Cost-effectiveness of cognitive remediation and supported employment for people with mental illness: a randomized controlled trial.

BACKGROUND: Little is known about the economic benefits of cognitive remediation and supported employment (CR + SE). The present study aimed to investigate the cost-effectiveness of CR + SE compared with traditional vocational services (TVS). METHOD: Individuals with mental illness and low cognitive function were recruited at six sites in Japan. A total of 111 participants were randomly allocated to the CR + SE group or the TVS group. Clinical and vocational outcomes were assessed at baseline and 12-month follow-up. Service utilization data were collected monthly. The data on outcomes and costs were combined to examine cost-effectiveness. RESULTS: The data were obtained from a total of 92 participants. The CR + SE group resulted in better vocational and clinical outcomes (employment rate, 62.2%; work tenures, 78.6 days; cognitive improvement, 0.5) than the TVS group (19.1%, 24.9 days and 0.2). There was no significant difference in mean total costs between the groups (CR + SE group: $9823, s.d. = $6372, TVS group: $11 063, s.d. = $11 263) with and without adjustment for covariates. However, mean cost for medical services in the CR + SE group was significantly lower than that in the TVS group after adjusting covariates (Β = -$3979, 95% confidence interval -$7816 to -$143, p = 0.042). Cost-effectiveness acceptability curves for vocational outcomes illustrated the high probabilities (approximately 70%) of the CR + SE group being more cost-effective than TVS when society is not willing to pay additional costs. CONCLUSIONS: CR + SE appears to be a cost-effective option for people with mental illness who have low cognitive functioning when compared with TVS.

Using spatial metrics and surveys for the assessment of trans-boundary deforestation in protected areas of the Maya Mountain Massif: Belize-Guatemala border.

Understanding the trans-boundary deforestation history and patterns in protected areas along the Belize-Guatemala border is of regional and global importance. To assess deforestation history and patterns in our study area along a section of the Belize-Guatemala border, we incorporated multi-temporal deforestation rate analysis and spatial metrics with survey results. This multi-faceted approach provides spatial analysis with relevant insights from local stakeholders to better understand historic deforestation dynamics, spatial characteristics and human perspectives regarding the underlying causes thereof. During the study period 1991-2014, forest cover declined in Belize's protected areas: Vaca Forest Reserve 97.88%-87.62%, Chiquibul National Park 99.36%-92.12%, Caracol Archeological Reserve 99.47%-78.10% and Colombia River Forest Reserve 89.22%-78.38% respectively. A comparison of deforestation rates and spatial metrics indices indicated that between time periods 1991-1995 and 2012-2014 deforestation and fragmentation increased in protected areas. The major underlying causes, drivers, impacts, and barriers to bi-national collaboration and solutions of deforestation along the Belize-Guatemala border were identified by community leaders and stakeholders. The Mann-Whitney U test identified significant differences between leaders and stakeholders regarding the ranking of challenges faced by management organizations in the Maya Mountain Massif, except for the lack of assessment and quantification of deforestation (LD, SH: 18.67, 23.25, U = 148, p > 0.05). The survey results indicated that failure to integrate buffer communities, coordinate among managing organizations and establish strong bi-national collaboration has resulted in continued ecological and environmental degradation. The information provided by this research should aid managing organizations in their continued aim to implement effective deforestation mitigation strategies.

Quantitative assessment of provability of radiation-related cancers considering unavoidable existence of unadjusted risk factors.

The attribution of stochastic effects to exposure to ionizing radiation has been qualitatively discussed by introducing two distinct concepts of provability and probability. This study aims to develop a method of quantitatively assessing the provability of radiation-related cancers. To this end, the 'minimum provable dose' (MPD) was developed and applied to actual cancer mortality in Japan. The background lifetime risk of cancer mortality was calculated for the esophagus, stomach, colon, liver, lungs, skin, breasts, ovaries, bladder, and bone marrow as well as the age-specific risk coefficients reproducing those given in the 2007 Recommendations of the International Commission on Radiological Protection (ICRP). Comparing the relative ratio of MPDs, which was defined herein as the 'provability index' (PI), we quantitatively ranked radiation-related cancers for different tissues and organs predicated on provability for ages of 10, 30, 50, and 0-85+ years at exposure. We discuss the radiological protection of male emergency workers focusing on cancers highly prioritized according to the ranking (i.e. colon, bone marrow, and bladder). The present study proposed the system to quantitatively evaluate the level of radiological protection taking into account the variations of the background cancer risk on the provability of radiation-related cancers.

Systematic and quantitative assessment of the effect of chronic kidney disease on CYP2D6 and CYP3A4/5.

Recent reviews suggest that chronic kidney disease (CKD) can affect the pharmacokinetics of nonrenally eliminated drugs, but the impact of CKD on individual elimination pathways has not been systematically evaluated. In this study we developed a comprehensive dataset of the effect of CKD on the pharmacokinetics of CYP2D6- and CYP3A4/5-metabolized drugs. Drugs for evaluation were selected based on clinical drug-drug interaction (CYP3A4/5 and CYP2D6) and pharmacogenetic (CYP2D6) studies. Information from dedicated CKD studies was available for 13 and 18 of the CYP2D6 and CYP3A4/5 model drugs, respectively. Analysis of these data suggested that CYP2D6-mediated clearance is generally decreased in parallel with the severity of CKD. There was no apparent relationship between the severity of CKD and CYP3A4/5-mediated clearance. The observed elimination-route dependency in CKD effects between CYP2D6 and CYP3A4/5 may inform the need to conduct clinical CKD studies with nonrenally eliminated drugs for optimal use of drugs in patients with CKD.

Assessment of the coronary calcification by optical coherence tomography.

AIMS: Optical coherence tomography (OCT) can delineate calcified plaque without artefacts. The aim of this study was to evaluate the ability of OCT to quantify calcified plaque in ex vivo human coronary arteries. METHODS AND RESULTS: Ninety-one coronary segments from 33 consecutive human cadavers were examined. By intravascular ultrasound (IVUS), 32 superficial calcified plaques, defined as the leading edge of the acoustic shadowing appears within the most shallow 50% of the plaque plus media thickness, were selected and compared with corresponding OCT and histological examinations. The area of calcification was measured by planimetry. IVUS significantly underestimated the area of calcification compared with histological examination (y = 0.39x + 0.14, r = 0.78, p < 0.001). Although OCT slightly underestimated the area of calcification (y = 0.67x + 0.53, r = 0.84, p < 0.001), it showed a better correlation with histological examination than IVUS. CONCLUSIONS: Both OCT and IVUS underestimated the area of calcification, but OCT estimates of the area of calcification were more accurate than those estimated by IVUS. Thus, OCT may be a more useful clinical tool to quantify calcified plaque.

Health Risk Appraisal using Internet technology.

OBJECTIVE: To develop a Web-based Health Risk Appraisal (HRA) system as a tool for health education based on personal health examination data. METHODS: A Japanese health examination database was analyzed to develop models for HRA, which were designed to predict each of ten laboratory values in a year with and without lifestyle modifications. The HRA models were embedded into a server. RESULTS: The Web-based HRA system has been introduced into a Japanese health care association having 37 branch centers. Following a health examination, an individual health education program using the Web-based HRA system is provided to a given client at each branch center or at a client's office. A measured laboratory value and corresponding predicted laboratory values in a year with and without lifestyle modifications are displayed on the screen in forms of both numerical values and graphs. A trained nurse or another health care provider operates the system and explains the HRA result. CONCLUSION: The Web-based HRA system will be a practical tool for individual health education following health examination.

The present and future organisation of Veterinary Services in Asia: the examples of the Republic of Korea and Japan.

The Veterinary Services of the Republic of Korea and Japan are reviewed and summarised. To cope with ever-increasing demands on Veterinary Services, both countries have made continued efforts to expand the services, which currently only have a limited number of government personnel. To overcome some of the problems associated with international trade, e.g. outbreaks of foot and mouth disease and classical swine fever (hog cholera), the authorities of the Republic of Korea are considering strengthening quarantine services by combining the National Veterinary Research and Quarantine Service and the National Plant Quarantine Service of the Ministry of Agriculture and Forestry (MAF). In the field of veterinary public health services, the Republic of Korea and Japan have different organisational structures. All Veterinary Services, including veterinary public health, are kept within the MAF in the Republic of Korea, whereas in Japan, the Ministry of Agriculture, Forestry and Fisheries (MAFF) deals with general animal production and health services and the Ministry of Health, Labour and Welfare (MHLW) deals with the safety of animal products, food poisoning and the prevention/control of zoonoses, such as rabies and Q fever. In Japan, after the occurrence of bovine spongiform encephalopathy in 2001, the authorities undertook a thorough review of the Veterinary Services, focusing particularly on food safety. A reorganisation of the administrative structure was proposed, and will be completed by the end of 2003. Subject to the approval of the Diet (House of Councillors), an independent 'Food Safety Commission' will be created within the cabinet office which will undertake risk analyses related to foods, and risk management will be carried out by the relevant ministry, i.e. the MAFF or the MHLW. The Animal Health Division of the MAFF will also be moved from the Livestock Industry Department to a new 'Consumer Safety Department' of the MAFF, where additional responsibilities in fish health control and feed safety control will be assumed.

Non-invasive automated assessment of the ratio of pulmonary to systemic flow in patients with atrial septal defects by the colour Doppler velocity profile integration method.

BACKGROUND: The recent introduction of the automated cardiac flow measurement (ACM) method, using spatiotemporal integration of the Doppler velocity profile, provides a quick and accurate automated calculation of cardiac output. OBJECTIVE: To evaluate the ACM method against oximetry during cardiac catheterisation for estimating the Qp/Qs (pulmonary to systemic flow) ratio in patients with an atrial septal defect. METHODS: Left and right ventricular stroke volume (LVSV, RVSV) were calculated by ACM in 22 patients with an atrial septal defect who underwent cardiac catheterisation and in 11 patients without heart disease (control group). With ACM, the Qp/Qs ratio was estimated from RVSV divided by LVSV. In the patients with an atrial septal defect, the Qp/Qs ratio was assessed by oximetry at the time of cardiac catheterisation. RESULTS: There was a good correlation between LVSV and RVSV obtained by ACM in the control group (r = 0.98, y = 0.97x + 0.25, SEE = 2.9 ml). The mean difference between LVSV and RVSV by ACM was -1.25 (2.76) ml. The Qp/Qs ratio obtained by ACM in the control group was 0.98 (0.06). The Qp/Qs ratio in patients with an atrial septal defect was significantly higher than in the control group (3.11 (1.20), p < 0.001). ACM determination of the Qp/Qs ratio correlated well with oximetry determination (r = 0.86, y = 0.75x + 0.55, SEE = 0.64). The mean difference between ACM and oximetry for the measurement of the Qp/Qs ratio was -0.28 (0.69). CONCLUSIONS: The newly developed ACM method is clinically useful for non-invasive automated estimations of the Qp/Qs ratio in patients with an atrial septal defect.

Cost effectiveness of reducing dioxin emissions from municipal solid waste incinerators in Japan.

The main sources of dioxin emissions are municipal solid waste incinerators. The Japanese national government has set an emission standard for dioxins to reduce dioxin exposure levels. In this study, cost-effectiveness analyses are carried out regarding countermeasures that were recently taken and are being taken at municipal solid waste incinerators in Japan. Annual costs were estimated by telephone survey and model calculations. Annual decrease in the incidence of cancer was estimated in three steps. First, the annual decrease in the volume of dioxin emissions was estimated. Next, using a mathematical model, the annual decrease in human exposure was estimated. Finally, the annual decrease in the incidence of cancer was estimated by applying the cancer slope factor. When annual costs are divided by the annual number of life-years saved, cost per life-year saved (CPLYS) was obtained. CPLYS was estimated to be 7.9 million yen for emergency countermeasures and 150 million yen for long-term countermeasures. However, it must be noted that these obtained CPLYSs are highly dependent on the cancer slope factor and should be considered as an upper limit since there may be a cancer effect threshold.

Effect of scattered radiation on image noise in cone beam CT.

Cone beam CT has a capability for the 3-dimensional imaging of large volumes with isotropic resolution, and has a potentiality for 4-dimensional imaging (dynamic volume imaging), because cone beam CT acquires data of a large volume with one rotation of an x-ray tube-detector pair. However, one of the potential drawbacks of cone beam CT is a larger amount of scattered x-rays, which may enhance the noise in reconstructed images, and thus affect the low-contrast detectablity. Our aim in this work was to estimate the scatter fractions and effects of scatter on image noise, and to seek methods of improving image quality in cone beam CT. First we derived a relationship between the noise in a reconstructed image and in an x-ray intensity measurement. Then we estimated the scatter to primary ratios in x-ray measurements using a Monte-Carlo simulation. From these we estimated the image noise under relevant clinical conditions. The results showed that the scattered radiation made a substantial contribution to the image noise. However, focused collimators could improve it by decreasing the scattered radiation drastically while keeping the primary radiation at nearly the same level. A conventional grid also improved the image noise, though the improvement was less than that of focused collimators.

[Assessment of the new TNM classification for resected lung cancer].

To evaluate the revised TNM classification, we investigated the prognoses of 552 consecutive patients who had resection of non-small-cell lung cancer between April 1982 and March 1996. According to the new classification, the 5-year survival rate was 76.9% for stage I A, 57.2% for stage I B (I A versus I B, p < 0.0005), 47.7% for stage IIA, 49.8% for stage IIB, 18.6% for stage IIIA (IIB versus IIIA, p = 0.005), 16.7% for stage IIIB, and 7.9% for stage IV (IIIB versus IV, p = 0.02). Especially for patients in stage I A, there was significant difference in survival between patients with the tumor size within 1.5 cm and those with larger than 1.5 cm. The survival rate for T3N0M0 patients was significantly better than that for T3N1-2M0, but there was no significant difference between patients with T3N0M0 disease and those with T2N1M0 disease. Concerning the pm1 patients, the survival rate was significantly better than other stage IIIB patients. Our results supported the revision for dividing stage I and putting T3N0M0 into stage IIB. However, the classification is controversial about dividing stage II and putting pm1 as T4 disease. Furthermore, subgrouping of T1N0M0 disease by tumor size, T3 by tumor invaded organ will be necessary in the next revisions.

Subjective symptoms acquisition system in a health promotion system for the elderly. Committee of System Development, Council of Japan AMHTS Institutions.

A previous report was concerned with the evaluation of quality of life using a Health Promotion System for the Elderly. In the present report, we describe one part of that system: a subjective symptoms acquisition and reporting system. The main purpose of this system is to permit any physician or nurse to uniformly employ questionnaires to acquire accurate subjective symptoms. This system is applied in three steps. First, the subjective answers to 21 questions displayed on a personal computer are obtained. These answers correspond to the basic subjective symptoms. Second, if a basic subjective symptom is "positive", more detailed questions are automatically generated. Finally, clear sentences regarding subjective symptoms are generated and output as a "finding report". This information is helpful to physicians and nurses in their health-counseling work. An artificial intelligence (AI) program based on "XpertRule" produces detailed questions which are generated by an interactive questionnaire using branching logical rules.

Assessment of human health risk of dioxins in Japan.

The human health risk of dioxins was evaluated for four Japanese receptor groups: the general population, local residents living near a municipal solid waste incinerator, heavy fish consumers, and their infants and fetuses. In describing the risk for these groups, four endpoints, namely, cancer, reproductive dysfunction, endometriosis and neurobehavioral effect, were considered, and the incremental cancer risk and margin of exposure (MOE) corresponding to these endpoints were calculated, based on three measures of dosimetry; average daily intake, area under the curve, and body burden. The uncertainties of these risk descriptors were also evaluated by probabilistic analysis. Although the estimated risk of cancer and reproductive dysfunction were not exceptionally high in the three adult receptor groups, the MOE values for endometriosis were not sufficiently high to guarantee safety against this endpoint. Furthermore, the MOE values for neurobehavioral effects on infants and fetuses suggest that dioxins may cause a considerable risk to those of local residents and heavy fish consumers.

Cost-effectiveness analysis of prostate cancer screening.

To determine the optimal strategy for prostate cancer screening, the cost-effectiveness of screening was analyzed using a medical decision model. One hundred thousand asymptomatic males between the ages of 40 and 69 were modeled with and without screening. The subjects were divided into three 10-year age groups. We used a 5-year survival rate as an effectiveness point and assumed after 5 year survival free from prostate cancer. We considered three potential programs: 1) screening with digital rectal examination (DRE), 2) screening with prostate specific antigen (PSA), and 3) screening with a combination of DRE and PSA. The study was analyzed from the payer's perspective, and only direct medical costs were included. For each of the three age groups, PSA screening was more cost-effective than either DRE screening or a combination of DRE and PSA screening. The cost-effectiveness ratio for the combination of DRE and PSA screening was 1.1-2.3 times more expensive dian that of PSA screening. If the compliance rate for work-up exams is 80%, the cost-effectiveness of prostate cancer screening is approximate to that of gastric cancer screening. In conclusion, PSA screening is the most cost-effective strategy for prostate cancer screening when compared with both DRE and the combination of DRE and PSA screening. But prostate cancer screening should be carefully conducted, taking the cost-effectiveness of the different strategies and target groups into consideration.

Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy.

BACKGROUND: Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear. PATIENTS AND METHODS: Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS: Injury to a large branch of the middle hepatic vein adjacent to the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS: Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound.

Economic evaluation of alternative indicators for screening for diabetes mellitus.

BACKGROUND: the optimal indicator for screening for diabetes mellitus without relying on fasting conditions was clarified. METHODS: the subjects were 891 men ages 26 through 80 years (48.5 +/- 8.5). The objectives of this study were (1) to elucidate the efficacy of 1,5-anhydroglucitol (1,5-AG), glycosylated hemoglobin, and fructosamine (FRA) as screening tests for non-insulin-dependent diabetes mellitus (NIDDM) or for impaired glucose tolerance (IGT) and (2) to perform an economic evaluation for each indicator. The efficacy of each indicator was evaluated by drawing the receiver operating characteristic curves and calculating the areas under these curves (AUCs). An original model was developed for the pur pose of cost-effectiveness analysis. RESULTS: each indicator was evaluated as a screening test for NIDDM alone and for both IGT and NIDDM. The AUCs of 1,5-AG and fasting plasma glucose were the largest in the case of the detection of NIDDM alone and the detection of both IGT and NIDDM, respectively. FRA was, however, the most cost-effective in Japan. CONCLUSION: using equations, we indicated the equi librium points at which the cost-effectiveness ratios of each indicator intersected in order to generalize the results. By calculating the appropriate-actual ratios of costs for each indicator, we could ascertain the optimal indicator for each country.

Easy assessment of ES cell clone potency for chimeric development and germ-line competency by an optimized aggregation method.

Production of germ-line competent chimeric mice from embryonic stem (ES) cells is an inevitable step in establishing gene-manipulated mouse lineages. A common method used for creating chimeric mice is the injection of ES cells into the blastocoelic cavity (blastocyst injection). The aggregation method is an alternative way to introduce ES cells to the host embryo which is less difficult than blastocyst injection. Here we re-examined the condition of embryo-ES cell coculture on the aggregation method and found improvement of germ-line competent chimeric production by a simple modification of the coculture medium. Moreover, R1 ES cell and its 10 gene-manipulated subclones were tested by this method. Although all ES cell clones showed good morphology and a normal karyotype, the efficiency of chimeric development and germ-line transmission varied among clones and were classified into three grades according to germ-line competency. In the first group (class A), both the incidence of chimera with high ES cell contribution and the rate of germ-line transmission were fairly high. Germ-line competent chimeras were obtained but with rather low efficiency in the second group (class B), while another group (class C) showed an absence of high ES cell-contributed chimeras and no germ-line transmission. These results suggest the usefulness of this modified aggregation method to predict the potency of ES cell clones for germ-line competency.

Noninvasive assessment of hemodynamic subsets in patients with acute myocardial infarction using digital color Doppler velocity profile integration and pulmonary venous flow analysis.

Four major hemodynamic subsets from cardiac index (CI) and mean pulmonary artery (PA) wedge pressure with a PA catheter usually reflect clinical status and prognosis of patients with acute myocardial infarction (AMI). Recently, a new color Doppler technique has been developed for automated cardiac output measurements (ACOM). Color Doppler echocardiography also provides noninvasive estimation of PA wedge pressure from pulmonary venous (PV) flow analysis. This study evaluates the value of ACOM and PV flow analysis by color Doppler echocardiography for the assessment of hemodynamic subsets in patients with AMI. We performed ACOM and PV flow analysis by color Doppler echocardiography in 55 patients with AMI who underwent hemodynamic assessment with a PA catheter. From both noninvasive and invasive methods, we classified hemodynamic subsets as follows: subset I: normal hemodynamics (CI >2.2 L/min/m2, PA wedge pressure < or =18 mm Hg); subset II: pulmonary congestion (CI >2.2 L/min/m2, PA wedge pressure >18 mm Hg); subset III: peripheral hypoperfusion (CI < or =2.2 L/min/m2, PA wedge pressure < or =18 mm Hg); and subset IV: pulmonary congestion and peripheral hypoperfusion (CI < or =2.2 L/min/m2, PA wedge pressure >18 mm Hg). Doppler assessment of hemodynamic subsets was possible in 50 of 55 patients (91%). CI from ACOM correlated well with that from the thermodilution method (r = 0.94) with close agreement. There was a good correlation between the systolic fraction (systolic velocity-time integral expressed as a fraction of the sum of systolic and diastolic velocity-time integrals) of PV flow and PA wedge pressure measured from cardiac catheterization (r = -0.83). When we determined the value of 45% in the systolic fraction as the cut-off point in predicting >18 mm Hg in PA wedge pressure, there was 90% (45 of 50 patients) agreement between noninvasive and invasive hemodynamic subsets. Thus, ACOM and PV flow analysis by color Doppler echocardiography is useful in the noninvasive assessment of hemodynamic subsets in patients with AMI.

New approach in the evaluation of a fitness program at a worksite.

The most common methods for the economic evaluation of a fitness program at a worksite are cost-effectiveness, cost-benefit, and cost-utility analyses. In this study, we applied a basic microeconomic theory, "neoclassical firm's problems," as the new approach for it. The optimal number of physical-exercise classes that constitute the core of the fitness program are determined using the cubic health production function. The optimal number is defined as the number that maximizes the profit of the program. The optimal number corresponding to any willingness-to-pay amount of the participants for the effectiveness of the program is presented using a graph. For example, if the willingness-to-pay is $800, the optimal number of classes is 23. Our method can be applied to the evaluation of any health care program if the health production function can be estimated.