation of wind turbines, demersal fishing) and the structure and function of the seabed assemblages. However, spatial differences in benthic assemblages based on empirical data are currently not adequately incorporated into decision-making processes regarding future licensable activities or wider marine spatial planning frameworks. This study demonstrates that, through harnessing a Big Data approach, large-scale, continuous coverage maps revealing differences in biological traits expressions of benthic assemblages can be produced. We present independent maps based on a suite of response traits (depicting differences in responses to natural or anthropogenically induced change) and effects traits (reflecting different functional potential), although maps derived using single traits or combinations of a range of traits are possible. Models predicting variations in response traits expression provide greater confidence than those predicting effects traits. We discuss how such maps may be used to assist in the decision-making process for the licensing of anthropogenic activities and as part of marine spatial planning approaches. The confidence in such maps to reflect spatial variations in marine benthic trait expression may, in the future, inherently be improved through (1) the inclusion of more empirical macrofaunal assemblage field data; (2) an improved knowledge of marine benthic taxa trait expression; and (3) a greater understanding of the traits responsible for determining a taxon's response to an anthropogenic pressure and a taxon's functional potential.

Perioperative Anticoagulation in Patients with Cancer.

PURPOSE OF REVIEW: There is a paucity of evidence for managing perioperative anticoagulation in patients with cancer. This review aims to provide clinicians who provide care for patients with cancer an overview of the available information and strategies needed to provide optimal care in a perioperative setting. RECENT FINDINGS: There is new evidence available around the management of perioperative anticoagulation in patients with cancer. The new literature and guidance were analyzed and summarized in this review. Management of perioperative anticoagulation in individuals with cancer is a challenging clinical dilemma. The approach to managing anticoagulation requires clinicians to review both disease and treatment specific patient factors that can contribute to both thrombotic and bleed risks. A thorough patient-specific assessment is essential in ensuring patients with cancer receive appropriate care in the perioperative setting.

What's hot and what's not: Making sense of biodiversity 'hotspots'.

Conserving biogeographic regions with especially high biodiversity, known as biodiversity 'hotspots', is intuitive because finite resources can be focussed towards manageable units. Yet, biodiversity, environmental conditions and their relationship are more complex with multidimensional properties. Assessments which ignore this risk failing to detect change, identify its direction or gauge the scale of appropriate intervention. Conflicting concepts which assume assemblages as either sharply delineated communities or loosely collected species have also hampered progress in the way we assess and conserve biodiversity. We focus on the marine benthos where delineating manageable areas for conservation is an attractive prospect because it holds most marine species and constitutes the largest single ecosystem on earth by area. Using two large UK marine benthic faunal datasets, we present a spatially gridded data sampling design to account for survey effects which would otherwise be the principal drivers of diversity estimates. We then assess γ-diversity (regional richness) with diversity partitioned between α (local richness) and ß (dissimilarity), and their change in relation to covariates to test whether defining and conserving biodiversity hotspots is an effective conservation strategy in light of the prevailing forces structuring those assemblages. α-, ß- and γ-diversity hotspots were largely inconsistent with each metric relating uniquely to the covariates, and loosely collected species generally prevailed with relatively few distinct assemblages. Hotspots could therefore be an unreliable means to direct conservation efforts if based on only a component part of diversity. When assessed alongside environmental gradients, α-, ß- and γ-diversity provide a multidimensional but still intuitive perspective of biodiversity change that can direct conservation towards key drivers and the appropriate scale for intervention. Our study also highlights possible temporal declines in species richness over 30 years and thus the need for future integrated monitoring to reveal the causal drivers of biodiversity change.

The testing of people with any risk factor for hepatitis C in community pharmacies is cost-effective.

New antiviral drugs with high efficacy mean the hepatitis C virus (HCV) can now be eliminated. To achieve this, it is necessary to identify undiagnosed cases of HCV. However, the costs of testing should be considered when judging the overall cost-effectiveness of treatment. This study describes the cost-effectiveness of a community pharmacy testing service in a population of people at risk of HCV living on the Isle of Wight (United Kingdom). Dry blood spot testing was conducted in anyone with a known risk factor for HCV in 20 community pharmacies. The outcomes and costs were entered into a Markov model. Cost and health utilities from the model were used to calculate an incremental cost-effectiveness ratio (ICER). In 24 months, 186 tests were conducted, 13 were positive for HCV RNA and six of these (46%) received treatment during the follow-up period. All achieved a sustained virological response at 3 months. The overall cost of the testing and treatment intervention was £242 183, and the ICER for the service was £3689 per quality-adjusted life year (QALY) gained. If screening had been restricted to just people with a history of injecting drug use (PWID) the ICER would have been £4865 per QALY gained. The service was effective at identifying people with HCV infection, and despite the additional cost of targeted testing, its cost-effectiveness was below the commonly accepted thresholds. In this setting, restricting targeted testing to PWID would not improve the cost-effectiveness.

Key scientific issues in developing drinking water guidelines for perfluoroalkyl acids: Contaminants of emerging concern.

Perfluoroalkyl acids (PFAAs), a group of synthetic organic chemicals with industrial and commercial uses, are of current concern because of increasing awareness of their presence in drinking water and their potential to cause adverse health effects. PFAAs are distinctive among persistent, bioaccumulative, and toxic (PBT) contaminants because they are water soluble and do not break down in the environment. This commentary discusses scientific and risk assessment issues that impact the development of drinking water guidelines for PFAAs, including choice of toxicological endpoints, uncertainty factors, and exposure assumptions used as their basis. In experimental animals, PFAAs cause toxicity to the liver, the immune, endocrine, and male reproductive systems, and the developing fetus and neonate. Low-dose effects include persistent delays in mammary gland development (perfluorooctanoic acid; PFOA) and suppression of immune response (perfluorooctane sulfonate; PFOS). In humans, even general population level exposures to some PFAAs are associated with health effects such as increased serum lipids and liver enzymes, decreased vaccine response, and decreased birth weight. Ongoing exposures to even relatively low drinking water concentrations of long-chain PFAAs substantially increase human body burdens, which remain elevated for many years after exposure ends. Notably, infants are a sensitive subpopulation for PFAA's developmental effects and receive higher exposures than adults from the same drinking water source. This information, as well as emerging data from future studies, should be considered in the development of health-protective and scientifically sound guidelines for PFAAs in drinking water.

Ruthenium-Cyclopentadienyl Bipyridine-Biotin Based Compounds: Synthesis and Biological Effect.

Prospective anticancer metallodrugs should consider target-specific components in their design in order to overcome the limitations of the current chemotherapeutics. The inclusion of vitamins, which receptors are overexpressed in many cancer cell lines, has proven to be a valid strategy. Therefore, in this paper we report the synthesis and characterization of a set of new compounds [Ru(η5-C5H5)(P(C6H4R)3)(4,4'-R'-2,2'-bpy)]+ (R = F and R' = H, 3; R = F and R' = biotin, 4; R = OCH3 and R' = H, 5; R = OCH3 and R' = biotin, 6), inspired by the exceptional good results recently obtained for the analogue bearing a triphenylphosphane ligand. The precursors for these syntheses were also described following modified literature procedures, [Ru(η5-C5H5)(P(C6H4R)3)2Cl], where R is -F (1) or -OCH3 (2). The structure of all compounds is fully supported by spectroscopic and analytical techniques and by X-ray diffraction studies for compounds 2, 3, and 5. All cationic compounds are cytotoxic in the two breast cancer cell lines tested, MCF7 and MDA-MB-231, and much better than cisplatin under the same experimental conditions. The cytotoxicity of the biotinylated compounds seems to be related with the Ru uptake by the cells expressing biotin receptors, indicating a potential mediated uptake. Indeed, a biotin-avidin study confirmed that the attachment of biotin to the organometallic fragment still allows biotin recognition by the protein. Therefore, the biotinylated compounds might be potent anticancer drugs as they show cytotoxic effect in breast cancer cells at low dose dependent on the compounds' uptake, induce cell death by apoptosis and inhibit the colony formation of cancer cells causing also less severe side effects in zebrafish.

A novel screening method for transition metal-based anticancer compounds using zebrafish embryo-larval assay and inductively coupled plasma-mass spectrometry analysis.

As novel metallodrugs continue to emerge, they are evaluated using models, including zebrafish, that offer unique sublethal endpoints. Testing metal-based anticancer compounds with high-throughput zebrafish toxicological assays requires analytical methods with the sensitivity to detect these sublethal tissue doses in very small sample masses (e.g., egg mass 100 µg). A robust bioanalytical model, zebrafish embryos coupled with inductively coupled plasma-mass spectrometry (ICPMS) for measurement of delivered dose, creates a very effective means for screening metal-based chemotherapeutic agents. In this study, we used ICPMS quantitation with the zebrafish embryo assays to detect metal equivalents at multiple response endpoints for two compounds, the chemotherapeutic agent cisplatin and ruthenium (Ru)-based prospective metallodrug, PMC79. We hypothesized that cisplatin and PMC79 have different mechanisms for inducing apoptosis and result in similar lesions but different potencies following water-borne exposure. An ICPMS method was developed to detect the metal in waterborne solution and tissue (detection limit: 5 parts per trillion for Ru or platinum [Pt]). The Ru-based compound was more potent (LC50 : 7.8 µm) than cisplatin (LC50 : 158 µm) and induced disparate lesions. Lethality from cisplatin exposure exhibited a threshold (values >15 mg/L) while no threshold was observed for delayed hatching (lowest observed adverse effect level 3.75 mg/L cisplatin; 8.7 Pt (ng)/organism). The Ru organometallic did not have a threshold for lethality. Cisplatin-induced delayed hatching was investigated further by larval-Pt distribution and preferentially distributed to the chorion. We propose that zebrafish embryo-larval assays coupled with ICPMS serve as a powerful platform to evaluate relative potency and toxic effects of metallodrug candidates.

Assessing Aromatic-Hydrocarbon Toxicity to Fish Early Life Stages Using Passive-Dosing Methods and Target-Lipid and Chemical-Activity Models.

Aromatic hydrocarbons (AH) are known to impair fish early life stages (ELS). However, poorly defined exposures often confound ELS-test interpretation. Passive dosing (PD) overcomes these challenges by delivering consistent, controlled exposures. The objectives of this study were to apply PD to obtain 5 d acute embryo lethality and developmental data and 30 d chronic embryo-larval survival and growth-effects data using zebrafish with different AHs; to analyze study and literature toxicity data using target-lipid (TLM) and chemical-activity (CA) models; and to extend PD to a mixture and test the assumption of AH additivity. PD maintained targeted exposures over a concentration range of 6 orders of magnitude. AH toxicity increased with log Kow up to pyrene (5.2). Pericardial edema was the most sensitive sublethal effect that often preceded embryo mortality, although some AHs did not produce developmental effects at concentrations causing mortality. Cumulative embryo-larval mortality was more sensitive than larval growth, with acute-to-chronic ratios of <10. More-hydrophobic AHs did not exhibit toxicity at aqueous saturation. The relationship and utility of the TLM-CA models for characterizing fish ELS toxicity is discussed. Application of these models indicated that concentration addition provided a conservative basis for predicting ELS effects for the mixture investigated.

The cost-effectiveness of second-eye cataract surgery in the UK.

BACKGROUND: Elective cataract surgery is the most commonly performed surgical procedure in developed countries. However, it is unclear whether cataract surgery on the second eye provides enough incremental benefit to be considered cost-effective. This study conducted a cost-effectiveness analysis of second-eye cataract surgery in the U.K. DESIGN: A cost-effectiveness analysis. METHODS: A decision-analytical model was developed to estimate the cost-effectiveness of second-eye cataract surgery, based on a comprehensive epidemiological and economic review to develop the parameters for the model. The model followed the clinical pathway of cohorts of patients receiving second-eye cataract surgery and included costs and health benefits associated with post-surgical complications. RESULTS: In the model, second-eye surgery generated 0.68 additional quality-adjusted life years (QALY) with an incremental cost-effectiveness ratio of £1,964 per QALY gained. In sensitivity analyses, model results were most sensitive to changes in the health-related quality of life (HRQoL) gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness to pay thresholds of £10,000 and £20,000 was 100%. CONCLUSION: Second-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, there are only a small number of clinical trials for second-eye cataract surgery, and these have not been conducted in recent years.

Particulate accumulations in the vital organs of wild Brevoortia patronus from the northern Gulf of Mexico after the Deepwater Horizon oil spill.

Histopathologic lesions were observed in the commercially important filter-feeding fish, Brevoortia patronus (Gulf menhaden), along the Louisiana Gulf Coast. Menhaden collected from Louisiana waters in 2011 and 2012, 1 and 2 years following the Deepwater Horizon oil spill, showed varying severities of gill lesions as well as an unusual accumulation of black particulates visible at necropsy in the heart and stomach vasculature. The PAH derived particulates were typically 1-4 µm in diameter, but larger aggregates were observed in the coronary vessels on the ventricle surfaces and their location and size was confirmed by light microscopy. Composited particulate composition was consistent with weathered petrogenic polycyclic aromatic hydrocarbon (PAH) mixtures based on GC-MS analysis. Particulates were present in 63 and 80% of fish hearts and 70 and 89% of stomach muscularis collected in 2011 and 2012, respectively. Tissue embedded particulates can lead to localized cellular damage from bioavailable compounds, as well as chronic effects from occlusion of sensitive tissues' blood flow. The PAH derived particulates appeared to act as emboli in small capillaries, and could associated with localized inflammation, focal necrosis and inappropriate collagen and fibroblast tissue repair. We believe large volume filter feeding teleosts, such as menhaden (up to 3 million gallons per year/fish) with high lipid content, have a higher exposure risk and greater potential for toxicity from toxic particulates than other higher trophic level finfish. Suspended PAH derived particulates following an oil spill therefore, should be considered when assessing long-term ecological impacts and not be limited to physical contact (coating) or water soluble fractions for assessing toxicity (gill and neurologic).

Comparative cost-effectiveness models for the treatment of multiple myeloma.

OBJECTIVES: To compare cost effectiveness models for the first-line treatment of multiple myeloma, and explore the differences between the models' structure, parameters, assumptions and results. METHODS: Three cost effectiveness models for the treatment of multiple myeloma, were compared that had been developed to inform resource allocation in the UK for the chemotherapy regimens bortezomib, melphalan and prednisolone (BMP); and melphalan, prednisolone and thalidomide (MPT) versus melphalan and prednisolone (MP). The models used alternative approaches and assumptions to estimate the overall survival and progression-free survival for each of the interventions. Through the use of sensitivity analyses, the most influential parameters and assumptions of each of the models were identified. RESULTS: The models developed by the manufacturers gave conflicting results, with each manufacturer favouring their drug. The differences between the model results were determined by two parameters: the hazard ratio for overall survival for MPT vs. MP and the cost of bortezomib. CONCLUSIONS: Using models developed for assessing treatments for multiple myeloma we demonstrated that it was feasible to compare models, which then aided decision makers in making reimbursement decisions.

Manipulation of the HIF-Vegf pathway rescues methyl tert-butyl ether (MTBE)-induced vascular lesions.

Methyl tert-butyl ether (MTBE) has been shown to be specifically anti-angiogenic in piscine and mammalian model systems at concentrations that appear non-toxic in other organ systems. The mechanism by which MTBE targets developing vascular structures is unknown. A global transcriptome analysis of zebrafish embryos developmentally exposed to 0.00625-5mM MTBE suggested that hypoxia inducible factor (HIF)-regulated pathways were affected. HIF-driven angiogenesis via vascular endothelial growth factor (vegf) is essential to the developing vasculature of an embryo. Three rescue studies were designed to rescue MTBE-induced vascular lesions: pooled blood in the common cardinal vein (CCV), cranial hemorrhages (CH), and abnormal intersegmental vessels (ISV), and test the hypothesis that MTBE toxicity was HIF-Vegf dependent. First, zebrafish vegf-a over-expression via plasmid injection, resulted in significantly fewer CH and ISV lesions, 46 and 35% respectively, in embryos exposed to 10mM MTBE. Then HIF degradation was inhibited in two ways. Chemical rescue by N-oxaloylglycine significantly reduced CCV and CH lesions by 30 and 32% in 10mM exposed embryos, and ISV lesions were reduced 24% in 5mM exposed zebrafish. Finally, a morpholino designed to knock-down ubiquitin associated von Hippel-Lindau protein, significantly reduced CCV lesions by 35% in 10mM exposed embryos. In addition, expression of some angiogenesis related genes altered by MTBE exposure were rescued. These studies demonstrated that MTBE vascular toxicity is mediated by a down regulation of HIF-Vegf driven angiogenesis. The selective toxicity of MTBE toward developing vasculature makes it a potentially useful chemical in the designing of new drugs or in elucidating roles for specific angiogenic proteins in future studies of vascular development.

Methyl tert butyl ether is anti-angiogenic in both in vitro and in vivo mammalian model systems.

Methyl-tertiary butyl ether (MTBE), a well known gasoline oxygenate, and US Food and Drug Administration approved gallstone treatment, has been previously shown to specifically target teleost embryonic angiogenesis. The studies reported here were to determine whether similar vascular disrupting effects occur in higher vertebrate models. Rat brain endothelial cells were isolated and allowed to form microcapillary-like tubes on Matrigel. MTBE (0.34-34.0 mm) exposure resulted in a dose-dependent reduction of tube formation, with the LOAEL at 0.34 mm, while MTBE's primary metabolite, tertiary butyl alcohol had no effect on tube formation. HUVECs, a primary cell line representing macrovascular cells, were able to form tubes on Matrigel in the presence of MTBE (1.25-80 mm), but the tubes were narrower than those formed in the absence of MTBE. In a mouse Matrigel plug implantation assay, 34.0 mm MTBE completely inhibited vessel invasion into plugs containing endothelial cell growth supplement (ECGS) compared with control plugs with ECGS alone. When timed-pregnant Fisher 344 rats were gavaged with MTBE (500-1500 mg kg(-1) ) from day 6 of organogenesis through 10 days post-parturition, no organ toxicity or histological changes in pup vasculature were observed. Results of the in vitro cell culture studies show that MTBE is anti-angiogenic at mm concentrations and has potential use as an anti-angiogenic treatment for solid tumors with minimal toxicity.

Perfluorooctanoic acid (PFOA), an emerging drinking water contaminant: a critical review of recent literature.

Perfluorooctanoic acid (PFOA) is an anthropogenic contaminant that differs in several ways from most other well-studied organic chemicals found in drinking water. PFOA is extremely resistant to environmental degradation processes and thus persists indefinitely. Unlike most other persistent and bioaccumulative organic pollutants, PFOA is water-soluble, does not bind well to soil or sediments, and bioaccumulates in serum rather than in fat. It has been detected in finished drinking water and drinking water sources impacted by releases from industrial facilities and waste water treatment plants, as well as in waters with no known point sources. However, the overall occurrence and population exposure from drinking water is not known. PFOA persists in humans with a half-life of several years and is found in the serum of almost all U.S. residents and in populations worldwide. Exposure sources include food, food packaging, consumer products, house dust, and drinking water. Continued exposure to even relatively low concentrations in drinking water can substantially increase total human exposure, with a serum:drinking water ratio of about 100:1. For example, ongoing exposures to drinking water concentrations of 10 ng/L, 40 ng/L, 100 ng/L, or 400 ng/L are expected to increase mean serum levels by about 25%, 100%, 250%, and 1000%, respectively, from the general population background serum level of about 4 ng/mL. Infants are potentially a sensitive subpopulation for PFOA's developmental effects, and their exposure through breast milk from mothers who use contaminated drinking water and/or from formula prepared with contaminated drinking water is higher than in adults exposed to the same drinking water concentration. Numerous health endpoints are associated with human PFOA exposure in the general population, communities with contaminated drinking water, and workers. As is the case for most such epidemiology studies, causality for these effects is not proven. Unlike most other well-studied drinking water contaminants, the human dose-response curve for several effects appears to be steepest at the lower exposure levels, including the general population range, with no apparent threshold for some endpoints. There is concordance in animals and humans for some effects, while humans and animals appear to react differently for other effects such as lipid metabolism. PFOA was classified as "likely to be carcinogenic in humans" by the USEPA Science Advisory Board. In animal studies, developmental effects have been identified as more sensitive endpoints for toxicity than carcinogenicity or the long-established hepatic effects. Notably, exposure to an environmentally relevant drinking water concentration caused adverse effects on mammary gland development in mice. This paper reviews current information relevant to the assessment of PFOA as an emerging drinking water contaminant. This information suggests that continued human exposure to even relatively low concentrations of PFOA in drinking water results in elevated body burdens that may increase the risk of health effects.

Behavioural interventions for the prevention of sexually transmitted infections in young people aged 13-19 years: a systematic review.

We systematically reviewed school-based skills building behavioural interventions for the prevention of sexually transmitted infections. References were sought from 15 electronic resources, bibliographies of systematic reviews/included studies and experts. Two authors independently extracted data and quality-assessed studies. Fifteen randomized controlled trials (RCTs), conducted in the United States, Africa or Europe, met the inclusion criteria. They were heterogeneous in terms of intervention length, content, intensity and providers. Data from 12 RCTs passed quality assessment criteria and provided evidence of positive changes in non-behavioural outcomes (e.g. knowledge and self-efficacy). Intervention effects on behavioural outcomes, such as condom use, were generally limited and did not demonstrate a negative impact (e.g. earlier sexual initiation). Beneficial effect on at least one, but never all behavioural outcomes assessed was reported by about half the studies, but this was sometimes limited to a participant subgroup. Sexual health education for young people is important as it increases knowledge upon which to make decisions about sexual behaviour. However, a number of factors may limit intervention impact on behavioural outcomes. Further research could draw on one of the more effective studies reviewed and could explore the effectiveness of 'booster' sessions as young people move from adolescence to young adulthood.

An economic model of school-based behavioral interventions to prevent sexually transmitted infections.

OBJECTIVES: Reducing sexually transmitted infections (STI) and teenage pregnancy through effective health education is a high priority for health policy. Behavioral interventions which teach skills to practice safer sex may reduce the incidence of STIs. We evaluated the cost-effectiveness of school-based behavioral interventions in young people. METHODS: We developed an economic model to estimate the total number of STI cases averted, consequent gain in health related quality of life (HRQoL) and savings in medical costs, based on changes in sexual behavior. The parameters for the model were derived from a systematic literature search on the intervention effectiveness, epidemiology of STIs, sexual behavior and lifestyles, HRQoL and health service costs. RESULTS: The costs of providing teacher-led and peer-led behavioral interventions were €5.16 and €18 per pupil, respectively. For a cohort of 1000 boys and 1000 girls aged 15 years, the model estimated that the behavioral interventions would avert two STI cases and save 0.35 Quality Adjusted Life Years (QALYs). Compared to standard education, the incremental cost-effectiveness of the teacher-led and peer-led interventions was €24,268 and €96,938 per QALY gained, respectively. CONCLUSIONS: School-based behavioral interventions which provide information and teach young people sexual health skills can bring about improvements in knowledge and increased self-efficacy, though these may be limited in terms of impact on sexual behavior. There was uncertainty around the results due to the limited effect of the intervention on behavioral outcomes and paucity of data for other input parameters.

Dose Uptake of Platinum- and Ruthenium-based Compound Exposure in Zebrafish by Inductively Coupled Plasma Mass Spectrometry with Broader Applications.

Metals and metal-based compounds comprise multifarious pharmaco-active and toxicological xenobiotics. From heavy metal toxicity to chemotherapeutics, the toxicokinetics of these compounds have both historical and modern-day relevance. Zebrafish have become an attractive model organism in elucidating pharmaco- and toxicokinetics in environmental exposure and clinical translation studies. Although zebrafish studies have the benefit of being higher-throughput than rodent models, there are several significant constraints to the model. One such limitation is inherent in the waterborne dosing regimen. Water concentrations from these studies cannot be extrapolated to provide reliable internal dosages. Direct measurements of the metal-based compounds allow for a better correlation with compound-related molecular and biological responses. To overcome this limitation for metals and metal-based compounds, a technique was developed to digest zebrafish larval tissue after exposure and quantify metal concentrations within tissue samples by inductively coupled plasma mass spectrometry (ICPMS). ICPMS methods were used to determine the metal concentrations of platinum (Pt) from cisplatin and ruthenium (Ru) from several novel Ru-based chemotherapeutics in zebrafish tissue. Additionally, this protocol distinguished concentrations of Pt that were sequestered in the chorion of the larval compared with the zebrafish tissue. These results indicate that this method can be applied to quantitate the metal dose present in larval tissues. Further, this method may be adjusted to identify specific metals or metal-based compounds in a broad range of exposure and dosing studies.

The CHD challenge: comparing four cost-effectiveness models.

OBJECTIVES: To compare four UK models evaluating the cost-effectiveness of interventions in coronary heart disease (CHD), exploring the relative importance of structure and inputs in accounting for differences, and the scope for consensus on structure and data. METHODS: We compared published cost-effectiveness results (incremental cost, quality-adjusted life year, and cost-effectiveness ratio) of three models conforming to the National Institute for Health and Clinical Excellence guidelines dealing with three interventions (statins, percutaneous coronary intervention, and clopidogrel) with a model developed in Southampton. Comparisons were made using three separate stages: 1) comparison of published results; 2) comparison of the results using the same data inputs wherever possible; and 3) an in-depth exploration of reasons for differences and the potential for consensus. RESULTS: Although published results differed by up to 73% (for statins), standardization of inputs (stage 2) narrowed these gaps. Greater understanding of the reasons for differences was achieved, but a consensus on preferred values for all data inputs was not reached. CONCLUSIONS: We found that published guidance on methods was important to reduce variation in important model inputs. Although the comparison of models did not lead to consensus for all model inputs, it provided a better understanding of the reasons for these differences, and enhanced the transparency and credibility of all models. Similar comparisons would be aided by fuller publication of models, perhaps through detailed web appendices.