Cost-effectiveness analysis of health tapestry, a complex primary care program for older adults: a post-hoc analysis.

BACKGROUND: We initially reported on the cost-effectiveness of a 6-month randomized controlled implementation trial which evaluated Health TAPESTRY, a primary care program for older adults, at the McMaster Family Health Team (FHT) site and 5 other FHT sites in Ontario, Canada. While there were no statistically significant between-group differences in outcomes at month 6 post randomization, positive outcomes were observed at the McMaster FHT site, which recruited 40% (204/512) of the participants. The objective of this post-hoc study was to determine the cost-effectiveness of Health TAPESTRY based on data from the McMaster FHT site. METHODS: Costs included the cost to implement Health TAPESTRY at McMaster as well as healthcare resource consumed, which were costed using publicly available sources. Health-related-quality-of-life was evaluated with the EQ-5L-5L at baseline and at month 6 post randomization. Quality-adjusted-life-years (QALYs) were calculated under an-area-under the curve approach. Unadjusted and adjusted regression analyses (two independent regression analyses on costs and QALYs, seemingly unrelated regression [SUR], net benefit regression) as well as difference-in-difference and propensity score matching (PSM) methods, were used to deal with the non-randomized nature of the trial. Sampling uncertainty inherent to the trial data was estimated using non-parametric bootstrapping. The return on investment (ROI) associated with Health TAPESTRY was calculated. All costs were reported in 2021 Canadian dollars. RESULTS: With an intervention cost of $293/patient, Health TAPESTRY was the preferred strategy in the unadjusted and adjusted analyses. The results of our bootstrap analyses indicated that Health TAPESTRY was cost-effective compared to usual care at commonly accepted WTP thresholds. For example, if decision makers were willing to pay $50,000 per QALY gained, the probability of Health TAPESTRY to be cost effective compared to usual care varied from 0.72 (unadjusted analysis) to 0.96 (SUR) when using a WTP of $50,000/QALY gained. The DID and ROI analyses indicated that Health Tapestry generated a positive ROI. CONCLUSION: Health TAPESTRY was the preferred strategy when implemented at the McMaster FHT. We caution care in interpreting the results because of the post-hoc nature of the analyses and limited sample size based on one site.

Polypharmacy and medicine regimens in older adults in residential aged care.

OBJECTIVE: To describe medicines regimens used by older people living in residential aged care facilities (RACFs). MATERIALS AND METHODS: This cross-sectional study presents baseline data from a randomised controlled trial in seventeen Australian RACFs that recruited residents aged 65 years and older at the participating facilities. The main outcome measures were to evaluation of medicines utilisation, including the number of medicines, medicine regimen complexity, potential under-prescribing and high-risk prescribing (prescribing cascades, anticholinergic or sedative medicines or other potentially inappropriate medicines) with data analysed descriptively. RESULTS: Medicines regimens were analysed for 303 residents (76% female) with a mean age of 85.0 ± 7.5 years, of whom the majority were living with dementia (72%). Residents were prescribed an average of 10.3 ± 4.5 regular medicines daily. Most participants (85%) had highly complex regimens. Most residents (92%) were exposed to polypharmacy (five or more medicines). Nearly all, 302 (98%) residents had at least one marker of potentially suboptimal prescribing. At least one instance of potential under-prescribing was identified in 86% of residents. At least one instance of high-risk prescribing was identified in 81% of residents including 16% of participants with at least one potential prescribing cascade. CONCLUSION(S): Potentially suboptimal prescribing affected almost all residents in this study, and most had highly complex medicines regimens. If generalisable, these findings indicate most older people in RACFs may be at risk of medicines-related harm from suboptimal prescribing, in addition to the burden of administration of complex medicines regimens for facility staff and residents.

Cs diffusion mechanisms in UO2 investigated by SIMS, TEM, and atomistic simulations.

Experimental investigations and atomistic simulations are combined to study the cesium diffusion processes at high temperature in UO2. After 133Cs implantation in UO2 samples, diffusion coefficients are determined using the depth profile evolution after annealing as measured by secondary ion mass spectrometry. An activation energy of 1.8 ± 0.2 eV is subsequently deduced in the 1300-1600 °C temperature range. Experimental results are compared to nudged elastic band simulations performed for different atomic paths including several types of uranium vacancy defects. Activation energies ranging from 0.49 up to 2.34 eV are derived, showing the influence of the defect (both in terms of type and concentration) on the Cs diffusion process. Finally, molecular dynamics simulations are performed, allowing the identification of preferential Cs trajectories that corroborate experimental observations.

[Feedback from rehabilitators in a cognitive-behavioural unit]. / Retour d'expérience des rééducateurs d'une unité cognitivo-comportementale.

Non-drug therapies are an integral part of inpatient care in cognitive-behavioural units. As such, the rehabilitators working in the Corentin-Celton Hospital unit participate in the individualized care and rehabilitation project for the patient by conducting numerous individual and group workshops in co-therapy.

Effect of the Oxygen Potential on the Mo Migration and Speciation in UO2 and UO2+ x.

Molybdenum is an abundant element produced by fission in the nuclear fuel UO2 in a pressurized water reactor. Although its radiotoxicity is low, this element has a key role on the fuel oxidation and other fission products migration, in particular in the case of an accidental scenario. This study aims to characterize the behavior of molybdenum in uranium dioxide as a function of environmental conditions (oxygen partial pressure, high temperature, UO2 oxidation) typical of an accidental scenario. To do so, molybdenum was introduced in UO2 or UO2+ x pellets by ion implantation, a technique that allows us to mimic the production of Mo in the nuclear fuel by fission. Then, thermal treatments at high temperature and different oxygen partial pressures were carried out. The mobility of Mo in UOX samples was followed by secondary ion mass spectrometry (SIMS), while the Mo chemical speciation was investigated by spectroscopic techniques (XANES, Raman). In parallel, ab initio calculations were performed showing the effect of interstitial oxygen atoms on the Mo incorporation sites in UO2. We show that the Mo mobility is directly connected to its chemical state, which in turn, is linked to the redox conditions. Indeed, under reducing atmosphere, Mo is present in UO2 or UO2+ x samples under a metallic state Mo(0). Its mobility, being quite low, is driven by a diffusion mechanism. An increase of pO2 entails the UO2 and Mo oxidation and, as a consequence, a strong release of this element. We show an increase of the Mo release rate with the increase of the UO2+ x hyper-stoichiometry x. After thermal treatment, Mo remaining in the samples is located in the grains under the MoO2 form. Our experimental results are assessed by ab initio calculations showing that in the presence of oxygen Mo atoms adopt in UO2 a local structure close to the octahedral local geometry of Mo oxides.

Early prosthetic joint infection due to Ureaplasma urealyticum: Benefit of 16S rRNA gene sequence analysis for diagnosis.

Detection of the most frequently bacteria involved in prosthetic joint infection (PJI) is usually performed by conventional cultures. We report a case of early PJI due to Ureaplasma urealyticum, diagnosed by 16S rRNA gene sequence analysis, which highlights the interest of molecular methods if fastidious bacteria are involved in PJI.

Fast synthesis of ultrathin ZnO nanowires by oxidation of Cu/Zn stacks in low-pressure afterglow.

The synthesis of ultrathin, single-crystalline zinc oxide nanowires was achieved by treating in a flowing microwave plasma oxidation process, zinc films coated beforehand by a sputtered thin buffer layer of copper. The aspect ratio of the nanowires can be controlled by the following experimental parameters: treatment duration, furnace temperature, oxygen concentration. An average diameter of 6 nm correlated with a mean length of 750 nm can be reached with a fairly high surface number density for very short treatments, typically less than 1 min. The oxidized samples are characterized by means of SEM, XRD, SIMS, HRTEM and EDX techniques. Structural characterization reveals that these nanowires are single-crystalline, with the wurtzite phase of ZnO. Nanowires are only composed of ZnO without copper particles inside or at the end of the nanowires. Temperature-dependent photoluminescence measurements confirm that ZnO nanowires are of high crystalline quality and thin enough to produce quantum confinement.

Links between serotonin reuptake inhibition during pregnancy and neurodevelopmental delay/spectrum disorders: A systematic review of epidemiological and physiological evidence.

OBJECTIVE: To investigate possible linkages between neurodevelopmental delay and neurodevelopmental spectrum disorders and exposure to medication with effects on serotonin reuptake inhibition during pregnancy. METHODS: We systematically reviewed the epidemiological literature for studies bearing on this relationship in children born with neurodevelopmental spectrum disorder and related conditions, as well as animal studies giving serotonin reuptake inhibitors to pregnant animals and in addition reviewed the literature for proposals as to possible mechanisms that might link effects on serotonin reuptake with cognitive changes post-partum.The epidemiological studies were analysed to produce Forest plots to illustrate possible relations. RESULTS: The odds ratio of Autistic Spectrum or related Disorders in children born to women taking serotonin reuptake inhibiting antidepressants during pregnancy in case control studies was 1.95 (95% C.I. 1.63, 2.34) and in prospective cohort studies was 1.96 (95% C.I. 1.33, 2.90). CONCLUSIONS: There appears to be a link between serotonin reuptake inhibition in pregnancy and developmental delay and spectrum disorders in infancy leading to cognitive difficulties in childhood. More work needs to be done to establish more precisely the nature of the difficulties and possible mechanisms through which this link might be mediated.

General practitioners' insight into deprescribing for the multimorbid older individual: a qualitative study.

INTRODUCTION: The majority of older people with chronic diseases are prescribed multiple medicines resulting in polypharmacy. The extrapolation of the 'single disease model' represented by disease-specific guidelines is a major driver for polypharmacy. Polypharmacy is associated with negative health outcomes. Safely reducing or discontinuing harmful medicines, commonly referred to as deprescribing, has been shown to reduce adverse health outcomes, healthcare costs and mortality. However, there are barriers to deprescribing such as time constraints, limited appropriate clinical resources and the influence of multiple prescribers. AIM: To explore general practitioners' (GPs') opinions and awareness of deprescribing in an older multimorbid patient. METHODS: A qualitative study design using face-to-face semi-structured interviews was implemented. GP practices were randomly selected from two cities in New Zealand. Face-to-face in depth interviews were carried out with participants. A hypothetical profile of a multimorbid patient was included to elicit discussions about whether medicines should be continued or discontinued. Interviews were transcribed verbatim for thematic analysis. Transcripts were read and re-read. Themes were identified with iterative building of a coding list until all data were accounted for. Interviews continued until saturation of ideas occurred. RESULTS: Forty GPs were contacted and 10 consented to participate. Responses to each medicine in the hypothetical patient profile varied. Opinions on deprescribing preventive and symptomatic medicines varied a great deal. Conflicting opinions existed particularly around the prescription of statins, dipyridamole and bisphosphonates. Dilemmas around the appropriate clinical management of reflux disease and insomnia in older people also came to light. CONCLUSION: Gaining an insight into GPs' current prescribing patterns is important in designing any interventions aimed at reducing inappropriate prescribing. This study highlights the lack of clarity around deprescribing in multimorbidity. The participants' individual responses varied considerably. Deprescribing guidelines may help to clarify evidence based medicine relating to controversial areas and could hence decrease this variation.

Clinical care and health disparities.

Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

Struvite formation from the supernatants of an anaerobic digestion pilot plant.

This work studied the influence of the characteristics of the supernatants on the struvite precipitation process. Eighteen experiments with the supernatants generated in an anaerobic digestion pilot plant were performed in a stirred reactor. In order to obtain the pH control during the crystallization process, a Fuzzy Logic based controller was used. High phosphorus precipitation and recovery efficiencies were obtained. The composition of the supernatants was analyzed in order to study its influence on the solids formed from those solutions. The presence of calcium reduced the percentage of phosphorus precipitated as struvite leading to the formation of amorphous calcium phosphate (ACP), which tended to be lost with the effluent of the reactor. Calcite was also formed when supernatants with high magnesium:phosphorus (Mg/P) and calcium:phosphorus (Ca/P) molar ratios were employed. Some ammonium volatilization by conversion to NH(3) occurred in all the experiments. The use of air to increase the pH to an adequate value showed to be feasible. Aeration cleaned struvite crystals from suspended solids, which makes aeration interesting for struvite separation. However, aeration slightly increased the loss of phosphorus with the effluent of the reactor and promoted ammonium volatilization.

A pilot-scale study of struvite precipitation in a stirred tank reactor: conditions influencing the process.

Currently, the two most developed techniques for recovering phosphorus from wastewater consist of the formation of calcium phosphates and struvite (MgNH(4)PO(4).6H(2)O). In this work the influence of the operational conditions on the struvite precipitation process (pH in the reactor, hydraulic retention time, and magnesium:phosphorus, nitrogen:phosphorus, and calcium:magnesium molar ratios) have been studied. Twenty-three experiments with artificial wastewater were performed in a stirred reactor. In order to obtain the pH value maintenance during the crystallization process, a fuzzy logic control has been developed. High phosphorus removal efficiencies were reliably achieved precipitating the struvite as easily dried crystals or as pellets made up of agglomerated crystals.

Diabetes care in rest homes in Christchurch, New Zealand.

AIM: To determine the prevalence and describe the management of known diabetes in a group of New Zealand rest homes. METHODS: A random sample of 54 rest homes in Christchurch were studied. Residents with known diabetes were identified by rest home staff and interviewed. Selected staff members of all rest homes were also interviewed using structured questionnaires. The medical and nursing records and laboratory results of all residents with known diabetes were reviewed and all information pertaining to diabetes management recorded. RESULTS: The prevalence of known diabetes in Christchurch rest homes was 11.7%. Residents with known diabetes had a mean of five other comorbidities and were prescribed a mean of 7.5 medications. Of residents with diabetes, 45% were taking oral glucose-lowering agents, 28% were on a diet alone and 27% on insulin treatment. The mean blood pressure was 134/73 mmHg. The mean HbA(1c) was 7.3%. Routine blood glucose monitoring was performed often but residents with possible hypoglycaemic episodes frequently did not have their blood glucose level checked. CONCLUSIONS: The prevalence of known diabetes in Christchurch rest homes is similar to that found in British studies but less than that found in studies from the USA. Indicators of quality of care in residents with diabetes in this study appeared to be satisfactory, in contrast to other studies. There was poor recognition by staff of the necessity of checking acutely blood glucose levels in residents with diabetes who became unwell.