Advance care planning for patients undergoing gastrostomy tube procedures; prevalence, outcomes, and disparities.

BACKGROUND: Advanced care planning (ACP) is the process of establishing goals for end-of-life care. We aimed to examine ACP's prevalence, associated factors, and impact in a cohort of patients undergoing gastrostomy tube procedures. METHODS: Adult patients who underwent gastrostomy tube placement from 2016 to 2021 â€‹at a tertiary center were identified. Variables evaluated included age, sex, race, comorbidities, and median income of patient home zip code. Primary outcomes included the presence of ACP, length of stay (LOS), and 90-day mortality. Analysis was performed using independent T tests, Mann Whitney U-tests, and Chi Square analysis. ACP, LOS, and 90-day mortality were analyzed with multivariate analysis. RESULTS: 877 patients underwent gastrostomy tube placement and 10.6 â€‹% had ACP. Black race was an isolated factor negatively associated with ACP (OR 0.423, p â€‹= â€‹0.013). There was no difference in the proportion of patients with or without ACP who died within 90 days of the procedure (17 â€‹% vs. 15 â€‹%, p â€‹= â€‹0.836). Average LOS was 6 days shorter for patients with ACP (p â€‹< â€‹0.001). CONCLUSION: This study highlights the significant underutilization and racial disparity in ACP, and found that ACP does not negatively impact outcomes or perioperative mortality for patients undergoing gastrostomy tube placement.

Characterisation of burden of illness measures associated with human (Fluoro)quinolone-resistant Campylobacter spp. infections - a scoping review.

Campylobacter spp. are one of the most common causes of bacterial gastroenteritis in Canada and worldwide. Fluoroquinolones are often used to treat complicated human campylobacteriosis and strains of Campylobacter spp. resistant to these drugs are emerging along the food chain. A scoping review was conducted to summarise how human (fluoro)quinolone-resistant (FQR; quinolones including fluoroquinolones) Campylobacter spp. infections are characterised in the literature by describing how burden of illness (BOI) associated with FQR is measured and reported, describing the variability in reporting of study characteristics, and providing a narrative review of literature that compare BOI measures of FQR Campylobacter spp. infections to those with susceptible infections. The review identified 26 studies that yielded many case reports, a lack of recent literature and a lack of Canadian data. Studies reported 26 different BOI measures and the most common were hospitalisation, diarrhoea, fever and duration of illness. There were mixed results as BOI measures reported in literature were inconsistently defined and there were limited comparisons between resistant and susceptible infections. This presents a challenge when attempting to assess the magnitude of the BOI due to FQR Campylobacter spp., highlighting the need for more research in this area.

SMART SKY EYE System for Preliminary Structural Safety Assessment of Buildings Using Unmanned Aerial Vehicles.

The development of unmanned aerial vehicles (UAVs) is expected to become one of the most commercialized research areas in the world over the next decade. Globally, unmanned aircraft have been increasingly used for safety surveillance in the construction industry and civil engineering fields. This paper presents an aerial image-based approach using UAVs to inspect cracks and deformations in buildings. A state-of-the-art safety evaluation method termed SMART SKY EYE (Smart building safety assessment system using UAV) is introduced; this system utilizes an unmanned airplane equipped with a thermal camera and programmed with various surveying efficiency improvement methods, such as thermography, machine-learning algorithms, and 3D point cloud modeling. Using this method, crack maps, crack depths, and the deformations of structures can be obtained. Error rates are compared between the proposed and conventional methods.

Deterring illegal smartphone use while driving: Are perceptions of risk information associated with the impact of informal sanctions?

Advertising campaigns have used threat appeals to increase the perceptions of risk associated with dangerous driving behaviours. Building on recent research that suggests increasing the pertinence of informal sanctions (sense of guilt, fear of peer disapproval, or fear of hurting oneself and others) decreases the likelihood of illegal smartphone engagement while driving, this study aimed to determine if perceptions of risk information, that is, how effective drivers believe the information is in deterring their illegal use, is associated with perceptions of informal sanctions. An online survey of 1027 Victorians who self-reported illegal smartphone use while driving asked participants to rate the personal deterrent effectiveness of five types of risks associated with illegal smartphone use while driving. A hierarchical linear regression model explored the associations between the most effective risks and each informal sanction. Female drivers were more likely than male drivers to experience guilt, fear of social loss and fear of physical loss when using their smartphones illegally. More frequent illegal smartphone engagement while driving was associated with decreased impact of informal sanctions. Female drivers were more likely than male drivers to perceive each risk as effective. The most effective piece of information was, "Contributes to 16% of Victorian road deaths and serious injuries annually"; it was also the least known (32.7% males, 26.7% females). This message, alongside, "Increases risk of a crash comparable to those associated with driving under the influence of alcohol or cannabis" and, "A 2 s glance at your phone while driving at 50 km/h effectively means driving blind for 27 m", were associated with stronger perceptions of guilt, fear of peer disapproval, or fear of hurting oneself and others when thinking about using a smartphone illegally while driving. These results suggest tailoring and targeting these specific risk information may be effective in deterring illegal smartphone use while driving.

Cost-Benefit Analysis of Robotic vs. Laparoscopic Hepatectomy: A Propensity-Matched Retrospective Cohort Study of American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Robotic and laparoscopic hepatectomies having increased utilization as minimally invasive techniques are explored for hepatobiliary malignancies. Although the data on outcomes from these 2 approaches are emerging, the cost-benefit analysis of these approaches remains sparse. This study compares the costs associated with robotic vs. laparoscopic liver resections, taking into account 30-day complications. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, a propensity-matched cohort of patients with laparoscopic or robotic liver resections between 2014 and 2017 was identified. Costs were assigned to perioperative variables, including operating room (OR) time, length of stay, blood transfusions, and 30-day complications. Cost estimates were obtained from the Centers for Medicare and Medicaid Services billing data (2017), American Hospital Association data (2017), relevant literature, and local institutional cost data. RESULTS: In our matched cohort of 454 patients (227 per group), total costs associated with laparoscopic liver resections were estimated at $5.5 M ($24 K per patient) vs. $6.8 M ($29.8 K per patient) for robotic liver resections (21.3% difference, P < .001). The higher cost associated with robotic hepatectomies was related to blood transfusions ($22.0 K vs. $12.1 K, P = .02), length of stay ($2.05 M vs. $1.76 M, P = .046), and OR time ($4.01 M vs. $3.24 M, P < .0001). DISCUSSION: Robotic hepatectomies were associated with higher costs compared to laparoscopic hepatectomies. The 2 major contributors to the cost disparity were increased OR time and increased length of stay. Future studies are warranted to analyze high-volume Minimally Invasive Surgery surgeons' impact in specialty centers on potentially mitigating this current cost disparity.

Understanding the deterrent impact formal and informal sanctions have on illegal smartphone use while driving.

The illegal use of a smartphone while driving increases the risk of crashes. As such, road authorities rely on countermeasures to reduce illegal smartphone use. Deterrence-based methods dominate road safety, however, perceptions and impact of formal (legal) and informal (non-legal) methods to deter illegal smartphone use in Australia have not yet been explored. The current study reports on a survey of 2774 drivers (47.0 % males) that own and regularly use a smartphone. The survey analysed the self-reported frequency of illegal smartphone use while driving, perceptions of formal and informal deterrence mechanisms, differences between perceived and informed deterrence, and deterrent predictors of illegal use. The findings revealed that illegal smartphone use is increasing in Victoria, Australia. Drivers that break the law perceive deterrent mechanisms significantly different from drivers that abide by the law, however, both groups view the prospect of hurting oneself as most impactful. Additionally, drivers tend to underestimate the consequences of illegal use, yet overestimate the certainty of apprehension. A binary logistic regression analysis revealed that only age, gender and informal sanctions such as social loss (stigma/peer disapproval), internal loss (shame/guilt/embarrassment), and physical loss (injury/property damage) were significant predictors of illegal use. None of the formal mechanisms were significant. Based on these findings, road safety interventions and future research should consider exploring the psychological characteristics of young people's perceptions of informal sanctions such as social loss (shame/embarrassment) and internal loss (guilt).

Probabilistic Quantitative Assessment of Coronary Heart Disease Risk From Dietary Exposure to Industrially Produced Trans-Fatty Acids in Partially Hydrogenated Oils.

We conducted a probabilistic evaluation of changes in coronary heart disease (CHD) risk and public health burdens from industrially produced trans-fatty acids (IP-TFAs) exposure from the uses of partially hydrogenated oils in food. Our analyses used four quantitative methods based on human studies considering the uncertainty associated with risk parameters for CHD and IP-TFA daily dietary exposure of 0.05% of energy. Method 1 used experimental controlled feeding trial data for changes in low-density lipoprotein cholesterol; Method 2 used changes in both low-density lipoprotein cholesterol and high-density lipoprotein cholesterol; Method 3 used changes in a combination of three emerging CHD risk factor biomarkers; and method 4 used prospective observational studies of CHD cases associated with long-term dietary exposure of trans-fatty acids. We estimated mean percent changes in CHD risk and annual CHD cases in U.S. adults, with lower and upper 95% uncertainty intervals. Our results show that consuming 0.05% of energy from IP-TFA, instead of cis-monounsaturated fatty acids, can cause annual mean increases in CHD cases of 814 (510-1151, method 1), 1502 (990-2043, method 2), or 6877 (3611-10 694, method 4) in U.S. adults. Results for method 3 were intermediate between those for methods 2 and 4. Sensitivity analyses using alternate risk parameters or an alternate exposure scenario resulted in minor changes in public health burden estimates. The results demonstrate that IP-TFA exposure as low as 0.05% of energy from partially hydrogenated oil uses in food can cause substantial public health burdens in the United States from increased CHD risk.

The perverse impact of external reference pricing (ERP): a comparison of orphan drugs affordability in 12 European countries. A call for policy change.

Objective: The study compared the relative cost differences of similar orphan drugs among high and low GDP countries in Europe: Bulgaria, France, Germany, Greece, Hungary, Italy, Norway, Poland, Romania, Spain, Sweden, UK. Methods: Annual treatment costs per patient were calculated. Relative costs were computed by dividing the costs by each economic parameter: nominal GDP per capita, GDP in PPP per capita, % GDP contributed by the government, government budget per inhabitant, % GDP spent on healthcare, % GDP spent on pharmaceuticals, and average annual salary. An international comparison of the relative costs was done using UK as the reference country and results were analysed descriptively. Results: 120 orphan drugs were included. The median annual costs of orphan drugs in all countries varied minimally (cost ratios: 0.87 to 1.08). When the costs were adjusted using GDP per capita, the EU-5 and Nordic countries maintained minimal difference in median cost. However, the lower GDP countries showed three to six times higher relative costs. The same pattern was evident when costs were adjusted using the other economic parameters. Conclusion: When the country's ability to pay is taken into consideration, lower GDP countries pay relatively higher costs for similarly available orphan drugs in Europe.

Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades.

BACKGROUND: Following a concerted public health response to the resurgence of tuberculosis (TB) in the United States in the late 1980s, annual TB incidence decreased substantially. However, no estimates exist of the number and cost savings of TB cases averted. METHODS: TB cases averted in the United States during 1995-2014 were estimated: Scenario 1 used a static 1992 case rate; Scenario 2 applied the 1992 rate to foreign-born cases, and a pre-resurgence 5.1% annual decline to US-born cases; and a statistical model assessed human immunodeficiency virus and TB program indices. We applied the cost of illness to estimate the societal benefits (costs averted) in 2014 dollars. RESULTS: During 1992-2014, 368 184 incident TB cases were reported, and cases decreased by two thirds during that period. In the scenarios and statistical model, TB cases averted during 1995-2014 ranged from approximately 145 000 to 319 000. The societal benefits of averted TB cases ranged from US$3.1 to US$6.7 billion, excluding deaths, and from US$6.7 to US$14.5 billion, including deaths. CONCLUSIONS: Coordinated efforts in TB control and prevention in the United States yielded a remarkable number of TB cases averted and societal economic benefits. We illustrate the value of concerted action and targeted public health funding.

International Comparison of Poststroke Resource Use: A Longitudinal Analysis in Europe.

BACKGROUND: Long-term costs often represent a large proportion of the total costs induced by stroke, but data on long-term poststroke resource use are sparse, especially regarding the trajectory of costs by severity. We used a multinational longitudinal survey to estimate patterns of poststroke resource use by degree of functional disability and to compare resource use between regions. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) is a multinational database of adults 50 years and older, which includes demographic information about respondents, age when stroke first occurred, current activity of daily living (ADL) limitations, and health care resource use in the year before interview. We modeled resource use with a 2-part regression for number of hospital days, home nursing hours, and paid and unpaid home caregiving hours. RESULTS: After accounting for time since stroke, number of strokes and comorbidities, age, gender, and European regions, we found that poststroke resource use was strongly associated with ADL limitations. The duration since the stroke event was significantly associated only with inpatient care, and informal help showed significant regional heterogeneity across all ADL limitation levels. CONCLUSIONS: Poststroke physical deficits appear to be a strong driver of long-term resource utilization; treatments that decrease such deficits offer substantial potential for downline cost savings. Analyzing internationally comparable panel data, such as SHARE, provide valuable insight into long-term cost of stroke. More comprehensive international comparisons will require registries with follow-up, particularly for informal and formal home-based care.

Dose assessment in contrast enhanced digital mammography using simple phantoms simulating standard model breasts.

Slabs of polymethyl methacrylate (PMMA) or a combination of PMMA and polyethylene (PE) slabs are used to simulate standard model breasts for the evaluation of the average glandular dose (AGD) in digital mammography (DM) and digital breast tomosynthesis (DBT). These phantoms are optimized for the energy spectra used in DM and DBT, which normally have a lower average energy than used in contrast enhanced digital mammography (CEDM). In this study we have investigated whether these phantoms can be used for the evaluation of AGD with the high energy x-ray spectra used in CEDM. For this purpose the calculated values of the incident air kerma for dosimetry phantoms and standard model breasts were compared in a zero degree projection with the use of an anti scatter grid. It was found that the difference in incident air kerma compared to standard model breasts ranges between -10% to +4% for PMMA slabs and between 6% and 15% for PMMA-PE slabs. The estimated systematic error in the measured AGD for both sets of phantoms were considered to be sufficiently small for the evaluation of AGD in quality control procedures for CEDM. However, the systematic error can be substantial if AGD values from different phantoms are compared.

Estimation of mean glandular dose for contrast enhanced digital mammography: factors for use with the UK, European and IAEA breast dosimetry protocols.

The UK, European and IAEA protocols for breast dosimetry in mammography use tabulations of conversion factors, which relate measurements of incident air kerma to the mean glandular dose to the breast. To supplement the existing tabulations, a Monte Carlo computer program has been used to calculate conversion factors for the high-energy spectra used for contrast enhanced digital mammography. The calculations were made for the x-ray spectra from a tungsten target (tube voltage range 40-50 kV) filtered by 0.28, 0.30 and 0.32 mm of copper, and from molybdenum and rhodium targets (tube voltage range 40-49 kV), each filtered by 0.30 mm of copper. The g-factors for all of these spectra were plotted for each breast thickness as a function of half value layer (HVL) and were found to lie on smooth curves within 0.3%. These reflect the fact that the characteristic x-rays present in the spectra from molybdenum and rhodium are heavily filtered and all the spectra are essentially Bremsstrahlung. As a consequence, the s-factor previously used in the dosimetry protocols to adjust for different target/filter combinations can be taken as unity for all of the spectra considered. Tables of g-factors and c-factors are provided for breast thicknesses in the range 20-110 mm and HVLs in the range 2.4-3.6 mm of aluminium. The tables of c-factors are given for breast glandularities in the range 0.1%-100% and for typical glandularities for women in the age bands 40-49 and 50-64 attending the UK national breast screening programme.

Simulation and assessment of realistic breast lesions using fractal growth models.

A new method of generating realistic three dimensional simulated breast lesions known as diffusion limited aggregation (DLA) is presented, and compared with the random walk (RW) method. Both methods of lesion simulation utilize a physics-based method for inserting these simulated lesions into 2D clinical mammogram images that takes into account the polychromatic x-ray spectrum, local glandularity and scatter. DLA and RW masses were assessed for realism via a receiver operating characteristic (ROC) study with nine observers. The study comprised 150 images of which 50 were real pathology proven mammograms, 50 were normal mammograms with RW inserted masses and 50 were normal mammograms with DLA inserted masses. The average area under the ROC curve for the DLA method was 0.55 (95% confidence interval 0.51-0.59) compared to 0.60 (95% confidence interval 0.56-0.63) for the RW method. The observer study results suggest that the DLA method produced more realistic masses with more variability in shape compared to the RW method. DLA generated lesions can overcome the lack of complexity in structure and shape in many current methods of mass simulation.

Phantoms for quality control procedures in digital breast tomosynthesis: dose assessment.

The recent introduction of digital breast tomosynthesis into clinical practice requires quality control procedures. In this study we have investigated whether the assessment of the average glandular dose for modelled standard breasts can be performed using a combination of polymethyl methacrylate (PMMA) and polyethylene (PE) slabs that matches standard breast thicknesses. For this purpose the energies absorbed per unit area of the image receptor when imaging standard breasts and PMMA-PE slabs have been matched taking account of both primary and scattered photons. To achieve this a two-step approach was used. Firstly, the behaviour of the scatter-to-primary ratio (SPR) of PMMA-PE phantoms and standard breasts was investigated using Monte Carlo simulations for various conditions. For imaging without an anti-scatter grid, it was found that the values of standard breast and phantom SPR were significantly different and it follows that these differences are relevant when matching the absorbed energy. In the second part, a set of PMMA-PE combinations is proposed which, for dosimetric purposes, can be used to simulate standard breasts in the thickness range 20 to 100 mm. The dosimetric error when using these PMMA-PE slabs was found to be below 6% for thicknesses up to 7 cm and increases to 10% for 10 cm thickness.

Accurately costing unilateral delayed DIEP flap breast reconstruction.

INTRODUCTION: Free tissue transfer for breast reconstruction is widely practiced in the UK and its availability forms part of the NICE guidelines in treating breast cancer. Free flap reconstruction scores highly on patient reported outcome measures for both immediate and delayed procedures. However there are significant resource implications and a concern that the financial burden is not adequately met by the fixed price tariff system (Payment by Results). This study aims to compare the cost of treatment with both local financial estimates and reimbursement. METHOD: We conducted a prospective costing analysis for 10 consecutive delayed unilateral DIEP breast reconstructions from August 2011 by a single surgeon in Frenchay Hospital, Bristol. Comparison was made to both the hospital's costing estimates and the Health Resource Group (HRG) tariffs received for 27 similar cases performed by the same surgeon in the 2010-11 financial year. RESULTS: The mean treatment cost for performing a delayed unilateral DIEP procedure was £7628 (±£754 Standard Deviation). This compared to an estimate from the financial department of £8072±(£1683 SD). These values were not significantly different (p=0.27). The HRG tariff was £8792 (±£423 SD). There was an average net income of £720 per case. Personnel in theatre represented the largest cost area at an average of 73% of total cost. CONCLUSIONS: This study highlights that the costs of this procedure have been estimated accurately by the financial department and that the current HRG code provides adequate reimbursement. The new HRG code for 2012-13, HRG JA14z, provides significantly less reimbursement at £7012 and measures need to be taken to address this. This study has identified that personnel costs are the greatest contributor to overall cost and allowed us to recognise and implement changes to improve efficiency.

Cost-effectiveness of epidermal growth factor receptor mutation testing and first-line treatment with gefitinib for patients with advanced adenocarcinoma of the lung.

BACKGROUND: Epidermal growth factor receptor (EGFR) testing and first-line therapy with gefitinib for patients with activating mutations is quickly becoming the standard option for the treatment of advanced lung adenocarcinoma. Yet, to date, little is known about the cost-effectiveness of this approach. METHODS: A decision-analytic model was developed to determine the cost-effectiveness of EGFR testing and first-line treatment with gefitinib for those patients who harbor activating mutations versus standard care, which includes first-line treatment with chemotherapy followed by gefitinib as second-line treatment. The model uses clinical and outcomes data from randomized clinical trials and societal costs from Singapore cancer centers. Health effects were expressed as quality-adjusted life-years. All costs and cost-effectiveness ratios were expressed in 2010 Singapore dollars. Sensitivity and different scenarios analyses were conducted. RESULTS: EGFR testing and first-line treatment with gefitinib is a dominant strategy (with lower costs and greater effectiveness) compared with standard care. Because the primary savings result from not providing gefitinib to those who are not likely to benefit, this finding holds regardless of the prevalence of activating mutations. In a secondary analysis, first-line treatment with gefitinib was also dominant when compared with first-line chemotherapy in patients with activating EGFR mutations. CONCLUSIONS: This strategy can be considered a new standard of care and should be of great interest for health care payers and decision makers in an era in which our greatest challenge is to balance hard-won and incremental, yet small, improvements in patient outcomes with exponentially rising costs.

Pupillometric assessment of sleepiness in narcolepsy.

PURPOSE: Excessive daytime sleepiness is highly prevalent in the general population, is the hallmark of narcolepsy, and is linked to significant morbidity. Clinical assessment of sleepiness remains challenging and the common objective multiple sleep latency test (MSLT) and subjective Epworth sleepiness scale (ESS) methods correlate poorly. We examined the relative utility of pupillary unrest index (PUI) as an objective measure of sleepiness in a group of unmedicated narcoleptics and healthy controls in a prospective, observational pilot study. METHODS: Narcolepsy (n = 20; untreated for >2 weeks) and control (n = 56) participants were tested under the same experimental conditions; overnight polysomnography was performed on all participants, followed by a daytime testing protocol including: MSLT, PUI, sleepiness visual analog scale (VAS), ESS, and the psychomotor vigilance test (PVT). RESULTS: The narcolepsy and control groups differed significantly on psychomotor performance and each measure of objective and subjective sleepiness, including PUI. Across the entire sample, PUI correlated significantly with objective (mean sleep latency, SL) and subjective (ESS and VAS) sleepiness, but none of the sleepiness measures correlated with performance (PVT). Among narcoleptics, VAS correlated with PVT measures. Within the control group, mean PUI was the only objective sleepiness measure that correlated with subjective sleepiness. Finally, in an ANCOVA model, SL and ESS were significantly predictive of PUI as measure of sleepiness. CONCLUSION: The role of PUI in quantifying and distinguishing sleepiness of narcolepsy from sleep-satiated healthy controls merits further investigation as it is a portable, brief, and objective test.