Reevaluating health metrics:Unraveling the limitations of disabilityadjusted life years as an indicator in disease burden assessment

In 1993,the World Bank released a global report on the efficacy of health promotion,introducing the disability-adjusted life years(DALY)as a novel indicator.The DALY,a composite metric incorporating temporal and qualitative data,is grounded in preferences regarding disability status.This review delineates the algorithm used to calculate the value of the proposed DALY synthetic indicator and elucidates key methodological challenges associated with its application.In contrast to the quality-adjusted life years approach,derived from multi-attribute utility theory,the DALY stands as an independent synthetic indicator that adopts the assumptions of the Time Trade Off utility technique to define Disability Weights.Claiming to rely on no mathematical or economic theory,DALY users appear to have exempted themselves from verifying whether this indicator meets the classical properties required of all indicators,notably content validity,reliability,specificity,and sensitivity.The DALY concept emerged primarily to facilitate comparisons of the health impacts of various diseases globally within the framework of the Global Burden of Disease initiative,leading to numerous publications in international literature.Despite widespread adoption,the DALY synthetic indicator has prompted significant methodological concerns since its inception,manifesting in inconsistent and non-reproducible results.Given the substantial diffusion of the DALY indicator and its critical role in health impact assessments,a reassessment is warranted.This reconsideration is imperative for enhancing the robustness and reliability of public health decisionmaking processes.

Understanding celiac disease monitoring patterns and outcomes after diagnosis:A multinational,retrospective chart review study

BACKGROUND Long-term outcomes and monitoring patterns in real-world practice are largely unknown among patients with celiac disease.AIM To understand patterns of follow-up and management of patients with celiac disease,and to characterize symptoms and villous atrophy after diagnosis.METHODS A retrospective chart review study was performed using medical chart data of patients diagnosed with celiac disease.Three gastroenterology referral centers,with substantial expertise in celiac disease,participated in the United Kingdom,United States,and Norway.Demographic and clinical data were collected from medical charts.Descriptive analyses were conducted on patients with biopsyconfirmed celiac disease,diagnosed between 2008 and 2012,with at least one follow-up visit before December 31,2017.Patient demographic and clinical characteristics,biopsy/serology tests and results,symptoms,and comorbidities were captured at diagnosis and for each clinic visit occurring within the study period(i.e.,before the study end date of December 31,2017).RESULTS A total of 300 patients were included in this study[72%female;mean age at diagnosis:38.9 years,standard deviation(SD)17.2].Patients were followed-up for a mean of 29.9 mo(SD 22.1)and there were,on average,three follow-up visits per patient during the study period.Over two-thirds(68.4%)of patients were recorded as having ongoing gastrointestinal symptoms and 11.0%had ongoing symptoms and enteropathy during follow-up.Approximately 80%of patients were referred to a dietician at least once during the follow-up period.Half(50.0%)of the patients underwent at least one follow-up duodenal biopsy and 36.6%had continued villous atrophy.Patterns of monitoring varied between sites.Biopsies were conducted more frequently in Norway and patients in the United States had a longer follow-up duration.CONCLUSION This real-world study demonstrates variable follow-up of patients with celiac disease despite most patients continuing to have abnormal histology and symptoms after diagnosis.

Clinical and socioeconomic determinants of survival in biliary tract adenocarcinomas

BACKGROUND Despite advances in detection and treatments,biliary tract cancers continue to have poor survival outcomes.Currently,there is limited data investigating the significance of socioeconomic status,race/ethnicity,and environmental factors in biliary tract cancer survival.Data from the Surveillance,Epidemiology,and End Results database for biliary and gallbladder adenocarcinomas were extracted from 1975 to 2016.Socioe-conomic data included smoking,poverty level,education,adjusted household income,and percentage of foreign-born persons and urban population.Survival was calculated with Cox proportional hazards models for death in the 5-year period following diagnosis.RESULTS Our study included 15883 gallbladder,11466 intrahepatic biliary,12869 extrahepatic biliary and 7268 ampulla of Vater adenocarcinoma cases.When analyzing county-specific demographics,patients from counties with higher incomes were associated with higher survival rates[hazard ratio(HR)=0.97,P<0.05].Similarly,counties with a higher percentage of patients with a college level education and counties with a higher urban population had higher 5-year survival rates(HR=0.96,P=0.002 and HR=0.97,P=0.004,respectively).CONCLUSION Worse survival outcomes were observed in lower income counties while higher income and education level were associated with higher 5-year overall survival among gallbladder and biliary malignancies.

Interrelationship between physical activity and depression in nonalcoholic fatty liver disease

BACKGROUND Nonalcoholic fatty liver disease(NAFLD)is associated with a sedentary lifestyle and depressive symptoms.It is also well established that physical inactivity and depressive symptoms are related.However,an investigation of the interaction between all of these factors in NAFLD has not been previously conducted.AIM To investigate the interrelationship between physical inactivity and depressive symptoms in individuals with NAFLD.METHODS Data from the Rancho Bernardo Study of Healthy Aging were utilized.589 individuals were included in the analyses(43.1%male;95.8%non-Hispanic white;aged 60.0±7.0 years).NAFLD was defined by using the hepatic steatosis index,depression using the Beck Depression Inventory,and physical activity by selfreport of number of times per week of strenuous activity.Multivariable generalized linear regression models with Gamma distribution were performed to investigate the proposed relationship.RESULTS About 40%of the sample had evidence of NAFLD,9.3%had evidence of depression,and 29%were physically inactive.Individuals with NAFLD and depression were more likely to be physically inactive(60.7%)compared to individuals with neither NAFLD nor depression(22.9%),individuals with depression without NAFLD(37.0%),and individuals with NAFLD without depression(33.3%).After accounting for various comorbidities(i.e.,age,sex,diabetes,hypertension,obesity),individuals with NAFLD and higher levels of physical activity were at a decreased odds of having depressive symptoms[16.1%reduction(95%confidence interval:-25.6 to-5.4%),P=0.004],which was not observed in those without NAFLD.CONCLUSION Individuals with NAFLD have high levels of physical inactivity,particularly those with depressive symptoms.Because this group is at high risk for poor outcomes,practitioners should screen for the coexistence of depressive symptoms and NAFLD.This group should receive appropriate interventions aimed at increasing both participation and levels of intensity of physical activity.

Breast Asymmetry Evaluation Using Objective Measures after Breast Cancer Surgery

Although a positive cosmetic outcome is an important goal of breast cancer reconstruction, the objective analysis of breast aesthetics has yet to reach a gold standard or unified method to quantify breast symmetry. Several scoring systems, both subjective and objective, have been developed over the years to ensure the desirable outcome in breast symmetry, but these methods have yet to reach the unanimous acceptance in terms of accuracy, value and ease of use to be implemented in the clinical setting. By assessing several existing symmetry scores, most of which are based on 2D imaging, along with our own set of symmetry parameters applied to 3D patient images, the goal of this study is to determine if there is an advantage of 3D imaging in formulating an accurate objective breast aesthetic score over the existing objective scores. A reliable breast aesthetic score would improve the decision-making in surgery as well as improve patient satisfaction. Additionally, knowing the quantity and degree of breast asymmetry objectively will improve outcome and reduce revision rates, minimizing patient suffering and improving the overall quality of patient life and body image.

Impact of surgical volume and resident involvement on patency rates after vasectomy reversaldA 14-year experience in an open access system

Objective:Evaluate the influence of fellowship training,resident participation,reconstruction type,and patient factors on outcomes after vasectomy reversals in a high volume,open access system.Methods:Retrospective review of all vasectomy reversals performed at a single institution from January 1,2002 to December 31,2016 was conducted.Patient and spouse demographics,patient tobacco use and comorbidities,surgeon training and case volume,resident participation,reconstruction type,and postoperative patency were collected and analyzed.Results:Five hundred and twenty-six vasectomy reversals were performed during the study period.Follow-up was available in 80.6%of the cohort and overall patency,regardless of reconstruction type was 88.7%.The mean time to reversal was 7.87 years(range of 0-34 years).The majority of cases included resident participation.Case volume was high with faculty and residents logging a mean of 37.0 and 38.7(median 18 and 37)cases respectively.Bilateral vasovasostomy was the most common reconstruction type(83%)and demonstrated a significantly better patency rate(89%)than all other reconstructions(p=0.0008).Overall patency and patency by reconstruction type were not statistically different among faculty surgeons and were not impacted by fertility fellowship training,resident participation or postgraduate year.Multivariate analysis demonstrated that increased time to reversal and repeat reconstructions had a negative impact on patency(p=0.0023 and p=0.043,respectively).Conclusions:Surgeons with a high volume of vasectomy reversals have outcomes consistent with contemporary series regardless of fellowship training in fertility.Patency was better for bilateral vasovasostomies.Patency was not negatively impacted by tobacco use,comorbidities,resident participation,or post-graduate year.

An Effective Management of Personal Paper Outcome Using Open Service

Abstract： Open collaboration-based R＆D （research and development） has become an important issue recently. Researchers＇ performance is necessary to be understood by analyzing researchers＇ paper outcome. To drive successful outcomes and co-research, researchers＇ paper outcome should be autonomously established. Therefore we propose an approach to manage and update easily paper outcome of researchers. The proposed approach makes researchers search their paper using the Google Scholar＇s opened API （application program interface） and update their outcome. Since researchers autonomously can establish the list of their own papers in our service using open service, researchers＇ personal outcome can be efficiently managed.

Simplified figure to present direct and indirect comparisons:Revisiting the graph 10 years later

A“simplified”figure was proposed in 2011 to summarize the results of controlled trials that evaluate different treatments aimed at the same disease condition.The original criteria for classifying individual binary comparisons included superiority,inferiority and no significance difference;hence,they did not differentiate between no proof of difference vs proof of no difference.We updated the criteria employed in the original“simplified”figure in order to include this differentiation.A revised version of the simplified figure is proposed and described herein.An example of application is also presented.The example is focused on first-line treatments for paroxysmal atrial fibrillation.Three treatments(medical therapy,cryoballoon ablation,radiofrequency ablation)are compared with one another through direct and indirect comparisons.

Treatment of intermediate-risk prostate cancer with active surveillance in the routine care—Long-term outcomes of a prospective noninterventional study(HAROW)

Background:We report here the long-term outcomes of patients with intermediate-risk prostate cancer(PCa)treated with active surveillance(AS)in a daily routine setting.Material andmethods:HAROW(2008–2013)was a noninterventional,health service research study investigating themanagement of localized PCa in a community setting.A substantial proportion of the study centers were office-based urologists.A follow-up examination of all intermediate-risk patients with AS was conducted.Overall,cancer-specific,metastasis-free,and treatment-free survival rates,as well as reasons for discontinuation,were determined and discussed.Results:Of the 2957 patients enrolled,52 with intermediate-risk PCa were managed with AS and were available for evaluation.The median follow-up was 6.8 years(interquartile range,3.4–8.6 years).Seven patients(13.5%)died of causes unrelated to PCa,of whom 4 were under AS or under watchful waiting.Two patients(3.8%)developed metastasis.The estimated 8-year overall,cancer-specific,metastasis-free,and treatment-free survival rates were 85%(95%confidence interval[CI],72%–96%),100%,93%(95%CI,82%–100%),and 31%(95%CI,17%–45%),respectively.Onmultivariable analysis,prostate-specific antigen density of≥0.2 ng/mL2 was significantly predictive of receiving invasive treatment(hazard ratio,3.29;p=0.006).Reasons for discontinuation were more often due to patient's or physician's concerns(36%)than due to observed clinical progression.Conclusions:Although survival outcome data for intermediate-risk patients managed with AS in real-life health care conditions were promising,rates of discontinuation were high,and discontinuation was often a patient's decision,even when the signs of disease progression were absent.This might be an indication of higher levels of mental burden and anxiety in this specific subgroup of patients,which should be considered when making treatment decisions.From a psychological perspective,not all intermediate-risk patients are optimal candidates for AS.

Research methods in complementary and alternative medicine： an integrative review

The scientific literature presents a modest amount ot evidence m the use or complementary ana al[erna- tire medicine （CAM）. On the other hand, in practice, relevant results are common. The debates among CAM practitioners about the quality and execution of scientific research are important, Therefore, the aim of this review is to gather, synthesize and describe the differentiated methodological models that encompass the complexity of therapeutic interventions. The process of bringing evidence-based medicine into clinical practice in CAM is essential for the growth and strengthening of complementary medicines worldwide.

China Patient-centered Evaluative Assessment of Cardiac Events Prospective Study of Acute Myocardial Infarction： Study Design

Background： Despite the rapid growth in the incidence of acute myocardial infarction （AMI） in China, there is limited information about patients＇ experiences after AMI hospitalization, especially on long-tern1 adverse events and patient-reported outcomes （PROs）. Methods： The China Patient-centered Evaluative Assessment of Cardiac Events （PEACE）-Prospective AMI Study will enroll 4000 consecutive AM I patients from 53 diverse hospitals across China and follow them longitudinally for 12 months to docunlent their treatment, recovery, and outcomes. Details of patients＇ medical history, treatment, and in-hospital outcomes are abstracted from medical charts. Comprehensive baseline interviews are being conducted to characterize patient demographics, risk factors, presentation, and healthcare utilization. As part of these interviews, validated instruments are administered to measure PROs, including quality of life, symptoms, mood, cognition, and sexual activity. Follow-up interviews, measuring PROs, medication adherence, risk factor control, and collecting hospitalization events are conducted at 1, 6, and 12 months after discharge. Supporting documents for potential outcomes are collected for adjudication by clinicians at the National Coordinating Center. Blood and urine samples are also obtained at baseline, 1 - and 12-month follow-up. In addition, we are conducting a survey of participating hospitals to characterize their organizational characteristics. Conclusion： The China PEACE-Prospective AMI study will be uniquely positioned to generate new information regarding patient＇s experiences and outcomes alter AMI in China and seiwe as a foundation for quality improveinent activities.