Systematic review of economic evaluation studies on preconception care interventions.

Implementation of preconception care interventions have been encouraged for improving maternal and child health outcomes; therefore, evidence on their cost-effectiveness is needed. We conducted the systematic review to examine the efficiency of those interventions by collecting evidence from published economic evaluation studies. Out of 14 included studies, almost all (12/14) were in high-income countries. All studies were not cost-utility analysis with genetic disease screening and diabetes management were the common interventions for evaluating their efficiency during preconception period. Preconception care interventions are likely to be cost-effective, especially in low-income countries which incremental benefits had a greater return than developed nations.

Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries.

BACKGROUND: Research suggests that desired family involvement (FI) in medical decision making may depend on cultural values. Unfortunately, the field lacks cross-cultural studies that test this assumption. As a result, providers may be guided by incomplete information or cultural biases rather than patient preferences. METHODS: Researchers developed 6 culturally relevant disease scenarios varying from low to high medical seriousness. Quota samples of approximately 290 middle-aged urban residents in Australia, China, Malaysia, India, South Korea, Thailand, and the USA completed an online survey that examined desired levels of FI and identified individual difference predictors in each country. All reliability coefficients were acceptable. Regression models met standard assumptions. RESULTS: The strongest finding across all 7 countries was that those who desired higher self-involvement (SI) in medical decision making also wanted lower FI. On the other hand, respondents who valued relational-interdependence tended to want their families involved - a key finding in 5 of 7 countries. In addition, in 4 of 7 countries, respondents who valued social hierarchy desired higher FI. Other antecedents were less consistent. CONCLUSION: These results suggest that it is important for health providers to avoid East-West cultural stereotypes. There are meaningful numbers of patients in all 7 countries who want to be individually involved and those individuals tend to prefer lower FI. On the other hand, more interdependent patients are likely to want families involved in many of the countries studied. Thus, individual differences within culture appear to be important in predicting whether a patient desires FI. For this reason, avoiding culture-based assumptions about desired FI during medical decision making is central to providing more effective patient centered care.

The Great Recession, insurance mandates, and the use of in vitro fertilization services in the United States.

OBJECTIVE: To investigate the relationship between economic activities, insurance mandates, and the use of in vitro fertilization (IVF) in the United States. DESIGN: We examined the correlation between the coincident index (a proxy for overall economic conditions) and IVF use at the national level from 2000 to 2011. We then analyzed the relationship at the state level through longitudinal regression models. The base model tested the correlation at the state level. Additional models examined whether this relationship was affected, both separately and jointly, by insurance mandates and the Great Recession. SETTING: Not applicable. PATIENT(S): Not applicable. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Direction and magnitude of the relationship between the coincident index and IVF use, and influences of insurance mandates and the Great Recession. RESULT(S): The coincident index was positively correlated with IVF use at the national level (correlation coefficient = 0.89). At the state level, an increase of one unit in the coincident index was associated with an increase of 16 IVF cycles per 1 million women, with a significantly greater increase in IVF use in states with insurance mandates than in states without mandates (27 versus 15 IVF cycles per 1 million women). The Great Recession did not alter the relationship between the coincident index and IVF use. CONCLUSION(S): Our study demonstrates a positive relationship between the economy and IVF use, with greater magnitude in states with insurance mandates. This relationship was not affected by the Great Recession regardless of mandated insurance coverage.

Costs and cost-effectiveness of 9-valent human papillomavirus (HPV) vaccination in two East African countries.

BACKGROUND: Current prophylactic vaccines against human papillomavirus (HPV) target two of the most oncogenic types, HPV-16 and -18, which contribute to roughly 70% of cervical cancers worldwide. Second-generation HPV vaccines include a 9-valent vaccine, which targets five additional oncogenic HPV types (i.e., 31, 33, 45, 52, and 58) that contribute to another 15-30% of cervical cancer cases. The objective of this study was to determine a range of vaccine costs for which the 9-valent vaccine would be cost-effective in comparison to the current vaccines in two less developed countries (i.e., Kenya and Uganda). METHODS AND FINDINGS: The analysis was performed using a natural history disease simulation model of HPV and cervical cancer. The mathematical model simulates individual women from an early age and tracks health events and resource use as they transition through clinically-relevant health states over their lifetime. Epidemiological data on HPV prevalence and cancer incidence were used to adapt the model to Kenya and Uganda. Health benefit, or effectiveness, from HPV vaccination was measured in terms of life expectancy, and costs were measured in international dollars (I$). The incremental cost of the 9-valent vaccine included the added cost of the vaccine counterbalanced by costs averted from additional cancer cases prevented. All future costs and health benefits were discounted at an annual rate of 3% in the base case analysis. We conducted sensitivity analyses to investigate how infection with multiple HPV types, unidentifiable HPV types in cancer cases, and cross-protection against non-vaccine types could affect the potential cost range of the 9-valent vaccine. In the base case analysis in Kenya, we found that vaccination with the 9-valent vaccine was very cost-effective (i.e., had an incremental cost-effectiveness ratio below per-capita GDP), compared to the current vaccines provided the added cost of the 9-valent vaccine did not exceed I$9.7 per vaccinated girl. To be considered very cost-effective, the added cost per vaccinated girl could go up to I$5.2 and I$16.2 in the worst-case and best-case scenarios, respectively. At a willingness-to-pay threshold of three times per-capita GDP where the 9-valent vaccine would be considered cost-effective, the thresholds of added costs associated with the 9-valent vaccine were I$27.3, I$14.5 and I$45.3 per vaccinated girl for the base case, worst-case and best-case scenarios, respectively. In Uganda, vaccination with the 9-valent vaccine was very cost-effective when the added cost of the 9-valent vaccine did not exceed I$8.3 per vaccinated girl. To be considered very cost-effective, the added cost per vaccinated girl could go up to I$4.5 and I$13.7 in the worst-case and best-case scenarios, respectively. At a willingness-to-pay threshold of three times per-capita GDP, the thresholds of added costs associated with the 9-valent vaccine were I$23.4, I$12.6 and I$38.4 per vaccinated girl for the base case, worst-case and best-case scenarios, respectively. CONCLUSIONS: This study provides a threshold range of incremental costs associated with the 9-valent HPV vaccine that would make it a cost-effective intervention in comparison to currently available HPV vaccines in Kenya and Uganda. These prices represent a 71% and 61% increase over the price offered to the GAVI Alliance ($5 per dose) for the currently available 2- and 4-valent vaccines in Kenya and Uganda, respectively. Despite evidence of cost-effectiveness, critical challenges around affordability and feasibility of HPV vaccination and other competing needs in low-resource settings such as Kenya and Uganda remain.

Imaging for appendicitis: should radiation-induced cancer risks affect modality selection?

PURPOSE: To compare life expectancy (LE) losses attributable to three imaging strategies for appendicitis in adults-computed tomography (CT), ultrasonography (US) followed by CT for negative or indeterminate US results, and magnetic resonance (MR) imaging-by using a decision-analytic model. MATERIALS AND METHODS: In this model, for each imaging strategy, LE losses for 20-, 40-, and 65-year-old men and women were computed as a function of five key variables: baseline cohort LE, test performance, surgical mortality, risk of death from delayed diagnosis (missed appendicitis), and LE loss attributable to radiation-induced cancer death. Appendicitis prevalence, test performance, mortality rates from surgery and missed appendicitis, and radiation doses from CT were elicited from the published literature and institutional data. LE loss attributable to radiation exposure was projected by using a separate organ-specific model that accounted for anatomic coverage during a typical abdominopelvic CT examination. One- and two-way sensitivity analyses were performed to evaluate effects of model input variability on results. RESULTS: Outcomes across imaging strategies differed minimally-for example, for 20-year-old men, corresponding LE losses were 5.8 days (MR imaging), 6.8 days (combined US and CT), and 8.2 days (CT). This order was sensitive to differences in test performance but was insensitive to variation in radiation-induced cancer deaths. For example, in the same cohort, MR imaging sensitivity had to be 91% at minimum (if specificity were 100%), and MR imaging specificity had to be 62% at minimum (if sensitivity were 100%) to incur the least LE loss. Conversely, LE loss attributable to radiation exposure would need to decrease by 74-fold for combined US and CT, instead of MR imaging, to incur the least LE loss. CONCLUSION: The specific imaging strategy used to diagnose appendicitis minimally affects outcomes. Paradigm shifts to MR imaging owing to concerns over radiation should be considered only if MR imaging test performance is very high.

Decision aid reduces misperceptions about hormone therapy: a randomized controlled trial.

OBJECTIVE: This study aims to evaluate the role of a decision aid intervention in knowledge of menopausal symptom management. METHODS: Five hundred fifteen U.S. women who had menopausal symptoms and had discussed symptom management with providers within the past 12 months were assigned to either receive a decision aid or not. Participants completed a telephone survey 2 weeks after enrollment to assess knowledge. Overall knowledge scores and knowledge scores for general symptoms, benefits of hormone therapy, and risks of HT were compared between the decision aid arm and the control arm. RESULTS: Four hundred one women completed the survey. Participants in the decision aid arm had a significantly higher mean (SD) knowledge score (63.3% [18.4%]) compared with the control arm (57.5% [16.4%]; P = 0.001). Specifically, participants in the decision aid arm had significantly higher scores for general symptoms (mean difference, 11.0; 95% CI, 5.3 to 16.6; P < 0.001) and knowledge about benefits of HT (mean difference, 4.2; 95% CI, 0.03 to 8.5; P = 0.048) compared with the control arm. However, scores on knowledge about HT risks were not different between the arms (mean difference, 2.1; 95% CI, -3.0 to 7.2; P = 0.422). CONCLUSIONS: The decision aid arm has greater knowledge of menopausal symptom management compared with the control arm, although the difference is small. In general, there is a considerable lack of knowledge about menopausal symptoms and HT risks.

How Much (More) Should CEOs Make? A Universal Desire for More Equal Pay.

Do people from different countries and different backgrounds have similar preferences for how much more the rich should earn than the poor? Using survey data from 40 countries (N = 55,238), we compare respondents' estimates of the wages of people in different occupations-chief executive officers, cabinet ministers, and unskilled workers-to their ideals for what those wages should be. We show that ideal pay gaps between skilled and unskilled workers are significantly smaller than estimated pay gaps and that there is consensus across countries, socioeconomic status, and political beliefs. Moreover, data from 16 countries reveals that people dramatically underestimate actual pay inequality. In the United States-where underestimation was particularly pronounced-the actual pay ratio of CEOs to unskilled workers (354:1) far exceeded the estimated ratio (30:1), which in turn far exceeded the ideal ratio (7:1). In sum, respondents underestimate actual pay gaps, and their ideal pay gaps are even further from reality than those underestimates.

Embryonic stem cell-derived granulosa cells participate in ovarian follicle formation in vitro and in vivo.

Differentiating embryonic stem cells (ESCs) can form ovarian follicle-like structures in vitro, consisting of an oocyte-like cell surrounded by somatic cells capable of steroidogenesis. Using a dual-fluorescence reporter system in which mouse ESCs express green fluorescent protein (GFP) under the control of a germ cell-specific Pou5f1 gene promoter and red fluorescent protein (Discosoma sp red [DsRed]) driven by the granulosa cell-specific Forkhead box L2 (Foxl2) gene promoter, we first confirmed in vitro formation of follicle-like structures containing GFP-positive cells surrounded by DsRed-positive cells. Isolated DsRed-positive cells specified from ECSs exhibited a gene expression profile consistent with granulosa cells, as revealed by the detection of messenger RNAs (mRNAs) for Foxl2, follistatin (Fst), anti-Müllerian hormone (Amh), and follicle-stimulating hormone receptor (Fshr) as well as by production of both progesterone and estradiol. In addition, treatment of isolated DsRed-expressing cells with follicle-stimulating hormone (FSH) significantly increased estradiol production over basal levels, confirming the presence of functional FSH receptors in these cells. Last, ESC-derived DsRed-positive cells injected into neonatal mouse ovaries became incorporated within the granulosa cell layer of immature follicles. These studies demonstrate that Foxl2-expressing ovarian somatic cells derived in vitro from differentiating ESCs express granulosa cell markers, actively associate with germ cells in vitro, synthesize steroids, respond to FSH, and participate in folliculogenesis in vivo.

Potential benefits of second-generation human papillomavirus vaccines.

BACKGROUND: Current prophylactic vaccines against human papillomavirus (HPV) target two oncogenic types (16 and 18) that contribute to 70% of cervical cancer cases worldwide. Our objective was to quantify the range of additional benefits conferred by second-generation HPV prophylactic vaccines that are expected to expand protection to five additional oncogenic types (31, 33, 45, 52 and 58). METHODS: A microsimulation model of HPV and cervical cancer calibrated to epidemiological data from two countries (Kenya and Uganda) was used to estimate reductions in lifetime risk of cervical cancer from the second-generation HPV vaccines. We explored the independent and joint impact of uncertain factors (i.e., distribution of HPV types, co-infection with multiple HPV types, and unidentifiable HPV types in cancer) and vaccine properties (i.e., cross-protection against non-targeted HPV types), compared against currently-available vaccines. RESULTS: Assuming complete uptake of the second-generation vaccine, reductions in lifetime cancer risk were 86.3% in Kenya and 91.8% in Uganda, representing an absolute increase in cervical cancer reduction of 26.1% in Kenya and 17.9% in Uganda, compared with complete uptake of current vaccines. The range of added benefits was 19.6% to 29.1% in Kenya and 14.0% to 19.5% in Uganda, depending on assumptions of cancers attributable to multiple HPV infections and unidentifiable HPV types. These effects were blunted in both countries when assuming vaccine cross-protection with both the current and second-generation vaccines. CONCLUSION: Second-generation HPV vaccines that protect against additional oncogenic HPV types have the potential to improve cervical cancer prevention. Co-infection with multiple HPV infections and unidentifiable HPV types can influence vaccine effectiveness, but the magnitude of effect may be moderated by vaccine cross-protective effects. These benefits must be weighed against the cost of the vaccines in future analyses.

Business on hope: a case study on private cord blood stem cell banking.

Traditionally, medical practice has been recognized as one of the professional practices with high honors. The interaction between physicians and patients is to provide health care services without the profit orientation. In modernized economy and in today's world of business, the relationship between doctors and patients has been dramatically changed. This transformation is very obvious in the private sector. Health care providers sell their services. Patients have been approached as customers. Decisions to make an investment on new medical technologies or new services would accompany with careful consideration on cost-benefit ratio, on marketing and also on short and long term return of the investment. However most of the medical services available in the past were focusing on the "real" and "tangible" products. This means that the patients or the customers would obtain diagnosis, treatment, palliation or prevention for the fees they paid. They can at least obtain and can feel some direct or indirect health benefits from the services. With the advancement of science and technology, there is recently a new model of business that sells only the hope for future use. Private cord blood stem cell banking is a good example for this business model. Actually, business on hope is not the brand new business model. Insurance is a well-known classical prototype of business on hope. However, when this kind of business model is applied for medical services, there should be some precautions and also intervention including an oversight system from the government sector to make sure that all the information delivered to the clients and family is accurate and unbiased. From the public policy perspective, this business of hope should be appropriately regulated to preserve consumer rights while promoting the advancement of science and technology through sustainable business development.

Policy roadmap for stem cell technology in Thailand.

Policy and technology roadmaps have been long and widely used in industry and business sectors. The primary objective of the roadmap is to be a policy and technology planning tool helping to deal with an increasingly competitive environment. The obvious benefit of roadmapping is to provide information to make better technology investment decisions by identifying critical technologies and technology gaps and identifying methods to improve research and development (R&D) investments. It can also be used as a marketing tool. Roadmapping is critical and necessary when the technology investment decision is not straightforward. This occurs when it is not clear which alternative to pursue, how soon the technology is needed, or when there is a need to coordinate the development of multiple technologies. Stem cell technology is still in its nascent stage and one of the technologies with obvious uncertainties. Moreover it involves many issues from bioethical, legal and public policy perspectives. Then, development of national policy and technology roadmap for stem cell technology is definitely required and crucial to make most benefit from this promising technology for Thailand. The present article will provide perspectives on stem cell policy roadmap and propose critical action plans for the next five-year period.

Science and society: a stem cell technology model.

Stem cell technology has been recognized as an emerging technology that could transform current supportive approach toward curing many chronic disorders and degenerative conditions. Regenerative medicine is the promising area of medical practice in the coming decade. However, stem cell technology also brings up controversial issues from the bioethical perspective such as the destruction of human embryos to derive embryonic stem cells or putting the egg donors at risk when retrieving oocytes used in somatic cell nuclear transfer technique. Recently, scientists have discovered a novel method to derive human embryonic stem cell-like cells (iPS; induced pluripotent stem cells) from human skin cells. This innovative approach would not only be a breakthrough discovery to advance the knowledge of stem cell research and the landmark for future stem cell-based therapy but will also provide viable solutions for social concerns on bioethical issues.

From embryonic stem cells to functioning germ cells: science, clinical and ethical perspectives.

Embryonic stem cells have been well recognized as cells having a versatile potential to differentiate into all types of cells in the body including germ cells. There are many research studies focusing on the differentiation processes and protocols to derive various types of somatic cells from embryonic stem cells. However, germ cells have unique differentiation process and developmental pathway compared with somatic cells. Consequently, they will require different differentiation protocols and special culture techniques. More understanding and established in vitro systems for gametogenesis will greatly contribute to further progression of knowledge and technology in germ cell biology, reproductive biology and reproductive medicine. Moreover if oocytes can be efficiently produced in vitro, this will play an important role on progression in nuclear transfer and nuclear reprogramming technology. The present article will provide concise review on past important discoveries, current ongoing studies and future views of this challenging research area. An ethical perspective has also been proposed to give comprehensive summary and viewpoint for future clinical application.

International trends in bioethics for embryonic stem cell research.

Embryonic stem cell (ESC) has been recognized as one of the most promising therapeutic tools for the next decade. However, there are many controversial issues in bioethics for this challenging research area. Each country has its own distinct regulations and policies for ESC research due to their differences in cultural background, religious belief and political influence. These differences will eventually play an important role on international ESC research collaboration. The present article will provide a concise summary of the different policies and regulations regarding bioethical points for ESC research worldwide and show current progress towards establishing standard bioethical guidelines for ESC research on the international level.

Future cancer management with stem cell knowledge and technology.

Cancer has been proposed as a result of abnormal control of growth and development of stem cells for more than century. This is the "cancer stem cell hypothesis". Both cancer and stem cells share many common especial properties. They are immortal and have good differentiation potential. In addition, organogenesis and carcinogenesis are very similar processes. Recently, more evidence and convincing data from stem cell biology research are supporting this concept. Furthermore, the research provides new promising approaches for cancer diagnosis and treatment based on stem cell knowledge and technology. Upcoming data and evidence may revolutionize cancer management, making it more effective and safer.

Embryonic stem cell bank.

Embryonic stem cell bank is a cornerstone for stem cell research. It is providing essential resources to support advances in research in this challenging field that promises broad-ranging cell and tissue therapy. It is important to make good quality and well characterized embryonic cell lines that will be available for both research and clinical purposes. This article provides a concise summary on embryonic stem cell banking processes from cell line characterization, storage, quality assurance, safety testing, distribution, and post-distribution monitoring. It also states the importance of an international network and collaboration for technology and knowledge transfer Moreover, the Bank should play a substantial role as a national reference and a training center for stem cell research.

Conventional and novel methods for embryonic stem cell line derivation.

Cell therapy is the promising therapeutic tool for the next decade. "Regenerative Medicine" based on cell and tissue replacement therapy is proposed as a revolutionary approach to various chronic and incurable conditions. The first key step for successful cell therapy is the establishment of clinical grade human Embryonic Stem Cell (hESC) lines. This article provides a concise summary on conventional and novel methods for hESC line derivation. There is also discussion on progression, future direction and problems in hESC line development. In Thailand, more advance knowledge, skill, and technology are required to develop the first human embryonic stem cell line and step forward to make cell therapy a reality.

Cell therapy: hype or hope.

Cell therapy is a promising therapeutic tool for the next decade. It has a potential to cure a number of chronic diseases and conditions related to aging processes or degenerative changes. In addition, it could be used to replace cells and tissues in injured organs. Furthermore, it may provide a novel approach to congenital anomalies and genetic disorders where current therapeutic options are limited However, many crucial questions need answers to ensure a safe, effective and successful solution in the field of cell therapy. In Thailand, innovative knowledge and expertise in stem cell biology and technology are required as the key elements to make cell therapy a "real" hope.

Introduction to stem cell medicine.

Embryonic stem cell is the promising novel therapeutic tool for various degenerative diseases and tissue injuries. With the concept of cell and tissue therapy, many chronic disorders will be curable. The present article provides basic knowledge of stem cell in areas of definition, classification and future clinical applications. In addition, stem cell application is not only focusing on regenerative purpose, but also concentrating on more understanding about the early human development and the pathophysiology of genetic diseases at the cellular level. However, there are some technical problems and ethical concern that should be resolved before applying stem cells into clinical practice.