Lifetime Health Consequences Research Articles

Assessing the Radon Exposure Variability and Lifetime Health Effects across Indoor Microenvironments and Sub-Populations

To assess the health impacts of radon exposure over a lifetime, in the present study, the annual effective dose (AED) and cumulative excess lifetime cancer risk (ELCR-C) were evaluated by considering various indoor microenvironmental exposures based on age-specific time–activity patterns using Monte Carlo simulations. Significant regional variations in indoor radon concentrations across the Republic of Korea were observed, with the highest levels found in schools and single detached houses. Based on the standard annual total of 8760 h spent indoors and outdoors, the AED varied by age group and dwelling type, with the ELCR-C for single detached houses being approximately 1.36 times higher than that for apartments on average. The present study highlights the importance of comprehensive health risk assessments that consider differences across indoor environments and age groups, indicating that limited evaluations of specific sites or areas may distort actual exposure levels.

The Lifetime Health and Economic Burden of Smokeless Tobacco use in Bangladesh, India, and Pakistan: Results From ASTRAMOD.

Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India, and Pakistan where the majority of ST users live. We developed a Markov-based state-transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, esophageal cancers, and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys, life tables, and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions. If there were no change in the current ST policies, the lifetime ST-attributable treatment costs would be over US$19 billion in India, over US$1.5 billion in Bangladesh, and over US$3 billion in Pakistan. For all countries, the attributable costs are higher for younger cohorts with costs declining with increasing age for those over 50. The model predicted that a typical 15-year-old male adoloscent would gain 0.07-0.18 life years, avert 0.07-0.19 DALYs, and generate a cost-savings of US$7-21 on healthcare spending if ST policies were changed to eliminate ST use. Policy interventions aimed at decreasing the uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST. This study provides the most comprehensive estimates of the lifetime health and economic burden of ST by 5-year age and sex cohorts. This is also the first study that highlights the scale of health and economic burden of ST in Bangladesh, India, and Pakistan if there were no changes in the current ST policies. Policymakers and practitioners can use the reported data to justify their decisions to improve current ST policies and practices in their country. Researchers can use the ASTRAMOD methodology to estimate the impact of future ST policy changes.

Cost-Effectiveness Analysis of Denosumab in the Prevention of Skeletal-Related Events Among Patients With Breast Cancer With Bone Metastasis in India.

Denosumab is clinically superior to zoledronic acid (ZA) for preventing and delaying time to first and subsequent skeletal-related events (SREs) among patients with breast cancer (BC) with bone metastases. We evaluated the cost and health benefits of denosumab and ZA (once every 4 weeks and once every 12 weeks) among four different molecular subtypes of BC with bone metastases in India. A Markov model was developed in Microsoft Excel to estimate lifetime health consequences and resulting costs among cohort of 1,000 patients with BC with bone metastasis, for three intervention scenarios, namely denosumab (once every 4 weeks), ZA (once every 4 weeks), and ZA (once every 12 weeks). The health outcomes were measured in terms of SREs averted and quality-adjusted life-years (QALYs) gained. The cost of each intervention scenario was measured using both the health system and the patient's perspectives. Indirect costs because of lost productivity were not included. The future costs and outcomes were discounted at the standard rate of 3%. Over a lifetime, the incremental number of SREs averted with use of denosumab once every 4 weeks (compared with ZA once every 4 weeks and once every 12 weeks) among patients with luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple negative breast cancer were estimated as 0.39, 0.26, 0.25, and 0.19, respectively. The number of QALYs lived were slightly higher in the denosumab arm (1.45-2.80) compared with ZA once every 4 weeks and once every 12 weeks arms (1.44-2.78). However, denosumab once every 4 weeks was not found to be a cost-effective alternative for either of the four molecular subtypes of breast cancer. ZA once every 12 weeks was found to be a cost-effective option with an average cost-effectiveness ratio ranging between ₹68,254 and ₹73,636. ZA once every 12 weeks is the cost-effective treatment option for BC with bone metastases in India. The present study findings hold significance for standard treatment guidelines under India's government-funded health insurance program.

Cost-Effectiveness of Newborn Screening for Spinal Muscular Atrophy in England.

We sought to evaluate the cost-effectiveness of newborn screening (NBS) versus no NBS for 5q spinal muscular atrophy (SMA) in England. A cost-utility analysis using a combination of decision tree and Markov model structures was developed to estimate the lifetime health effects and costs of NBS for SMA, compared with no NBS, from the perspective of the National Health Service (NHS) in England. A decision tree was designed to capture NBS outcomes, and Markov modeling was used to project long-term health outcomes and costs for each patient group following diagnosis. Model inputs were based on existing literature, local data, and expert opinion. Sensitivity and scenario analyses were conducted to assess the robustness of the model and the validity of the results. The introduction of NBS for SMA in England is estimated to identify approximately 56 (96% of cases) infants with SMA per year. Base-case results indicate that NBS is dominant (less costly and more effective) than a scenario without NBS, with a yearly cohort of newborns accruing incremental savings of £62,191,531 and an estimated gain in quality-adjusted life-years of 529years over their lifetime. Deterministic and probabilistic sensitivity analyses demonstrated the robustness of the base-case results. NBS improves health outcomes for patients with SMA and is less costly compared with no screening; therefore, it is a cost-effective use of resources from the perspective of the NHS in England.

The multitarget fecal immunochemical test versus the fecal immunochemical test for programmatic colorectal cancer screening: a cross-sectional intervention study with paired design

BackgroundMany screening programs for colorectal cancer (CRC) use the fecal immunochemical test (FIT) to triage individuals for colonoscopy. Although these programs reduce CRC incidence and CRC-related mortality, the detection of advanced precursor lesions (advanced adenomas and advanced serrated polyps) by FIT could be improved. As an alternative for FIT, the antibody-based multitargetFIT (mtFIT) has been proposed. The mtFIT measures three protein markers: hemoglobin, calprotectin, and serpin family F member 2. In a retrospective diagnostic accuracy study in a large colonoscopy-controlled series (n = 1284), mtFIT showed increased sensitivity for advanced neoplasia (AN), at equal specificity, compared to FIT (42.9% versus 37.3%; p = 0.025). This increase was mainly due to a higher sensitivity of mtFIT for advanced adenomas (37.8% versus 28.1% for FIT; p = 0.006). The present mtFIT study aims to prospectively validate these findings in the context of the Dutch national CRC screening program.MethodThe mtFIT study is a cross-sectional intervention study with a paired design. Eligible subjects for the Dutch FIT-based national CRC screening program are invited to perform mtFIT in addition to FIT. Samples are collected at home, from the same bowel movement, and are shipped to a central laboratory by postal mail. If either one or both tests are positive, participants are referred for colonoscopy. Detailed colonoscopy and pathology data are centrally stored in a national screening database (ScreenIT; Topicus, Deventer, the Netherlands) that is managed by the screening organization, and will be retrieved for this study. We aim to determine the relative sensitivity for AN, comprising of CRC, advanced adenomas and advanced serrated polyps, of mtFIT compared to FIT at an equal positivity rate. Additionally, we will use the Adenoma and Serrated Pathway to Colorectal CAncer model to predict lifetime health effects and costs for programmatic mtFIT- versus FIT-based screening. The target sample size is 13,131 participants.DiscussionThe outcome of this study will inform on the comparative clinical utility of mtFIT versus FIT in the Dutch national CRC screening program and is an important step forward in the development of a new non-invasive stool test for CRC screening.Trial registrationClinicaltrials.gov; NCT05314309, registered April 6th 2022, first inclusions March 25th 2022 https://clinicaltrials.gov/ct2/results?cond=&term=NCT05314309&cntry=&state=&city=&dist=.

A scoping review on the health effects of smoke haze from vegetation and peatland fires in Southeast Asia: Issues with study approaches and interpretation.

Smoke haze due to vegetation and peatland fires in Southeast Asia is a serious public health concern. Several approaches have been applied in previous studies; however, the concepts and interpretations of these approaches are poorly understood. In this scoping review, we addressed issues related to the application of epidemiology (EPI), health burden estimation (HBE), and health risk assessment (HRA) approaches, and discussed the interpretation of findings, and current research gaps. Most studies reported an air quality index exceeding the ‘unhealthy’ level, especially during smoke haze periods. Although smoke haze is a regional issue in Southeast Asia, studies on its related health effects have only been reported from several countries in the region. Each approach revealed increased health effects in a distinct manner: EPI studies reported excess mortality and morbidity during smoke haze compared to non-smoke haze periods; HBE studies estimated approximately 100,000 deaths attributable to smoke haze in the entire Southeast Asia considering all-cause mortality and all age groups, which ranged from 1,064–260,000 for specified mortality cause, age group, study area, and study period; HRA studies quantified potential lifetime cancer and non-cancer risks due to exposure to smoke-related chemicals. Currently, there is a lack of interconnection between these three approaches. The EPI approach requires extensive effort to investigate lifetime health effects, whereas the HRA approach needs to clarify the assumptions in exposure assessments to estimate lifetime health risks. The HBE approach allows the presentation of health impact in different scenarios, however, the risk functions used are derived from EPI studies from other regions. Two recent studies applied a combination of the EPI and HBE approaches to address uncertainty issues due to the selection of risk functions. In conclusion, all approaches revealed potential health risks due to smoke haze. Nonetheless, future studies should consider comparable exposure assessments to allow the integration of the three approaches.

Cost-Effectiveness of Newborn Screening for Spinal Muscular Atrophy in The Netherlands

ObjectivesSpinal muscular atrophy (SMA) is a rare genetic disorder that causes progressive muscle weakness and paralysis. In its most common and severe form, the majority of untreated infants die before 2 years of age. Early detection and treatment, ideally before symptom onset, maximize survival and achievement of age-appropriate motor milestones, with potentially substantial impact on health-related quality of life. Therefore, SMA is an ideal candidate for inclusion in newborn screening (NBS) programs. We evaluated the cost-effectiveness of including SMA in the NBS program in The Netherlands. MethodsWe developed a cost-utility model to estimate lifetime health effects and costs of NBS for SMA and subsequent treatment versus a treatment pathway without NBS (ie, diagnosis and treatment after presentation with overt symptoms). Model inputs were based on literature, local data, and expert opinion. Sensitivity and scenario analyses were conducted to assess model robustness and validity of results. ResultsAfter detection of SMA by NBS in 17 patients, the number of quality-adjusted life-years gained per annual birth cohort was estimated at 320 with NBS followed by treatment compared with treatment after clinical SMA diagnosis. Total healthcare costs, including screening, diagnostics, treatment, and other healthcare resource use, were estimated to be €12 014 949 lower for patients identified by NBS. ConclusionsNBS for early identification and treatment of SMA versus later symptomatic treatment after clinical diagnosis improves health outcomes and is less costly and, therefore, is a cost-effective use of resources. Results were robust in sensitivity and scenario analyses.

Clinical characteristics influence cultivable-bacteria composition in the meconium of Indonesian neonates

BackgroundMicrobial colonization of a neonate's gastrointestinal tract has significant perinatal and lifetime health consequences. However, information regarding the profile of meconium microbiota in neonates and the influence of clinical parameters are lacking in the Indonesian population. This study aimed to preliminary investigate the profile of cultivable bacterial diversity of meconium isolated from neonates born at Cipto Mangunkusumo Hospital (CMH), Jakarta. The cultivable bacteria were isolated from meconium samples and were then processed for cultivation and molecular identification. ResultsFourteen neonates were enrolled as described, i.e., seven hyperbilirubinemia (Hyp) and seven non-Hyp with ten neonates delivered by cesarean section (CS) and four others by vaginal route (VR), and with five exclusive breastfeeding (Ebf), four formula milk, and five combinations. Microbiological identification, molecular 16S rDNA PCR-Sanger sequencing, and PCA analysis of cultivable bacteria isolated from meconium showed Firmicutes' predominance (84.41%), with an abundant population of Staphylococcus, which consist of S. hominis, S. epidermidis, and S. haemolyticus. The influence of mode of delivery showed a lower diversity than the CS populates the VR, but their composition was similar. Concurrently, between feeding patterns, the genera profile did not show much difference; in the non-Ebf group, the total amount of Staphylococcus and Bacillus showed a higher amount but a less diverse. Interestingly, the non-Hyp group showed more abundant and diverse Staphylococcus than that of the Hyp group. In contrast, neonates diagnosed with NEC and proven sepsis showed the same pattern of Staphylococcus domination. ConclusionStaphylococcus predominated the composition of cultivable bacteria in neonates meconium. Due to the small sample size, only the hyperbilirubinemia parameter significantly influenced the profile, i.e., Staphylococcus's proportion (p = 0.037).

Bacterial profile of meconium of neonates born at National Referral Hospital Cipto Mangunkusumo, Jakarta, Indonesia

Microbial colonization of a neonate’s gastrointestinal tract has significant perinatal and lifetime health consequences, with some clinical outcomes that have been linked to differences in the diversity and composition of gut microbiota. The effort to engineer intestinal ecosystem has led us to preserve the cultivable commensal microbiota. Here we investigated the association of cultivable bacterial diversity of neonates meconium from Indonesian National Referral Hospital Cipto Mangunkusumo (NRHCM) with mode of delivery and feeding patterns, as well as hyperbilirubinemia. We performed a cross-sectional study of meconium and clinical data collected from 14 Indonesian neonates born at NRHCM. Culture-dependent identification of bacterial isolates was conducted by performing simultaneous microbiological and molecular 16S rDNA PCR-Sanger sequencing methods. Phylogenetic tree and principal components analysis were employed to determine the bacterial profile and their association with clinical characteristics and outcomes. Cultivable bacterial profile indicates the predominance of Firmicutes (84,41%), with an abundant population of Staphylococcus (53.24%) with top three most significant population present are, i.e. S. hominis (12.99%), S. epidermidis (11.68%), and S. haemolyticus (10.39%). Bacterial diversity was associated with mode of delivery which showed that vaginal route populated by lower diversity of cultivable bacteria but by fewer opportunistics one than that of cesarean, with Staphylococcus hominis dominates the population, whereas with feeding patterns showed that the exclusive breast-fed was most populated by Staphylococcus, whereas non-exclusive one shared the same proportion of Staphylococcus and Bacterioides. While, non-hyperbilirubinemia group showed more abundant and diverse Staphylococcus than that of the opposite group.

Lifetime Costs of Surviving Cancer-A Queensland Study (COS-Q): Protocol of a Large Healthcare Data Linkage Study.

Australia-wide, there are currently more than one million cancer survivors. There are over 32 million world-wide. A trend of increasing cancer incidence, medical innovations and extended survival places growing pressure on healthcare systems to manage the ongoing and late effects of cancer treatment. There are no published studies of the long-term health service use and cost of cancer survivorship on a population basis in Australia. All residents of the state of Queensland, Australia, diagnosed with a first primary malignancy from 1997–2015 formed the cohort of interest. State and national healthcare databases are linked with cancer registry records to capture all health service utilization and healthcare costs for 20 years (or death, if this occurs first), starting from the date of cancer diagnosis, including hospital admissions, emergency presentations, healthcare costing data, Medicare services and pharmaceuticals. Data analyses include regression and economic modeling. We capture the whole journey of health service contact and estimate long-term costs of all cancer patients diagnosed and treated in Queensland by linking routinely collected state and national healthcare data. Our results may improve the understanding of lifetime health effects faced by cancer survivors and estimate related healthcare costs. Research outcomes may inform policy and facilitate future planning for the allocation of healthcare resources according to the burden of disease.

The long run health consequences of rural‐urban migration

Rural‐urban migration is an integral part of the structural transformation as societies move from a traditional agricultural economy to a modern economy. This process has many potential consequences for migrants. Our study focuses on the lifetime health effects of the large mid‐20th century migration out of rural U.S. Northern Great Plains states, primarily to urban locations in the West and Midwest. An analysis of marginal treatment effects (MTEs) shows that (a) migrants are positively selected, and (b) the causal impact of migration is decreased longevity. Our evidence suggests that elevated mortality among migrants is linked to increased smoking and alcohol consumption.

Association of prenatal organochlorine pesticide-dichlorodiphenyltrichloroethane exposure with fetal genome-wide DNA methylation

AimsTo investigate whether intrauterine organochlorine pesticide (OCP)-dichlorodiphenyltrichloroethane (DDT) exposure could lead to epigenetic alterations by DNA methylation with possible important lifetime health consequences for offspring. Main methodsWe used Illumina Infinium HumanMethylation 450 K BeadChip to explore the pattern of genome-wide DNA methylation containing >485,000 gene sites in cord blood of 24 subjects in a 12 mother-newborn pairs birth cohort. Based on the genome-wide DNA methylation data, we chose one potential gene, BRCA1, to verify the results in another group comprising 126 subjects. Key findingsWe identified 1,131 significantly different CpG sites which included 690 hypermethylation sites and 441 hypomethylation sites in the DNA methylation level between case and control group. The identified sites were located in 598 unique genes. In subsequent validation studies, we found that the DNA methylation level of the identified CpGs of BRCA1 increased with increased exposure to dichlorodiphenyltrichloroethane (DDT) and the level of gene expression in the identified CpGs of BRCA1 decreased with increased exposure to dichlorodiphenyltrichloroethane (DDT). SignificanceThe results indicated that epigenetic processes played a possible role in the development of fetuses affected by maternal OCP-DDT exposure. Early prenatal exposure to DDT may affect fetal BRCA1 gene methylation, and increased exposure leads to a higher DNA methylation level and lower gene expression level.

Molecular stool testing as an alternative for surveillance colonoscopy: a cross-sectional cohort study

BackgroundAs in many other European countries, a nationwide screening program for colorectal cancer (CRC) has recently been introduced in the Netherlands. As a side effect, such a screening program will inherently yield an increase in the demand for surveillance after removal of polyps/adenomas or CRC. Although these patients are at increased risk of metachronous colorectal neoplasia, solid evidence on CRC-related mortality reduction as a result of colonoscopy-based surveillance programs is lacking. Furthermore, colonoscopy-based surveillance leads to high patient burden, high logistic demands and high costs. Therefore, new surveillance strategies are needed. The aim of the present study, named Molecular stool testing for Colorectal CAncer Surveillance (MOCCAS), is to determine the performance characteristics of two established non-invasive tests, i.e., the multitarget stool DNA test Cologuard® and the faecal immunochemical test (FIT) in the detection of CRC and advanced adenomas as an alternative for colonoscopy surveillance.MethodsIn this observational cross-sectional cohort study, subjects aged 50 to 75 years will be approached to collect (whole-) stool samples for molecular testing and a FIT prior to their scheduled surveillance colonoscopy. The results of the tests will allow calculation of test sensitivities and specificities in the context of surveillance. This will provide the required input for the Dutch ASCCA model (Adenoma and Serrated pathway to Colorectal CAncer) to simulate surveillance strategies differing in frequency and duration. The model will allow predictions of lifetime health effects and costs. Multiple centres in the Netherlands will participate in the study that aims to include 4,000 individuals.DiscussionThe outcome of this study will inform on the (cost-) effectiveness of stool based molecular testing as an alternative for colonoscopy in the rapidly expanding surveillance population.Trial registrationClinicalTrials.gov (https://clinicaltrials.gov/): NCT02715141. Retrospectively registered 17 February 2016.

Lower thresholds for lifetime health effects in mammals from high-LET radiation – Comparison with chronic low-LET radiation

Lower threshold dose rates and confidence limits are quantified for lifetime radiation effects in mammalian animals from internally deposited alpha-emitting radionuclides. Extensive datasets on effects from internal alpha-emitters are compiled from the International Radiobiological Archives. In total, the compiled database includes 257 records, which are analyzed by means of non-parametric order statistics. The generic lower threshold for alpha-emitters in mammalian animals (combined datasets) is 6.6·10−5 Gy day−1. Thresholds for individual alpha-emitting elements differ considerably: plutonium and americium - 2.0·10−5 Gy day−1; radium – 2.1·10−4 Gy day−1. Threshold for chronic low-LET radiation is previously estimated at 1·10−3 Gy day−1.For low exposures, the following values of alpha radiation weighting factor wR for internally deposited alpha-emitters in mammals are quantified: wR(α) = 15 as a generic value for the whole group of alpha-emitters; wR(Pu) = 50 for plutonium; wR(Am) = 50 for americium; wR(Ra) = 5 for radium. These values are proposed to serve as radiation weighting factors in calculations of equivalent doses to non-human biota.The lower threshold dose rate for long-lived mammals (dogs) is significantly lower than comparing with the threshold for short-lived mammals (mice): 2.7·10−5 Gy day−1, and 2.0·10−4 Gy day−1, respectively. The difference in thresholds is exactly reflecting the relationship between the natural longevity of these two species.Graded scale of severity in lifetime radiation effects in mammals is developed, based on compiled datasets. Being placed on the severity scale, the effects of internal alpha-emitters are situated in the zones of considerably lower dose rates than effects of the same severity caused by low-LET radiation. RBE values, calculated for effects of equal severity, are found to depend on the intensity of chronic exposure: different RBE values are characteristic for low, moderate, and high lifetime exposures (30, 70, and 13, respectively).The results of the study provide a basis for selecting correct values of radiation weighting factors in dose assessment to non-human biota.

Cost-Effectiveness Analysis of Six Strategies to Treat Recurrent Clostridium difficile Infection

ObjectiveTo assess the cost-effectiveness of six treatment strategies for patients diagnosed with recurrent Clostridium difficile infection (CDI) in Canada: 1. oral metronidazole; 2. oral vancomycin; 3.oral fidaxomicin; 4. fecal transplantation by enema; 5. fecal transplantation by nasogastric tube; and 6. fecal transplantation by colonoscopy.PerspectivePublic insurer for all hospital and physician services.SettingOntario, Canada.MethodsA decision analytic model was used to model costs and lifetime health effects of each strategy for a typical patient experiencing up to three recurrences, over 18 weeks. Recurrence data and utilities were obtained from published sources. Cost data was obtained from published sources and hospitals in Toronto, Canada. The willingness-to-pay threshold was $50,000/QALY gained.ResultsFecal transplantation by colonoscopy dominated all other strategies in the base case, as it was less costly and more effective than all alternatives. After accounting for uncertainty in all model parameters, there was an 87% probability that fecal transplantation by colonoscopy was the most beneficial strategy. If colonoscopy was not available, fecal transplantation by enema was cost-effective at $1,708 per QALY gained, compared to metronidazole. In addition, fecal transplantation by enema was the preferred strategy if the probability of recurrence following this strategy was below 8.7%. If fecal transplantation by any means was unavailable, fidaxomicin was cost-effective at an additional cost of $25,968 per QALY gained, compared to metronidazole.ConclusionFecal transplantation by colonoscopy (or enema, if colonoscopy is unavailable) is cost-effective for treating recurrent CDI in Canada. Where fecal transplantation is not available, fidaxomicin is also cost-effective.

Genome-wide DNA methylation in neonates exposed to maternal depression, anxiety, or SSRI medication during pregnancy

Despite the high prevalence of depression, anxiety, and use of antidepressant medications during pregnancy, there is much uncertainty around the impact of high levels of distress or antidepressant medications on the developing fetus. These intrauterine exposures may lead to epigenetic alterations to the DNA during this vulnerable time of fetal development, which may have important lifetime health consequences. In this study we investigated patterns of genome-wide DNA methylation using the Illumina Infinium Human Methylation450 BeadChip in the umbilical cord blood of neonates exposed to non-medicated maternal depression or anxiety (n = 13), or selective serotonin reuptake inhibitors (SSRIs) during pregnancy (n = 22), relative to unexposed neonates (n = 23). We identified 42 CpG sites with significantly different DNA methylation levels in neonates exposed to non-medicated depression or anxiety relative to controls. CpG site methylation was not significantly different in neonates exposed to SSRIs relative to the controls, after adjusting for multiple comparisons. In neonates exposed either to non-medicated maternal depression or SSRIs, the vast majority of CpG sites displayed lower DNA methylation relative to the controls, but differences were very small. A gene ontology analysis suggests significant clustering of the top genes associated with non-medicated maternal depression/anxiety, related to regulation of transcription, translation, and cell division processes (e.g., negative regulation of translation in response to oxidative stress, regulation of mRNA export from the nucleus, regulation of stem cell division). While the functional consequences of these findings are yet to be determined, these small DNA methylation differences may suggest a possible role for epigenetic processes in the development of neonates exposed to non-medicated maternal depression/anxiety.

Cost-effectiveness of changes in alcohol taxation in Denmark: a modelling study

IntroductionExcessive alcohol consumption is a public health problem in many countries including Denmark, where 6% of the burden of disease is due to alcohol consumption, according to the new estimates from the Global Burden of Disease 2010 study. Pricing policies, including tax increases, have been shown to effectively decrease the level of alcohol consumption.MethodsWe analysed the cost-effectiveness of three different scenarios of changed taxation of alcoholic beverages in Denmark (20% and 100% increase and 10% decrease). The lifetime health effects are estimated as the difference in disability-adjusted life years between a Danish population that continues to drink alcohol at current rates and an identical population that changes their alcohol consumption due to changes in taxation. Calculation of cost offsets related to treatment of alcohol-related diseases and injuries, was based on health care system costs from Danish national registers. Cost-effectiveness was evaluated by calculating cost-effectiveness ratios (CERs) compared to current practice.ResultsThe two scenarios of 20% and 100% increased taxation could avert 20,000 DALY and 95,500 DALY respectively, and yield cost savings of -€119 million and -€575 million, over the life time of the Danish population. Both scenarios are thus cost saving. The tax decrease scenario would lead to 10,100 added DALY and an added cost of €60 million. For all three interventions the health effects build up and reach their maximum around 15–20 years after implementation of the tax change.ConclusionOur results show that decreased taxation will lead to an increased burden of disease and related increases in health care costs, whereas both a doubling of the current level of alcohol taxation and a scenario where taxation is only increased by 20% can be cost-saving ways to reduce alcohol related morbidity and mortality. Our results support the growing evidence that population strategies are cost-effective and should be considered for policy making and prevention of alcohol abuse.

Do integrated stroke services impact on the ‘cost’ of stroke?

Evaluation of: Baeten SA, van Exel NJ, Dirks M, Koopmanschap MA, Dippel DW, Niessen LW. Lifetime health effects and medical costs of integrated stroke services – a nonrandomized controlled cluster-trial based life table approach. Cost Eff. Resour. Alloc. 8, 21 (2010).The clinical efficacy of specialist stroke care is proven; however, corresponding economic analyses are limited. Baeten and colleagues present an analysis of the effects of an integrated stroke service and report cost–effectiveness compared with usual care. Improving efficiency of the stroke survivor’s journey is an attractive intervention and this article is a welcome addition to the emerging literature on the subject. Overall, data on integrated services are encouraging, but not definitive. The article highlights the challenges of performing longer-term economic analysis in stroke care and highlights certain deficiencies in our current understanding of the economics of post-acute stroke care.

Lifetime health effects and medical costs of integrated stroke services - a non-randomized controlled cluster-trial based life table approach.

BackgroundEconomic evaluation of stroke services indicates that such services may lead to improved quality of life at affordable cost. The present study assesses lifetime health impact and cost consequences of stroke in an integrated service setting.MethodsThe EDISSE study is a prospective non-randomized controlled cluster trial that compared stroke services (n = 151 patients) to usual care (n = 187 patients). Health status and cost trial-data were entered in multi-dimensional stroke life-tables. The tables distinguish four levels of disability which are defined by the modified Rankin scale. Quality-of-life scores (EuroQoL-5D), transition and survival probabilities are based on concurrent Dutch follow-up studies. Outcomes are quality-adjusted life years lived and lifetime medical cost by disability category. An economic analysis compares outcomes from a successful stroke service to usual care, by bootstrapping individual costs and effects data from patients in each arm.ResultsLifetime costs and QALYs after stroke depend on age-of-onset of first-ever stroke. Lifetime QALYs after stroke are 2.42 (90% CI - 0.49 - 2.75) for male patients in usual care and 2.75 (-0.61; 6.26) for females. Lifetime costs for men in the usual care setting are €39,335 (15,951; 79,837) and €42,944 (14,081; 95,944) for women. A comparison with the stroke service results in an ICER of €11,685 saved per QALY gained (€14,211 and €7,745 for men and women respectively). This stroke service is with 90% certainty cost-effective.ConclusionsOur analysis shows the potential of large health benefits and cost savings of stroke services, taking a lifetime perspective, also in other European settings.

The effects of soft drink taxes on child and adolescent consumption and weight outcomes

Childhood and adolescent obesity is associated with serious adverse lifetime health consequences and its prevalence has increased rapidly. Soft drink consumption has also expanded rapidly, so much so that soft drinks are currently the largest single contributors to energy intake. In this paper, we investigate the potential for soft drink taxes to combat rising levels of child and adolescent obesity through a reduction in consumption. Our results, based on state soft drink sales and excise tax information between 1989 and 2006 and the National Health Examination and Nutrition Survey, suggest that soft drink taxation, as currently practiced in the United States, leads to a moderate reduction in soft drink consumption by children and adolescents. However, we show that this reduction in soda consumption is completely offset by increases in consumption of other high-calorie drinks.