The economic burden of zoonotic Plasmodium knowlesi malaria on households in Sabah, Malaysia compared to malaria from human-only Plasmodium species.

Background: The emergence of the zoonotic monkey parasite Plasmodium knowlesi as the dominant cause of malaria in Malaysia has disrupted current national WHO elimination goals. Malaysia has free universal access to malaria care; however, out-of-pocket costs are unknown. This study estimated household costs of illness attributable to malaria due to P. knowlesi against other non-zoonotic Plasmodium species infections in Sabah, Malaysia. Methodology/Principal Findings: Household costs were estimated from patient-level surveys collected from four hospitals between 2013 and 2016. Direct costs including medical and associated travel costs, and indirect costs due to lost productivity were included. One hundred and fifty-two malaria cases were enrolled: P. knowlesi (n=108), P. vivax (n=22), P. falciparum (n=16), and P. malariae (n=6). Costs were inflated to 2022 Malaysian Ringgits and reported in United States dollars (US$). Across all cases, the mean total costs were US$138 (SD=108), with productivity losses accounting for 58% of costs (US$80; SD=73). P. vivax had the highest mean total household cost at US$210, followed by P. knowlesi (US$127), P. falciparum (US$126), and P. malariae (US$105). Most patients (80%) experienced direct health costs above 10% of monthly income, with 58 (38%) patients experiencing health spending over 25% of monthly income, consistent with catastrophic health expenditure. Conclusions/Significance: Despite Malaysia's free health-system care for malaria, patients and families face other related medical, travel, and indirect costs. Household out-of-pocket costs were driven by productivity losses; primarily attributed to infections in working-aged males in rural agricultural-based occupations. Costs for P. knowlesi were comparable to P. falciparum and lower than P. vivax. The higher P. vivax costs related to direct health facility costs for repeat monitoring visits given the liver-stage treatment required. AUTHOR SUMMARY: Knowlesi malaria is due to infection with a parasite transmitted by mosquitos from monkeys to humans. Most people who are infected work or live near the forest. It is now the major type of malaria affecting humans in Malaysia. The recent increase of knowlesi malaria cases in humans has impacted individuals, families, and health systems in Southeast Asia. Although the region has made substantial progress towards eliminating human-only malaria species, knowlesi malaria threatens elimination targets as traditional control measures do not address the parasite reservoir in monkeys. The economic burden of illness due to knowlesi malaria has not previously been estimated or subsequently compared with other malaria species. We collected data on the cost of illness to households in Sabah, Malaysia, to estimate their related total economic burden. Medical costs and time off work and usual activities were substantial in patients with the four species of malaria diagnosed during the time of this study. This research highlights the financial burden which households face when seeking care for malaria in Malaysia, despite the free treatment provided by the government.

Health-related quality of life in patients with extremity bone sarcoma after surgical treatment: a systematic review.

PURPOSE: We conducted a systematic review of studies reporting on measurement of health-related quality of life (HRQoL), with a special focus on the use of the preference-weighted instruments, in patients with extremity bone sarcoma treated with limb-salvage surgery or amputation. METHODS: We searched MedLine, Embase, Cochrane Library and Web of Science for English-language studies reporting on HRQoL of patients with bone sarcoma from inception to 28 August 2023. All records found were independently reviewed by two reviewers. We used the Newcastle-Ottawa Scale (NOS) and the CONSORT 2010 checklist to assess the quality of the cohort and randomised studies, respectively. RESULTS: The search identified 1225 records, of which 16 studies were included for data extraction. Only one study used a preference-weighted instrument for measuring HRQoL in a small sample of patients (n = 28). Ten studies used the generic SF-36 questionnaire, but no preference-weighted HRQoL based on SF-6D was derived from the SF-36 scores. Most studies comparing HRQoL between amputation and limb-salvage surgery reported no significant differences. Twelve cohort studies scored six or more out of nine points based on the NOS. The only randomised study scored 54% on the CONSORT 2010 checklist. CONCLUSIONS: The approaches used to measure HRQoL were inconsistent and outcome scores varied substantially. Only one study used preference-weighted instruments for HRQoL measurement. Future research into the surgical treatment of extremity bone sarcoma should consider the use of preference-weighted instruments to measure HRQoL, which will therefore enable economic evaluation for the growing orthopaedic armamentarium of novel surgical interventions. REGISTRATION: This systematic review was registered with the PROSPERO International prospective register of systematic reviews (CRD42021282380).

Telehealth in oncology: a cost analysis to evaluate the financial impact of implementing regional trial hubs within a phase 3 cancer clinical trial.

This cost analysis, from a societal perspective, compared the cost difference of a networked teletrial model (NTTM) with four regional hubs versus conventional trial operation at a single metropolitan specialist centre. The Australian phase 3 cancer interventional randomised controlled trial included 152 of 328 regional participants (patient enrolment 2018-2021; 6-month primary end point). The NTTM significantly reduced (AU$2155 per patient) patient travel cost and time and lost productivity.

Safety of use of the ENDOSWIR near-infrared optical imaging device on human tissues: prospective blind study.

Cancer surgery requires removing the tumor tissue in necessary and sufficient quantities. Spectral optical imaging in the short-wave infrared (900-1700 nm) could provide an intraoperative guidance to the surgeon based on the absorption of the tissues without contrast agent. Our objective was to ensure the safety of our ENDOSWIR device on human tissues. Histological analysis of fresh human tonsils exposed to the SWIR light or not was compared and showed no histological differences. This demonstrates the safety of using the SWIR device on human tissues and allows us to initiate a clinical study for the resection of tumors intraoperatively.

Costing of an Australian general practice COVID-19 drive-through testing and respiratory clinic.

BACKGROUND: Responding to the COVID-19 pandemic requires safe and efficient testing on a large scale over a prolonged period. Outpatient testing facilities can clinically assess and test symptomatic individuals and test asymptomatic contacts. This study identified the resources required to establish and maintain an Australian general practitioner (GP) led testing facility that combined a respiratory clinic for clinical assessment and testing with a drive-through testing facility. METHODS: Data were taken from clinic administrative records to identify the number of patients tested over the period April-June 2020. An independent auditor's report identified the resources used in establishing, running, and staffing both clinics for the same period. Analyses were performed using the minimum and maximum daily throughput to understand the effect of demand on price per sample collected. RESULTS: The respiratory clinic tested an average of 19 patients per day, at an estimated cost of $340.04 AUD. This varied to $687.99 AUD during the lowest demand scenario, and $281.04 AUD during the high demand scenario. The drive-through clinic tested an average of 47 patients per day, at an estimated cost of $153.57 AUD. This varied to $279.51 AUD during the lowest demand scenario, and $99.92 AUD during the high demand scenario. CONCLUSION: This study provides insight into the cost of testing at a drive through and respiratory clinic in Australia. The evidence highlights importance of considering variation in demand and the impact on efficiency, particularly where resource use is fixed in the short term.

Association of Simulated COVID-19 Policy Responses for Social Restrictions and Lockdowns With Health-Adjusted Life-Years and Costs in Victoria, Australia.

Importance: Countries have varied enormously in how they have responded to the COVID-19 pandemic, ranging from elimination strategies (eg, Australia, New Zealand, Taiwan) to tight suppression (not aiming for elimination but rather to keep infection rates low [eg, South Korea]) to loose suppression (eg, Europe, United States) to virtually unmitigated (eg, Brazil, India). Weighing the best option, based on health and economic consequences due to lockdowns, is necessary. Objective: To determine the optimal policy response, using a net monetary benefit (NMB) approach, for policies ranging from aggressive elimination and moderate elimination to tight suppression (aiming for 1-5 cases per million per day) and loose suppression (5-25 cases per million per day). Design Setting and Participants: Using governmental data from the state of Victoria, Australia, and other collected data, 2 simulation models in series were conducted of all residents (population, 6.4 million) for SARS-CoV-2 infections for 1 year from September 1, 2020. An agent-based model (ABM) was used to estimate daily SARS-CoV-2 infection rates and time in 5 stages of social restrictions (stages 1, 1b, 2, 3, and 4) for 4 policy response settings (aggressive elimination, moderate elimination, tight suppression, and loose suppression), and a proportional multistate life table (PMSLT) model was used to estimate health-adjusted life-years (HALYs) associated with COVID-19 and costs (health systems and health system plus gross domestic product [GDP]). The ABM is a generic COVID-19 model of 2500 agents, or simulants, that was scaled up to the population of interest. Models were specified with data from 2019 (eg, epidemiological data in the PMSLT model) and 2020 (eg, epidemiological and cost consequences of COVID-19). The NMB of each policy option at varying willingness to pay (WTP) per HALY was calculated: NMB = HALYs × WTP - cost. The estimated most cost-effective (optimal) policy response was that with the highest NMB. Main Outcome and Measures: Estimated SARS-CoV-2 infection rates, time under 5 stages of restrictions, HALYs, health expenditure, and GDP losses. Results: In 100 runs of both the ABM and PMSLT models for each of the 4 policy responses, 31.0% of SARS-CoV-2 infections, 56.5% of hospitalizations, and 84.6% of deaths occurred among those 60 years and older. Aggressive elimination was associated with the highest percentage of days with the lowest level of restrictions (median, 31.7%; 90% simulation interval [SI], 6.6%-64.4%). However, days in hard lockdown were similar across all 4 strategies. The HALY losses (compared with a scenario without COVID-19) were similar for aggressive elimination (median, 286 HALYs; 90% SI, 219-389 HALYs) and moderate elimination (median, 314 HALYs; 90% SI, 228-413 HALYs), and nearly 8 and 40 times higher for tight suppression and loose suppression, respectively. The median GDP loss was least for moderate elimination (median, $41.7 billion; 90% SI, $29.0-$63.6 billion), but there was substantial overlap in simulation intervals between the 4 strategies. From a health system perspective, aggressive elimination was optimal in 64% of simulations above a WTP of $15 000 per HALY, followed by moderate elimination in 35% of simulations. Moderate elimination was optimal from a GDP perspective in half of the simulations, followed by aggressive elimination in a quarter. Conclusions and Relevance: In this simulation modeling economic evaluation of estimated SARS-CoV-infection rates, time under 5 stages of restrictions, HALYs, health expenditure, and GDP losses in Victoria, Australia, an elimination strategy was associated with the least health losses and usually the fewest GDP losses.

Induction of hypomanic episode with transcranial direct current stimulation.

We report on the case of a 57-year-old man who experienced an episode of hypomania while participating in a clinical trial of transcranial direct current stimulation for the treatment of major depressive disorder. Although hypomania and mania have been reported after transcranial magnetic stimulation to the dorsolateral prefrontal cortex in the past, to our knowledge, this is the first report of mania after transcranial direct current stimulation to the dorsolateral prefrontal cortex.