Adolescence and the next generation.

Adolescent growth and social development shape the early development of offspring from preconception through to the post-partum period through distinct processes in males and females. At a time of great change in the forces shaping adolescence, including the timing of parenthood, investments in today's adolescents, the largest cohort in human history, will yield great dividends for future generations.

Publisher Correction: Adolescence and the next generation.

In Fig. 4a of this Analysis, owing to an error during the production process, the year in the header of the right column was '2016' rather than '2010'. In addition, in the HTML version of the Analysis, Table 1 was formatted incorrectly. These errors have been corrected online.

Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services.

The global burden of non-communicable diseases (NCDs) is growing, and there is an urgent need to estimate the costs and benefits of an investment strategy to prevent and control NCDs. Results from an investment-case analysis can provide important new evidence to inform decision making by governments and donors. We propose a methodology for calculating the economic benefits of investing in NCDs during the Sustainable Development Goals (SDGs) era, and we applied this methodology to cardiovascular disease prevention in 20 countries with the highest NCD burden. For a limited set of prevention interventions, we estimated that US$120 billion must be invested in these countries between 2015 and 2030. This investment represents an additional $1·50 per capita per year and would avert 15 million deaths, 8 million incidents of ischaemic heart disease, and 13 million incidents of stroke in the 20 countries. Benefit-cost ratios varied between interventions and country-income levels, with an average ratio of 5·6 for economic returns but a ratio of 10·9 if social returns are included. Investing in cardiovascular disease prevention is integral to achieving SDG target 3.4 (reducing premature mortality from NCDs by a third) and to progress towards SDG target 3.8 (the realisation of universal health coverage). Many countries have implemented cost-effective interventions at low levels, so the potential to achieve these targets and strengthen national income by scaling up these interventions is enormous.

Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents.

Investment in the capabilities of the world's 1·2 billion adolescents is vital to the UN's Sustainable Development Agenda. We examined investments in countries of low income, lower-middle income, and upper-middle income covering the majority of these adolescents globally to derive estimates of investment returns given existing knowledge. The costs and effects of the interventions were estimated by adapting existing models and by extending methods to create new modelling tools. Benefits were valued in terms of increased gross domestic product and averted social costs. The initial analysis showed high returns for the modelled interventions, with substantial variation between countries and with returns generally higher in low-income countries than in countries of lower-middle and upper-middle income. For interventions targeting physical, mental, and sexual health (including a human papilloma virus programme), an investment of US$4·6 per capita each year from 2015 to 2030 had an unweighted mean benefit to cost ratio (BCR) of more than 10·0, whereas, for interventions targeting road traffic injuries, a BCR of 5·9 (95% CI 5·8-6·0) was achieved on investment of $0·6 per capita each year. Interventions to reduce child marriage ($3·8 per capita each year) had a mean BCR of 5·7 (95% CI 5·3-6·1), with the effect high in low-income countries. Investment to increase the extent and quality of secondary schooling is vital but will be more expensive than other interventions-investment of $22·6 per capita each year from 2015 to 2030 generated a mean BCR of 11·8 (95% CI 11·6-12·0). Investments in health and education will not only transform the lives of adolescents in resource-poor settings, but will also generate high economic and social returns. These returns were robust to substantial variation in assumptions. Although the knowledge base on the impacts of interventions is limited in many areas, and a major research effort is needed to build a more complete investment framework, these analyses suggest that comprehensive investments in adolescent health and wellbeing should be given high priority in national and international policy.

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Comparative effectiveness of the SNaP™ Wound Care System.

Diabetic lower extremity wounds cause substantial burden to healthcare systems, costing tens of thousands of dollars per episode. Negative pressure wound therapy (NPWT) devices have been shown to be cost-effective at treating these wounds, but the traditional devices use bulky electrical pumps that require a durable medical equipment rental-based procurement process. The Spiracur SNaP™ Wound Care System is an ultraportable NPWT system that does not use an electric pump and is fully disposable. It has superior healing compared to standard of care with modern dressings and comparable healing to traditional NPWT devices while giving patients greater mobility and giving clinicians a simpler procurement process. We used a mathematical model to analyse the costs of the SNaP™ system and compare them to standard of care and electrically powered NPWT devices. When compared to standard of care, the SNaP™ system saves over $9000 per wound treated and more than doubles the number of patients healed. The SNaP system has similar healing time to powered NPWT devices, but saves $2300 in Medicare payments or $2800 for private payers per wound treated. Our analysis shows that the SNaP™ system could save substantial treatment costs in addition to allowing patients greater freedom and mobility.

Microbialite resurgence after the Late Ordovician extinction.

Microbialites, including biogenic stromatolites, thrombolites and dendrolites, were formed by various microbial mats that trapped and bound sediments or formed the locus of mineral precipitation. Microbialites were common and diverse during the Proterozoic, but declined in abundance and morphological diversity when multicellular life diversified during the Cambrian Radiation. A second decline occurred during the Ordovician Radiation of marine animals, and from then until the present microbialites have been confined largely to high-stress environments where multicellular organisms are rare. The microbialite declines in the Phanerozoic are attributed to disruption of the mats by animals. A resurgence of stromatolite abundance and size during reduced animal diversity after the Permian extinction has been documented anecdotally. Here we show, with statistical support, that a microbialite resurgence also occurred after the Late Ordovician extinction event in western North America. The resurgences were associated with loss of mat-inhibiting animals, providing insights into shallow-water community structures after extinction events.

An overview of peripheral neuropathy in diabetes.

 This article will discuss new concepts and treatments of neuropathy.

Employment and Productivity Benefits of Enhanced Educational Outcomes: A Preliminary Modelling Approach.

PURPOSE: The aims of the study were to develop methods to estimate the impact of better secondary schooling in developing countries on the employment and productivity of adolescents and provide initial results through application to 72 developing countries. METHODS: We model two effects here: the impact of longer and better quality secondary schooling on productivity in given job types and of increased school completion rates on the type of job obtained. Model parameter values are derived from the existing literature, supplemented by new empirical work. The impact of better schooling is studied, for each country, through the effects on the 20-24 years cohort, with the employment paths of successive cohorts traced through to 2030. RESULTS: For the education scenario studied-an increase of 65% in secondary school completions and of 90% in school quality by 2030-strong employment outcomes are obtained. Productivity per employee in the 20-24 years cohort is up by 37% by 2030, and employment by 3%. Nearly half of the productivity gain comes from better school quality, with 30% from additional schooling and 20% from shifts in employment structure. Productivity gains are much stronger in low-income countries than in upper middle-income countries. CONCLUSIONS: The model shows strong effects of better education through the various channels, especially for low-income countries, indicating the need for increased investment in secondary schooling, especially in school quality. Further work is required on the quality of education and on employment structure to enable derivation of parameter estimates with a stronger evidence base.

Better Secondary Schooling Outcomes for Adolescents in Low- and Middle-Income Countries: Projections of Cost-Effective Approaches.

PURPOSE: The purpose of this article was to identify effective interventions to reduce secondary school dropout rates, increase the quality of learning in secondary schools in developing countries, and estimate the cost and educational impact of a sustained program to implement a selection of these interventions. METHODS: Dropout risk is analyzed by multivariable regression using micro-datasets for 44 developing countries for which Demographic and Health Surveys are available. The analysis of interventions accesses recent meta-analyses of educational interventions in developing countries. We incorporate these results into a model of progression in secondary school-by grade, age, and gender, augmented by learning measures and by a facility to allow interventions to reduce dropout rates and improve learning-to estimate the impact and cost of a package of interventions out to 2030. RESULTS: Poverty, female gender, and rural location are key risk factors for secondary school dropout. In terms of interventions, school proximity for rural students is critical. Better teaching both reduces dropout and improves learning, whereas instruction in the mother tongue improves also improves learning. Systematic implementation of nine interventions in the 44 countries,1 costing US$10.5 per capita per annum, would increase secondary completion rates by about 25% and more than double the index of learning achieved by 2030, with the effects being more pronounced in low-income countries. CONCLUSIONS: Powerful interventions are available to change the trajectory of schooling in developing countries but the costs are substantial, and a coordinated funding effort will be required.

Evaluating the Employment Benefits of Education and Targeted Interventions to Reduce Child Marriage.

PURPOSE: This study sets out to identify effective interventions to reduce child marriage, estimate their economic benefits achieved through enhanced productivity, and undertake a benefit-cost analysis of the interventions. METHODS: We model the effects of a set of identified child marriage and education interventions for 31 low- and middle-income countries,1 focusing on the reduction in child marriage rates and increasing secondary school attendance and completions. These lead to higher productivity, which generates increased gross domestic product per capita. The comparison of these benefits with the costs of the interventions generates benefit-cost ratios. RESULTS: Both types of interventions have significant effects on marriage rates for girls aged 15-17 years, which fall from 13.2% in 2015 to 5.2% in 2050. Both interventions lead to sharp increases in school attendance and secondary completion, which is 19.3% points higher by 2030. The productivity improvement is 22.7% by 2030. The average benefit-cost ratio for the 31 countries is 7.4 (standard deviation of 1.0) at a 3% discount rate. CONCLUSIONS: The results indicate that there are substantial economic gains to reducing child marriage by specific child marriage and education interventions.

Reduced Road Traffic Injuries for Young People: A Preliminary Investment Analysis.

PURPOSE: Deaths and serious injuries from road accidents remain a serious issue in developing countries, including for young people, for whom they are the largest cause of death. This article provides an assessment of interventions to reduce these deaths and injuries for adolescents in 75 developing countries. METHODS: We draw on new data on deaths and injuries by age, gender, and accident type for the 75 countries and on the road safety experience of developed and, more recently, developing countries. Critical tasks are to identify key interventions in road safety and estimate their impact and cost. We incorporate these impact and cost estimates in a modeling framework to calculate the reduction in deaths and serious injuries achieved out to 2030, relative to the base case. Finally, established methods are used to value the economic and social benefits arising from these reductions, and hence to calculate benefit-cost ratios. RESULTS: For the unchanged policy case, we estimate that there will be about 3 million deaths and 7.4 million serious injuries from road accidents for persons aged 10-24 years in the 75 countries to 2030. The preferred interventions avert one million of these deaths and 3 million serious injuries, at a cost of $6.5 billion per annum over 2016-2030, or $1.2 per capita across the total population of these countries. After valuing the benefits of the deaths and serious injuries averted, we find a benefit-cost ratio of 7.6 for 2016-2030, but of 9.9 if the interventions continue to 2050. CONCLUSIONS: Proven methods, suitably adjusted to local conditions, are available to reduce the tragic toll of road accidents in developing countries. These initiatives are likely to have strong economic and social returns, and should be given high priority.

A Health System-Based Investment Case for Adolescent Health.

PURPOSE: This study argues that investments in the health of the world's 1.2 billion adolescents is a critical component of the overall investment case for adolescents and is vital for achieving the United Nation's Sustainable Development Agenda. We undertake a benefit cost analysis of a range of interventions to improve adolescent health. METHODS: We examined investments in intervention-specific costs, program costs, and health systems costs at a country level for 40 low- and middle-income countries that account for about 90% of adolescents in low- and middle-income countries. Intervention-specific costs and impacts were computed using the OneHealth Tool, whereas other published resources were used for the program and health systems costs. Interventions modeled include those addressing physical, sexual, and reproductive health; maternal and newborn health; and some noncommunicable diseases. Two coverage scenarios were simulated: an unchanged coverage scenario and one in which the coverage increases to achieve a high coverage by 2030. RESULTS: Key outcomes included estimates of the costs, health-related impacts, and benefit-cost ratios (BCRs). For the 66 adolescent health interventions modeled for 40 countries, the total cost for the period of 2015-2030 was $358.4 billion or an average of $4.5 per capita each year. From 2015 to 2030, there were 7.0 million deaths averted, and 1.5 million serious disabilities averted. At a 3% discount rate, the average BCR were 12.6, 9.9, and 6.4 for low-income, lower middle-income, and upper middle-income countries, respectively. Countries with adolescent mortality rates ≥200 per 100,000 had an average BCR of 14.8 compared with countries with adolescent mortality rates <100 per 100,000 had an average BCR of 5.7. CONCLUSIONS: The results show that there are substantial benefits from a program of interventions to improve adolescent health.

Total-contact casting as an adjunct to promote healing of pressure ulcers in amputees.

Partial foot amputations have become increasingly prevalent among long-lived diabetic patients. These patients have lower extremity neuropathy and are prone to ulceration at their amputation site. These ulcers are difficult to heal, and they place a significant financial and resource burden on the healthcare system. We examined the efficacy of total-contact casts (TCC) in diabetic amputees with nonhealing partial foot amputation site neuropathic ulcers. Data were collected retrospectively on all patients with amputations who were treated with a total-contact cast between December 2000 and December 2003. Seventeen patients (13 men, 4 women) with amputation site ulceration were identified. All patients were diagnosed with neuropathy secondary to diabetes and none had wound healing compromised by ischemia. The initial ulcer averaged 1,169 mm(2) with a depth of 2.77 mm. Patients were treated with an average of 7.9 cast applications over 8.4 weeks; 47% (8/17) of ulcers healed, but 29% (5/17) of patients were unable to complete their recommended treatment course secondary to complications from the TCC. Of the patients who were able to complete their treatment course, the healing rate was 66.7% (8/12). The recurrence rate for healed ulcers was 63% (5/8). Partial foot amputations with neuropathic ulcers present a very difficult problem to the vascular surgeon. Patient compliance and underlying medical comorbidities limit the success rate. In patients who can complete a TCC treatment course, good short term results can be expected. However, recurrence rates are high following discontinuation of mechanical TCC off-loading.

Minimally invasive revascularization strategies for chronic lower limb ischemia.

Lower extremity wounds resulting from ischemia are increasingly becoming a common indication for surgical revascularization. Techniques in minimally invasive vascular surgery for the treatment of lower extremity chronic ischemia have expanded rapidly in recent years. The current standard of care with which all new modalities should be compared is the restoration of arterial flow via direct arterial revascularization using the autogenous reversed saphenous vein that can yield limb salvage rates of approximately 95%. Percutaneous transluminal angioplasty and stenting (PTA/S), cryoplasty, catheter-directed atherectomy, laser-assisted PTA/S, drug-eluting stents, and subintimal angioplasty are emerging minimally invasive modalities used for the treatment of lower extremity ischemia. Early success rates using many of these techniques have been promising. The outcomes of randomized controlled trials with long-term follow-ups are needed to make confident remarks about the effectiveness of these techniques.

Development of a content-validated venous ulcer guideline.

Evidence-based practice for venous ulcers may improve healing and reduce costs of care. The Association for the Advancement of Wound Care Government and Regulatory Task Force developed a content-validated venous ulcer guideline based on best available evidence supporting each aspect of venous ulcer care. After compiling all-inclusive lists of elements in venous ulcer algorithms published before August 2002, the Task Force objectively rated and summarized up to five best references from MEDLINE, CINAHL, and EMBASE literature searches covering each aspect of care. Sixteen multidisciplinary wound care professionals and educators used judgment quantification to content validate all steps. A 2004 email survey of AAWC members (N = 1,514) clarified effects of under-reimbursement on evidence-based venous practice. The Venous Ulcer Guideline containing all elements with A-level evidence plus those with a Content Validity Index >0.75 now resides on the AAWC and the Agency for Healthcare Research and Quality National Guideline Clearinghouse websites. However, a review of US healthcare environment components, including reimbursement policies, and the results of the survey identified many barriers to implementation of A-level evidence supported steps (sustained graduated high compression, autolytic debridement, and moist wound environments) in practice. Sufficient evidence supports improved venous ulcer care in the US but inadequate and/or inconsistent reimbursement policies impede quality evidence-based venous ulcer practice, delaying healing and increasing the burden of venous ulcers on society.

Scaling-up treatment of depression and anxiety: a global return on investment analysis.

BACKGROUND: Depression and anxiety disorders are highly prevalent and disabling disorders, which result not only in an enormous amount of human misery and lost health, but also lost economic output. Here we propose a global investment case for a scaled-up response to the public health and economic burden of depression and anxiety disorders. METHODS: In this global return on investment analysis, we used the mental health module of the OneHealth tool to calculate treatment costs and health outcomes in 36 countries between 2016 and 2030. We assumed a linear increase in treatment coverage. We factored in a modest improvement of 5% in both the ability to work and productivity at work as a result of treatment, subsequently mapped to the prevailing rates of labour participation and gross domestic product (GDP) per worker in each country. FINDINGS: The net present value of investment needed over the period 2016-30 to substantially scale up effective treatment coverage for depression and anxiety disorders is estimated to be US$147 billion. The expected returns to this investment are also substantial. In terms of health impact, scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period. Placing an economic value on these healthy life-years produces a net present value of $310 billion. As well as these intrinsic benefits associated with improved health, scaled-up treatment of common mental disorders also leads to large economic productivity gains (a net present value of $230 billion for scaled-up depression treatment and $169 billion for anxiety disorders). Across country income groups, resulting benefit to cost ratios amount to 2·3-3·0 to 1 when economic benefits only are considered, and 3·3-5·7 to 1 when the value of health returns is also included. INTERPRETATION: Return on investment analysis of the kind reported here can contribute strongly to a balanced investment case for enhanced action to address the large and growing burden of common mental disorders worldwide. FUNDING: Grand Challenges Canada.