The clinical benefit of blood transfusion: a hypothetical experiment based on a nationwide survey of severe maternal morbidity

Background It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high‐resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands. Study Design and Methods Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100 000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group. Results The observed MMR was 13 per 100 000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100 000 maternities (relative risk 6·5; 95% confidence interval 4·2–10·0). Conclusions It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5‐fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource‐poor settings.     

On the magnetic field dependence of deuterium metabolic imaging

Deuterium metabolic imaging (DMI) is a novel MR‐based method to spatially map metabolism of deuterated substrates such as [6,6'‐²H₂]‐glucose in vivo. Compared with traditional ¹³C‐MR‐based metabolic studies, the MR sensitivity of DMI is high due to the larger ²H magnetic moment and favorable T₁ and T₂ relaxation times. Here, the magnetic field dependence of DMI sensitivity and transmit efficiency is studied on phantoms and rat brain postmortem at 4, 9.4 and 11.7 T. The sensitivity and spectral resolution on human brain in vivo are investigated at 4 and 7 T before and after an oral dose of [6,6'‐²H₂]‐glucose. For small animal surface coils (Ø 30 mm), the experimentally measured sensitivity and transmit efficiency scale with the magnetic field to a power of +1.75 and ?0.30, respectively. These are in excellent agreement with theoretical predictions made from the principle of reciprocity for a coil noise‐dominant regime. For larger human surface coils (Ø 80 mm), the sensitivity scales as a +1.65 power. The spectral resolution increases linearly due to near‐constant linewidths. With optimal multireceiver arrays the acquisition of DMI at a nominal 1 mL spatial resolution is feasible at 7 T.     

Understanding and using comparative healthcare information; the effect of the amount of information and consumer characteristics and skills

ABSTRACT: BACKGROUND: Consumers are increasingly exposed to comparative healthcare information (information about the quality of different healthcare providers). Partly because of its complexity, the use of this information has been limited. The objective of this study was to examine how the amount of presented information influences the comprehension and use of comparative healthcare information when important consumer characteristics and skills are taken into account. METHODS: In this randomized controlled experiment, comparative information on total hip or knee surgery was used as a test case. An online survey was distributed among 800 members of the NIVEL Insurants Panel and 76 hip- or knee surgery patients. Participants were assigned to one of four subgroups, who were shown 3, 7, 11 or 15 quality aspects of three hospitals. We conducted Kruskall-Wallis tests, Chi-square tests and hierarchical multiple linear regression analyses to examine relationships between the amount of information and consumer characteristics and skills (literacy, numeracy, active choice behaviour) on one hand, and outcome measures related to effectively using information (comprehension, perceived usefulness of information, hospital choice, ease of making a choice) on the other hand. RESULTS: 414 people (47%) participated. Regression analysis showed that the amount of information slightly influenced the comprehension and the perceived usefulness of comparative healthcare information. It did not affect consumers hospital choice and ease of making this choice. Consumer characteristics (especially age) and skills (especially literacy) were the most important factors affecting the comprehension of information and the ease of making a hospital choice. For the perceived usefulness of comparative information, active choice behaviour was the most influencing factor. CONCLUSION: The effects of the amount of information were not unambiguous. It remains unclear what the ideal amount of quality information to be presented would be. Reducing the amount of information will probably not automatically result in more effective use of comparative healthcare information by consumers. More important, consumer characteristics and skills appeared to be more influential factors contributing to information comprehension and use. Consequently, we would suggest that more emphasis on improving consumers skills is needed to enhance the use of comparative healthcare information.     

A cost analysis of producing vaccines in developing countries

Developing country vaccine manufacturers (DCVMs) supply over half of the vaccines used in developing country immunisation programs. Decisions by developing countries to establish vaccine manufacturing should be based on economic viability, however reliable assessments of vaccine production costs are lacking. This study aimed to quantify the cost of establishing vaccine manufacturing facilities and producing vaccines in developing countries.This study estimates vaccine production costs in developing countries based on twelve vaccines produced by eight DCVMs. The results were based on estimates of the capital and operating costs required to establish vaccine manufacturing facilities under three hypothetical scenarios of production scale and scope. Cost patterns were then compared to vaccine prices paid by countries in both industrialized and developing country markets.The cost of producing vaccines in developing countries was estimated to be on average US$ 2.18 per dose, ranging between US$ 0.98 and US$ 4.85 for different vaccine types and formulations. Vaccine costs-per-dose decrease as production scale and scope increase. Cost-per-dose is mainly driven by fixed costs, but at a scale of production over 20 million doses per year it becomes driven by variable costs. Under the three hypothetical scenarios used, costs-per-dose of vaccines produced by developing countries were around 47% lower than vaccine prices in developing-country markets and 84% lower than prices in industrialized-country markets.This study has found that local production of vaccines in developing countries exhibits both economies of scale and economies of scope. The lower costs relative to prices suggests that a producer surplus and potential profits may be attainable in both developing and developed country markets, supporting sustainable production.     

Development of an art-therapy intervention for patients with personality disorders: an intervention mapping study

Art therapy for people diagnosed with personality disorders (PD) cluster B/C seems valuable to explore dysfunctional patterns in managing emotions. Current art therapy interventions are based on practical beliefs or commonsense approaches, without a sound basis in research results. To increase the effectiveness of art therapy for this target group, a planned, systematic and theory-based approach is needed. The principles of Intervention Mapping were applied to guide the development, implementation, and planned evaluation of the art therapy intervention. Empirical findings, theoretical models, and clinical practice experience were combined to construct a programme tailored to the needs of the target group. A structured 10-session art therapy intervention programme for patients was developed, aimed at: experiencing a (more) stable and positive sense of self, being able to express and regulate emotions, understanding emotions, thoughts and behaviours, using improved social and problem solving skills. Implementation took place and evaluation of the intervention is being carried out. The systematically developed art therapy intervention seems to be promising for PD patients in learning to deal with their problems. The results of the evaluation study may contribute to the knowledge about the use of art therapy for PD problems.     

Stability of the unlinked Latitude total elbow prosthesis: A biomechanical in vitro analysis

BackgroundThe purpose of this study is to assess the valgus and varus laxity of the unlinked version of the Latitude total elbow prosthesis and the effects of radial head preservation or replacement.MethodsBiomechanical analysis of the valgus and varus laxity of the unlinked Latitude was performed in fourteen upper limb specimens in the following conditions: (1) native elbow, (2) native elbow after the surgical approach and closing all layers again, (3) elbow with humeral and ulnar component implanted, unlinked, with the native radial head preserved, (4) elbow with humeral and ulnar component implanted, unlinked, with the native radial excised, (5) elbow with humeral, ulnar, and radial head component implanted.FindingsAfter implantation of the Latitude total elbow prosthesis both the valgus and varus laxity slightly increase from mid to maximal flexion when compared to the native elbow after surgical approach. The unlinked Latitude total elbow prosthesis provides both valgus and varus stability in elbows with intact ligamentous constraints. With intact ligamentous constraints the radial head component only slightly contributes to the stability of the elbow after implantation of the unlinked Latitude total elbow prosthesis.InterpretationThe unlinked Latitude total elbow prosthesis provides both valgus and varus stability in elbows with intact ligamentous constraints. The radial head component contributes only slightly to the stability.