Towards low-cost QEPAS sensors for nitrogen dioxide detection.

Increasing awareness of the adverse health effects of air pollution leads to a demand of low-cost sensors for the measurement of pollutants such as NO2. However, commercially available low-cost sensors lack accuracy and long-term stability, and suffer from cross-sensitivity to other gases. These drawbacks can be overcome by the method of quartz-enhanced photoacoustic spectroscopy (QEPAS). In QEPAS modulated light is absorbed by the NO2 molecules, which results in the production of a sound wave. The sound wave is detected by resonance of a quartz tuning fork, which results in a measurable electric signal. Due to the small size of the tuning forks, the gas sensing element can be smaller than 1 cm3. We present the first bare fork QEPAS setup for the ppb-level detection of NO2, which is ideally suited for environmental trace gas detection without the need of using micro-resonators. Micro-resonators are commonly used to amplify photoacoustic signals. However, micro-resonators have different dependencies on environmental conditions than tuning forks, which makes them difficult to operate in changing conditions. In contrast, our bare fork QEPAS setup is more robust and easily adopted by the use of a low-cost temperature and humidity sensor. By using acoustic filters the integration time could be increased to offer higher sensitivity at a continuous flow rate of 200 std cm3 min-1. The 1σ noise equivalent concentration is determined to 21 ppb NO2 in synthetic air for 120 s measurement time, allowing detection which satisfies international health and safety standards thresholds.

Cost-effectiveness of fine-needle aspiration cytology (FNAC) and watchful observation for incidental thyroid nodules.

OBJECTIVES: A trial-based comparison of the use of resources, costs and health utility outcomes of fine-needle aspiration cytology (FNAC), and watchful observation for incidental small (< 2 cm) thyroid nodules was performed using data from the randomized controlled trial (RCT). METHODS: Using data from 314 patients, healthcare-related use of resources, costs, health utility, and quality-adjusted life years (QALYs) were estimated at 12 months after first presentation of incidental thyroid nodule(s) on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for FNAC versus watchful management at 12 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data. RESULTS: FNAC management was associated with greater use of healthcare resources and mean direct healthcare costs per patient (US$542.47 vs US$411.55). Lower mean 12-month QALYs per patient in FNAC was observed in comparison to watchful observation (0.752 versus 0.758). The probability that FNAC management was cost-effective compared with watchful management at a willingness-to-pay threshold of US50,000 per QALY gained was 26.5%. CONCLUSION: Based on 12-month data from RCT, watchful observation appeared cost-saving compared to FNAC in patients with incidental thyroid nodules that have a low-suspicion sonographic pattern and measure between 1.0 and 2.0 cm from healthcare provider perspective. CLINICALTRIALS. GOV IDENTIFIER: NCT02398721.

Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America.

BACKGROUND: The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA). METHODS: The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting. RESULTS: One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups. CONCLUSIONS: Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.

Initial attributable cost and economic burden of clinically-relevant differentiated thyroid cancer: A health care service provider perspective.

BACKGROUND: Rapid rise in differentiated thyroid cancer (DTC) may impose a heavy economic burden on future healthcare. We aimed to calculate the average first-year monetary cost/patient for DTC and estimate the projected cost burden on our local healthcare system. METHODS: Medical records of 270 clinically-relevant DTC patients were reviewed to calculate the amount of services utilized during the first-year. Only direct costs were included with estimates derived from government gazette. Cancer incidences were derived from the territory-wide cancer registry. Total annual cost equaled to the incidence multiplied by the cost/patient. RESULTS: The average first-year cost of DTC was USD11,560/patient. Initial surgery accounted for 66.9% of total cost. Male and female annual percentage increases for DTC were 4.86% and 4.28%, respectively. Female DTC is projected to surpass rectal cancer in 2019 (20.4/100,000 vs. 20.0/100,000) and colon cancer (47.2/100,000 vs. 46.8/100,000) in 2039. However, the projected incidence of DTC in 2026 would still be about one fourth that of CRC (19.5/100,000 vs. 83.2/100,000). CONCLUSIONS: The average first-year monetary cost of DTC care was relatively low. Initial surgery accounted for most of the cost. Despite a rapid incidence rise, the projected first-year cost for DTC is unlikely to impose substantial economic burden on our local future healthcare system.

Bone mineral density in juvenile dermatomyositis: assessment using dual x-ray absorptiometry.

OBJECTIVE: To determine the bone mineral density (BMD) status of our juvenile dermatomyositis (DM) population and to compare the frequency of osteopenia in patients with active disease requiring corticosteroids with that in patients with inactive disease who are not receiving corticosteroids. METHODS: Medical charts of all children diagnosed as having juvenile DM at our institution between 1989 and 1999 were reviewed for demographic and clinical data, including disease activity and duration of corticosteroid therapy. BMD measurements of the lumbar spine (L1-L4) were performed using dual x-ray absorptiometry (DXA). Z scores were calculated from the BMD data for comparison with published normative data. RESULTS: A total of 15 patients were assessed: 10 with active disease, and 5 with inactive disease who had not taken corticosteroids for an average of 6.0 years (range 3.4-8.1 years). Baseline BMD measurements demonstrated osteopenia or frank osteoporosis in the majority of patients, including 6 of the 10 patients with active disease and 4 of the 5 patients whose disease was in remission. Fourteen patients had serial BMD measurements. Persistent or worsening osteopenia was documented in all patients who had ongoing active disease, except for 3 patients who had been treated with bisphosphonates because of vertebral compression fractures. CONCLUSION: Osteopenia is common in patients with juvenile DM, and it usually worsens with ongoing disease. It can persist for many years after the disease enters remission. Bisphosphonates appeared to beneficially affect bone mineralization in our patients. Treatment to prevent the long-term complications of osteoporosis in patients with juvenile DM should be considered and requires further study.

[Structural quality of acute internal medicine rheumatology clinics--Project Group of the Association of Rheumatologic Acute Clinics]. / Strukturqualität akut-internistischer rheumatologischer Kliniken--Projektgruppenarbeit des VRA.

A study group representing the VRA (Association of Rheumatology Clinics in Germany) has worked out the structural quality paper presented here. Five guidelines for structural quality have been established by the VRA and are laid out in this paper. Required space and personnel for implementing these guidelines are considered. A highly competent, multi-disciplinary team must be available to ensure the long-term quality of in-patient treatment of rheumatic patients, the majority of whom are chronically ill and are suffering from chronic pain of varying intensity which restricts their daily activities. The necessity for such in-patient treatment is reflected in a 6-point-questionnaire (draft) adapted to the Appropriateness Evaluation Protocol. Considering the introduction of a flat-rate fee system (DRG-system) the structural quality paper describes the implementation of a specified electronic data processing documentation which is linked to a central hospital information system. According to the concept of benchmarking, the paper takes into account future developments of the German health system. It will be adjusted continuously to changing political guidelines for health services.

Assessment of indoor fine aerosol contributions from environmental tobacco smoke and cooking with a portable nephelometer.

Personal monitoring studies have indicated that environmental tobacco smoke (ETS) and cooking are major indoor particulate sources in residential and nonindustrial environments. Continuous monitoring of fine particles improves exposure assessment by characterizing the effect of time-varying indoor sources. We evaluated a portable nephelometer as a continuous monitor of indoor particulate levels. Simultaneous sampling with the nephelometer and PM2.5 impactors was undertaken to determine the relationship between particle light scattering extinction coefficient (sigma(sp)) and particle mass concentration in field and environmental chamber settings. Chamber studies evaluated nephelometer measurements of ETS and particles produced from toasting bread and frying foods. Field measurements were conducted in 20 restaurants and bars with different smoking restrictions, and in five residential kitchens. Additional measurements compared the nephelometer to a different mass measurement method, a piezobalance, in a well-characterized residence where various foods were cooked and ETS was produced. Since the piezobalance provides 2-min average mass concentration measurements, these comparisons tested the ability of the nephelometer to measure transient particle concentration peaks and decay rate curves. We found that sigma(sp) and particle mass were highly correlated (R2 values of 0.63-0.98) over a large concentration range (5-1600 microg/m3) and for different particle sources. Piezobalance and gravimetric comparisons with the nephelometer indicated similar sigma(sp) vs. mass slopes (5.6 and 4.7 m2/g for piezobalance and gravimetric comparisons of ETS, respectively). Somewhat different sigma(sp) vs. particle mass slopes (1.9-5.6 m2/g) were observed for the different particle sources, reflecting the influence of particle composition on light scattering. However, in similar indoor environments, the relationship between particle light scattering and mass concentration was consistent enough to use independent nephelometer measurements as estimates of short-term mass concentrations. A method to use nephelometer measurements to determine particulate source strengths is derived and an example application is described.

A new computer-assisted method for fabrication of crowns and fixed partial dentures.

The availability of high-technology systems that use computer-aided design and computer-aided machining is on the increase. One such system is the Procera system, which is currently providing cost-effective, high-quality dental restorative services to dental laboratories and to dentists. A reduction in cost to the dentist, and ultimately to the patient, is a major advantage of the Procera system. Cost benefits combined with its continued success in producing crowns and fixed partial dentures that meet professional standards of care should enhance the acceptance of this new technology.

The role of the implant impression in abutment selection: a technical note.

Selecting the abutment at second-stage implant surgery should combine the experience of both the surgeon and the restorative dentist to avoid complications during prosthetic reconstructions. If an inappropriate abutment is selected, the resultant removal of the abutment and replacement of it with a completely different one is both costly and inefficient. The availability of the healing abutment component has eliminated many of these problems. Making an impression at the implant level allows the dentist ample time to study the restorative needs before selecting the final abutment.

A review of traditional therapies in complete dentures.

The number of persons in the United States and Canada over 65 years of age who are edentulous and in need of complete dentures appears to be decreasing as a percent of the total population (by the year 2030), but the total number of patients needing these services will be almost the same as it is today. Administering complete denture prosthodontics to geriatric patients will continue to be a formidable part of the general dentistry practice well into the next century despite changing demographics. Careful dental evaluation of the patient through a well-structured examination and care based on sound principles and concepts continues to be the standard that must be provided. A lifetime commitment by the patient to a program of recall and maintenance for continuous monitoring of the dentures and the oral tissues is essential for older adult edentulous patients. We should periodically review these traditional therapies to improve our knowledge.

Guidelines for professional quality dentures for the financially disadvantaged.

The purpose of this project was to evaluate and report on the timing of procedures involved in complete denture service based on criteria for assessment of quality and to determine the effectiveness of a model of such a delivery system in terms of success of treatment and reduction of cost. It can be concluded that the denture care system may and can be used as a model to provide the base line reference to compare with other denture care delivery systems; the use of criteria for assessment of quality is not only efficient, but is also practical; and a complete denture treatment service of the quality defined by the criteria developed for this model can be provided to patients.