A taste of space: Remote animal observations and discrete-choice models provide new insights into foraging and density dynamics for a large subarctic herbivore.

Competition for resources and space can drive forage selection of large herbivores from the bite through the landscape scale. Animal behaviour and foraging patterns are also influenced by abiotic and biotic factors. Fine-scale mechanisms of density-dependent foraging at the bite scale are likely consistent with density-dependent behavioural patterns observed at broader scales, but few studies have directly tested this assertion. Here, we tested if space use intensity, a proxy of spatiotemporal density, affects foraging mechanisms at fine spatial scales similarly to density-dependent effects observed at broader scales in caribou. We specifically assessed how behavioural choices are affected by space use intensity and environmental processes using behavioural state and forage selection data from caribou (Rangifer tarandus granti) observed from GPS video-camera collars using a multivariate discrete-choice modelling framework. We found that the probability of eating shrubs increased with increasing caribou space use intensity and cover of Salix spp. shrubs, whereas the probability of eating lichen decreased. Insects also affected fine-scale foraging behaviour by reducing the overall probability of eating. Strong eastward winds mitigated negative effects of insects and resulted in higher probabilities of eating lichen. At last, caribou exhibited foraging functional responses wherein their probability of selecting each food type increased as the availability (% cover) of that food increased. Space use intensity signals of fine-scale foraging were consistent with density-dependent responses observed at larger scales and with recent evidence suggesting declining reproductive rates in the same caribou population. Our results highlight potential risks of overgrazing on sensitive forage species such as lichen. Remote investigation of the functional responses of foraging behaviours provides exciting future applications where spatial models can identify high-quality habitats for conservation.

A systematic review and cost effectiveness analysis of reusable vs. single-use flexible bronchoscopes.

The cost effectiveness of reusable vs. single-use flexible bronchoscopy in the peri-operative setting has yet to be determined. We therefore aimed to determine this and hypothesised that single-use flexible bronchoscopes are cost effective compared with reusable flexible bronchoscopes. We conducted a systematic review of the literature, seeking all reports of cross-contamination or infection following reusable bronchoscope use in any clinical setting. We calculated the incidence of these outcomes and then determined the cost per patient of treating clinical consequences of bronchoscope-induced infection. We also performed a micro-costing analysis to quantify the economics of reusable flexible bronchoscopes in the peri-operative setting from a high-throughput tertiary centre. This produced an accurate estimate of the cost per use of reusable flexible bronchoscopes. We then performed a cost effectiveness analysis, combining the data obtained from the systematic review and micro-costing analysis. We included 16 studies, with a reported incidence of cross-contamination or infection of 2.8%. In the micro-costing analysis, the total cost per use of a reusable flexible bronchoscope was calculated to be £249 sterling. The cost per use of a single-use flexible bronchoscope was £220 sterling. The cost effectiveness analysis demonstrated that reusable flexible bronchoscopes have a cost per patient use of £511 sterling due to the costs of treatment of infection. The findings from this study suggest benefits from the use of single-use flexible bronchoscopes in terms of cost effectiveness, cross-contamination and resource utilisation.

Personalized rheumatic medicine through dose reduction reduces the cost of biological treatment - a retrospective intervention analysis.

Objective: The effects of a dose-reduction intervention of biological disease-modifying anti-rheumatic drugs (bDMARDs) in patients in remission were analysed with epidemiology and health economics strategies. The aims were to analyse changes in bDMARD dosage, evaluate potential disease worsening, and estimate cost reduction. Method: This uncontrolled single-centre observational study analysed bDMARD-treated patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and spondyloarthritis (SpA). bDMARD expenditure constituted a proxy for bDMARD doses, which enabled group-level analysis. Interrupted time-series regression was used to analyse changes in treatment cost due to the dose reduction. Disease activity and treatment durations were monitored to investigate disease worsening. Results: In total, 997 biological treatment cases were analysed. This involved 527 bDMARD patients, where an unknown fraction of patients was given reduced doses. Disease activity of RA and PsA patients decreased from 2001 to 2009 and remained stable after that, while disease activity for SpA patients was unchanged, indicating no disease worsening from the intervention. The dose tapering resulted in decreased bDMARD expenditure, indicating a decrease in bDMARD consumption, which led to an accumulated cost reduction of 4 178 000 EUR. Conclusions: The results suggest that dose reduction can be safely performed in patients in treatment remission on a group level without compromising treatment efficacy. Subcutaneous bDMARDs, including abatacept, adalimumab, and etanercept, were observed to be well suited to customizing dosage. This study highlights the potential for individualized and personalized rheumatic medicine by providing dose reduction to individual patients, while monitoring disease activity.

The long-term effects of using telehomecare technology on functional health literacy: results from a randomized trial.

OBJECTIVES: The association between the use of telehomecare technology and functional health literacy is rather unexplored in the current literature. This relationship could prove important in the future management of chronic diseases, as technology has become a more integrated part of modern healthcare systems. Therefore, the purpose of this study was to explore how the use of telehomecare technology affects the level of functional health literacy over a period of 10 months. STUDY DESIGN: Randomized controlled trial. METHODS: Our sample comprised 116 patients diagnosed with chronic obstructive pulmonary disease. A face-to-face interview and an objective test of functional health literacy were conducted with each patient at baseline and again at follow-up after 10 months. Twenty-six patients were lost to follow-up and thus, providing a total of 47 chronic obstructive pulmonary disease patients in the intervention group and 43 in the control group for this follow-up study. The level of functional health literacy was assessed with the Danish Test of Functional Health Literacy in Adults. The difference from baseline to follow-up, in both the functional health literacy score and the mean response time to the entire Danish Test of Functional Health Literacy in Adults (TOFHLA), was tested for statistical significance between the intervention group and the control group. RESULTS: A significant increase in functional health literacy is observed in both the groups from baseline to follow-up, but there is no statistical difference between groups (P-value = 0.62). CONCLUSIONS: A significant increase in the functional health literacy score was observed in both groups, but the findings of this present study provide no information on what causes the increase, so further research is needed to explore the increase in functional health literacy score more thoroughly and establish if the use of telehomecare technology is a part of the explanation.

Cost-effectiveness analysis of sacral nerve stimulation as treatment for severe irritable bowel syndrome.

AIM: Early results from sacral nerve stimulation (SNS) for severe irritable bowel syndrome (IBS) are promising but estimates of cost-effectiveness are lacking. Our object was to perform a cost-effectiveness analysis for SNS as an alternative to no treatment of IBS. METHOD: This retrospective analysis was based on the results from a randomized controlled crossover study with a cost-utility analysis performed on patient-level data and modelling of censored data over a projected period of time of up to 20 years. The analysis was conducted on an intention-to-treat approach. For estimation of the uncertainty of the incremental cost-effectiveness ratio a bias corrected bootstrap analysis was performed. RESULTS: Cost-effectiveness was not reached for 4 years after permanent implantation (£31 270 per quality-adjusted life years), which was the upper limit for patient follow-up, but our data imply a cost-effectiveness from a 7-year perspective onwards. CONCLUSION: The study indicates the SNS treatment for IBS is cost effective from a 7-year perspective onwards.

Sensitivity of mGROWA-simulated groundwater recharge to changes in soil and land use parameters in a Mediterranean environment and conclusions in view of ensemble-based climate impact simulations.

This study examines the impact of changing climatic conditions on groundwater recharge in the Riu Mannu catchment in southern Sardinia. Based on an ensemble of four downscaled and bias corrected combinations of Global and Regional Climate Models (GCM-RCMs), the deterministic distributed water balance model mGROWA was used to simulate long-term mean annual groundwater recharge in the catchment for four 30-year periods between 1981 and 2100. The four employed GCM-RCM combinations project an adverse climatic development for the study area: by the period 2071-2100, annual rainfall will decrease considerably, while grass reference evapotranspiration will rise. Accordingly, ensemble results for our base scenario showed a climate-induced decrease in the median of annual groundwater recharge in areas covered by Macchia from 42-48mm/a to 25-35mm/a between the periods 1981-2010 and 2071-2100, corresponding to a reduction of 17-43%. To take into account the influence of additional plant available water storage in weathered bedrock on groundwater recharge generation, the model was extended by a regolith zone for regions covered by Mediterranean Macchia. In a set of model runs ("scenarios"), parameter values controlling the water storage capacity of this zone were increased step-wise and evaluated by comparison to the base scenario to analyze the sensitivity of the model outcome to these changes. The implementation of a regolith zone had a considerable impact on groundwater recharge and resulted in a decrease of the median in annual groundwater recharge: by 2071-2100, the 35% scenario (available water content in the regolith of 3.9 to 5.7vol.%) showed a reduction of 67-82% as compared to the period 1981-2010 in the base scenario. In addition, we also examined the influence of changes in the crop coefficients (Kc) as well as different soil texture distributions on simulated groundwater recharge.

Cost-effectiveness of ultrasound vs nerve stimulation guidance for continuous sciatic nerve block.

BACKGROUND: This study assessed the cost-effectiveness of ultrasound (US) vs nerve stimulation (NS) guidance for continuous sciatic nerve block in Danish elective patients undergoing major foot and ankle surgery. METHODS: > A cost-effectiveness analysis was conducted alongside a randomized controlled trial. A total of 100 consecutive patients were randomly assigned to either traditional electrical NS or US technique for catheter insertion guidance. Information on effects and costs were collected prospectively. An incremental cost-effectiveness ratio (ICER) was calculated as the extra cost per extra successful nerve block. The robustness of the ICER was investigated using 4000 non-parametric bias-corrected bootstrap replicates to calculate the likelihood that US leads to better effect and lower costs compared with NS guidance. RESULTS: The mean ICER was negative, indicating that US was a dominating technology providing both higher quality and lower costs. The likelihood of US being more effective and cheaper than NS was estimated to 84.7%. CONCLUSIONS: In this trial, US was cost-effective. Assuming that the results are fairly generalizable, US should be the preferred catheter insertion technique in larger anaesthesia departments.

Cost-effectiveness of transanal irrigation versus conservative bowel management for spinal cord injury patients.

STUDY DESIGN: Cost-effectiveness analysis following international guidelines and taking the societal viewpoint. OBJECTIVES: To estimate the cost-effectiveness of transanal irrigation using a self-administered irrigation system when compared with conservative bowel management. SETTING: A randomized clinical trial was conducted at five spinal centres situated in Denmark, Germany, Italy, United Kingdom and Sweden. Estimates of resources and unit costs were made for the German health care system. METHODS: Efficacy outcomes were drawn from a randomized controlled trial conducted in 2003-2005. Adult spinal cord-injured patients with neurogenic bowel dysfunction were randomized to 10 weeks with either transanal irrigation using Peristeen Anal Irrigation or to conservative bowel management. Costs were calculated based on results from the clinical trial and on 24 interviews conducted in Germany. Unit costs were obtained from the Federal Statistical Office Germany and product list prices. RESULTS: When comparing outcome measures at termination, transanal irrigation significantly reduced symptoms of neurogenic bowel dysfunction. Product-related costs were higher for transanal irrigation using the self-administered system; however, costs for a carer to help with bowel management and changes/washing due to leakage were lower. For transanal irrigation, costs associated with urinary tract infections and patient time spent were reduced. Thus, the total cost to society is lower when patients use transanal irrigation. The results were shown to be robust in the sensitivity analysis. CONCLUSION: Transanal irrigation using a self-administered system reduces symptoms of neurogenic bowel dysfunction and results in a lower total cost to society than conservative bowel management. SPONSORSHIP: The study was supported by Coloplast A/S.

Discordance between intramuscular triglyceride and insulin sensitivity in skeletal muscle of Zucker diabetic rats after treatment with fenofibrate and rosiglitazone.

AIM: Intramyocellular triglyceride (IMTG) correlates with insulin resistance, but there is no clear causal relationship. Insulin resistance and associated hyperinsulinaemia may increase IMTG, via the insulin-regulated transcription factor, sterol regulatory element-binding protein 1 (SREBP-1). PPAR agonists may also affect IMTG via changes in insulin sensitivity, SREBP-1 or other factors. METHODS: We examined skeletal muscle IMTG and SREBP-1 expression, and metabolic parameters in Zucker diabetic fatty rats (ZDF) after 25 weeks of PPAR-gamma or PPAR-alpha administration. RESULTS: Compared with Zucker lean rats (ZL), untreated ZDF had significantly higher weights, serum glucose, insulin, free fatty acids, total cholesterol and triglycerides. IMTG and SREBP-1c messenger RNA (mRNA) were also higher in untreated ZDF; both were decreased by fenofibrate (FF). Rosiglitazone (Rosi), despite marked improvement in glycaemia, hyperinsulinaemia and hyperlipidaemia, failed to affect SREBP-1 expression, and increased body weight and IMTG. Rosi/FF combination caused less weight gain and no IMTG increase, despite metabolic effects similar to Rosi alone. CONCLUSIONS: IMTG and SREBP-1c mRNA are high in the ZDF. FF and Rosi both improved insulin sensitivity but had opposite effects on IMTG. Thus, there was a clear discordance between insulin sensitivity and IMTG with PPAR agonists, indicating that IMTG and insulin sensitivity do not share a simple relationship.

Dementia with impaired temporal glucose metabolism in late-onset metachromatic leukodystrophy.

An unusual case of very-late-onset metachromatic leukodystrophy (MLD) with dementia was studied. The patient was a 41-year-old male who presented with mild dementia and a single generalized tonic clonic seizure. Neuropsychological assessment demonstrated mild amnesia, visuospatial dysfunction and attention deficits with a slow psychomotor speed. MR brain imaging displayed confluent hyperintensities of periventricular and subcortical white matter. Low levels of arylsulfatase A confirmed the diagnosis. Impaired cortical glucose metabolism especially of the medial temporal and frontal cortices was observed using positron emission tomography and fluor-18-labeled fluorodesoxyglucose. The neuropsychological deficits are related to the location of deficits in glucose metabolism.

Peer reviewed: making watershed management work.

New York City's watershed management strategy is unprecedented in its scope, scale, and cost.

Pain and new cultural diseases.

The purpose of this article is to recount a piece of medical history, even though it has been told many times before. Everyone has heard about patients who visit their doctors time and again with physical complaints without the physician being able to find an adequate organic cause. The oldest descriptions of this illness can be found on ancient Egyptian papyrus rolls, dating back to about the year 1900 BC (Shorter F. A history of psychosomatic illness in the modern era. New York: Macmillan; 1992). The need to tell these stories repeatedly can be attributed to the chameleonic nature of the illness which is difficult to spot because of its changing expression, which one could say takes on the appearance of its surroundings. Throughout history, humans have had the capacity to develop symptoms almost identical with the real diseases of the time. The term somatize is often used descriptively about patients with physical complaints without any recognizable organic basis. Shorter proposes that mankind has a shared "symptom-pool" containing all existing symptoms. Patients who convert their mental state into bodily symptoms--somatization--take their symptoms from this symptom-pool, albeit it is possible for new symptoms to emerge. For centuries patients have presented with sensory symptoms such as paresthesias. In the 19th century patients began to exhibit motorial symptoms with attacks of hysteria. According to Shorte's theory, this multitude of manifestations should be perceived as culturally determined or as different expressions of the same underlying phenomenon.

Peer reviewed: will risk-based cleanup work at navy facilities?

Process requirements include attention to long-term risk, public involvement, enforcement, and use of uncertainty analysis.

[A clinic for the study of dementia--110 consecutive patients]. / Klinik for demensudredning--110 konsekutive patienter.

Case reports of 110 patients referred to a neurological dementia clinic were reviewed to evaluate a standardized diagnostic program. The patients were evaluated by a neurologist, a gerontopsychiatrist, and a neuropsychologist. ICD-10 criteria were used. Fifty-two patients had dementia while 58 had not; of these, 27 suffered from other non-dementia diseases and 31 were without dementia or other psychiatric or neurological disease. Thirteen patients with Alzheimer's disease were treated with tacrine. Four patients underwent cobalamin substitution treatment and seven started antidepressant medication. Ten patients received acetylsalicylic acid (150 mg Q.D.) and two a levo-dopa-type drug. Twenty-six patients were followed by gerontopsychiatric district care. Because only 47% of the patients suspected of dementia actually fulfilled dementia criteria, the evaluation suggests that patients suspected of dementia benefit from a standardized diagnostic program in a specialist setting.

Appreciation of emotional expressions in the visual and auditory modality in normal and brain-damaged patients.

Right-handed patients with right-sided, left-sided or without brain lesions, were tested for their appreciation of pictures of faces and tape-recorded voices carrying emotional expressions. The right hemisphere group was impaired in relation to the left and normal group. On the auditory test the impaired right-sided group showed confusion of all emotional categories. On the visual test, the same patients evaluated all emotional qualities to be happy or neutral. It is suggested that different mechanisms explain these findings: one of defective perceptual analysis, prominent in the auditory test, and one of change of mood in an euphoric direction specific to patients suffering damage to the right hemisphere.