Correction: Valuation of the EQ-5D-5L in Taiwan.

[This corrects the article DOI: 10.1371/journal.pone.0209344.].

Challenges and Opportunities in Interdisciplinary Research and Real-World Data for Treatment Sequences in Health Technology Assessments.

With an ever-increasing number of treatment options, the assessment of treatment sequences has become crucial in health technology assessment (HTA). This review systematically explores the multifaceted challenges inherent in evaluating sequences, delving into their interplay and nuances that go beyond economic model structures. We synthesised a 'roadmap' of literature from key methodological studies, highlighting the evolution of recent advances and emerging research themes. These insights were compared against HTA guidelines to identify potential avenues for future research. Our findings reveal a spectrum of challenges in sequence evaluation, encompassing selecting appropriate decision-analytic modelling approaches and comparators, deriving appropriate clinical effectiveness evidence in the face of data scarcity, scrutinising effectiveness assumptions and statistical adjustments, considering treatment displacement, and optimising model computations. Integrating methodologies from diverse disciplines-statistics, epidemiology, causal inference, operational research and computer science-has demonstrated promise in addressing these challenges. An updated review of application studies is warranted to provide detailed insights into the extent and manner in which these methodologies have been implemented. Data scarcity on the effectiveness of treatment sequences emerged as a dominant concern, especially because treatment sequences are rarely compared in clinical trials. Real-world data (RWD) provide an alternative means for capturing evidence on effectiveness and future research should prioritise harnessing causal inference methods, particularly Target Trial Emulation, to evaluate treatment sequence effectiveness using RWD. This approach is also adaptable for analysing trials harbouring sequencing information and adjusting indirect comparisons when collating evidence from heterogeneous sources. Such investigative efforts could lend support to reviews of HTA recommendations and contribute to synthesising external control arms involving treatment sequences.

Beyond 10-year lead-times in EQ-5D-5L: leveraging alternative lead-times in willingness-to-accept questions to capture preferences for worse-than-dead states and their implication.

BACKGROUND: A fixed 10-year lead-time in composite time-trade-off (C-TTO) tasks might compromise the precision of utility values below - 1. This study explored how alternative lead-times (ALTs) influence EQ-5D-5L value sets and their implications in economic evaluations. METHODS: Leveraging data from Taiwan's EQ-5D-5L valuation and capitalizing on its exploratory willingness-to-accept question, we explored participants' quantification of "worse-than-dead (WTD)" health states with ALTs up to 50 years. We then derived alternative value sets incorporating these ALTs through interval regression and compared them against those from conventional models. To evaluate their impact on health change valuation, we simulated utility differences for all possible EQ-5D-5L health-state-pairs using each value set. RESULTS: With a salient floor effect observed in the C-TTO values, the model with ALT led to a wider range of predicted utilities ( - 2.3897 ~ 1), compared with those of conventional models (generalized least squares (GLS): - 0.7773 ~ 1; Tobit-GLS: - 0.9583 ~ 1). Compared to the Tobit-GLS model, the model with ALT increased the numerical distance in 80% of health-state-pairs, with 11% decreasing and 9% altering direction (e.g., positive to negative) in utility differences. CONCLUSIONS: While ALTs offer insights into patient preferences, their integration into economic evaluations might require rescaling. Future research should prioritize advanced rescaling methods or enhanced elicitation strategies for populations with substantial censoring. This is pivotal for improving the elicitation of extreme WTD states and accurately discerning the relative distances between health states. Countries developing EQ-5D-5L value sets should consider pilot studies and incorporating region-specific questions on social determinants, especially where pronounced floor effects are suspected.

The Anionic Polymerization of a tert-Butyl-Carboxylate-Activated Aziridine.

N-Sulfonyl-activated aziridines are known to undergo anionic-ring-opening polymerizations (AROP) to form polysulfonyllaziridines. However, the post-polymerization deprotection of the sulfonyl groups from polysulfonyllaziridines remains challenging. In this report, the polymerization of tert-butyl aziridine-1-carboxylate (BocAz) is reported. BocAz has an electron-withdrawing tert-butyloxycarbonyl (BOC) group on the aziridine nitrogen. The BOC group activates the aziridine for AROP and allows the synthesis of low-molecular-weight poly(BocAz) chains. A 13C NMR spectroscopic analysis of poly(BocAz) suggested that the polymer is linear. The attainable molecular weight of poly(BocAz) is limited by the poor solubility of poly(BocAz) in AROP-compatible solvents. The deprotection of poly(BocAz) using trifluoroacetic acid (TFA) cleanly produces linear polyethyleneimine. Overall, these results suggest that carbonyl groups, such as BOC, can play a larger role in the in the activation of aziridines in anionic polymerization and in the synthesis of polyimines.

The role of response domain and scale label in the quantitative interpretation of patient-reported outcome measure response options.

PURPOSE: Uncertainties exist in how respondents interpret response options in patient-reported outcome measures (PROMs), particularly across different domains and for different scale labels. The current study assessed how respondents quantitatively interpret common response options. METHODS: Members of the general public were recruited to this study via an online panel, stratified by age, gender, and having English as a first language. Participants completed background questions and were randomised to answer questions on one of three domains (i.e. loneliness (negatively phrased), happiness or activities (positively phrased)). Participants were asked to provide quantitative interpretations of response options (e.g. how many times per week is equal to "often") and to order several common response options (e.g. occasionally, sometimes) on a 0-100 slider scale. Chi-squared tests and regression analyses were used to assess whether response options were interpreted consistently across domains and respondent characteristics. RESULTS: Data from 1377 participants were analysed. There was general consistency in quantifying the number of times over the last 7 days to which each response option referred. Response options were consistently assigned a lower value in the loneliness than happiness and activities domains. Individual differences, such as age and English as a second language, explained some significant variation in responses, but less than domain. CONCLUSION: Members of the public quantify common response options in a similar way, but their quantification is not equivalent across domains or every type of respondent. Recommendations for the use of certain scale labels over others in PROM development are provided.

Influenza Vaccination Among Pregnant Women in the United States: Findings from the 2012-2016 National Health Interview Survey.

Background: The issue of suboptimal influenza vaccination coverage among pregnant women remains relevant. Our study aimed to explore the determinants and coverage of influenza vaccination among pregnant women in the United States using a nationally representative sample. Materials and Methods: This study was conducted with the 2012-2016 U.S. National Health Interview Survey. The Andersen's Health Behavior Model was applied as the conceptual framework to explore potential factors that may influence the influenza vaccination rate. A series of individual determinants, categorized into predisposing, enabling, and need factors, were compared using logistic regressions between women who received an influenza vaccination before or during pregnancy and those who did not. Results: An average of 36% women received an influenza vaccination before or during pregnancy among an estimated five million pregnant women. Even though the percentage increased from 31% in 2012 to 40% in 2016, it remained lower than the Healthy People 2020 target of 80%. The odds of receiving an influenza vaccination before or during pregnancy were lower among women who had public or no insurance coverage (odds ratio [OR]; 95% confidence interval, 0.510 [0.323-0.806] and 0.351 [0.175-0.705], respectively), lived in South (0.546 [0.336-0.887]), ever smoked 100 cigarettes (0.622 [0.419-0.923]), and had infrequent to light alcohol consumption in the past year (0.670 [0.457-0.983], reference: no alcohol consumption in the past year). Having a bachelor's degree increased the odds of getting an influenza vaccine compared to a high school diploma or less (2.086 [1.353-3.215]). Conclusions: Our study found that the influenza vaccination coverage among pregnant women remains suboptimal, and disparities may still exist across women with different sociodemographic and socioeconomic status. Clinicians should actively recommend influenza vaccination for pregnant women, and policy makers may consider developing interventions to improve the vaccination rate.

Crystal Structure of PigA: A Prolyl Thioester-Oxidizing Enzyme in Prodigiosin Biosynthesis.

Prodigiosin is an intensely red pigment comprising three pyrroles. The biosynthetic pathway includes a two-step proline oxidation catalyzed by phosphatidylinositol N-acetylglucosaminyltransferase subunit A (PigA), with flavin adenine dinucleotide (FAD) as its cofactor. The enzyme is crystallized in the apo form and in complex with FAD and proline. As an acyl coenzyme A dehydrogenase (ACAD) family member, the protein folds into a ß-sheet flanked by two α-helical domains. PigA forms a tetramer, which is consistent with analytical ultracentrifugation results. FAD binds to PigA in a similar way to that in the other enzymes of the ACAD family. The variable conformations of loop ß4-ß5 and helix αG correlate well with the structural flexibility required for substrate entrance to the Re side of FAD. Modeling with PigG, the acyl carrier protein, suggests a reasonable mode of interaction with PigA. The structure helps to explain the proline oxidation mechanism, in which Glu244 plays a central role by abstracting the substrate protons. It also reveals a plausible pocket for oxygen binding to the Si side of FAD.

Valuation of the EQ-5D-5L in Taiwan.

OBJECTIVES: To date, a value set for the EQ-5D-5L based on the health state preferences of the general Taiwanese population has not been available. This study aimed to develop a Taiwanese value set for EQ-5D-5L to facilitate health technology assessment for medical products and services. METHODS: An international standardized protocol for EQ-5D-5L valuation studies developed by the EuroQol group was adopted. Adult members of the general public were recruited from six geographic regions in Taiwan. In computer-based face-to-face interviews, each participant completed 10 composite time trade-off (C-TTO) tasks and 7 discrete choice experiment (DCE) tasks. The C-TTO and DCE data were modeled alone or in combination (using hybrid models) with additive models containing 20 dummy variables as main effects. The model performance was assessed both quantitatively and qualitatively (mainly logical consistency and prediction patterns). RESULTS: Of 1,073 recruited participants, 1,000 completed the study. Approximately 13% of observed utility values were -1 in the C-TTO tasks. The hybrid model, using all available data that assumed C-TTO response values left-censored at -1 and with main effects coefficients with logical consistency (monotonicity), was considered as the most appropriate model. The predicted utility ranged from -1.0259 to 1. CONCLUSIONS: An EQ-5D-5L value set was developed for Taiwan using an established study protocol and a representative sample of the general population. This may facilitate health economic evaluations and decision making on resource allocation under Taiwan's national health insurance program in the future.

Cost-effectiveness of the pharmacist-assisted warfarin monitoring program at a Medical Center in Taiwan.

OBJECTIVE: To investigate the cost-effectiveness of the first patient self-paying pharmacist-assisted warfarin monitoring (PAWM) program in Taiwan. DESIGN: A Markov model with a 1-month cycle length and a 20-year time horizon was employed in this study. The model is composed of the following eight states: three no-event states (i.e. 'subtherapeutic,' 'within therapeutic' and 'supratherapeutic' states), two serious adverse events (AEs) (i.e. bleeding and thromboembolism), two sequelae states and death. The likelihood of events, costs and utilities were derived from local databases and literature, if applicable. This study was conducted with a payer's perspective and all costs were discounted with a rate of 3%. SETTING: A pharmacist-led clinic. PARTICIPANTS: A hypothetical cohort of 10 000 participants. INTERVENTION(S): PAWM versus usual care. MAIN OUTCOME MEASURE(S): Average quality-adjusted life-years (QALYs) gained and cost increments per patient, and incremental cost-effectiveness ratios (ICERs). RESULTS: The PAWM program resulted in an average of 0.13 QALYs gained and a cost increment of NT$53 850 (US$1683) per patient. As the ICER (NT$410 749 [US$12 836]) was less than the gross domestic product per capita (NT$631 142 [US$19 723]), the PAWM was considered to be very cost-effective. The sensitivity analyses suggested that our result was robust and that the PAWM program had an 86% probability of being very cost-effective. CONCLUSIONS: Even if the costs saved from avoiding AEs were thought to be minimal due to the low-medical expenditures in Taiwan, the PAWM program was demonstrated to be economical. According to our findings, the policymakers should consider reimbursing such a service.

NMR investigation of magnesium chelation and cation-induced signal shift effect of testosterone.

We have previously reported that testosterone (Tes) is able to interact with magnesium chloride dissolved in methanol. In this study, we have applied 1H and 13C NMR spectroscopies to a series of Tes solutions containing Mg2+ at various concentrations. High-resolution 13C NMR spectra of Tes/Mg2+ revealed well-resolved 13C signals, and the intensities of those arising from C3, C5, C16, and C17 decreased linearly with increasing Mg2+ concentration. The magnitude of the chelation affinity could be deduced from the slopes of the 13C intensity variations; typically, the greater the slope the higher the chelation affinity. The results revealed Tes/Mg2+ chelation to be mediated by the oxygen atom attached to C3 in ring A, and the hydroxyl group attached to C17 in ring D. With regard to the chelation specificity, we showed that Tes chelates Mg2+, but not Ca2+ or Zn2+. We also explored the cation-induced signal shift effects of Tes in the presence of Mg2+, Ca2+, or Zn2+. We demonstrate that high-resolution 13C NMR spectroscopy provides a better probe than 1H NMR for the detection of cation chelation and cation-induced signal shift effects for steroid compounds such as Tes.

Nursing students' experiences of their first encounter with death during clinical practice in Taiwan.

AIMS AND OBJECTIVES: The aim of this study was to elucidate the experiences of first encountering death by nursing students during clinical practice. The objective is to assist nursing educational and clinical professionals to provide essential assistance for nursing students who encounter patient death. BACKGROUND: Increasingly, deaths are occurring in hospitals. However, there has been little qualitative research in Taiwan on the experiences of nursing students who encounter patient death for the first time. DESIGN: A descriptive qualitative method was employed to explore nursing students' first experience with death during clinical practice in Taiwan. METHODS: Purposive sampling, one-on-one, in-depth with semi-structured interviews were conducted to collect data. Participants were selected from an acute haematological ward in a major teaching hospital in Central Taiwan. Narratives were analysed using Colaizzi's seven-step method. RESULTS: Data saturation was achieved after interviewing 12 nursing students. The average age of the students was 20, and seven and half days was the average time spent attending dying patients. Three themes and eleven sub-themes were identified: Providing Care During the Dying Period (feelings of dread and terror, hardship of experiencing patient's life fading away, devotion to patient care and self-affirmation); Facing the Moment of Patient Death (state of being scared or trapped, emotional breakdown); Adjustment after Patient Death (acceptance or avoidance, growth or escape). CONCLUSIONS: Findings demonstrate the importance of understanding such first experiences, and the results are beneficial to clinical instructors and nursing personnel in understanding the students' pressure and difficulties experienced before, during and after the patients' death. RELEVANCE TO CLINICAL PRACTICE: Several recommendations have been made, including teaching and support not only in the period of dying, but at the moment of patient death and postmortality. Avoiding topics about death in local culture have been noted.