Hypertension treatment for older people-navigating between Scylla and Charybdis

Hypertension is a common condition in older people, but is often one of many conditions, particularly in frail older people, and so is rarely managed in isolation in the real world-which belies the bulk of the evidence upon which is treatment decisions are often based. In this article, we discuss the issues of ageing, including frailty and dementia, and their impact upon blood pressure management. We examine the evidence base for managing hypertension in older people, and explore some therapeutic ideas that might influence treatment decisions and strategies, including shared decision making.</p

Use of varenicline for smoking cessation treatment in UK primary care: an association rule mining analysis

BACKGROUND: Varenicline is probably the most effective smoking cessation pharmacotherapy, but is less widely used than nicotine replacement therapy. We therefore set out to identify the characteristics of numerically important groups of patients who typically do, or do not, receive varenicline in the UK. METHODS: We used association rule mining to analyse data on prescribing of smoking cessation pharmacotherapy in relation to age, sex, comorbidity and other variables from 477,620 people aged 16 years and over, registered as patients throughout 2011 with one of 559 UK general practices in The Health Improvement Network (THIN) database, and recorded to be current smokers. RESULTS: 46,685 participants (9.8% of all current smokers) were prescribed any smoking cessation treatment during 2011, and 19,316 of these (4% of current smokers, 41% of those who received any therapy) were prescribed varenicline. Prescription of varenicline was most common among heavy smokers aged 31–60, and in those with a diagnosis of COPD. Varenicline was rarely used among smokers who were otherwise in good health, or were aged over 60, were lighter smokers, or had psychotic disorders or dementia. CONCLUSIONS: Varenicline is being underused in healthy smokers, or in older smokers, and in those with psychotic disorders or dementia. Since varenicline is probably the most effective available single cessation therapy, this study identifies under-treatment of substantial public health significance

Implementing and operationalising integrative approaches to sustainability in Higher Education: The role of project-oriented learning.

Higher education institutions across the world are increasingly placing an emphasis on students’ acquisition of a broader range of skills or attributes within the taught curriculum, which should lead to a widening of their chances of academic success, in particular in the employment market. Among other issues, matters related to sustainable development are playing a key role, but many universities do not yet cater for integrative approaches, which may help them to approach sustainability issues in a transformative way. It is therefore necessary to develop new approaches and methods, which may address this gap. Based on the importance of meeting this perceived research need, this paper defines the role of project-oriented learning, also designated as Project Based Learning, as a tool to support integrative approaches to sustainability in a higher education context. The scientific value of the paper lies in the provision of some examples of successful approaches to Project Based Learning and the identification of some of the trends that characterise it. The paper makes clear why project-oriented learning should be more widely used in support of integrative approaches to sustainability, and why it needs to become part of the routine of higher education institutions. The outline of some of the initiatives recently and currently being undertaken may inspire others and assist in the implementation of Project Based Learning

What’s in a Name?

Numerous concerns have been raised about the sustainability of the biomedical research enterprise in the United States. Improving the postdoctoral training experience is seen as a priority in addressing these concerns, but even identifying who the postdocs are is made difficult by the multitude of different job titles they can carry. Here, we summarize the detrimental effects that current employment structures have on training, compensation and benefits for postdocs, and argue that academic research institutions should standardize the categorization and treatment of postdocs. We also present brief case studies of two institutions that have addressed these challenges and can provide models for other institutions attempting to enhance their postdoctoral workforces and improve the sustainability of the biomedical research enterprise

Societal Costs and Benefits of Treatment with Trastuzumab in Patients with Early HER2neu-Overexpressing Breast Cancer in Singapore

<p>Abstract</p> <p>Background</p> <p>Trastuzumab has revolutionized the way we treat early Her2Neu-positive breast cancer, as it significantly improves disease-free and overall survival. Little is known about the societal costs and benefits of treatment with trastuzumab in the adjuvant setting in Southeast Asia.</p> <p>Methods</p> <p>Societal costs (benefits) were estimated as the sum of direct and indirect costs minus benefits in the base case. Direct costs were derived from 4 treatment centers in Singapore (2 private and 2 public, comprising 60-70% of all patients with cancer seen in the island-nation); indirect costs were assessed as the loss of productivity caused by the disease or treatment. Benefits to society were based on extra years of productivity, as measured by GNI per capita, resulting from the quality adjusted life-years (QALYs) saved with the use of trastuzumab as determined in the models by Kurian, Liberato and Garrison.</p> <p>Results</p> <p>Incremental costs in Singapore, in 2005 US dollars, were $26,971.05. Average Cost per QALY was$19,174.59 (Median: $18,993.70). Costs (benefits) to society ranged from a cost of$79.42 to a benefit of $9,263.06, depending on the model used (Average benefit:$4,375.89, Median $3,944.03). Sensitivity analysis ranged from a cost of$10,685.00 to a Benefit of US$17,298.79</p> <p>Conclusions</p> <p>Treatment with adjuvant trastuzumab is likely to generate net societal economic benefits in Singapore. Nevertheless, the lower range of possible outcomes does not refute the possibility that treatment may actually generate costs. These costs however clearly fall within the usual range of acceptable cost-effectiveness.</p

Linked Pharmacometric-Pharmacoeconomic Modeling and Simulation in Clinical Drug Development

Market access and pricing of pharmaceuticals are increasingly contingent on the ability to demonstrate comparative effectiveness and cost-effectiveness. As such, it is widely recognized that predictions of the economic potential of drug candidates in development could inform decisions across the product life cycle. This may be challenging when safety and efficacy profiles in terms of the relevant clinical outcomes are unknown or highly uncertain early in product development. Linking pharmacometrics and pharmacoeconomics, such that outputs from pharmacometric models serve as inputs to pharmacoeconomic models, may provide a framework for extrapolating from early-phase studies to predict economic outcomes and characterize decision uncertainty. This article reviews the published studies that have implemented this methodology and used simulation to inform drug development decisions and/or to optimize the use of drug treatments. Some of the key practical issues involved in linking pharmacometrics and pharmacoeconomics, including the choice of final outcome measures, methods of incorporating evidence on comparator treatments, approaches to handling multiple intermediate end points, approaches to quantifying uncertainty, and issues of model validation are also discussed. Finally, we have considered the potential barriers that may have limited the adoption of this methodology and suggest that closer alignment between the disciplines of clinical pharmacology, pharmacometrics, and pharmacoeconomics, may help to realize the potential benefits associated with linked pharmacometric-pharmacoeconomic modeling and simulation

Neurosurgical treatment for addiction:Lessons from an untold story in China and a path forward

Addiction is a major public-health crisis associated with significant disability and mortality. Although various pharmacological and behavioral treatments are currently available, the clinical efficacy of these treatments is limited. Given this situation, there is a growing interest in finding an effective neurosurgical treatment for addiction. First, we discuss the use of ablative surgery in treating addiction. We focus on the rise and fall of nucleus accumbens ablation for addiction in China. Subsequently, we review recent studies that have explored the efficacy and safety of deep-brain-stimulation treatment for addiction. We conclude that neurosurgical procedures, particularly deep-brain stimulation, have a potentially valuable role in the management of otherwise intractable addictive disorders. Larger well-controlled clinical trials, however, are needed to assess clinical efficacy and safety. We end by discussing several key issues involved in this clinical field and identifying some areas of progress

Regionalização de Vazões Médias de Longo Período e de Volumes de Reservatórios de Regularização

No presente trabalho foi utilizada regionalização para estimativa de vazões médias de longo período e de volumes de reservatórios de regularização em bacias hidrográficas. Para a regionalização de vazões médias de longo período foram analisadas três metodologias: Eletrobrás (1985a), interpolação linear e Chaves et al. (2002). A obtenção das características físicas e climáticas utilizadas na regionalização foi feita através de Sistemas de Informações Geográficas (SIG). As características físicas, extraídas a partir de Modelo Digital de Elevação Hidrologicamente Consistente (MDEHC), foram: área de drenagem, comprimento do rio principal, declividade média da bacia, declividade entre a nascente e a foz do rio principal e densidade de drenagem. A precipitação média anual foi escolhida para representar as características climáticas da região de estudo. Na regionalização, pelo método de Eletrobrás (1985a), foi realizada seleção inicial de grupos de estações que apresentaram boas perspectivas de formarem sub-regiões homogêneas, pela análise de classes de resíduos da equação de regressão inicial e de curvas de frequência individuais de vazões adimensionalizadas. Os modelos de regressão analisados mais detalhadamente foram escolhidos a partir de diferentes parâmetros estatísticos. Pela metodologia Eletrobrás (1985a) foram obtidas as melhores estimativas. A variável explicativa mais expressiva nas equações de regressão foi a área de drenagem. Equações apresentando combinações da área com precipitação, declividade média da bacia e declividade entre a nascente e a foz também corresponderam aos melhores ajustes observados. Para a aplicação dos métodos de interpolação linear e Chaves et al. (2002), foram utilizados registros de estações próximas, localizadas em uma mesma bacia. Interpolação e Chaves et al. (2002) apresentaram erros mais significativos nas situações em que as diferenças entre áreas de drenagem, das seções transversais das estações fluviométricas e das seções para as quais estavam sendo feitas estimativas, eram relativamente grandes. Quanto à regionalização de curvas de regularização, foram definidas curvas adimensionais regionais médias, considerando vazões de regularização correspondentes a diferentes percentagens da vazão média. As curvas foram selecionadas por meio da análise de coeficiente de determinação e de erros percentuais. Grande parte dos modelos de curva de regularização obtidos apresentaram erros significativos para as menores regularizações da vazão média