Cost-effectiveness and resource allocation (CERA) 18 years of evolution: maturity of adulthood and promise beyond tomorrow.

Since its inception in 2003, Cost Effectiveness and Resource Allocation journal has come a long way over the past 18 years. Possibly much longer than many of its contemporaries in the blossoming science of health economics might have anticipated. Today, entering 2020 it celebrates the Age of Maturity. We believe that in the third decade of XXI century the interdisciplinary science of health economics, will rejuvenate and come back to us younger than ever from its early historical roots almost a century ago. The spreading of economic globalization in several distinctive ways, either led by multinational business corporations or newly emerged Asian leadership, or both, is likely to make challenges for contemporary health systems far more serious. The fourth industrial revolution (cyber physical systems and artificial intelligence technology) and accelerated innovation in the field of E-Health and digital health, will probably change the workflow in medical and health care, and inevitably transform the labour market in the upcoming decades. So, let us be up to the task. Let us provide academic centres, industry-sponsored pharmaceutical and medical device innovation hubs, and governing authorities alike, with a powerful forum for debate on cost-effective resource allocation in the years to come.

If I value myself, I value school: the protective effect of self-esteem among abused females.

Children who have been severely maltreated tend to perform significantly below their non-maltreated peers in standardized tests, earn lower grades and have the most discipline issues in the school setting. There is evidence that self-esteem (SE) may be a protective factor for youth with regard to negative emotional outcomes. The role of self-esteem needs to be explored further in more collectivistic cultures. The purpose of this study was to explore the relationship between physical abuse, SE and school attitudes. Participants included 14 females rescued from a city landfill in Nicaragua (ages 7-17 years, M=12.44), half of whom had reported being beaten. SE and attitude toward school (ATS) were assessed using the Spanish Behavior Assessment System for Children. Grade point average (GPA) was obtained from their schools. Females who were beaten had significantly lower SE and a more negative ATS. Their GPA was lower, but not significantly. When SE and abuse were considered together, the effect of abuse on school attitudes was non-significant, suggesting that SE is a protective factor for the effects of abuse on ATS.

The poverty puzzle: the surprising difference between wealthy and poor students for self-efficacy and academic achievement.

This study explored the relationship between intellectual ability, socioeconomic status (SES), academic achievement and self-efficacy in a cross-cultural sample. Data from 90 students (63 students from Central America and 27 from the US) showed that regardless of culture or IQ, students from low SES families had significantly lower grade point averages than students from medium- or high-SES families. Unexpectedly, data showed that regardless of culture or IQ, students from high-SES families had the lowest self-efficacy, but the highest academic performance. Results suggest that self-efficacy is likely to be related to expectations and self-perception beyond IQ or culture.

The need for evidence-based, non-drug medicine.

Evidence-based medicine (EBM) is defined as "the integration of best research evidence with clinical expertise and patient values." EBM is based on three equally important key factors: i) the best available scientific evidence; ii) the physician's experience and intuition; and, iii) the preferences and values of the patient. EBM uses a hierarchy of evidence and critical appraisal of the sources, which makes it possible to balance high quality evidence with documented effectiveness. A treatment that is more safe and effective, but less well documented may very well be the treatment of choice. Ethics (not putting the patient at risk of harm with a treatment if this can be avoided at all) is an important part of EBM. Many pharmaceutical drugs have a number needed to treat (NNT) of approximately 20 [NNT=20, confidence interval CI (5-50)] and the number needed to harm is less well understood and documented. The adverse effect profile of pharmacological agents can be more harmful than non-drug medicine. Most EBM-treatments are likely to be non-drug treatments in the future. There are six steps to the practice of EBM: i) the patients and the physician must work together to define the problem; ii) the patients and the physician must explore the patient's values and preferences; iii) the information about the possible alternative medical interventions must be discussed and critically appraised; iv) the best, relevant evidence must be applied to the patient as a treatment or cure; v) together, the patient and the physician must evaluate how useful the intervention was; and vi) if the intervention did not help sufficiently, the process must begin again. In this review, we explain, in our opinion, how non-drug EBM should be practiced.

Residential care centers for persons with intellectual disability in Israel. Trends in the number of children 1999-2008.

In 1998, a questionnaire was developed by the Health Services, Office of the Medical Director at the Ministry of Social Affairs and Social Services. This questionnaire was aimed to assess, on a yearly basis, the health of the residents with intellectual disability and the services provided to them by specific residential care centers within Israel. The present study was conducted to examine trends in the number of children with intellectual disability in residential care centers in Israel during 1999-2008. We demonstrated a clear downward trend with regard to the percent of children living in residential care facilities, from 18.1% of the total population in 1999 to 12.8% in 2008.

Level of training of nursing staff and the autonomy given to psychiatric inpatients: a multicenter study.

This research examines the influence of the level of professional training of the caretaking staff in psychiatric wards, the type of wards in which a patient is treated and the patient's age compared with the level of limitation put on patient autonomy. Detailed questionnaires were administered to 296 nurses from five mental health centers who met inclusion criteria for the study. The level of autonomy restriction was measured using six representative cases from fieldwork of the interviewees. These cases were analyzed by the authors based on Collopy's theory, by categorizing the data according to the six polarities of autonomy presented in his work. Our findings suggest a positive correlation between the level of professional training of the nursing staff, patient's age and the level of autonomy given. Our findings did not show a significant relationship between the type of ward and level of autonomy, although there could be a tendency for higher autonomy within closed wards.

Asian innovation in pharmaceutical and medical device industry - beyond tomorrow.

The Asian region has passed a long and rocky road during the past several decades to establish itself as the second leading regional biotech market globally. China has become the second largest pharmaceutical market while Japan holds a strong second position as the global hub for medical devices development and innovation. Pharmaceutical expenditure continues to outpace real GDP growth in most of these countries. The trend is likely to be continued for a decade ahead, driven by a myriad of factors ranging from aging populations, rapidly growing welfare and increased citizen expectations raising demand for novel medicines and technologies. Satisfaction of these unmet needs in terms of supply is coming from the large multinational companies in wealthier among these societies. Domestic born and largely state-owned manufacturing industries continue to play a crucial role in an array of middle-income countries. Global biotech hub of Singapore is hosting over 1.5 times more headquarters of large pharmaceutical companies than Beijing, Tokyo, Shanghai and Hong Kong combined together. Japanese Takeda, Astellas, Daiichi Sankyo and Otsuka and Chinese Sinopharm, Guangzhou Pharmaceuticals Corporation, SPH and Yunnan Baiyao are now enlisted in leading Top 25 pharmaceutical companies rankings as per their annual net revenues in 2020-2021. Global industry landscape is evolving with ever more Asian companies obtaining the sharp innovative competitiveness leading development of cutting-edge medical technologies. Asian societies demand for pharmaceuticals and medical services continue to be characterized with unmet needs and striving to increase supply capacities. Financial obstacles of affordability of life saving medicines to the ordinary citizens shall be gradually overcome with an array of reimbursement strategies and extended insurance coverage policies. Observing the broad landscape throughout Asian region, we may witness that optimism in terms of domestic real GDP growth and consecutive biotech industry forecasts remains firmly rooted in years to come. Biosimilars are not a focus of the paper.

Aging in persons with Rett syndrome: an updated review.

Rett syndrome (RS) is a neurological disease affecting mainly females, characterized by an arrest of brain development caused by an X-linked mutation. Rett syndrome is the first human disease found to be caused by defects in a protein involved in regulating gene expression through its interaction with methylated DNA. The disease has been traced to a defective gene called MECP2. The case stories presented here and recent findings show that females with RS are able to live into old age. Due to the observed longevity of individuals with RS, and the fact that individuals with RS present the therapist/physician with specific clinical challenges, it is suggested that proper, long-term, and individually tailored, intensive care should be provided at all ages in the hope to prevent or at least reduce the age-related deterioration that is typical of this population.

A review of the Danish National Drug Directory: who provides the data for the register?

We have analyzed the Danish national drug directory (Medicine.dk) and found that it provides the information from industrial drug trials instead of the more objective and reliable information on the drugs provided by meta-analyses made by researchers independent of the pharmaceutical industry, like the Cochrane collaboration. The consequence of this is a strong bias, as a large fraction of the drugs are presented more positive and less harmful than they actually are. Whole classes of drugs that in independent meta-analyses have been found to be of little clinical value, or even harmful, are still listed in the national drug directories as beneficial drugs, i.e. anticancer chemotherapy, the anti-depressive drugs, and the anti-psychotic drugs. To solve this serious problem of misguidance, we have identified the core principles for rational listening of data regarding positive and negative effects of the pharmaceutical drugs. An outline of a standard list of positive and negative drug effects is suggested. Information on each drug should be provided with due regard to dose, indication of use, all clinically relevant outcomes, method of drug study used for documentation, including placebo type, and the quality of the study. We recommend the use of Number Needed to Treat (NNT) and Number Needed to Harm (NNH) for each single situation. When more objective and reliable data exist, they should be preferred rather than more doubtful data from studies of lower quality. We warn physicians and patients that the existing drug directory is strongly biased and not a reliable source of information.

National survey 2004 on medical services for persons with intellectual disability in residential care in Israel.

In Israel, the Office of the Medical Director of the Ministry of Social Affairs is responsible for the medical service in residential-care centers for persons with intellectual disability (ID). A standard annual questionnaire was developed during 1997-1998, and the first national survey study was conducted in 1998. This present paper presents the findings of the seventh national survey in 2004, for which the following information was gathered via questionnaires: age, gender, and level of intellectual disability of persons served at the residential care center in question, status of the population served, functional profile, nursing, medical, and allied professional staff, number of annual examinations, preventive medicine aspects, medications, number of annual cases of infectious disease, annual unintentional injuries, number of deaths, number of hospitalizations, internal residential center hospitalization, ambulatory out-patient use, use of outside laboratory examinations, and dental care. In 2004, 6,610 persons were served in nine government, 37 private, and 12 public centers. The average number of persons served per center was 113.97 (range 23 to 372). The survey in 2004 showed that 79.2% of the population with ID in residential care in Israel was between 20 and 60 years of age; 48.8% had severe or profound ID, 41% had moderate ID, and 10% had mild ID; 23% were nursing patients; 19% were confined to a wheelchair; 31% had epilepsy; 83% were receiving medication daily for chronic illness; and 52.5% were receiving psychotropic medication for psychiatric illness.

National survey 2007 on medical services for persons with intellectual disability in residential care in Israel.

In Israel, the Office of the Medical Director of the Ministry of Social Affairs is responsible for the medical service in residential-care centers for persons with intellectual disability (ID). A standard annual questionnaire was developed during 1997-1998, and the first national survey study was conducted in 1998. This present paper presents the findings of the seventh national survey in 2007, for which the following information was gathered via questionnaires: age, gender, and level of intellectual disability of persons served at the residential care center in question, status of the population served, functional profile, nursing, medical, and allied professional staff, number of annual examinations, preventive medicine aspects, medications, number of annual cases of infectious disease, annual unintentional injuries, number of deaths, number of hospitalizations, internal residential center hospitalization, ambulatory out-patient use, use of outside laboratory examinations, and dental care. In 2007, 6,872 persons were served in 9 government, 37 private, and 13 public centers. The average number of persons served per center was 116.47 (range 24 to 341). The survey in 2007 showed that 79% of the population with ID in residential care in Israel was between the ages of 20 and 60 years old, 44% with severe or profound ID, 43% with moderate and 13% with mild ID. Twenty-seven percent were nursing patients, and 18% were confined to a wheelchair, 34% had epilepsy, 86% were found to be receiving medication daily for chronic illness, and 51% received psychotropic medication for psychiatric illness.

A clinical primer on intellectual disability.

Between 1% and 3% of persons in general population are estimated to have some degree of intellectual disability. A diagnosis of intellectual disability is based on clinical history, level of intellectual ability and level of adaptive function. Both, the intellectual and adaptive functioning are measured using individually administered standardized tests. More than 75% of persons who have intellectual disability have mild intellectual disability and an underlying specific etiology is less likely to be identified; whereas, in a small percentage of persons with severe intellectual disability, an underlying specific biologic cause is highly likely to be identified. Genetic abnormalities, inborn errors of metabolism and brain malformations are major categories of causes identified in severe to profound intellectual disability. The initial clinical presentation and recognition depends on the severity and underlying cause of intellectual disability. The etiology, severity, cognitive abilities, and adaptive function, vary among persons with intellectual disability and need consideration in developing a treatment plan. The physician plays an essential role in the evaluation, treatment of associated medical conditions and preventive care, and in facilitating and coordinating consultative services and community based care.

Cerebral palsy in children: a clinical overview.

Cerebral palsy (CP) is a disorder characterized by abnormal tone, posture and movement and clinically classified based on the predominant motor syndrome-spastic hemiplegia, spastic diplegia, spastic quadriplegia, and extrapyramidal or dyskinetic. The incidence of CP is 2-3 per 1,000 live births. Prematurity and low birthweight are important risk factors for CP; however, multiple other factors have been associated with an increased risk for CP, including maternal infections, and multiple gestation. In most cases of CP the initial injury to the brain occurs during early fetal brain development; intracerebral hemorrhage and periventricular leukomalacia are the main pathologic findings found in preterm infants who develop CP. The diagnosis of CP is primarily based on clinical findings. Early diagnosis is possible based on a combination of clinical history, use of standardized neuromotor assessment and findings on magnetic resonance imaging (MRI); however, in most clinical settings CP is more reliably recognized by 2 years of age. MRI scan is indicated to delineate the extent of brain lesions and to identify congenital brain malformations. Genetic tests and tests for inborn errors of metabolism are indicated based on clinical findings to identify specific disorders. Because CP is associated with multiple associated and secondary medical conditions, its management requires a multidisciplinary team approach. Most children with CP grow up to be productive adults.

Residential care centers for persons with intellectual disability in Israel: trends in contraception methods 1999-2006.

BACKGROUND: The past 100 years has revealed a controversial history around the menstrual and contraceptive management of women with intellectual disability in residential care settings. The present study was conducted to examine the trends of contraceptive methods for females with intellectual disability in residential care centers in Israel. MATERIAL/METHODS: An annual survey of all medical clinics in residential care centers in Israel has been conducted since 1998 by the Office of the Medical Director of the Ministry of Social Affairs and data were extracted from the national surveys for 1999-2006. RESULTS: In the 1999-2006 period, 11-16% of females in residential care centers in Israel used oral or injected contraceptives. Depot medroxyprogesterone acetate (DMPA) was the most used method due to its convenience and effectiveness. CONCLUSIONS: It is recommended that a more detailed study of contraceptive methods be conducted in Israel to get a clearer picture since the data collected from annual surveys only give a rudimentary picture of the actual situation in the field.

Residential care centers for persons with intellectual disability in Israel: trends in mortality from food choking during 1991-2004.

BACKGROUND: Unintentional injuries are the fifth leading cause of death in the general population, but even more of a concern in the population of persons with intellectual disability. The present study was conducted to investigate trends in choking resulting in death of persons with intellectual disability in residential care centers in Israel over the period of 1991-2004. MATERIAL/METHODS: Data for this study came from the Office of the Medical Director (OMD), Division for Mental Retardation (DMR), Ministry of Social Affairs and Social Services. Every case of death in residential centers is reported to the OMD, which has registered the place of residence, date of birth, age at death, sex, ethnic background, level of ID, cause of death, autopsy, and review committee, if this was established, in a data register since 1991. Data concerned with food choking were extracted from the mortality register for the 1991-2004 period. RESULTS: Over the study period (14 years) there was a total of 1019 cases of death with 27 (2.65%) caused by food choking. The average rate was 42.6 per 100,000 study population for food choking. CONCLUSIONS: The solution is prevention. In recent years the OMD together with other professionals have produced educational material and seminars on feeding and preventive measures. Not every case can be prevented, but it is important to identify risk factors, educate care givers, and ensure that food products that are common choking hazards are kept away from residents who are at risk.

Increased aging in persons with intellectual disability in residential care centers in Israel 1999-2006.

BACKGROUND: In the last decade it has been observed worldwide that people with intellectual disanility (ID) now experience increased lifespan. The present study was conducted to monitor the trends in aging in persons with ID in residential care centers in Israel. MATERIAL/METHODS: Since 1998-1999, an annual survey of medical-clinic activity for all residential care centers for people with ID has been conducted and data from these surveys were used to investigate the trends in aging. RESULTS: The residential care center population today comprises about 7,000 persons of all ages. From 1999 to 2006, the population of 40-49 year olds remained stable, but the 50-59 year olds increased by 5.6%, while the 60 years and older group increased by 2.9%. CONCLUSIONS: Recommendations for service for this population and age group are discussed. Older people with ID have the same needs as other older people do, and they are subject to the same age-related impairments and illnesses (9). Moreover, because many disabled individuals live together with their families, the burden is double because the family members are also aging and with time, will not be able to continue their care-giving. As with older people in general, older people with intellectual disability also have social needs, housing needs, medical needs, the need for activity or work and special care needs for age-associated conditions, such as Alzheimer's disease and related dementias, increasing fragility, or conditions or diseases compromising independent functioning.

Meta-analysis of positive effects, side effects and adverse events of holistic mind-body medicine (clinical holistic medicine): experience from Denmark, Sweden, United Kingdom and Germany.

UNLABELLED: About 50% of the general population has a chronic disease not cured by biomedicine. OBJECTIVES: Meta-analysis of holistic clinical medicine for which chronic patients were treated and outcomes were, 1) global quality of life, 2) self-rated physical/mental health, quality of life or ability of functioning, or 3) patients felt cured for a specific disease of dysfunction. METHOD: MEDLINE and PsycLNFO and specific journals were searched in January 2009. RESULTS: Eleven clinical studies (18,500 participants) were identified. Positive effects: Quality of life Number Needed to Treat (NNT) = 2, physical health problems NNT = 3, mental health problems NNT = 2, sexual dysfunctions NNT = 2, self esteem NNT = 2, working/studying ability NNT = 2, anorgasmia NNT = 1, other specific sexual dysfunctions NNT = 2. Of 791 patients treated was 617, or 78.0% cured (NNT = 1). Side effects and adverse events: re-traumatization Number Needed to Harm (NNH) > 18,500; brief reactive psychosis (if mentally ill) NNH = 4,625; brief reactive psychosis (if not mentally ill) NNH > 9,250; brief reactive psychosis, all patients NNH = 9,250; depression NNH > 18,500; depersonalization and derealization NNH > 18,500; iatrogenic disturbances NNH > 18,500; minor bone fractures (ribs, hand) NNH = 4,625; serious bone fractures (spine, scull, pelvis) NNH > 18,500; suicides during or less than three month after therapy NNH > 18,500; suicide attempts during or less than three month after therapy NNH > 18,500. Suicide was prevented NNT = 1. Therapeutic value TV = NNH/NNT = 9,250. CONCLUSIONS: Holistic clinical medicine is an efficient complementary and alternative medicine (CAM) treatment for chronic illnesses and health related problems. Every second patient with physical and mental disorders, sexual dysfunctions, and existential problems were healed. Holistic clinical medicine had no significant side effects or adverse events.