Cost-effectiveness of two screening strategies based on Chinese diabetes risk score for pre-diabetes in China.

Objective: Studies have shown that screening for pre-diabetes mellitus (pre-DM) is essential to prevent type 2 diabetes mellitus (T2DM). This study evaluates the cost-effectiveness of two screening strategies that apply the Chinese Diabetes Risk Score (CDRS) to screen for pre-DM in China. Methods: A Markov microsimulation model was conducted from a social perspective, and the input parameters were obtained from published literature or publicly available data. Two screening strategies for pre-DM based on CDRS were built and compared with the control group to determine the cost-effective strategy. The screening strategy of the control group was screening for pre-DM by fasting plasma glucose (FPG) test in adults undergoing annual health examination and no screening in adults without an annual health examination (status quo). Two screening strategies were strategy 1: screening for pre-DM using CDRS in all adults (including with or without an annual health examination); and strategy 2: supplemental self-screening for pre-DM using CDRS in adults without an annual health examination, based on the status quo. We focus on the cumulative prevalence of T2DM and the incremental cost-effectiveness ratio which signifies the cost per case of T2DM prevented. We also evaluated the cost-effectiveness from the health system perspective. One-way and probabilistic sensitivity analyses were conducted to verify the robustness of the results. Results: The costs a case of T2DM prevented for strategy 1 compared with the control group and strategy 2 were $299.67 (95% CI 298.88, 300.46) and $385.89 (95% CI 381.58, 390.20), respectively. In addition, compared with the control group, the cost of strategy 2 to prevent a case of T2DM was $272.23 (95% CI 271.50, 272.96). Conclusions: Screening for pre-DM using CDRS in all adults was the most cost-effective health policy. We suggest that medical institutions replace FPG with CDRS for pre-DM screening; at the same time, self-screening for pre-DM using CDRS is widely promoted among adults without an annual health examination. There were still some disputes about how CDRS is included in the health examination projects, so strategy 2 should be considered as an alternative screening strategy. Findings provide a reference for the application of the CDRS in pre-DM screening and contribute to T2DM prevention.

Cerebrolysin for vascular dementia.

BACKGROUND: Although vascular dementia is the second most common cause of dementia globally, evidence-based treatments are still lacking. Cerebrolysin is a porcine brain-derived preparation that is said to have neurotrophic and neuroprotective activity. In many parts of the world Cerebrolysin, given as a series of daily intravenous infusions, is used as a potential intervention for vascular dementia. A previous Cochrane Review on Cerebrolysin in vascular dementia yielded inconsistent results. We wished to update the review to add new studies from the international literature and employ contemporary methods for appraising the strength of the evidence. This is the first update of a review first published in 2013. OBJECTIVES: Primary: to assess the effect of Cerebrolysin on cognitive function, global function, and all-cause mortality in people living with vascular dementia. Secondary: to assess the adverse effects of Cerebrolysin and to assess the effect of Cerebrolysin on quality of life and caregiver burden. SEARCH METHODS: We searched ALOIS, MEDLINE, Embase, PsycINFO, CINAHL, ISI Web of Knowledge, LILACS, the Cochrane Library, ClinicalTrials.gov, and the WHO ICTRP on 16 June 2017, 9 May 2018, and 9 May 2019. We expanded the search by adding four Chinese databases, searched from 1 January 2012 to 19 May 2019. We checked bibliographies of relevant papers identified and contacted pharmaceutical companies, trial authors, and experts in the field to identify any additional published or unpublished data. SELECTION CRITERIA: We included all randomised controlled trials of Cerebrolysin used in people living with vascular dementia. We applied no language restriction. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion and evaluated their methodological quality. Data were extracted and analysed using mean differences (MDs) or standardised mean differences (SMDs) with 95% confidence intervals (95% CI) for continuous outcomes. We reported dichotomous outcomes as risk ratio (RR) with 95% CI. We assessed the strength of the available evidence using the GRADE approach. MAIN RESULTS: We identified six randomised controlled trials with a total of 597 participants that were eligible for inclusion in the 2013 review. No new studies were eligible for inclusion in this update. Participants in the included studies, where dementia severity was reported, had mild to moderate severity of vascular dementia (four trials). The included studies tested varying doses and duration of Cerebrolysin treatment. Follow-up ranged from 15 days to three years. Five of included studies were conducted in China (three studies), Russia (one study), and Romania (one study), while relevant information of other study was unclear. Where details of funding were available, all studies were supported by the pharmaceutical industry (three studies). Cognitive function was measured using the Mini-Mental State Examination (MMSE) or Alzheimer's Disease Assessment Scale Cognitive Subpart, extended version (ADAS-cog+). Combining the MMSE and ADAS-cog+ data (three studies, 420 people), there was a beneficial effect of Cerebrolysin (SMD 0.36, 95% CI 0.13 to 0.58; very low-quality evidence). Global function was measured by Clinician's Interview-Based Impression of Change plus Caregiver Input (CIBIC+) or Investigator's Clinical Global Impression (CGI). We assessed response rates on these measures (the proportion of participants with a CIBIC+ score of < 3; or at least moderate improvement of the CGI rating at the last visit). There was a beneficial effect of Cerebrolysin (two studies, 379 participants, RR 2.69, 95% CI 1.82 to 3.98; very low-quality evidence). Only one trial described mortality and reported no deaths. Four studies reported adverse events; data from two studies (379 people) were in a format that permitted meta-analysis, and there was no difference in rates of adverse effects (RR 0.91, 95% CI 0.29 to 2.85; very low-quality evidence). No studies reported on quality of life or caregiver burden. AUTHORS' CONCLUSIONS: Courses of intravenous Cerebrolysin improved cognition and general function in people living with vascular dementia, with no suggestion of adverse effects. However, these data are not definitive. Our analyses were limited by heterogeneity, and the included papers had high risk of bias. If there are benefits of Cerebrolysin, the effects may be too small to be clinically meaningful. There have been no new studies of Cerebrolysin in vascular dementia since the last Cochrane Review. Cerebrolysin continues to be used and promoted as a treatment for vascular dementia, but the supporting evidence base is weak. Adequately powered, methodologically robust trials are needed to properly assess the effects of Cerebrolysin in vascular dementia.

Comparison of the flexible parametric survival model and Cox model in estimating Markov transition probabilities using real-world data.

BACKGROUND AND OBJECTIVE: Markov micro-simulation models are being increasingly used in health economic evaluations. An important feature of the Markov micro-simulation model is its ability to consider transition probabilities of heterogeneous subgroups with different risk profiles. A survival analysis is generally performed to accurately estimate the transition probabilities associated with the risk profiles. This study aimed to apply a flexible parametric survival model (FPSM) to estimate individual transition probabilities. MATERIALS AND METHODS: The data were obtained from a cohort study investigating ischemic stroke outcomes in Western China. In total, 585 subjects were included in the analysis. To explore the goodness of fit of the FPSM, we compared the estimated hazard ratios and baseline cumulative hazards, both of which are necessary to the calculate individual transition probabilities, and the Markov micro-simulation models constructed using the FPSM and Cox model to determine the validity of the two Markov micro-simulation models and cost-effectiveness results. RESULTS: The flexible parametric proportional hazards model produced hazard ratio and baseline cumulative hazard estimates that were similar to those obtained using the Cox proportional hazards model. The simulated cumulative incidence of recurrent ischemic stroke and 5-years cost-effectiveness of Incremental cost-effectiveness Ratios (ICERs) were also similar using the two approaches. A discrepancy in the results was evident between the 5-years cost-effectiveness and the 10-years cost-effectiveness of ICERs, which were approximately 0.9 million (China Yuan) and 0.5 million (China Yuan), respectively. CONCLUSIONS: The flexible parametric survival model represents a good approach for estimating individual transition probabilities for a Markov micro-simulation model.

[Health Utility of Patients with Stroke Measured by EQ-5D and SF-6D].

OBJECTIVE: To compare EQ-5D and SF-6D for measuring health utility of stroke patients in health economic evaluation studies. METHODS: A prospective cohort study was conducted on 596 stroke patients in the West China Hospital of Sichuan University from 2010 to 2016. Data were collected at baseline through face to face interviews and at the follow-up stages through telephone interviews with a three-month interval. EQ-5D and SF-6D were used for measuring health utility scores of the participants. The consistency of the two instruments was assessed using Bland-Altman plot and Intraclass correlation coefficient (ICC) . Logistic regression models were established to identify predictors of health utility. RESULTS: The participants had a mean utility score of 0.78 (95% confidence interval:0.76, 0.80) in EQ-5D,compared with 0.74 (95% confidence interval: 0.73, 0.76) in SF-6D,and a median (interquartile range) of 0.86 (0.68, 1.00) in EQ-5D and 0.73 (0.62, 0.86) in SF-6D. The 95% limits of agreement between the two instruments ranged from -0.28 to 0.35,with an ICC of 0.67 (95% confidence interval: 0.62,0.71). EQ-5D had a higher ceiling effect. The health utility score of stroke patients changed there rapidly in acute phase (less than 3 months) but barely changed there after.Severity of stroke was a major predictor of health utility scores. CONCLUSION: The two instruments generate inconsistent results in health utility. SF-6D is better for measuring health utility in patients with stroke in China.

Assessment of Utilization and Cost-Effectiveness of Telemedicine Program in Western Regions of China: A 12-Year Study of 249 Hospitals Across 112 Cities.

BACKGROUND: The imbalance in healthcare between urban and rural areas is still a problem in China. In recent decades, China has aimed to develop telemedicine. We assessed the implementation, utilization, and cost-effectiveness of a large telemedicine program across western China. MATERIALS AND METHODS: In 2002-2013, a government-sponsored major telemedicine program was established by West China Hospital of Sichuan University (hub), covering 249 spoke hospitals in 112 cities throughout western China and in 40 medical expertise areas. We analyzed the cross-sectional data from 11,987 consultations conducted at West China Hospital using the telemedicine network over a 12-year period. The types of diseases as well as the diagnosis and treatment changes were assessed. We also performed a cost-savings analysis and a one-way sensitivity analysis. RESULTS: Of the 11,987 teleconsultations, we noted that neoplasms (19.4%), injuries (13.9%), and circulatory diseases (10.3%) were the three most common diagnoses. Teleconsultations resulted in a change of diagnosis in 4,772 (39.8%) patients, and 3,707 (77.7%) of them underwent major diagnosis changes. Moreover, it led to a change of treatment in 6,591 (55.0%) patients, including 3,677 (55.8%) changes not linked to diagnosis changes. The telemedicine network resulted in an estimated net saving of $2,364,525 (if the patients traveled to the hub) or $3,759,014 (if the specialists traveled to the spoke hospitals). CONCLUSIONS: The introduction of telemedicine in China, linking highly specialized major hospitals (hub) with hundreds of small rural hospitals (spoke), can greatly improve the quality, efficiency, and cost-effectiveness of healthcare delivery and utilization. This new Internet-based healthcare model should be utilized more widely in developing countries.

Global assessment of cadmium concentrations in the skin of free-ranging sperm whales (Physeter macrocephalus).

Cadmium is a non-essential, toxic metal found accumulated in the organs of stranded cetaceans. Currently, there is no baseline cadmium concentration reported in a free-ranging, pelagic cetacean. The aim was to determine cadmium concentrations in the skin of free-ranging sperm whales (n=340) collected from 16 regions around the world during the voyage of the Odyssey (2000-2005) considering region, gender, and age in males. Cadmium was detected in 81% of skin biopsies with a mean of 0.3±0.04µg/g ww (0.02 to 12.4µg/g ww). These concentrations were higher than reported in literature in toothed whale skin (0.002-0.1µg/g ww). Concentrations by region were significantly different (p<0.0001) with the highest mean in Maldives and the Sea of Cortez (0.8 and 0.6µg/g ww, respectively). There was no significant difference in cadmium concentration by gender (p=0.42). Cadmium is known to have a long biological half-life, and cadmium concentrations in males were significantly higher in adults with a mean of 0.3µg/g ww compared to subadults with 0.2µg/g ww (p=0.03). Selenium, an element that binds to cadmium inhibiting its toxicity, had a moderately positive correlation with cadmium (r=0.41). Mercury, a toxic metal that positively correlates with cadmium in cetacean tissue, had a weakly positive relationship (r=0.20). The regional baselines reported in this study may be used to develop residue criteria for prediction of toxicological risk in sperm whale skin. Additionally, this study shows the extent of cadmium exposure in a pelagic cetacean that has global distribution.

[Preliminary study of assessment of mental health level among oral tumor patients and difference of relevant material basis].

OBJECTIVE: To investigate the difference in mental health status of oral tumor patients and their spouses, and explore the differences on the basis of relevant materials. METHODS: Forty patients with oral cancer, eighteen spouses, and thirty-five patients with oral benign tumor were diagnosed in the West China Hospital of Stomatology between December 2011 and August 2012 and assessed with symptom checklist-90 (SCL90) (the 5-grade scoring). Participants were assessed independently according to their conditions. Blood samples were obtained from the participants by syringe on the second admission day. A method was developed to determine the concentrations of catecholamine and glucocorticoid in the serum using high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). RESULTS: The scores for compel, depression and rests in the cancer group and benign tumor group were statistically significant (P<0.05). The scores for compel, dread and stubborn in the cancer group and their spouses were statistically significant (P<0.05). The differences between the total and other monomial factor scores were not statistically significant. However, the contents of epinephrine, norepinephrine, cortisone and hydrocortisone in the serum, as determined by HPLC-MS/MS, were significantly different (P<0.001). CONCLUSION: Psychiatric factors do not show a simple factor effect on patients. Symptoms of patients may be based on tumorigenesis and developed in small molecules. Further research is required.

Global assessment of arsenic pollution using sperm whales (Physeter macrocephalus) as an emerging aquatic model organism.

Arsenic is an oceanic pollutant of global concern due to its toxicity, ability to bioaccumulate and continued input into the environment by anthropogenic activities. The sperm whale (Physeter macrocephalus) is an emerging aquatic model for both human disease and ocean health having global distribution and high trophic level. The aim of this study was to establish global and regional baselines of total arsenic concentrations using free-ranging sperm whales. Skin biopsies (n=342) were collected during the voyage of the Odyssey (2000-2005) from 17 regions considering gender and age in males. Arsenic was detectable in 99% of samples with a global mean of 1.9µg/g ww ranging from 0.1 to 15.6µg/g ww. Previous work in toothed whale skin found mean concentrations 3 fold lower with 0.6µg/g ww. A significant gender-related effect was found with males having higher mean arsenic concentrations than females. There was no significant age-related effect between adult and subadult males. Arsenic concentrations in sloughed skin samples were similar to levels in skin biopsies indicating that arsenic excretion can occur by skin sloughing. Regional mean concentrations were highest in the Maldives, Seychelles and Sri Lanka with 3.5, 2.5, and 2.4µg/g ww, respectively, raising concern for arsenic pollution in the Indian Ocean. Literature suggests that arsenic exposure is emitted from natural sources and the heavy use of arsenic-containing pesticides and herbicides in this region. These data suggest that research is needed in determining the extent and source of arsenic pollution in the Indian Ocean.

Global assessment of oceanic lead pollution using sperm whales (Physeter macrocephalus) as an indicator species.

Lead (Pb) is an oceanic pollutant of global concern. Anthropogenic activities are increasing oceanic levels, but to an unknown extent. The sperm whale (Physeter macrocephalus) has a global distribution and high trophic level. The aim of this study was to establish a global baseline of oceanic Pb concentrations using free-ranging sperm whales as an indicator species. Skin biopsies (n=337) were collected during the voyage of the Odyssey (2000-2005) from 17 regions considering gender and age. Pb was detectable in 315 samples with a global mean of 1.6 ug/gww ranging from 0.1 to 129.6 ug/gww. Papua New Guinea, Bahamas and Australia had the highest regional mean with 6.1, 3.4, and 3.1 ug/gww, respectively. Pb concentrations were not significantly different between sex and age in males. This is the first global toxicological dataset for Pb in a marine mammal and confirms Pb is widely distributed with hotspots in some regions.

[Assessment of mental health status in oral squamous cell carcinoma patients and its correlation with catecholamines level].

PURPOSE: To investigate the relationship between mental health status and catecholamines level in oral squamous cell carcinoma patients. METHODS: Forty patients with oral squamous carcinoma (OSCC) who were diagnosed in West China School of Stomatology between Dec. 2011 and Aug. 2012, were assessed with symptom checklist-90 (the 5-grade scoring of 0 to 4 points was used) independently according to their actual conditions. Blood sample was taken on the second admission day and fresh tumor tissue with the weight of 0.5 g was obtained. A method was developed for determination of catecholamine and glucocorticoid in serum using liquid chromatography-tandem mass spectrometry (HPLC-MS-MS). SPSS19.0 software package was used for statistical analysis. RESULTS: Forty patients were included in the study. Compared with the scores of SCL-90 in national norms, the scores were all higher in oral squamous carcinoma patients except the interpersonal relationship. Epinephrine(E) and norepinephrine(NE) in serum was (70.27±34.50) pg/mL and (316.73±109.22) pg/mL, respectively. E and NE in tumor tissues was (6.66±3.58) pg/mg and (12.67±5.27) pg/mg respectively. As the concentrations of NE and E from circulating serum increasing, the stage and grade of oral squamous carcinoma were promoted. CONCLUSIONS: Psychiatric factors have an important impact on OSCC patients. The increased level of catecholamines is closely related to clinical stage and grade of OSCC. Supported by National Natural Science Foundation of China (81172578) and Natural University Students Innovation Training Program (201210610096).

A global assessment of chromium pollution using sperm whales (Physeter macrocephalus) as an indicator species.

Chromium (Cr) is a well-known human carcinogen and a potential reproductive toxicant, but its contribution to ocean pollution is poorly understood. The aim of this study was to provide a global baseline for Cr as a marine pollutant using the sperm whale (Physeter macrocephalus) as an indicator species. Biopsies were collected from free-ranging whales around the globe during the voyage of the research vessel The Odyssey. Total Cr levels were measured in 361 sperm whales collected from 16 regions around the globe detectable levels ranged from 0.9 to 122.6 microg Cr g tissue(-1) with a global mean of 8.8+/-0.9 microg g(-1). Two whales had undetectable levels. The highest levels were found in sperm whales sampled in the waters near the Islands of Kiribati in the Pacific (mean=44.3+/-14.4) and the Seychelles in the Indian Ocean (mean=19.5+/-5.4 microg g(-1)). The lowest mean levels were found in whales near the Canary Islands (mean=3.7+/-0.8 microg g(-1)) and off of the coast of Sri Lanka (mean=3.3+/-0.4 microg g(-1)). The global mean Cr level in whale skin was 28-times higher than mean Cr skin levels in humans without occupational exposure. The whale levels were more similar to levels only observed previously in human lung tissue from workers who died of Cr-induced lung cancer. We conclude that Cr pollution in the marine environment is significant and that further study is urgently needed.

[A Markov model to access long-term effects of rosiglitazone natrium on the treatment of type 2 diabetes].

OBJECTIVE: The aim of this study was to estimate the long-term treatment effects of Rosiglitazone-natrium in type 2 diabetes. METHODS: A Markov decision model was developed to predict, over 10 years, mortality with or without Rosiglitazone-natrium treatment. RESULTS: During 10 years research, 14.2% patients developed to complications of type 2 diabetes mellitus, 3.8% patients should be dead in Rosiglitazone-natrium treatment group. 22.7% patients developed to complications of type 2 diabetes, 6.6% patients should be dead in non-Rosiglitazone-natrium treatment group. CONCLUSION: Markov decision model should be useful in accessing the long-term effects of drug treatment. Evidence on long-term benefit of Rosiglitazone-natrium could be of importance for future decision making.