High Societal Costs Research Articles

Disease Burden Attributable to the First Wave of COVID-19 in China, and the Effect of Timing on the Cost-Effectiveness of Movement Restriction Policies

Background: Movement restriction policies (MRPs) are effective in preventing/delaying COVID-19 transition but are associated with high societal cost. This study aims to estimate the health burden of the first wave of COVID-19 in China, and the cost-effectiveness of early versus late implementation of MRPs so to inform preparation for future waves. Methods: The SEIR (susceptible, exposed, infectious and recovered) modelling framework was adapted to simulate the health and cost outcomes of initiating MRPs at different times: rapid implementation (23 rd January, the real-world scenario), delayed by one week, delayed by two weeks and delayed by four weeks. The end point was set as the day when newly confirmed cases reached zero. Two costing perspectives were adopted: healthcare and societal. Input data were obtained from official statistics and published literature. The primary outcomes were disability adjusted life-years (DALY), cost and net monetary benefit. Costs were reported in both Chinese currency Renminbi (RMB) and US Dollar value in 2019 (USD). Findings: The first wave of COVID-19 in China resulted in 55,337 DALYs lost and 382 billion USD losses. The rapid implementation strategy dominated all other delayed strategies. This conclusion was robust to all scenarios tested. At a willingness-to-pay threshold of 70,892 (RMB) per DALY saved, the probability for the rapid implementation to be the optimal strategy was 89%. Interpretation: Early implementation of MRPs in response to COVID-19 reduced both the health burden and societal cost and thus should be used for future waves of COVID-19.Funding National Social Science Foundation and Shanghai Municipal Commission of Health and the Family. Funding Statement: This work is supported by National Social Science Foundation (No. 18BGL235) and Shanghai Municipal Commission of Health and the Family Foundation for Young Talents (2017YQ023). Declaration of Interests: MP received personal fees from Merck, outside the submitted work. Other than these, the authors declare no competing interests. Ethics Approval Statement: This study did not access individual patient data. Hence, ethical approval and patient informed consents were not required.

A clinical study of single intraneural platelet-rich plasma injection in peripheral nerve repair

Background: Peripheral nerve injuries cause great morbidity leaving many with long-term disabilities with high societal costs. Direct tension-free microsurgical repair and/or the transplantation of a nerve autograft to bridge the gap are the gold standard treatments. However, such treatments may not recreate the suitable cellular and molecular microenvironment and in some cases, the functional recovery of nerve injuries is incomplete. Aims and Objectives: The purpose of the study is to investigate if, and to what extent, PRP can improve the clinical condition after nerve repair. To study the effects and therapeutic potential of platelet rich plasma in traumatic nerve injury. Materials and Methods: A hospital based Non-Randomized control trial was conducted in a tertiary hospital setup in Manipur, India, for a period of 2 years. This study was done on 12 patients who underwent peripheral nerve repair. Materials and method The selected sample will be divided into two groups. Control group was treated with direct tension-free epineural microsurgical repair and the treatment group was treated with direct tension-free epineural microsurgical repair along with intraoperative infiltrating the nerve stumps perineurally and intraneurally with a single dose of autologous PRP injection. Comparison was done on the basis of subjective and objective outcomes between the groups over a period of 1 year. Statistical analysis Statistical analysis was done by using IBM SPSS Version 21 for windows. Descriptive statistics such as mean, proportion, percentage were used to present the result. Chi square test was used to see the association of proportions. Student's t- test and repeated ANOVA were used for the continuous variables. P-value Results: A total of 12 patients were included in the study, who were divided into 2 groups i.e., Case group and Control group, with 6 patients in each. The two groups were comparable with regards to patient characteristics, nerve injured and time interval to surgery. The patients in the case group, had significant improved outcome, when compare to control group, in terms of subjective (quickDASH) and objective tests (2-point discrimination, sensory recovery, motor strength and nerve conduction studies). Conclusion: In this study we found that intraoperative PRP injection can improve the clinical outcome after nerve repair in traumatic nerve injury.

Identification of DNA methylation associated enrichment pathways in adults with non-specific chronic low back pain.

Chronic low back pain (cLBP) that cannot be attributable to a specific pathoanatomical change is associated with high personal and societal costs. Still, the underlying mechanism that causes and sustains such a phenotype is largely unknown. Emerging evidence suggests that epigenetic changes play a role in chronic pain conditions. Using reduced representation bisulfite sequencing (RRBS), we evaluated DNA methylation profiles of adults with non-specific cLBP (n = 50) and pain-free controls (n = 48). We identified 28,325 hypermethylated and 36,936 hypomethylated CpG sites (p < 0.05). After correcting for multiple testing, we identified 159 DMRs (q < 0.01and methylation difference > 10%), the majority of which were located in CpG island (50%) and promoter regions (48%) on the associated genes. The genes associated with the differentially methylated regions were highly enriched in biological processes that have previously been implicated in immune signaling, endochondral ossification, and G-protein coupled transmissions. Our findings support inflammatory alterations and the role of bone maturation in cLBP. This study suggests that epigenetic regulation has an important role in the pathophysiology of non-specific cLBP and a basis for future studies in biomarker development and targeted interventions.

Employment in Personality Disorders and the Effectiveness of Individual Placement and Support: Outcomes from a Secondary Data Analysis

Purpose Personality disorders (PDs) are associated with severe functional impairment and subsequent high societal costs, increasing the need to improve occupational functioning in PD. Individual placement and support (IPS) is an effective, evidence-based method of supported employment, which so far has been tested in various mixed patient populations with severe mental illness (SMI, including PDs). However, the effectiveness of IPS for PDs per se remains uninvestigated. Methods Data from the SCION trial were used, including 31 SMI patients with PDs and 115 SMI patients with other primary diagnoses (primarily psychotic disorders). First, the interaction effect of diagnosis (PD vs other SMI) and intervention (IPS vs traditional vocational rehabilitation) was studied. Second, in the IPS condition, difference between diagnostic groups in time to first job was studied. Results We did not find evidence of a moderating effect of PD diagnosis on the primary effect of IPS (proportion who started in regular employment) (OR = 0.592, 95% CI 0.80–4.350, p = 0.606) after 30 months. Also, PD diagnosis did not moderate the effect of time until first job in IPS. Conclusions From the present explorative analysis we did not find evidence for a moderating effect of PD diagnosis on the effectiveness of IPS among PD participants. This indicates that IPS could be as effective in gaining employment in participants with PD as it is in participants with other SMI. Future studies, implementing larger numbers, should confirm whether IPS is equally effective in PDs and study whether augmentations or alterations to the standard IPS model might be beneficiary for PD.

StopBlues: a French e-health device to prevent suicide in the general population

Abstract Background France is one of the Western European countries most affected by suicide, an epidemiological burden and high societal cost of several million euros/year. Several European projects have either implemented web-based interventions for care of mental disorders or recommended online actions which have demonstrated their effectiveness for suicide prevention. The objective of the project was the construction of an application and website to prevent suicide in the general population, with its promotion being supported at the local authority level. Methods The detailed content of the devices and promotional tools available to local authorities was determined through literature reviews and expert groups (psychiatrists, local authorities’ workers and potential users). Results An application and website were constructed with two parts: a public interface with videos (psychological suffering, coping strategies and help available), an emergency button, a map with local resources and contact information (psychiatrists, psychologists, associations...), tips and videos to overcome a period of psychological suffering; and a private interface requiring registration giving access to self-assessment questionnaires and a safety plan to fill in case of crisis. 40 local authorities are involved in StopBlues promotion, with a referent each, responsible of contact with our team, and local organization of promotion. Conclusions Since 04-2018, StopBlues is available at www.stopblues.fr and can be downloaded on iOs and Android. Its promotion is part of a cluster randomized trial with 3 arms: a control group with no promotion, a group with promotion by local authorities, and a group with promotion by local authorities and general practitioner’s waiting room. As promotion could have different intensities depending on budgets and referent’s involvement, we decided to extend it for another year, with local authorities of group control receiving additional financial and organizational support. Key messages As the first e-health program for suicide primary prevention in the French general population, StopBlues’ main goal is to help people find solutions that suit them and direct them to the right help. Local authorities are a key level to promote primary health prevention programs.

Predictive factors of high societal costs among chronic low back pain patients.

BackgroundSocietal costs of low back pain (LBP) are high, yet few studies have been performed to identify the predictive factors of high societal costs among chronic LBP patients. This study aimed to determine which factors predict high societal costs in patients with chronic LBP.MethodsData of 6,316 chronic LBP patients were used. In the main analysis, high societal costs were defined as patients in the top 10% of cost outcomes. Sensitivity analyses were conducted using patients in the top 5% and top 20% of societal costs. Potential predictive factors included patient expectations, demographic factors (e.g. age, gender, nationality), socio‐economic factors (e.g. employment, education level) and health‐related factors (e.g. body mass index [BMI], general health, mental health). The final prediction models were obtained using backward selection. The model's prognostic accuracy (Hosmer–Lemeshow X 2, Nagelkerke's R 2) and discriminative ability (area under the receiver operating curve [AUC]) were assessed, and the models were internally validated using bootstrapping.ResultsPoor physical health, high functional disability, low health‐related quality of life, high impact of pain experience, non‐Dutch nationality and decreasing pain were found to be predictive of high societal costs in all models, and were therefore considered robust. After internal validation, the models' fit was good, their explained variance was relatively low (≤14.1%) and their AUCs could be interpreted as moderate (≥0.71).ConclusionFuture studies should focus on understanding the mechanisms associated with the identified predictors for high societal costs in order to design effective cost reduction initiatives.SignificanceIdentifying low back pain patients who are at risk (risk stratification) of becoming high‐cost users and making appropriate initiatives could help in reducing high costs.

De-individualising the ‘NEET problem’: An ecological systems analysis

Periods of being NEET (not in education, employment or training) can have long-term consequences for individuals’ future job opportunities, earnings, psycho-social well-being and health, all with high societal costs. Therefore, policy-makers across Europe seek interventions that successfully reduce NEET numbers. Drawing on a longitudinal qualitative study in London, this paper explores the processes and mechanisms that contribute to young people becoming NEET after leaving education. Through analysis of 53 young NEETs’ accounts of their school and transition experiences, we draw upon Bronfenbrenner’s ecological systems theory to explore the multitude of factors and structures of disadvantage that might have contributed to these young people’s marginalisation in education and employment. We discuss how unfulfilled support needs, a lack of career advice and socio-economic disadvantage can lead to educational disengagement, dropping out and, ultimately, becoming NEET. While many of these issues were presented as personal difficulties, in this article we reject the individualisation of the ‘NEET problem’. Instead, we argue that negative school experiences need to be understood in the context of structural conditions, including funding cuts in education and support services, transformations in the labour market and socio-economic deprivation.

Closing the survivorship gap in children and adolescents with Hodgkin lymphoma.

The treatment of Hodgkin lymphoma (HL) is one of early success. However, disease-free survival (DFS) does not reflect latent organ injury and its impact on health status and well-being beyond 5years. In fact, we are at a crossroads, in terms of needing individualized approaches to maintain DFS, while minimizing late effects and preserving health-related quality of life (HRQoL). Premature morbidity and mortality translate to a high societal cost associated with the potential number of productive life years ahead in this population who are young at diagnosis. The discordance between short-term lymphoma-free survival and long-term health and HRQoL creates a "survivorship gap" which can be characterized for individuals and for subgroups of patients. The current review delineates contributors to compromised outcomes and health status in child and adolescent (paediatric) HL and frames the survivorship gap in terms of primary and secondary prevention. Primary prevention aims to titrate therapy. Secondary prevention entails strategies to intervene against late effects. Bridging the survivorship gap will be attained with enhanced knowledge of and attention to biology of the tumour and microenvironment, host genetic factors, HRQoL and sub-populations with disparate outcomes.

Cost-Effectiveness of Therapist-Guided Internet-Based Cognitive Behavioral Therapy for Stress-Related Disorders: Secondary Analysis of a Randomized Controlled Trial.

BackgroundStress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation.ObjectiveThe objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective.MethodsHealth economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre- and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results.ResultsThe ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60% probability of being cost-effective at a willingness to pay (WTP) of US $0 and a 96% probability of being cost-effective at a WTP of US $1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results.ConclusionsThe results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs.Trial RegistrationClinicalTrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317

Type 2 diabetes as a familial illness: Findings from a focus group study.

Type 2 diabetes mellitus (T2DM) is a prevalent illness with high societal and personal costs. Whereas there is some systemic research, there are still many pieces yet unknown about T2DM and families. The purpose of the current study is to understand the transgenerational health experiences related to T2DM for both patients and caregivers. Focus groups were the primary methodology. Interviews were recorded, transcribed, and coded for themes. Participants were recruited via community fliers and e-mail listservs. The primary inclusion criterion was having a (a) family history of T2DM or (b) personal history of T2DM. Participants also needed to be at least 18 years old and be able to read and speak English. In 4 focus groups, 32 people were interviewed. The sample was entirely rural yet reasonably diverse. Five dominant themes emerged from the data: physical health comorbidities, T2DM is a lifestyle illness affecting the whole family, mental health stresses and comorbidities, personal and family relationship with T2DM, and sharing knowledge. Participants indicated that their families had been influenced by T2DM and that the illness had both physical and mental health comorbidities-both of which caused considerable stressors. Participants also reported that they valued the sharing of knowledge related to T2DM with each other and people in their lives. Limitations to the study include lack of generalizability because of small sample size and the majority of recruitment being done via technology. Future research should include larger, more diverse samples and quantitative data collection. Implications are also discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Fire risks in suspension bridges

ABSTRACTLong‐span suspension bridges provide vital support to society and its development. With ever increasing road traffic, such bridges are increasingly exposed to greater risks from fires. Experience shows that a significant fire in a truck without dangerous goods (like the 2013 New Little Belt Bridge fire in Denmark) can grow rapidly to reach temperatures above 1000°C, thereby making it a fire comparable to the hydrocarbon fire test standard. Compared to fuel tankers, the relatively high frequencies of trucks carrying normal (but flammable) goods make such significant truck fires more likely. Significant fires on a suspension bridge can lead to strength reduction or cable failure that could result in a reduction in bridge load rating and a need for long‐lasting repairs. Such outcomes mean high societal costs due to long‐term disruption of the connectivity provided by the bridge. Hence, there is a need to systematically assess fire risks in suspension bridges, focusing on a) fire frequencies and proportion of significant fires that can affect key bridge elements, b) fire consequences to key bridge elements and c) implementing mitigation measures when needed. Main cables in a suspension bridge are vital for structural integrity and at the same time difficult and expensive to replace during the bridge lifetime. This means that, in addition to ensuring no cable failure and no bridge collapse during fire, non‐exceedance of critical temperatures that could result in extensive damages and/or irreversible strength loss after fire is also important. Evaluating cable performance with respect to such criteria requires a detailed modelling of heat transfer into the cable, taking into account the nature of fire, multiple heat transfer modes, packing arrangement within the cable and geometrical exposure conditions.The above issues are addressed and useful insights are provided to help in understanding the fire risk picture for suspension bridges.

Sciatica: Medical treatment or Physiotherapy?

Low back pain is usually self-limiting. It has a sizeable impact on patients, and is associated with high healthcare and societal costs as much as $16 billion each year. Patients are commonly treated in primary care but a small proportion is referred to secondary care and may eventually have surgery. There are numerous treatment approaches for sciatica. Many people receive only medical treatment and are unaware of the availability and efficacy of the physiotherapy treatment. Objective of this study is to find out best treatment by comparison between medical interventions versus physiotherapy treatment for Sciatica. This study is a quasi-experimental study which includes patients presenting with sciatica divided into two groups. One group received medical treatment from a general physician and other group received physical therapy treatment from physiotherapist along with medical treatment from general physician. The study was conducted at Fatima Memorial Hospital, Services Hospital, Mayo Hospital and Hamid Latif Hospital, Lahore. The study was completed within the time duration from February 2017 to July 2017. Non-probability purposive sampling technique was used to collect data. Pre-treatment evaluation was done with Visual Analogue Scale, Oswestry Disability Index and Straight Leg Raising Test. The physical inspection involved the straight leg raising test and active knee extension tests. The data was managed and analyzed using SPSS version 21. Physiotherapy along with medical treatment is observed to give better interventional outcomes. Key words: Sciatica, medical intervention, physiotherapy, oswestry disability index, straight leg raising test

One-stop routing for surgical interventions: a cost-analysis of endoscopic groin repair.

Single-visit (SV) totally extraperitoneal (TEP) inguinal hernia repair is an efficient service without impairment of safety or complication rate. Data on the economic impact of this approach are rare. The aim of this study was to compare the costs between the SV TEP and the regular TEP in an employed healthy population from a hospital and societal point of view. Retrospectively collected hospital costs and prospectively collected societal costs were obtained from patients treated between July 2016 and January 2018. Outcome measures consisted of all documented institutional care, productivity loss and medical consumption. For analysing the hospital costs, a total of 116 SV patients were matched to 116 regular patients. The hospital costs of a mean SV patient were €1148.78 compared to €1242.84 for a regular patient, with a mean difference of €94.06. Prospective analyses of 50 SV patients and 50 regular patients demonstrated higher societal costs for a mean regular patient (€2188.33) compared to a mean SV patient (€1621.44). The mean total cost difference between a SV TEP repair and a regular TEP repair equalled €660.95 corresponding to a 19.3% decrease in costs. This comprehensive cost-analysis showed that in an employed, healthy population, the SV TEP repair outprices the regular TEP repair, with savings of €660.95 per patient, reflecting a 19.3% decrease in costs. This routing is mainly interesting from a societal point of view as the difference is mainly impacted by a decrease in societal costs.

Hospitalisation rates and predictors in people with dementia: a systematic review and meta-analysis

BackgroundHospitalisation is often harmful for people with dementia and results in high societal costs, so avoidance of unnecessary admissions is a global priority. However, no intervention has yet reduced admissions of community-dwelling people with dementia. We therefore aimed to examine hospitalisation rates of people with dementia and whether these differ from people without dementia and to identify socio-demographic and clinical predictors of hospitalisation.MethodsWe searched MEDLINE, Embase, and PsycINFO from inception to 9 May 2019. We included observational studies which (1) examined community-dwelling people with dementia of any age or dementia subtype, (2) diagnosed dementia using validated diagnostic criteria, and (3) examined all-cause general (i.e. non-psychiatric) hospital admissions. Two authors screened abstracts for inclusion and independently extracted data and assessed included studies for risk of bias. Three authors graded evidence strength using Cochrane’s GRADE approach, including assessing for evidence of publication bias using Begg’s test. We used random effects meta-analysis to pool estimates for hospitalisation risk in people with and without dementia.ResultsWe included 34 studies of 277,432 people with dementia: 17 from the USA, 15 from Europe, and 2 from Asia. The pooled relative risk of hospitalisation for people with dementia compared to those without was 1.42 (95% confidence interval 1.21, 1.66) in studies adjusted for age, sex, and physical comorbidity. Hospitalisation rates in people with dementia were between 0.37 and 1.26/person-year in high-quality studies. There was strong evidence that admission is associated with older age, and moderately strong evidence that multimorbidity, polypharmacy, and lower functional ability are associated with admission. There was strong evidence that dementia severity alone is not associated.ConclusionsPeople with dementia are more frequently admitted to hospital than those without dementia, independent of physical comorbidities. Future interventions to reduce unnecessary hospitalisations should target potentially modifiable factors, such as polypharmacy and functional ability, in high-risk populations.

An economic evaluation attached to a single-centre, parallel group, unmasked, randomized controlled trial of a 3-day intensive social cognitive treatment (can do treatment) in patients with relapsing remitting multiple sclerosis and low disability

Aims: This trial-based economic evaluation (EE) assesses from a societal perspective the cost-effectiveness of an intensive 3-day cognitive theory-based intervention (CDT), compared to care-as-usual, in patients with relapsing remitting multiple sclerosis (RRMS) and low disability (Expanded Disability Status Scale [EDDS] score < 4.0).Materials and methods: The trial of the EE was registered in the Dutch Trial Register: Trial NL5158 (NTR5298). The incremental cost-effectiveness ratio (ICER) was expressed in cost on the Control sub-scale of the Multiple Sclerosis Self-Efficacy Scale (MSSES) and the incremental cost-utility ratio (ICUR) in the cost per Quality Adjusted Life Years (QALY) using the EQ-5D-5L. Bootstrap, sensitivity, and sub-group analyses were performed to determine the robustness of the findings.Results: The two groups of 79 patients were similar in baseline characteristics. The base case ICER is situated in the northeast quadrant (€72 (40.74/€2,948)) due to a higher MSSES Control score and higher societal costs in the CDT group. The ICUR is situated in the northwest (inferior) quadrant due to losses in QALY and higher societal costs for the CDT group (−0.02/€2,948). Overall, bootstrap, sensitivity, and sub-group analyses confirm the base case findings. However, when the SF-6D is used as a study outcome, there is a high probability that the ICUR is situated in the northeast quadrant.Limitations: The relative short follow-up time (6 months) and the unexpected increase in MSSES Control in the control group.Conclusions: When using the EQ-5D-5L to calculate a QALY, CDT is not a cost-effective alternative in comparison to care as usual. However, when using self-efficacy or SF-6D as outcomes, there is a probability that CDT is cost-effective. Based on the current results, CDT for patients with RRMS clearly show its potential. However, an extended follow-up for the economic evaluation is warranted before a final decision on implementation can be made.

Healthcare Policy Changes in Osteoporosis Can Improve Outcomes and Reduce Costs in the United States.

ABSTRACTIn the United States, osteoporosis affects over 10 million adults, has high societal costs ($22 billion in 2008), and is currently being underdiagnosed and undertreated. Given an aging population, this burden is expected to rise. We projected the fracture burden in US women by modeling the expected demographic shift as well as potential policy changes. With the anticipated population aging and growth, annual fractures are projected to increase from 1.9 million to 3.2 million (68%), from 2018 to 2040, with related costs rising from $57 billion to over $95 billion. Policy‐driven expansion of case finding and treatment of at‐risk women could lower this burden, preventing 6.1 million fractures over the next 22 years while reducing payer costs by $29 billion and societal costs by $55 billion. Increasing use of osteoporosis‐related interventions can reduce fractures and result in substantial cost‐savings, a rare and fortunate combination given the current landscape in healthcare policy. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Costs and outcomes for individuals with psychosis prior to hospital admission and following discharge in Bulgaria.

To examine the cost of psychotic disorders in Bulgaria prior to hospital admission and following discharge from two perspectives: healthcare and societal; and to evaluate the association between the costs and the patient's characteristics. 96 individuals with psychosis experiencing psychotic exacerbation and their primary caregivers were evaluated upon the patients' hospital admission. The participants were followed up after 12months. The costs were evaluated from healthcare and societal perspective using the Client's Sociodemographic and Service Receipt Inventory (CSSRI-EU). The psychopathology, functioning, quality of life and caregiver's burden were measured using standardized instruments. The mean differences in the costs and the associations with the clinical and socio-demographic characteristics of the patients were evaluated. The healthcare costs increase from EUR 120.66 (SD = 163.85) at baseline to EUR 177.54 (SD = 136.98) at follow-up. The total cost from societal perspective are up to sixfold higher than the healthcare costs at both assessments [EUR 717.41 (SD = 402.33) and 880.40 (SD = 1592.00), respectively] and do not change significantly. A major shift in the subtypes of costs, and significant associations of the costs with the socio-demographic and clinical characteristics, were found. Psychotic disorders and psychotic exacerbations have high societal costs. The underfunding of mental healthcare in Bulgaria is at the expense of high caregivers' and societal cost. The treatment of psychotic exacerbation is effective and investment in mental healthcare for the improvement of the psychopathology, social functioning, quality of life and the burden of informal care should be viewed as a sustainable investment.

Disease mortality in domesticated animals is predicted by host evolutionary relationships

Infectious diseases of domesticated animals impact human well-being via food insecurity, loss of livelihoods, and human infections. While much research has focused on parasites that infect single host species, most parasites of domesticated mammals infect multiple species. The impact of multihost parasites varies across hosts; some rarely result in death, whereas others are nearly always fatal. Despite their high ecological and societal costs, we currently lack theory for predicting the lethality of multihost parasites. Here, using a global dataset of >4,000 case-fatality rates for 65 infectious diseases (caused by microparasites and macroparasites) and 12 domesticated host species, we show that the average evolutionary distance from an infected host to other mammal host species is a strong predictor of disease-induced mortality. We find that as parasites infect species outside of their documented phylogenetic host range, they are more likely to result in lethal infections, with the odds of death doubling for each additional 10 million years of evolutionary distance. Our results for domesticated animal diseases reveal patterns in the evolution of highly lethal parasites that are difficult to observe in the wild and further suggest that the severity of infectious diseases may be predicted from evolutionary relationships among hosts.

Are Magnetic Resonance Imaging Technologies Crucial to Our Understanding of Spinal Conditions?

Persistent spinal (traumatic and nontraumatic) pain is common and contributes to high societal and personal costs globally. There is an acknowledged urgency for new and interdisciplinary approaches to the condition, and soft tissues, including skeletal muscles, the spinal cord, and the brain, are rightly receiving increased attention as important biological contributors. In reaction to the recent suspicion and questioned value of imaging-based findings, this paper serves to recognize the promise that the technological evolution of imaging techniques, and particularly magnetic resonance imaging, is allowing in characterizing previously less visible morphology. We emphasize the value of quantification and data analysis of several contributors in the biopsychosocial model for understanding spinal pain. Further, we highlight emerging evidence regarding the pathobiology of changes to muscle composition (eg, atrophy, fatty infiltration), as well as advancements in neuroimaging and musculoskeletal imaging techniques (eg, fat-water imaging, functional magnetic resonance imaging, diffusion imaging, magnetization transfer imaging) for these important soft tissues. These noninvasive and objective data sources may complement known prognostic factors of poor recovery, patient self-report, diagnostic tests, and the "-omics" fields. When combined, advanced "big-data" analyses may assist in identifying associations previously not considered. Our clinical commentary is supported by empirical findings that may orient future efforts toward collaborative conversation, hypothesis generation, interdisciplinary research, and translation across a number of health fields. Our emphasis is that magnetic resonance imaging technologies and research are crucial to the advancement of our understanding of the complexities of spinal conditions. J Orthop Sports Phys Ther 2019;49(5):320-329. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8793.

The erring brain: Error‐related negativity as an endophenotype for OCD—A review and meta‐analysis

Obsessive-compulsive disorder (OCD) is a complex and heterogeneous disorder that is associated with high personal and societal costs. Feelings of doubt, worry, and repetitive behavior, key symptoms of OCD, have been linked to hyperactive error signals in the brain. The error-related negativity (ERN) represents a validated marker of error processing in the ERP. Increased ERN amplitudes in OCD have been reported very robustly over the last 20years. This article integrates results from 38 studies analyzing the ERN in OCD, using a quantitative meta-analysis. Meta-regressions were used to examine potential moderators such as task type, symptom severity, age, and sample size. The meta-analysis reveals a robust increase of ERN in OCD patients compared to healthy participants in response-conflict tasks (SMD -0.55) that is not modulated by symptom severity and age. No increase in ERN in OCD was observed in tasks that do not induce response conflict (SMD -0.10). In addition to the meta-analysis, the current article reviews evidence supporting that increased ERN amplitudes in OCD fulfill central criteria for an endophenotype. Further, the specificity of increased ERN amplitudes for OCD and its suitability as a potential transdiagnostic endophenotype is discussed. Finally, the clinical utility and clinical applications are examined. Overall, the evidence that increased ERN amplitudes represent a promising endophenotype indicating vulnerability for OCD is compelling. Furthermore, alterations in ERN are not limited to OCD and may constitute a transdiagnostic endophenotype. Altered neural error signals might serve as a diagnostic or predictive marker and represent a promising target for interventions.