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Cost-effectiveness analysis of procalcitonin and lung ultrasonography guided antibiotic prescriptions in primary care.
Full text linkAntimicrobial resistance comes with high morbidity and mortality burden, and ultimately high impact on healthcare and social costs. Efficient strategies are needed to limit antibiotic overuse. This paper investigates the cost-effectiveness of testing patients with lower respiratory tract infection with procalcitonin, either at the point-of-care only or combined with lung ultrasonography. These diagnostic tools help detect the presence of bacterial pneumonia, guiding prescription decisions. The clinical responses of these strategies were studied in the primary care setting. Evidence is needed on their cost-effectiveness. We used data from a cluster-randomized bi-centric clinical trial conducted in Switzerland and estimated patient-level costs using data on resource use to which we applied Swiss tariffs. Combining the incremental costs of the two strategies and the reduction in the 28-days antibiotic prescription rate (APR) compared to usual care, we calculated Incremental Cost-Effectiveness Ratios (ICER). We also used the Cost-Effectiveness Acceptability Curve as an analytical decision-making tool. The robustness of the findings is ensured by Probabilistic Sensitivity Analysis and scenario analysis. In the base case scenario, the ICER compared to usual care is 4.4 for procalcitonin-ultrasound combined. Furthermore, we found that for a willingness to pay per patient of more than $2 per pp reduction in the APR, procalcitonin is the strategy with the highest probability to be cost-effective. Our findings suggest that testing patients with respiratory symptoms with procalcitonin to guide antibiotic prescription in the primary care setting represents good value for money
Pulsed-field vs. Cryoballoon vs. Radiofrequency ablation: outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation.
No full textBACKGROUND
Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patient with paroxysmal atrial fibrillation (AF) OBJECTIVE: To compare the procedural and long-term outcomes of patients with persistent AF undergoing PVI using PFA, CBA, or RFA.
METHODS
Consecutive patients with persistent AF undergoing a first PVI with PFA, CBA, or RFA were included. Patients underwent 7d-Holter-ECG at 3, 6, and 12 months post-ablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events.
RESULTS
A total of 533 patients with persistent AF underwent PVI using PFA (n=214), CBA (n=190), or RFA (n=129). Procedures with PFA guided by fluoroscopy were shorter compared to CBA (median 60 min, IQR 53-80 vs. 84 min, IQR 68-101, p=<0.001), and procedures with PFA in combination with 3D-electroanatomical mapping were shorter compared to RFA (median 101 min, IQR 85-126 vs. 171 min, IQR 141-204, p<0.001). Acute safety events occurred in 2.3%, 2.6% and 0.8% in the PFA, CBA and RFA group (p=0.545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA and 48.3% for RFA (CBA vs. PFA p=0.79, CBA vs. RFA p=0.009; PFA vs. RFA p=0.010).
CONCLUSION
In patients with persistent AF undergoing a first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA compared to RFA
A Core Outcome Set for Intact Abdominal Aortic Aneurysm Repair.
No full textOBJECTIVE
Technology and advances in clinical care have changed the management of abdominal aortic aneurysms (AAAs) but the clinical effectiveness of continuing advances needs to be assessed. To facilitate rapid synthesis of new evidence and improve stakeholder representation, including patients, the concept of core outcome sets has been developed. Core outcome sets, reflecting the needs of all stakeholders, have been established across several surgical specialties. This study aimed to develop an international core outcome set for intact AAA repair.
METHODS
Following COMET methodology, potential outcomes were identified from a systematic review of published outcomes and focus groups involving patients, carers, and nurses. A 38 question Delphi consensus survey in lay language was developed (with translation to local languages); this included 35 themes identified from the findings of the systematic review and three themes from the focus groups. All three of the themes identified by the focus groups (cognitive, physical, and social functioning) can be evaluated from quality of life instruments, with overall quality of life being identified from the systematic review. The survey was completed by patients, carers or family members, vascular nurses, vascular surgeons, trainees, interventional radiologists, anaesthetists, and industry partners from six European countries. After two rounds of the survey, the top outcomes were discussed at a face to face multistakeholder consensus meeting.
RESULTS
The 38 item questionnaire was amended after piloting among all stakeholder groups. After the first round of the Delphi survey (98 respondents), 15 questions were eliminated and 11 further questions were eliminated after round two (90 respondents). This left two outcome questions for discussion at the consensus meeting, where the top six outcomes were unanimously endorsed: mortality at 30 days (or in hospital if longer), secondary AAA rupture, overall quality of life and retention of cognitive functioning after recovery, 5 year survival, and continued sac growth.
CONCLUSION
Six core outcomes are recommended for use as a minimum framework in all future studies and registries of intact open and endovascular AAA repair. Further work to select instruments for quality of life and define instruments for cognitive functioning is needed
The Effect of Different Intraoral Scanners on The Accuracy of Bite Registration in Edentulous Maxillary and Mandibular Arches.
No full textOBJECTIVES
The objective of this study was to use in vitro models to examine the bite registration accuracy of four different intraoral scanners (IOS) for edentulous maxillary and mandibular arches. The objective was to assess the trueness and precision of the IOS and determine if there were significant differences between them.
METHODS
An Asiga Max UV 3D printer was used to print maxillary and mandibular edentulous models based on the shape of Frasaco models (artificial dental arch models). Four dental implants were placed symmetrically in both models using Straumann BLT RC implants. Digital impressions were taken with Primescan, Trios 3, Trios 4, and Medit i500 intraoral scanners (n = 10 for each IOS). Digital bite registrations were made, and scanning data was exported in STL format. The accuracy of the interarch distance (the distance between the metrological spheres attached to the mandibular and maxillary models) was estimated for each IOS.
RESULTS
The results showed significant differences in trueness and precision between different IOS (p .05). Primescan provided the most accurate results, followed by Medit i500, Trios 3, and Trios 4, respectively.
CONCLUSIONS
within the limitations of this study, the IOS type affects the accuracy of interocclusal bite registration in in vitro design. Only Primescan achieved clinically acceptable accuracy for the interocclusal recording of edentulous arches.
CLINICAL RELEVANCE
The comparison of the accuracy of bite registration between different intraoral scanners will help increase the efficiency of the clinical application of digitalized interarch registration
Conquering Class Imbalances in Deep Learning-based Segmentation of Dental Radiographs with Different Loss Functions.
No full textOBJECTIVE
The imbalanced nature of real-world datasets is an ongoing challenge in the field of machine and deep learning. In medicine and in dentistry, most data samples represent patients not affected by pathologies, and on imagery, pathologic image areas are often smaller than healthy ones. Selecting suitable loss functions during deep learning is essential and may help to overcome the resulting imbalance. We assessed six different loss functions for one exemplary task, tooth structure segmentation on bitewing radiographs, for their performance.
METHODS
Six different loss functions (Focal Loss, Dice Loss, Tversky Loss and hybrid losses of Cross-Entropy and Dice Loss, Focal and Dice Loss, Focal and Generalized Dice Loss) were compared on a tooth structure segmentation task of 1,625 bitewing radiographs. Training was performed using three different model architectures (U-Net, Linknet, DeepLavbV3+) over a 5-fold cross-validation. Tooth structures consisted of the classes (occurrence in % of samples/captures areas measured on pixel level) enamel (100%/25%), dentin (100%/50%), root canal (100%/10%), filling (81%/8%) and crown (28%/5%).
RESULTS
Hybrid loss functions significantly outperformed standalone ones and provided robust results over the different architectures for the classes enamel, dentin, root canal and filling. Specifically, the Dice Focal loss reached high performance to conquer both image level and pixel level class imbalance, respectively.
CLINICAL SIGNIFICANCE
In dental use cases it is often important to predict minority classes such as pathologies accurately. Using specific loss function may be an effective strategy to overcome data imbalance when training deep learning models
Quantitative evaluation for the sources and aging processes of organic aerosols in urban Guangzhou: Insights from a comprehensive method of dual‑carbon isotopes and macro tracers.
No full textOrganic carbon aerosol (OC) is a pivotal component of PM2.5 in the atmospheric environment, yet its emission sources and atmospheric behaviors remain poorly constrained in many regions. In this study, a comprehensive method based on the combination of dual‑carbon isotopes (13C and 14C) and macro tracers was employed in the PRDAIO campaign performed in the megacity of Guangzhou, China. The 14C analysis showed that 60 ± 9 % of OC during the sampling campaign was associated with non-fossil sources such as biomass burning activities and biogenic emissions. It should be noted that this non-fossil contribution in OC would significantly decrease when the air masses came from the eastern cities. Overall, we found that non-fossil secondary OC (SOCNF) was the largest contributor (39 ± 10 %) to OC, followed by fossil secondary OC (SOCFF: 26 ± 5 %), fossil primary OC (POCFF: 14 ± 6 %), biomass burning OC (OCbb: 13 ± 6 %) and cooking OC (OCck: 8 ± 5 %). Also, we established the dynamic variation of 13C as a function of aged OC and the volatile organic compounds (VOCs) oxidized OC to explore the impact of aging processes on OC. Our pilot results showed that atmospheric aging was highly sensitive to the emission sources of seed OC particles, with a higher aging degree (86 ± 4 %) when more non-fossil OC particles were transferred from the northern PRD
Empires of Opportunity: German naturalists in British India and the frictions of transnational science
No full textThis article examines the little-known but exceptionally well-documented German Schlagintweit brothers’expedition to India and Central Asia in 1854-1858, under the auspices of the British East India Company and theking of Prussia. The brothers’ careers present an instructive study of the opportunities and conflicts inherentwithin transnational science and the imperial labour market in colonial India over the nineteenth century. Untilnow, historians have largely emphasised the ways in which European East India Companies provided scientificpractitioners with professional mobility from the seventeenth to the mid-nineteenth century. In these accounts,German scientific practitioners are represented as especially mobile, moving more or less freely within foreignempires, because there existed at the time no ‘German’ empire that might compete for allegiances and makethem appear suspect. My article, in contrast, offers a revisionist account of this globalising picture in two senses.First, a close look at the local everyday practices of the Schlagintweit brothers’ expedition highlights theconsiderable tensions and frictions which accompanied imperial recruitment to South Asia – even for Germanscientific practitioners. What emerges instead is a rich picture of the contradictory interpretations amongcontemporaries of supposedly cooperative projects, and the instrumentalisation of scientific activities forpolitical ends in the Indian subcontinent, for both established and aspiring colonial powers. Second, the ways inwhich the Schlagintweits’ scientific expedition was represented and remembered in the subsequent decadesshows how the politics around transnational science projects only intensified with German unification
An APRI+ALBI Based Multivariable Model as Preoperative Predictor for Posthepatectomy Liver Failure.
Full text linkOBJECTIVE AND BACKGROUND
Clinically significant posthepatectomy liver failure (PHLF B+C) remains the main cause of mortality after major hepatic resection. This study aimed to establish an APRI+ALBI, aspartate aminotransferase to platelet ratio (APRI) combined with albumin-bilirubin grade (ALBI), based multivariable model (MVM) to predict PHLF and compare its performance to indocyanine green clearance (ICG-R15 or ICG-PDR) and albumin-ICG evaluation (ALICE).
METHODS
12,056 patients from the National Surgical Quality Improvement Program (NSQIP) database were used to generate a MVM to predict PHLF B+C. The model was determined using stepwise backwards elimination. Performance of the model was tested using receiver operating characteristic curve analysis and validated in an international cohort of 2,525 patients. In 620 patients, the APRI+ALBI MVM, trained in the NSQIP cohort, was compared with MVM's based on other liver function tests (ICG clearance, ALICE) by comparing the areas under the curve (AUC).
RESULTS
A MVM including APRI+ALBI, age, sex, tumor type and extent of resection was found to predict PHLF B+C with an AUC of 0.77, with comparable performance in the validation cohort (AUC 0.74). In direct comparison with other MVM's based on more expensive and time-consuming liver function tests (ICG clearance, ALICE), the APRI+ALBI MVM demonstrated equal predictive potential for PHLF B+C. A smartphone application for calculation of the APRI+ALBI MVM was designed.
CONCLUSION
Risk assessment via the APRI+ALBI MVM for PHLF B+C increases preoperative predictive accuracy and represents an universally available and cost-effective risk assessment prior to hepatectomy, facilitated by a freely available smartphone app
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