Retrospective costing of warfarin

In Ireland, there are four anticoagulants available for prescribing to patients with atrial fibrillation for stroke prevention. A key feature of the three most recent anticoagulants is that monitoring is redundant. Despite this, there is continued prescribing of the incumbent anticoagulant, warfarin, which requires monitoring. Lack of information regarding the cost of monitoring, and the extra burden it places on health budgets and patients, motivated this costing study. Using micro costing, the costs of warfarin treatment (including monitoring) was disaggregated and isolated from both the patients' and health care provider's perspectives in a Cork hospital. Costs to the health care provider per patient per clinic visited were 21.57 Euros. Patient costs incurred per patient per clinic were 48.50 Euros. Thus, the total costs per patient per visit were 70.07 Euros. This result reveals that while the pharmaceutical cost of warfarin is low; it is not an inexpensive therapy when monitoring costs are considered.

The food choice at work study: effectiveness of complex workplace dietary interventions on dietary behaviours and diet-related disease risk - study protocol for a clustered controlled trial

BACKGROUND

Dietary behaviour interventions have the potential to reduce diet-related disease. Ample opportunity exists to implement these interventions in the workplace. The overall aim is to assess the effectiveness and cost-effectiveness of complex dietary interventions focused on environmental dietary modification alone or in combination with nutrition education in large manufacturing workplace settings.

METHODS/DESIGN

A clustered controlled trial involving four large multinational manufacturing workplaces in Cork will be conducted. The complex intervention design has been developed using the Medical Research Council's framework and the National Institute for Health and Clinical Excellence (NICE) guidelines and will be reported using the TREND statement for the transparent reporting of evaluations with non-randomized designs. It will draw on a soft paternalistic 'nudge' theoretical perspective. It will draw on a soft paternalistic "nudge" theoretical perspective. Nutrition education will include three elements: group presentations, individual nutrition consultations and detailed nutrition information. Environmental dietary modification will consist of five elements: (a) restriction of fat, saturated fat, sugar and salt, (b) increase in fibre, fruit and vegetables, (c) price discounts for whole fresh fruit, (d) strategic positioning of healthier alternatives and (e) portion size control. No intervention will be offered in workplace A (control). Workplace B will receive nutrition education. Workplace C will receive nutrition education and environmental dietary modification. Workplace D will receive environmental dietary modification alone. A total of 448 participants aged 18 to 64 years will be selected randomly. All permanent, full-time employees, purchasing at least one main meal in the workplace daily, will be eligible. Changes in dietary behaviours, nutrition knowledge, health status with measurements obtained at baseline and at intervals of 3 to 4 months, 7 to 9 months and 13 to 16 months will be recorded. A process evaluation and cost-effectiveness economic evaluation will be undertaken.

DISCUSSION

A 'Food Choice at Work' toolbox (concise teaching kit to replicate the intervention) will be developed to inform and guide future researchers, workplace stakeholders, policy makers and the food industry.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN35108237.

Right care, right time, right place, every time

By improving its patient flow, Intermountain Healthcare was able to increase capacity and improve resource utilization. The project's guiding principle was to remove variation from patient flow processes, increase collaboration, and enhance the quality of care. A pilot project to redesign patient flow at Intermountain Medical Center focused on patient placement and care coordination. The pilot resulted in the creation of 21 virtual beds, reduced severity-adjusted average length of stay, enhanced patient satisfaction, and improved bed turn-around time.

Emerging adulthood in developmental co-ordination disorder: parent and young adult perspectives

Recent research widely acknowledges that developmental co-ordination disorder (DCD) is a pervasive and enduring disorder, which persists into adolescence and adulthood (Cousins & Smyth, 2003; Kirby, Sugden, Beveridge, & Edwards, 2008). However, few studies have given detailed consideration to the range and level of functioning difficulties in emerging adults with DCD, and no studies to date have gained a parental perspective. Current functioning of 19 young adults with DCD was examined using the Adult Dyspraxia/DCD Checklist (ADC, Kirby, Edwards, Sugden, & Rosenblum, 2010) and parents' views of their child's current functioning was also obtained. Results suggest that whilst some motor skills such as handwriting continue to impact in emerging adulthood, not all skills are as problematic, such as self-care skills. Additionally, executive functioning, and social skills seem to be a key areas of concern for both young adults and their parents. Results provide guidance for areas of intervention that need to be considered, especially focusing on executive functioning skills. Also they highlight the need for gathering information from more than one source to gain a complete picture of functioning.

The association of fatty acid deficiency symptoms (FADS) with actual essential fatty acid status in cheek cells

Seven clinical symptoms have been utilised in several studies as a means of potentially identifying children with a deficiency in essential polyunsaturated fatty acids (PUFAs). The purpose of this study was to investigate whether there was any correlation between parental reports of the frequency of these seven 'fatty acid deficiency symptoms' (FADS) with actual levels of fatty acids in buccal cell samples of 450 children aged 8-10 years old. Additionally, the relationship between FADS and cognitive test performance, ratings of attention and behaviour and other somatic complaints were explored. The severity of reported FADS was not related to the levels of omega-6 or omega-3 in buccal cell samples. There was a relationship between parental reports of child behaviour and reported FADS; with high FADS being related to higher ratings of behaviour problems. Using FADS as a marker of PUFA deficiency may not be appropriate especially when assessing typically developing children.

A double-blind, placebo-controlled study investigating the effects of omega-3 supplementation in children aged 8-10 years from a mainstream school population

Despite the increased interest in the effects of omega-3 supplementation on children's learning and behaviour, there are a lack of controlled studies of this kind that have utilised a typically developing population. This study investigated the effects of omega-3 supplementation in 450 children aged 8-10 years old from a mainstream school population, using a randomised, double-blind, placebo-controlled design. Participants were supplemented with either active supplements (containing docosahexaenoic acid, DHA and eicosapentaenoic acid, EPA) or a placebo for 16 weeks. Cheek cell fatty acid levels were recorded pre- and post-supplementation and a range of cognitive tests and parent and teacher questionnaires were used as outcome measures. After supplementation, changes in the relationship between omega-6 and omega-3 were significant in the active group. Despite the wide range of cognitive and behavioural outcome measures employed, only three significant differences between groups were found after 16 weeks, one of which was in favour of the placebo condition. Exploring the associations between changes in fatty acid levels and changes in test and questionnaire scores also produced equivocal results. These findings are discussed in relation to previous findings with clinical populations and future implications for research.

Childrens' learning and behaviour and the association with cheek cell polyunsaturated fatty acid levels

Increasing interest in the role of omega-3 fatty acids in relation to neurodevelopmental disorders (e.g. ADHD, dyslexia, autism) has occurred as a consequence of some international studies highlighting this link. In particular, some studies have shown that children with ADHD may have lower concentrations of polyunsaturated fatty acids (PUFAs), particularly omega-3, in their red blood cells and plasma, and that supplementation with omega-3 fatty acids may alleviate behavioural symptoms in this population. However, in order to compare levels it seems appropriate to establish fatty acid levels in a mainstream school aged population and if levels relate to learning and behaviour. To date no study has established this. For this study, cheek cell samples from 411 typically developing school children were collected and analysed for PUFA content, in order to establish the range in this population. In addition, measures of general classroom attention and behaviour were assessed in these children by teachers and parents. Cognitive performance tests were also administered in order to explore whether an association between behaviour and/or cognitive performance and PUFA levels exists. Relationships between PUFA levels and socio-economic status were also explored. Measures of reading, spelling and intelligence did not show any association with PUFA levels, but some associations were noted with the level of omega-3 fatty acids and teacher and parental reports of behaviour, with some evidence that higher omega-3 levels were associated with decreased levels of inattention, hyperactivity, emotional and conduct difficulties and increased levels of prosocial behaviour. These findings are discussed in relation to previous findings from omega-3 supplementation studies with children.

Multigenic control of tuberculosis resistance: analysis of a QTL on mouse chromosome 7 and its synergism with sst1

Tuberculosis remains a significant global health problem: one-third of the human population is infected with Mycobacterium tuberculosis (MTB) and 10% of those are at lifetime risk of developing tuberculosis. In the majority of individuals infected, genetic determinants of susceptibility remain largely unknown due to complex multigenic control and the influence of genes--environment interactions. Genetic variation of host resistance to MTB in animal models reflects heterogeneity among humans. Stepwise dissection of these interactions will permit the deciphering of MTB's complex virulence strategy. Previously, we have characterized a mouse supersusceptibility locus (sst1) controlling antituberculosis immunity. In this study, eight host resistance quantitative trait loci (QTLs) were mapped that counter-balance the devastating effect of sst1, among which a QTL on chromosome 7 (Chr7) was most prominent. The Chr7 and sst1 loci independently control distinct resistance mechanisms to MTB, but their effects apparently converge on macrophages in remarkable synergy. Combining these resistance alleles on a C3HeB/FeJ-susceptible background reduced the lung pathology and improved survival after MTB challenge accounting for half of the difference between susceptible and resistant parental strains. These data reveal novel gene interactions controlling MTB resistance and will enable the identification of resistance gene(s) encoded within Chr7 locus.

Whole-genome association study of bipolar disorder

We performed a genome-wide association scan in 1461 patients with bipolar (BP) 1 disorder, 2008 controls drawn from the Systematic Treatment Enhancement Program for Bipolar Disorder and the University College London sample collections with successful genotyping for 372,193 single nucleotide polymorphisms (SNPs). Our strongest single SNP results are found in myosin5B (MYO5B; P=1.66 x 10(-7)) and tetraspanin-8 (TSPAN8; P=6.11 x 10(-7)). Haplotype analysis further supported single SNP results highlighting MYO5B, TSPAN8 and the epidermal growth factor receptor (MYO5B; P=2.04 x 10(-8), TSPAN8; P=7.57 x 10(-7) and EGFR; P=8.36 x 10(-8)). For replication, we genotyped 304 SNPs in family-based NIMH samples (n=409 trios) and University of Edinburgh case-control samples (n=365 cases, 351 controls) that did not provide independent replication after correction for multiple testing. A comparison of our strongest associations with the genome-wide scan of 1868 patients with BP disorder and 2938 controls who completed the scan as part of the Wellcome Trust Case-Control Consortium indicates concordant signals for SNPs within the voltage-dependent calcium channel, L-type, alpha 1C subunit (CACNA1C) gene. Given the heritability of BP disorder, the lack of agreement between studies emphasizes that susceptibility alleles are likely to be modest in effect size and require even larger samples for detection.

Obesogenic island: the financial burden of private transport on low-income households

BACKGROUND

The physical and social environment influences access to a healthy lifestyle, of which transport is one determining factor. This paper estimates the cost of transport on the island of Ireland.

METHODS

Budget standards were developed on the basis of costs of baskets of core goods and services required for daily living. The transport budget was based on the needs of an urban living family. Financial capacity of the family relative to transport basket costs was determined.

RESULTS

Transport costs vary depending on family type and car ownership. The motoring costs for a family with two unemployed adults, with a weekly financial capacity of 388.28 euros and 427.70 euros, respectively, for the Republic of Ireland and Northern Ireland, amount to 94.78 euros and 74.68 euros, representing 18 and 10% of the family's weekly income.

CONCLUSION

The prohibitive costs of private transport present an opportunity for policy makers to consider creating supportive environments incorporating the more cost-effective and environmentally friendly options of public transport. Without such measures, dependence on private transport will exacerbate the incidence of food poverty and the health inequalities consequent upon it.