The Economic Analyses of the Drosophila suzukii's Invasions: A Mini-review

The objective of this paper is to bring to the fore the type of economic analyses that have been carried out on the invasion of the Drosophila suzukii Matsumura (Diptera: Drosophilidae) and what has been learned. The analysis is limited to the original research articles published in peer-reviewed journals and book chapters. A total of 20 relevant studies are identified. The studies are analysed based on their main purpose, which is either economic impact assessment or economic evaluation of management programmes. The analysis also considers the key methodological points highlighted in recent reviews of the economic literature on alien invasive species. Over time, the focus of these studies has gradually shifted from raising awareness of the magnitude of the impact, particularly on agricultural production, to supporting the decision-making process concerning effective pest management. Most studies have been conducted from a private perspective, measuring private costs and providing guidance to the industry. However, some papers include, or focus on, the societal costs caused by the invasions of D. suzukii. This review has found few impact studies in the recently invaded areas and no economic evaluation of management programmes. There are not only geographical areas, but also themes that need more attention and analysis in the economic studies on D. suzukii. Assessing the economic effectiveness of integrated pest management programmes in specific settings, included the Latin American countries, is crucial.

Translocation of deadwood in ecological compensation: A novel way to compensate for habitat loss

Restoration of degraded habitat is frequently used in ecological compensation. However, ecological restoration suffers from innate problems of long delivery times of features shown to be good proxies for biodiversity, e.g., large dead trees. We tested a possible way to circumvent this problem; the translocation of hard-to-come deadwood substrates from an impact area to a compensation area. Following translocation, deadwood density in the compensation area was locally equivalent to the impact area, around 20 m3 ha-1, a threshold for supporting high biodiversity of rare and red-listed species. However, deadwood composition differed between the impact and compensation area, showing a need to include more deadwood types, e.g., late decomposition deadwood, in the translocation scheme. To guide future compensation efforts, the cost for translocation at different spatial scales was calculated. We conclude that translocation of deadwood could provide a cost-efficient new tool for ecological compensation/restoration but that the method needs refinement.

Alterations in rat brain modular organization during unconsciousness are dependent on communication efficiency and metabolic cost

Spontaneous brain activity exhibits a highly structured modular organization that varies across individuals and reconfigures over time. Although it has been proposed that brain organization is shaped by an economic trade-off between minimizing costs and facilitating efficient information transfer, it remains untested whether modular variability and its changes during unconscious conditions might be constrained by the economy of brain organization. We acquired functional MRI and FDG-PET in rats under three different levels of consciousness induced by propofol administration. We examined alterations in brain modular variability during loss of consciousness from mild sedation to deep anesthesia. We also investigated the relationships between modular variability with glucose metabolism and functional connectivity strength as well as their alterations during unconsciousness. We observed that modular variability increased during loss of consciousness. Critically, across-individual modular variability is oppositely associated with functional connectivity strength and cerebral metabolism, and with deepening dosage of anesthesia, becoming increasingly dependent on basal metabolism over functional connectivity. These results suggested that, propofol-induced unconsciousness may lead to brain modular reorganization, which are putatively shaped by re-negotiations between energetic resources and communication efficiency.

Migration from inorganic to organic fertilization for a more sustainable oil palm agro-industry

The rapid growth in oil palm production has raised environmental concerns due to the massive discharge of liquid and solid waste. To address this issue, waste generated need to be optimized by composting and converting the waste into organic fertilizer. The practice of pure inorganic fertilization must also be discontinued due to the rising cost of imported fertilizers and their detrimental effect on the soil. Furthermore, several studies have established that recycling self-produced organic waste as fertilizer is an excellent method to achieve sustainability. Therefore, this study investigates a significant response to organic fertilization treatment. The bioorganic empty fruit bunch (EFB) compost was tested on Podzols soil (Typic Placorthods) in the nursery and in the young mature stage of the palm that was treated from the beginning of planting. The results showed that organic fertilization using low and high concentrations of fresh and composted EFB had a more significant effect on seedling growth. A high dose of composted EFB positively affected the N and K content of the leaf. Composted EFB had added value, especially in improving soil chemical properties and assimilation of N nutrients by oil palm seedlings, especially Podzols (Typic Placorthods). Pure inorganic fertilization on Podzols (Typic Placorthods) could not have been more practical due to inadequate nutrient uptake. Composted EFB had a positive effect superior that of the fresh EFB on the chemical composition of the soil, such as improving the saturation rate of the cation exchange capacity and the exchangeable K and Mg. Fresh EFB was good, but composted EFB was better for maintaining yield and less attractivity to Oryctes, which is essential in replanting.

The status and preparation for the next decade of biosimilars in the Middle Eastern and North African region

INTRODUCTION

Little is known about the status and the future potential of biosimilars in the Middle East and North Africa (MENA) region.

AREAS COVERED

This perspective provides insights into the current regulatory landscape of some MENA countries, currently available biosimilars, the potential of biosimilars in the next decade, and challenges to overcome.

EXPERT OPINION

Given the economic and demographic heterogeneity across the MENA countries, biosimilars could reduce significant economic unmet needs in these countries. In the next decade, biosimilars may witness higher approval rates and market share over their originators in the MENA countries. We argue that the regulatory bodies in the MENA countries should adopt the new policies of the FDA, the EMA, and the WHO, that aim to ease the biosimilar approval process. These policies are to adopt technology in the process of approval; engage health technology assessment bodies in price assessment; provide educational materials to increase awareness among providers, patients, and payers. Further, MENA countries should upgrade the external-reference pricing systems to more sophisticated ones that consider the heterogeneity in economics and needs.

Follow-up and outcomes of patients with a pregnancy of unknown location: A comparison of two prediction models

BACKGROUND

The time period while delineating the final diagnosis following presentation with a pregnancy of unknown location (PUL) can be an anxious time, as well as being time and resource intensive. Prediction models have been utilised in order to tailor counselling, frame expectations and plan care.

OBJECTIVES

We aimed to review diagnoses of PUL in our population and assess the value of two prediction models.

STUDY DESIGN

We reviewed all 394 PUL diagnoses over a three year period in a tertiary level maternity hospital. We then retrospectively applied the M1 and M6NP models to assess their accuracy when compared to the final diagnosis.

RESULTS

PUL comprises of 2.9% (394/13401) of attendances in our unit, requiring 752 scans and 1613 separate blood tests. Just under one in ten women (9.9%, n = 39) presenting with a PUL had a viable pregnancy at discharge, however of the remainder, only 18.0% (n = 83) required medical or surgical treatment for a PUL. The M1 model was more successful at predicting an ectopic pregnancy than the M6NP, with the latter over-predicting viable pregnancies (33.4%, n = 77).

CONCLUSIONS

We demonstrate that the management of women with a PUL could be stratified through the application of outcome prediction models, having positive results for framing expectations and potentially reducing this resource-intensive diagnosis.

Aerial and underwater drones for marine litter monitoring in shallow coastal waters: factors influencing item detection and cost-efficiency

Although marine litter monitoring has increased over the years, the pollution of coastal waters is still understudied and there is a need for spatial and temporal data. Aerial (UAV) and underwater (ROV) drones have demonstrated their potential as monitoring tools at coastal sites; however, suitable conditions for use and cost-efficiency of the methods still need attention. This study tested UAVs and ROVs for the monitoring of floating, submerged, and seafloor items using artificial plastic plates and assessed the influence of water conditions (water transparency, color, depth, bottom substrate), item characteristics (color and size), and method settings (flight/dive height) on detection accuracy. A cost-efficiency analysis suggests that both UAV and ROV methods lie within the same cost and efficiency category as current on-boat observation and scuba diving methods and shall be considered for further testing in real scenarios for official marine litter monitoring methods.

Examining the determinants of bank efficiency in transition: empirical evidence from Ghana

This paper measures and evaluates the relative pure technical efficiency and cost-efficiency of Ghanaian banks over the period 2008–2019 using a nonparametric DEA technique. The study also examines the factors that determines bank efficiency in Ghana using both static panel and dynamic panel regression estimators. The results show that the overall average bank efficiency (pure-technical and cost) levels in Ghana are relatively low compared to the benchmark “best-practice” efficiency level of 1. However, the results indicate that there are remarkable improvements in both the pure technical efficiency and cost-efficiency levels since the coming into effect of the new banking Act in 2016. Further, the study depicts bank size, GDP growth rate and inflation to be the most important factors that must be considered in the determination of bank efficiency in Ghana. Also, bank capitalization is depicted to have a significant impact on bank cost-efficiency. In contrast, the findings reveal that return on assets (ROA), liquidity and loan loss provision are, however, not important factors in the determination of both banks pure technical and cost-efficiency. Bank capital is further depicted to have insignificant impact in the determination of bank pure technical efficiency in Ghana.

First-line immunotherapy of neuronal surface antibody-mediated autoimmune encephalitis: Assessment of therapeutic effectiveness and cost-efficiency

OBJECTIVE

To evaluate the therapeutic effectiveness and cost-efficiency of first-line immunotherapies on neuronal surface antibody-mediated autoimmune encephalitis (AE) based on a real-world observational study in China.

METHODS

Our study retrospectively collected the clinical and paraclinical data of patients with definite neuronal surface antibody-mediated AE between July 2014 and July 2020. Regular follow-up was performed after administering standard regimens of first-line immunotherapies, including intravenous methylprednisolone (IVMP) and / or intravenous immunoglobulin (IVIG). Therapeutic effectiveness was reflected by modified Rankin Scale scores. The health resource utilization and direct medical costs were extracted to analyze the cost-efficiency.

RESULTS

Among the 78 eligible patients, 48 (61.5%) were males with a median age of 40 years. More than half (56, 71.8%) were treated with combination therapy, with the rest receiving IVMP and IVIG monotherapy (both of 11, 14.1%). Related objective variables, i.e., sex, onset age, disease course, onset symptoms, antibody types, abnormal paraclinical results, disease severity, and the health insurance, showed insignificant differences on the selection of therapy. Each therapy showed similar short-term (4-week) and long-term (1-year) therapeutic effects. Yet the single or combination of IVIG had a slightly better effectiveness but higher cost than the monotherapy of IVMP.

CONCLUSION

The combination of IVMP and IVIG was used more frequently than either alone, which may be associated with neurologist's personal experience and patient's wishes. Though with similar therapeutic effectiveness, the use of IVMP alone might be a better choice with a better cost-efficiency.

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial

Background

Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial.

Methods

Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve.

Results

69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72–80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care.

Conclusion

These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients’ perception of this model of care are needed.

Clinical trial registration

The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05201-3.

Hospital competition in a national health service: Evidence from a patient choice reform

We study the impact of exposing hospitals in a National Health Service (NHS) to non-price competition by exploiting a patient choice reform in Norway in 2001. The reform facilitates a difference-in-difference approach due to plausibly exogenous (geographical) variation in pre-reform market structure. Employing rich, administrative data, covering the universe of hospital admissions from 1998 to 2005, we estimate models with hospital and treatment (DRG) fixed-effects and use only emergency admissions to limit patient selection issues. The results show that hospitals in more competitive areas have a sharper reduction in AMI mortality but no effect on stroke mortality. We also find that exposure to competition reduces all-cause mortality, shortens length of stay, but increases readmissions, though the effects are small in magnitude. In years with high (DRG) prices, the negative effect on readmissions almost vanishes. Finally, exposure to competition tends to reduce waiting times and increase admissions, but the effects must be interpreted with care as the outcomes include elective treatments.

Group testing can improve the cost-efficiency of prospective-retrospective biomarker studies

BACKGROUND

Cancer treatment is increasingly dependent on biomarkers for prognostication and treatment selection. Potential biomarkers are frequently evaluated in prospective-retrospective studies in which biomarkers are measured retrospectively on archived specimens after completion of prospective clinical trials. In light of the high costs of some assays, random sampling designs have been proposed that measure biomarkers for a random sub-sample of subjects selected on the basis of observed outcome and possibly other variables. Compared with a standard design that measures biomarkers on all subjects, a random sampling design can be cost-efficient in the sense of reducing the cost of the study substantially while achieving a reasonable level of precision.

METHODS

For a biomarker that indicates the presence of some molecular alteration (e.g., mutation in a gene), we explore the use of a group testing strategy, which involves physically pooling specimens across subjects and assaying pooled samples for the presence of the molecular alteration of interest, for further improvement in cost-efficiency beyond random sampling. We propose simple and general approaches to estimating the prognostic and predictive values of biomarkers with group testing, and conduct simulation studies to validate the proposed estimation procedures and to assess the cost-efficiency of the group testing design in comparison to the standard and random sampling designs.

RESULTS

Simulation results show that the proposed estimation procedures perform well in realistic settings and that a group testing design can have considerably higher cost-efficiency than a random sampling design.

CONCLUSIONS

Group testing can be used to improve the cost-efficiency of biomarker studies.

A brain-inspired network architecture for cost-efficient object recognition in shallow hierarchical neural networks

The brain successfully performs visual object recognition with a limited number of hierarchical networks that are much shallower than artificial deep neural networks (DNNs) that perform similar tasks. Here, we show that long-range horizontal connections (LRCs), often observed in the visual cortex of mammalian species, enable such a cost-efficient visual object recognition in shallow neural networks. Using simulations of a model hierarchical network with convergent feedforward connections and LRCs, we found that the addition of LRCs to the shallow feedforward network significantly enhances the performance of networks for image classification, to a degree that is comparable to much deeper networks. We found that a combination of sparse LRCs and dense local connections dramatically increases performance per wiring cost. From network pruning with gradient-based optimization, we also confirmed that LRCs could emerge spontaneously by minimizing the total connection length while maintaining performance. Ablation of emerged LRCs led to a significant reduction of classification performance, which implies these LRCs are crucial for performing image classification. Taken together, our findings suggest a brain-inspired strategy for constructing a cost-efficient network architecture to implement parsimonious object recognition under physical constraints such as shallow hierarchical depth.

Pathologic response at the epicenter of the treatment decision-making process in Human Epidermal Receptor-Type 2 overexpressing (Her2+) Early Breast Cancer (EBC): Challenges and opportunities for financially-constrained healthcare systems

After more than two decades of intensive research, tremendous progress has been achieved in the management of Human Epidermal Receptor-2 overexpressing (Her2+) Early Breast Cancer (EBC). In the latest years, major clinical trials have explored the neoadjuvant scenario, in addition to the prognostic role of pathologic complete response (pCR) and the possibility of a 'tumor biology-driven' patient selection provided by the assessment pathologic response. However, the introduction of new agents has been a major burden for financially-constrained healthcare systems-which includes those from most emerging markets (currently representing 85% of the world population) but also, to some extent, public systems from welfare states. This manuscript addresses evidence-based opportunities to promote a more rational utilization of the available resources in Her2+ EBC, in addition to areas of interest for future research in cost-efficiency.

Developing improved methods for identifying the cost-efficient abatement set in coastal water quality protection

Eutrophication of coastal waters is a recognised problem in estuaries around the globe. To analyse cross-boundary water quality management, such as protection of the Baltic Sea, economic nutrient abatement models commonly operate on a large scale, grouping river systems to large catchment areas. Theoretical deliberation suggests that modelling abatement in such a way removes the opportunity of targeting measures to the most vulnerable regions within the catchment, while overestimating the capacity of abatement measures in the upstream areas. However, the implications on designing environmental policy depend on catchment characteristics and the stringency of the abatement targets. In this study a model of the catchment area is built with zones that are an increasing distance away from the coast to show what kind of bias in the optimal abatement set is caused by the assumption of spatial homogeneity. By solving the model with and without the zones for good ecological status at the South-West coast of Sweden, it is shown that while assuming homogeneity prevents from perceiving the abatement measures where they would be the most effective, it also leads to ignoring spatial limitations that are more relevant to a subset of abatement measures, such as the wetlands and buffer zones. Following from the relatively large nitrogen abatement targets, the overall effect of assuming catchment homogeneity is to underestimate the abatement costs and to overestimate the potential of wetlands to reduce nitrogen.

First Successful Large-Scale Introduction of an Enhanced Recovery after Bariatric Surgery (ERABS) Program in the Middle East: The Results and Lessons Learned of Tawam Hospital/Johns Hopkins, a Tertiary Governmental Center in the UAE

BACKGROUND

Although enhanced recovery after bariatric surgery (ERABS) has proven to be safe and cost-effective, this concept is relatively new in the Middle East.

METHODS

A retrospective analysis of consecutive registered cohorts of patients who underwent primary and purely laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were compared before introduction of ERABS (2010-2014) and after ERABS (2015-2017) at Tawam Hospital/Johns Hopkins, the UAE.

RESULTS

A total of 462 eligible bariatric patients (LSG 414 and LRYGB 48) were operated on before and 1602 (LSG 1436 and LRYGB 166) after introduction of the ERABS. Significant improvements of mean patient time of the patient being within the OR for LSG (from 2:27 to 1:23 min, p = 0.000) and LRYGB (from 3:17 to 1:59 min, p = 0.000) were achieved when comparing pre-ERABS with after introduction of ERABS. Furthermore, there was a significant decrease in LOS in both LSG (from 3.2 to 1.5 days, p = 0.000) and in LRYGB (from 3.5 to 1.7 days, p = 0.000). Major (CD classification III-IV) complications decreased significantly in LSG (from 13.8 to 0.8%, p = 0.000) and were similar in LRYGB (from 4.2% to 3.0%, p = NS). The readmission rate for LSG (from 2.9 to 2.6%, p = NS) or LRYGB (from 0 to 4.8%, p = NS) and the reoperation rates after LSG (from 0.7 to 0.5%, p = NS) and LRYGB (from 0 to 2.4%, p = NS) did not differ between both groups following introduction of ERABS.

CONCLUSIONS

Implementation of a standardized ERABS program in the Middle East is feasible and safe and leads to reduced LOS and OR times.

Evidence for the world as an external memory: A trade-off between internal and external visual memory storage

We use visual working memory (VWM) to maintain the visual features of objects in our world. Although the capacity of VWM is limited, it is unlikely that this limit will pose a problem in daily life, as visual information can be supplemented with input from our external visual world by using eye movements. In the current study, we influenced the trade-off between eye movements and VWM utilization by introducing a cost to a saccade. Higher costs were created by adding a delay in stimulus availability to a copying task. We show that increased saccade cost results in less saccades towards the model and an increased dwell time on the model. These results suggest a shift from making eye movements towards taxing internal VWM. Our findings reveal that the trade-off between executing eye-movements and building an internal representation of our world is based on an adaptive mechanism, governed by cost-efficiency.

Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis

OBJECTIVES

To evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions.

DESIGN

A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2012-2015.

SETTING

Two HA specialist rehabilitation services in England, providing different service models for HA rehabilitation.

PARTICIPANTS

All patients admitted to each of the units with an admission rehabilitation complexity M score of ≥3 (N=190; mean age 46 (SD16) years; males:females 63:37%). Diagnoses were acquired brain injury (n=166; 87%), spinal cord injury (n=9; 5%), peripheral neurological conditions (n=9; 5%) and other (n=6; 3%).

INTERVENTION

Specialist in-patient multidisciplinary rehabilitation combined with management and stabilisation of intercurrent medical and surgical problems.

OUTCOME MEASURES

Rehabilitation complexity and medical acuity: Rehabilitation Complexity Scale-version 13. Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK FIM+FAM).

PRIMARY OUTCOMES

(1) reduction in dependency and (2) cost-efficiency, measured as the time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of on-going care in the community.

RESULTS

The mean length of stay was 103 (SD66) days. Some differences were observed between the two units, which were in keeping with the different service models. However, both units showed a significant reduction in dependency and acuity between admission and discharge on all measures (Wilcoxon: p<0.001). For the 180 (95%) patients with complete NPCNA data, the mean episode cost was £77 119 (bootstrapped 95% CI £70 614 to £83 894) and the mean reduction in 'weekly care costs' was £462/week (95% CI 349 to 582). The mean time to offset the cost of rehabilitation was 27.6 months (95% CI 13.2 to 43.8).

CONCLUSIONS

Despite its relatively high initial cost, specialist HA rehabilitation can be highly cost-efficient, producing substantial savings in on-going care costs, and relieving pressure in the acute care services.

Coupling systematic planning and expert judgement enhances the efficiency of river restoration

Ineffectiveness of current river restoration practices hinders the achievement of ecological quality targets set by country-specific regulations. Recent advances in river restoration help planning efforts more systematically to reach ecological targets at the least costs. However, such approaches are often desktop-based and overlook real-world constraints. We argue that combining two techniques commonly used in the conservation arena - expert judgement and systematic planning - will deliver cost-effective restoration plans with a high potential for implementation. We tested this idea targeting the restoration of spawning habitat, i.e. gravel bars, for 11 rheophilic fish species along a river system in Germany (Havel-Spree rivers). With a group of local fish experts, we identified the location and extent of potential gravel bars along the rivers and necessary improvements to migration barriers to ensure fish passage. Restoration cost of each gravel bar included the cost of the action itself plus a fraction of the cost necessary to ensure longitudinal connectivity by upgrading or building fish passages located downstream. We set restoration targets according to the EU Water Framework Directive, i.e. relative abundance of 11 fish species in the reference community and optimised a restoration plan by prioritising a subset of restoration sites from the full set of identified sites, using the conservation planning software Marxan. Out of the 66 potential gravel bars, 36 sites which were mainly located in the downstream section of the system were selected, reflecting their cost-effectiveness given that fewer barriers needed intervention. Due to the limited overall number of sites that experts identified as being suitable for restoring spawning habitat, reaching abundance-targets was challenged. We conclude that coupling systematic river restoration planning with expert judgement produces optimised restoration plans that account for on-the-ground implementation constraints. If applied, this approach has a high potential to enhance overall efficiency of future restoration efforts.

Water protection in the Baltic Sea and the Chesapeake Bay: institutions, policies and efficiency

The Baltic Sea and the Chesapeake Bay share many characteristics. Both are shallow, brackish marine areas that suffer from eutrophication. Successful policies targeting point source pollution have lowered nutrient loads in both areas, but achieving the desired marine quality will require further abatement: efforts may be extended to more complicated and expensive pollution sources, notably agricultural nonpoint loads. Despite their ecological similarities, the two watersheds have different histories and institutional settings and have thus adopted different policies. Comparing and contrasting the policies reveal ways to improve the efficiency of each and ways to avoid the path of trial and error. No comparison of the parallel protection efforts, which involve expenditures of hundreds of millions of dollars annually, has been carried out to date. The present paper analyzes the policies applied in the two regions, distilling the results into six recommendations for future steps in preserving what are valuable sea areas.

Is kyphoplasty necessary?

We describe four cases of delayed union in female patients with severe osteoporotic vertebral fractures, which were treated in a similar but less costly method to kyphoplasty. Due to domestic regulations, inflatable tamps for kyphoplasty are not available to every clinical orthopedists in Japan. In our clinical experience of four cases of delayed lumbar spine union between 2009 and 2010, we performed vertebroplasty using a reduction and spreading prod (Oyamada prod) for fracture reduction and a pediatric uromatic balloon (Medicon Co. Ltd.) to enlarge the pre-existing cavity. Our clinical results were comparable to those of kyphoplasty procedures performed in the USA. Our procedure could be used to overcome the shortage of medical supplies in developing countries or in countries such as Japan, which often prioritize financial concerns over providing optimal health care. Our method could serve as a useful compromise for moribund patients considering its cost efficiency.

Cost-utility of molecular adsorbent recirculating system treatment in acute liver failure

AIM: To determine the short-term cost-utility of molecular adsorbent recirculating system (MARS) treatment in acute liver failure (ALF).

METHODS: A controlled retrospective study was conducted with 90 ALF patients treated with MARS from 2001 to 2005. Comparisons were made with a historical control group of 17 ALF patients treated from 2000 to 2001 in the same intensive care unit (ICU) specializing in liver diseases. The 3-year outcomes and number of liver transplantations were recorded. All direct liver disease-related medical expenses from 6 mo before to 3 years after ICU treatment were determined for 31 MARS patients and 16 control patients. The health-related quality of life (HRQoL) before MARS treatment was estimated by a panel of ICU doctors and after MARS using a mailed 15D (15-dimensional generic health-related quality of life instrument) questionnaire. The HRQoL, cost, and survival data were combined and the incremental cost/quality-adjusted life years (QALYs) was calculated.

RESULTS: In surviving ALF patients, the health-related quality of life after treatmeant was generally high and comparable to the age- and gender-matched general Finnish population. Compared to the controls, the average cost per QALY was considerably lower in the MARS group (64 732€vs 133 858€) within a timeframe of 3.5 years. The incremental cost of standard medical treatment alone compared to MARS was 10 928€, and the incremental number of QALYs gained by MARS was 0.66.

CONCLUSION: MARS treatment combined with standard medical treatment for ALF in an ICU setting is more cost-effective than standard medical treatment alone.