Terms Of Life Expectancy Research Articles

Need to reform education in graduate schools of public health in Japan: Toward outcome-based education to cultivate competencies.

Japan, known for its good healthcare access via universal health insurance, leads the world in terms of life expectancy, and possesses a public health system that has improved health standards markedly in the 20th century. However, we currently face major challenges to maintain and promote people's health. Although these complicated problems pose numerous threats to public welfare, education of public health for health professionals still retains 20th-century standards. This also means that graduate education of public health in Japan is traditionally based on obtaining licensure as a medical professional, conducting research and writing papers, and on-the-job training. Since graduate school education is expected to produce competent public health leaders, Japan requires a reform toward a new education design that caters to the current societal needs. The current global trend in the education of health professionals leans toward outcome-based education to meet core competencies. Here, "competency" refers to a set of features or particular behavioral patterns possessed by highly qualified persons. In 2006, the World Health Organization (WHO) established a general health professional competency standard that includes both management and leadership competencies. Moreover, the Lancet Commission concluded that there was a need for transformative education based on a "health system approach." In brief, this means that our education should correspond to the needs of the health system to allow for the resolution of problems by educated professionals with satisfactory levels of competencies. In addition, as "change agents," these competent professionals are expected to promote societal change toward the realization of better public health. In Japan, the Central Education Council has produced several reports on professional graduate school reform since 2000. These reports indicate that graduate school curricula require reform to allow the health professionals to work locally and globally, as well as to solve problems through the application of systematic knowledge that matches practice with theory. Therefore, with reference to the current Japanese health situation, global trends in education, and the Japanese educational policies, transformational changes are needed toward a new era of Japanese public health education specifically through outcome-based education to improve the health professionals competencies. We hope that education in the new schools of public health will contribute to solve authentic public health problems and create a healthy future with competent professionals.

Making the Grade: The Impact of Low-Grade Toxicities on Patient Preference for Treatment With Novel Agents.

Targeted therapies have shown clinical benefit in the treatment of solid tumors. The toxicity profiles and treatment duration and schedule of these agents differ considerably from those of traditional chemotherapy. Many studies of targeted therapies report sizeable numbers of grade 1 or 2 toxicities. We sought to determine whether anticipation of low-grade toxicities and treatment logistics impact patient willingness to undergo therapy. A total of 209 patients with cancer (101 lung and 108 breast) were surveyed at the Vanderbilt-Ingram Cancer Center regarding willingness to comply with treatment based on anticipated efficacy, dosing convenience, and toxicity profiles. All toxicities were Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 grade 1 and 2. Willingness to comply with treatment depending on toxicity, anticipated benefit, cancer type, and dosing convenience was compared. A substantial number of patients (2.9%-48.8%, depending on the toxicity described) professed unwillingness to undergo treatment because of anticipated grade 1 and 2 toxicities. Gastrointestinal and constitutional toxicities had a stronger negative impact on patient willingness to undergo therapy than dermatologic toxicity. Patients with lung cancer were significantly more likely to accept dermatologic and gastrointestinal toxicities than those with breast cancer. Willingness to tolerate toxicities correlated with expected benefit in terms of life expectancy and chance of cure. Lengthy travel distance for treatment negatively impacted willingness to undergo treatment. Anticipation of low-grade toxicities and dosing inconvenience negatively impacts patient willingness to be treated, which may affect adherence and therapeutic outcomes from therapy. Long-term tolerability should be considered when developing and assessing the impact of novel agents.

When Opportunity Knocks Twice: Dual Living Kidney Donation, Autonomy and the Public Interest.

Living kidney transplantation offers the best treatment in terms of life‐expectancy and quality of life for those with end‐stage renal disease. The long‐term risks of living donor nephrectomy, although real, are very small, with evidence of good medium‐term outcomes. Who should be entitled to donate, and in which circumstances, is nevertheless a live question. We explore the ethical dimensions of a request by an individual to donate both of their kidneys during life: ‘dual living kidney donation’. Our ethical analysis is tethered to a hypothetical case study in which a father asks to donate a kidney to each of his twin boys. We explore the autonomy of the protagonists, alongside different dimensions of the public interest, such as the need to protect not only the recipients, but also the donor and even the wider community.Whilst acknowledging objections to ‘dual‐donation’, not least by reference to the harms that the donor might be expected to endure, we suggest there is a prima facie case for permitting this, provided that both donor and recipients are willing and that due attention is paid to such considerations as the autonomy and welfare of all parties, as well as to the wider ramifications of acting on such a request. We argue for broader interpretations of the concepts of autonomy and welfare, recognizing the importance of relationships and the relevance of more than merely physical well‐being. Equipped with such a holistic assessment, we suggest there is a prima facie case for allowing ‘dual living kidney donation’.

Abstract P1-10-03: NSABP B-43 is unlikely to produce a cost-effective treatment strategy for HER2+ DCIS

Abstract Background. National Surgical Adjuvant Breast and Bowel Project (NSABP) B-43 is an ongoing randomized clinical trial that compares breast conserving surgery, radiation therapy, and two infusions of trastuzumab to breast-conserving surgery and radiation only for HER2+ ductal carcinoma in situ (DCIS). We sought to identify, from a societal perspective, the level of risk reduction observed in this trial that would be required to make treating HER2+ DCIS patients with trastuzumab cost-effective. Methods. We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER) over 15 years. The results of NSABP B-43 are pending. We therefore assumed the hazard reduction to be 36%, based on the statistical considerations of the trial protocol and explored this in sensitivity analyses. A series of one and two-way sensitivity tests were conducted. Results. The baseline ICER for switching from a breast-conserving surgery and radiation strategy without trastuzumab treatment to a breast-conserving surgery and radiation strategy with trastuzumab treatment is $1.57 million per life-year gained and $299,616.73 per QALY gained. Compared to a societal willingness-to-pay threshold of $100,000 per QALY gained, adding Herceptin treatment is not cost-effective in the treatment of DCIS under these baseline conditions. In a one-way sensitivity test, we found that the Herceptin strategy only became cost-effective at an 88.3% risk reduction for local recurrence. The model was not sensitive to any costs or probabilities within 20% of baseline values. The model was sensitive to the utilities of having had breast-conserving surgery and radiation with and without trastuzumab treatment. It was not sensitive to other utilities within 0.05 of baseline values. Conclusions. High risk DCIS treated with breast-conserving surgery and radiation has a low risk of local recurrence as demonstrated in multiple randomized trials. The addition of a costly drug in order to reduce this small risk further is very unlikely to be cost-effective and could be considered overtreatment of a non-fatal disease that is sufficiently managed with local treatment. Prospective cost-effectiveness analyses have the potential to guide allocation of valuable resources for breast cancer research, and should be regularly integrated into the protocol design of large clinical trials. Citation Format: Michael D Alvarado, Mitchell T Hayes, Rajni Sethi, Elissa Ozanne. NSABP B-43 is unlikely to produce a cost-effective treatment strategy for HER2+ DCIS [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-10-03.

Sa1118 Withdrawing or Continuing Maintenance Treatment With Thiopurines in Patients With Crohn's Disease in Sustained Clinical Remission: A Lifetime Risk-Benefit Analysis

Introduction: Long-term treatment of Crohn's disease (CD) with thiopurines modifies the risk of various cancers, depending on gender and age for lymphomas, and presence of extensive colitis (EC) for colorectal cancer. We evaluated risks and benefits of withdrawing or continuing thiopurines in patients with CD in sustained clinical remission. Methods: We developed a Markov model assessing risks and benefits of withdrawing or continuing thiopurines in a lifetime horizon. We simulated a cohort of CD patients in stable clinical remission for 5 years under thiopurines. The model was stratified by age, gender and presence of EC. Parameter estimates were taken from French hospital Diagnosis Related Groups (DRGs) databases, the French cancer and death national registries (FRANCIM), the CESAME cohort, the Saint-Antoine hospital database (MICISTA)), and from the literature. The primary outcome was life expectancy. Secondary outcomes included the probability of CD relapse, cancers, and causes-of-deaths. We conducted threshold analyses on age to assess potential age-related changes in best life expectancy according to the two strategies. Results: The continuing strategy was globally associated with decreased lifetime risk of flares and increased risk of lymphoma. However, life-expectancy and risks associated with the two strategies differed markedly according to age at decision, gender and presence or absence of EC, as illustrated in Table 1. In terms of life expectancy, in patients without EC, withdrawal strategy was associated with increased life expextancy after the age of 41.7 years for men, and 47.0 years for women. In patients with EC, continuing thiopurines was associated with increased life expectancy, regardless of age. Conclusion: Factors determining life expectancy associated with withdrawal or continuation of thiopurines in patients with CD and 5-year sustained clinical remission vary substantially according to gender, age and presence of EC. Individual decisions to continue or withdraw thiopurines in patients with CD in sustained remission should take into account age, gender, and presence of EC. Table 1 : Life expectancy, relapse, cancers and causes of death associated with continuing (C) or withdrawing (W) maintenance treatment with thiopurines

Sa1119 Clinical Features of Active Tuberculosis Developed During Anti-Tumor Necrosis Factor-α Therapy in Patients With Inflammatory Bowel Diseases

Introduction: Long-term treatment of Crohn's disease (CD) with thiopurines modifies the risk of various cancers, depending on gender and age for lymphomas, and presence of extensive colitis (EC) for colorectal cancer. We evaluated risks and benefits of withdrawing or continuing thiopurines in patients with CD in sustained clinical remission. Methods: We developed a Markov model assessing risks and benefits of withdrawing or continuing thiopurines in a lifetime horizon. We simulated a cohort of CD patients in stable clinical remission for 5 years under thiopurines. The model was stratified by age, gender and presence of EC. Parameter estimates were taken from French hospital Diagnosis Related Groups (DRGs) databases, the French cancer and death national registries (FRANCIM), the CESAME cohort, the Saint-Antoine hospital database (MICISTA)), and from the literature. The primary outcome was life expectancy. Secondary outcomes included the probability of CD relapse, cancers, and causes-of-deaths. We conducted threshold analyses on age to assess potential age-related changes in best life expectancy according to the two strategies. Results: The continuing strategy was globally associated with decreased lifetime risk of flares and increased risk of lymphoma. However, life-expectancy and risks associated with the two strategies differed markedly according to age at decision, gender and presence or absence of EC, as illustrated in Table 1. In terms of life expectancy, in patients without EC, withdrawal strategy was associated with increased life expextancy after the age of 41.7 years for men, and 47.0 years for women. In patients with EC, continuing thiopurines was associated with increased life expectancy, regardless of age. Conclusion: Factors determining life expectancy associated with withdrawal or continuation of thiopurines in patients with CD and 5-year sustained clinical remission vary substantially according to gender, age and presence of EC. Individual decisions to continue or withdraw thiopurines in patients with CD in sustained remission should take into account age, gender, and presence of EC. Table 1 : Life expectancy, relapse, cancers and causes of death associated with continuing (C) or withdrawing (W) maintenance treatment with thiopurines

Treatment as prevention--where next?

Uptake of antiretroviral regimens with associated durable virologic suppression has been shown to reduce the risk of HIV transmission. Expanding antiretroviral therapy (ART) programs at a population level may serve as a vital strategy in the elimination of the AIDS epidemic. The global expansion of ART programs has greatly improved access to life-saving therapies and is likely to achieve the target of 15 million individuals on therapy set by UNAIDS. In addition to the incontrovertible gains in terms of life expectancy, growing evidence demonstrates that durable virologic suppression is associated with significant reductions in HIV transmission amongst heterosexual couples and men who have sex with men. Expansion of successful ART programs, best monitored by a program-level continuum of care cascade to assess progress in diagnosis, retention in care, and virologic suppression, is associated with reductions in HIV incidence at a population level. Expanding and sustaining successful ART delivery at a global level is a key component in a comprehensive approach to combating the HIV epidemic over the next two decades.

Morbidity in children with frequently relapsing nephrosis: 10-year follow-up of a randomized controlled trial.

To investigate the long-term outcome in children with frequently relapsing nephrotic syndrome (FRNS) we conducted a follow-up of a previous randomized controlled trial (RCT) 10years after the initiation of the treatment protocol. We previously conducted an RCT on the efficacy of cyclosporine for treating children with FRNS. After 2years of treatment, a recommended a management protocol of steroids, and immunosuppressants was provided. Valid information was available for 46 of the 56 patients (82.1%) enrolled in the original RCT. The median follow-up period was 10.3years from the start of protocol treatment with cyclosporine. At last follow-up (mean age 18.7years), only ten patients (21.7%) showed disease-free remission (no relapse for at least 2years). In contrast, 23 (50.0%) continued to relapse frequently or were on immunosuppressants, eight patients (17.4%) had infrequent relapses without immunosuppressants. Adverse effects attributable to treatment included short stature (6 patients), osteoporosis (six patients), obesity (4 patients), cataracts (3 patients) and hypertension (3 patients). No lethal event or renal dysfunction occurred during follow-up. This 10-year follow-up study shows that most children with FRNS experience relapses after 2years of cyclosporine treatment, in adolescence and into adulthood. Outcomes in terms of life expectancy and renal function are favorable.

Survival of Persons with Down Syndrome in Italy

Down syndrome (DS) is a major cause of congenital malformation and disability. No updated data are available on life expectancy of persons with DS in Europe. We collected information on age, sex and area of birth of 3,217 persons with DS died from 1997 to 2009 in Italy. Survivals rates and mean survival time was calculated using a life tables calculated from cross sectional data. Some factors influencing the survival were also analysed using a semi-proportional hazard model. Survival rates of 91.4% at one year and 88.3% at ten years were found. Mean survival time at birth was 47.1 years (C.I. 95%: 46.5-47.7). There was 8-year significant difference in survival between north-central regions and southern regions. Male life expectancy was 46.9 years (C.I. 95%: 46.1-47.8), lower than females 47.3 years (C.I. 95%: 46.5-48.2) even though not statistically significant (p=0.23). Almost nine out ten children with DS now survive at least 10 years. Adequate educational and health service provisions needs to be made for them. The disadvantage of Down persons born in the Southern regions in terms of life expectancy is impressive. Quality of medical care provided in the South of Italy in the first months of life is the most likely determinant of the high mortality observed among persons with DS born in that area.

Costs and cost-effectiveness of 9-valent human papillomavirus (HPV) vaccination in two East African countries.

BackgroundCurrent prophylactic vaccines against human papillomavirus (HPV) target two of the most oncogenic types, HPV-16 and -18, which contribute to roughly 70% of cervical cancers worldwide. Second-generation HPV vaccines include a 9-valent vaccine, which targets five additional oncogenic HPV types (i.e., 31, 33, 45, 52, and 58) that contribute to another 15–30% of cervical cancer cases. The objective of this study was to determine a range of vaccine costs for which the 9-valent vaccine would be cost-effective in comparison to the current vaccines in two less developed countries (i.e., Kenya and Uganda).Methods and FindingsThe analysis was performed using a natural history disease simulation model of HPV and cervical cancer. The mathematical model simulates individual women from an early age and tracks health events and resource use as they transition through clinically-relevant health states over their lifetime. Epidemiological data on HPV prevalence and cancer incidence were used to adapt the model to Kenya and Uganda. Health benefit, or effectiveness, from HPV vaccination was measured in terms of life expectancy, and costs were measured in international dollars (I$). The incremental cost of the 9-valent vaccine included the added cost of the vaccine counterbalanced by costs averted from additional cancer cases prevented. All future costs and health benefits were discounted at an annual rate of 3% in the base case analysis. We conducted sensitivity analyses to investigate how infection with multiple HPV types, unidentifiable HPV types in cancer cases, and cross-protection against non-vaccine types could affect the potential cost range of the 9-valent vaccine. In the base case analysis in Kenya, we found that vaccination with the 9-valent vaccine was very cost-effective (i.e., had an incremental cost-effectiveness ratio below per-capita GDP), compared to the current vaccines provided the added cost of the 9-valent vaccine did not exceed I$9.7 per vaccinated girl. To be considered very cost-effective, the added cost per vaccinated girl could go up to I$5.2 and I$16.2 in the worst-case and best-case scenarios, respectively. At a willingness-to-pay threshold of three times per-capita GDP where the 9-valent vaccine would be considered cost-effective, the thresholds of added costs associated with the 9-valent vaccine were I$27.3, I$14.5 and I$45.3 per vaccinated girl for the base case, worst-case and best-case scenarios, respectively. In Uganda, vaccination with the 9-valent vaccine was very cost-effective when the added cost of the 9-valent vaccine did not exceed I$8.3 per vaccinated girl. To be considered very cost-effective, the added cost per vaccinated girl could go up to I$4.5 and I$13.7 in the worst-case and best-case scenarios, respectively. At a willingness-to-pay threshold of three times per-capita GDP, the thresholds of added costs associated with the 9-valent vaccine were I$23.4, I$12.6 and I$38.4 per vaccinated girl for the base case, worst-case and best-case scenarios, respectively.ConclusionsThis study provides a threshold range of incremental costs associated with the 9-valent HPV vaccine that would make it a cost-effective intervention in comparison to currently available HPV vaccines in Kenya and Uganda. These prices represent a 71% and 61% increase over the price offered to the GAVI Alliance ($5 per dose) for the currently available 2- and 4-valent vaccines in Kenya and Uganda, respectively. Despite evidence of cost-effectiveness, critical challenges around affordability and feasibility of HPV vaccination and other competing needs in low-resource settings such as Kenya and Uganda remain.

Opportunity cost of funding drugs for rare diseases: the cost-effectiveness of eculizumab in paroxysmal nocturnal hemoglobinuria.

Both ethical and economics concerns have been raised with respect to the funding of drugs for rare diseases. This article reports both the cost-effectiveness of eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria (PNH) and its associated opportunity costs. Analysis compared eculizumab plus current standard of care v. current standard of care from a publicly funded health care system perspective. A Markov model covered the major consequences of PNH and treatment. Cost-effectiveness was assessed in terms of the incremental cost per life year and per quality-adjusted life year (QALY) gained. Opportunity costs were assessed by the health gains foregone and the alternative uses for the additional resources. Eculizumab is associated with greater life years (1.13), QALYs (2.45), and costs (CAN$5.24 million). The incremental cost per life year and per QALY gained is CAN$4.62 million and CAN$2.13 million, respectively. Based on established thresholds, the opportunity cost of funding eculizumab is 102.3 discounted QALYs per patient funded. Sensitivity and subgroup analysis confirmed the robustness of the results. If the acquisition cost of eculizumab was reduced by 98.5%, it could be considered cost-effective. The nature of rare diseases means that data are often sparse for the conduct of economic evaluations. When data were limited, assumptions were made that biased results in favor of eculizumab. This study demonstrates the feasibility of conducting economic evaluations in the context of rare diseases. Eculizumab may provide substantive benefits to patients with PNH in terms of life expectancy and quality of life but at a high incremental cost and a substantial opportunity cost. Decision makers should fully consider the opportunity costs before making positive reimbursement decisions.

Low Alcohol Consumption as a Predictor of Higher CD4+ Cell Count in HIV-Treated Patients

Low Alcohol Consumption as a Predictor of Higher CD4+ Cell Count in HIV-Treated Patients

A review of life expectancy and infant mortality estimations for Australian Aboriginal people

BackgroundSignificant variation exists in published Aboriginal mortality and life expectancy (LE) estimates due to differing and evolving methodologies required to correct for inadequate recording of Aboriginality in death data, under-counting of Aboriginal people in population censuses, and unexplained growth in the Aboriginal population attributed to changes in the propensity of individuals to identify as Aboriginal at population censuses.The objective of this paper is to analyse variation in reported Australian Aboriginal mortality in terms of LE and infant mortality rates (IMR), compared with all Australians.MethodsPublished data for Aboriginal LE and IMR were obtained and analysed for data quality and method of estimation. Trends in reported LE and IMR estimates were assessed and compared with those in the entire Australian population.ResultsLE estimates derived from different methodologies vary by as much as 7.2 years for the same comparison period. Indirect methods for estimating Aboriginal LE have produced LE estimates sensitive to small changes in underlying assumptions, some of which are subject to circular reasoning. Most indirect methods appear to under-estimate Aboriginal LE. Estimated LE gaps between Aboriginal people and the overall Australian population have varied between 11 and 20 years.Latest mortality estimates, based on linking census and death data, are likely to over-estimate Aboriginal LE.Temporal LE changes by each methodology indicate that Aboriginal LE has improved at rates similar to the Australian population overall. Consequently the gap in LE between Aboriginal people and the total Australian population appears to be unchanged since the early 1980s, and at the end of the first decade of the 21st century remains at least 11–12 years.In contrast, focussing on the 1990–2010 period Aboriginal IMR declined steeply over 2001–08, from more than 12 to around 8 deaths per 1,000 live births, the same level as Australia overall in 1993–95. The IMR gap between Aboriginal people and the total Australian population, while still unacceptable, has declined considerably, from over 8 before 2000 to around 4 per 1,000 live births by 2008.ConclusionsRegardless of estimation method used, mortality and LE gaps between Aboriginal and non-Aboriginal people are substantial, but remain difficult to estimate accurately.

Diabetic women suffer more years of life lost than diabetic men.

We read with interest the recent paper by Harjutsalo and colleagues [1] which reported that the standardized mortality ratio due to ischemic heart disease was higher in women than in men in the cohort of type 1 diabetes: within the early-onset (0–14 years) cohort, the standardized mortality ratio was 52.8 (95% confidence interval 36.3–74.5) in women compared with 12.1 (9.2–15.8) in men; within the late-onset (15–29 years) cohort, the standardized mortality ratio was 15.8 (11.8–20.7) in women compared with 5.0 (4.3–5.8) in men. Their results are in agreement with epidemiologic data from China. Based on the death registry data from Shanghai CDC, female diabetic patients (both type 1 and type 2) suffer more Years of Life Lost (YLLs) than male diabetic patients [2]. Specifically, the average of YLLs per diabetic patients, defined as the sum of YLLs divided by total number of female or male diabetic patients, was higher in female diabetic patients than male diabetic patients from 1976 to 1996 (Figure 1(a)); the average of YLLs per resident, defined as the sum of YLL divided by total number of female or male residents in Shanghai, was higher in female residents than male residents (Figure 1(b)). Figure 1 The average of Years of Life Loss (a) per diabetic patient and (b) per resident in Shanghai between 1976 and 1996. An earlier population-based study in China showed that female diabetic patients were more likely to have chronic diabetic complications [3]. Of the 255 diabetic patients who were identified by fasting-glucose screening in a cross-sectional survey of 1960 adult residents enrolled through a multistage sampling scheme from 8 communities in Shanghai, the prevalence of diabetic complications (including any of diabetic retinopathy, diabetic nephropathy, diabetic foot ulcer, or diabetic cardiovascular complications) in diabetic women was higher than that in diabetic men (37.7% versus 24.8%, odds ratio 1.74, 95% confidence interval 1.01–3.06, P = 0.05) [3]. These two studies are, to our knowledge, the first to report the gender difference in diabetic mortality [2] and chronic diabetic complications [3] in Chinese population, supported by data from other countries [1, 4–6]. These findings suggest the loss of female gender as a protective factor in terms of life expectancy and a variety of chronic diseases, for example, cardiovascular disease, in the setting of diabetes. In summary, diabetic women are at higher risk of chronic complication and mortality than diabetic men. Further studies investigating the underlying mechanisms are warranted More efforts are needed for controlling diabetic complications for women, for example, health education for both patients and health professionals.

Суспільно-географічні аспекти старіння населення

Ukraine belongs to countries with a high intensity depopulation processes which conditioned by a number of diverse factors of economic, socio-cultural, institutional character. The extensive and prolonged depopulation stands now as a part and one of the most expressive manifestation of the general crisis of the demographic situation in Ukraine. This article investigates the impact of trends in life expectancy to the indicators of the population aging. It was conducted regional analysis and determined regional differences in terms of life expectancy and the parameters of population aging. The reasons of such a stress situation were identified.

Ghosts Haunting the Norwegian House: Racialization in Norway and <em>The Kautekeino Rebellion</em>

Ghosts Haunting the Norwegian House:Racialization in Norway and The Kautokeino Rebellion Adriana Margareta Dancus (bio) In 2011, for the ninth year in a row, Norway topped the United Nation’s Human Development Index composite that measures life standard in terms of life expectancy, educational attainment, and income.1 Numbers released by the Norwegian Ministry of Finance in May 2012 further show that Norway has managed to successfully surf the wave of global recession reporting economic growth and low unemployment also in 2011.2 It comes as no surprise then that people around the world look at Norway as an attractive place to which to move. Most recent counts made by Norway Statistics indicate historically high migration: 14 percent of Norway’s total population has an immigrant background, either immigrants themselves or children born to immigrant parents; Oslo is the county with the highest concentration of immigrants, 30 percent; the largest immigrant group in Norway is the Poles, the majority of whom have come as guest workers after Poland joined the European Union (EU) in 2004; the Pakistani started migrating into Norway in the late 1960s and represent the largest non-European ethnic community living in Norway, third in size after Poles and Swedes; in comparison to the 1970s, when the largest proportion of immigrants was from Western Europe and North America, in 2012, 48.5 percent of all the immigrants come from Asia, Africa, and South and Central America.3 If Asians, Africans, or Eastern Europeans are newer additions to the national community, the indigenous Sami, as well as other national minorities, such as tatere (the Romani), the Kvens, or the Jews, have long cohabited with the Norwegian majority.4 This cohabitation has not been without frictions. The case of the Sami is a well-documented example of how the Norwegian nation-state has [End Page 121] backed up oppressive assimilation policies meant to discipline this indigenous group.5 Click for larger view View full resolution Figure 1. An unrepentant Sami rebel on the scaffold in Nils Gaup’s film Kautokeino-opprøret/The Kautokeino Rebellion (2008). Click for larger view View full resolution Figure 2. About to witness something not meant for a child’s eyes in Nils Gaup’s film Kautokeinoopprøret/The Kautokeino Rebellion (2008). One of the most recent commentaries on the relationship between the Sami minority and the Norwegian majority is Nils Gaup’s film Kautokeino-opprøret/The Kautokeino Rebellion (DK/NO/SE, 2008). Gaup is an acclaimed Norwegian director of Sami descent and his film is based on a true event in 1852 when the [End Page 122] Sami of Kautokeino turned to violence against representatives of the Norwegian authorities. The reception of the film focused on the revisionist attempt to explain history from the Sami point of view, with many welcoming Gaup’s insider perspective and some accusing him of light treatment of Sami religious extremism and terror. But how does the Sami experience as conveyed by Gaup in 2008 pertain to the current moment of accelerated migration into Norway? What is the film’s relevance to current debates on integration and discrimination? This paper analyzes Gaup’s film against the background of changing demographics and heated immigration debates in Norway. In addition, it looks at the cinematic context from which The Kautokeino Rebellion emerges, to be precise, Gaup’s epic in comparison to other cinematic representations of Sami and immigrant others in Norwegian features. Race and Racism in Norway Analyzing notions of Norwegian nationalism and nationhood, anthropologist Marianne Gullestad underscores that Norway, in comparison to other nation-states, does not have a well-organized extremist and racist movement.6 Instead, there are more subtle forms of everyday discrimination that are institutionalized by state and everyday practices, in structured economic inequalities or in discursive resources available to a wide range of people.7 For example, take the use of the term innvandrer (immigrant). Quoting an earlier study conducted by Hernes and Knudsen that shows nine out of ten ethnic Norwegians use innvandrer to refer to people with dark skin, Gullestad contends that the term “immigrant” is racially coded.8 “Immigrant” does not simply denote anyone who has permanently moved to Norway...

Would you recommend screening colonoscopy for the very elderly?

Life expectancy in Korea has increased, and the number of screening colonoscopies in the elderly has also dramatically increased. The net benefit of colonoscopy in the very elderly (≥80 years of age as defined by the World Health Organization) may be reduced because of the competing risk of mortality due to other diseases. Therefore, the decision to perform screening colonoscopy may be more complex in this age group. As the potential increase in life expectancy due to screening colonoscopy is significantly reduced in the very elderly, this procedure should be limited to those among the very elderly who have substantial life expectancies. Furthermore, considering the common major complications associated with colonoscopy, poor bowel preparation, and the possibility of incomplete colonoscopies in the very elderly, the performance of screening colonoscopy in the very elderly may not be an ideal recommendation. In terms of providing the greatest benefit to the most number of people, patients with the highest potential gain in terms of life expectancy, relative to the diagnostic yield, should be targeted for colonoscopy screening. This review addresses the unique considerations regarding screening colonoscopy in the very elderly and the individualized approach, which involves the weighing of the risks and benefits for each individual with consideration of their overall health status.

Late-onset spinal motor neuronopathy – A common form of dominant SMA

We previously described two Finnish families with a new autosomal dominant late-onset spinal motor neuronopathy that was mapped to chromosome 22q11.2–q13.2. In the current screening study of 43 lower motor neuron disease patients from Finland and Sweden, we identified 26 new late-onset spinal motor neuronopathy patients sharing the founder haplotype. In addition to the main symptoms and signs: painful cramps, fasciculations, areflexia and slowly evolving muscle weakness, new features such as mild bulbar findings, were identified. The disease is relatively benign in terms of life expectancy and rate of disability progression, and it is therefore noteworthy that three patients were initially misdiagnosed with ALS. Significant recombinants in this new patient cohort restricted the disease locus by 90% to 1.8Mb. Late-onset spinal motor neuronopathy seems not to be very rare, at least not in Finland, with 38 patients identified in a preliminary ascertainment.

Conservative Management Vs. Allogeneic Hematopoietic Cell Transplantation For Polycythemia Vera: A Systematic Review and Decision-Analysis

BackgroundConservative treatment which typically includes phlebotomy or hydroxyurea or other cytoreductive therapy (plus aspirin) (ConsRxAsa) is effective treatment with acceptable complications for management of polycythemia Vera (PV) but is not considered curative [thus resulting in a shorter life expectancy (LE) in comparison to LE in the general population]. On the other hand, an allogeneic hematopoietic cell transplantation (allo-HCT) from a HLA compatible donor is considered a curative treatment option, but is potentially associated with high-risk of life-threatening complications. We sought to answer the question of which of these two treatment options results in better survival. MethodsBecause there are no direct randomized controlled trials (RCT) addressing the question if ConsRxAsa is superior to allo-HCT, we resorted to a decision-analysis to answer this question. We constructed a Markov model to represent and analyze the decision of ConsRxAsa vs. Allo-HCT. The results of the model were expressed in terms of life expectancy (LE) and survival probabilities. We performed a systematic review (and when possible a meta-analysis) to inform parameters in the model. ConsRxAsa arm was modeled by simulating the natural history of PV. For Allo-HCT arm, we adopted our previously published model (Biol Blood Marrow Transplant 2009;15:1415-21) but modified it to evaluate the effect of both conventional and reduced-intensity allo-HCT performed in chronic phase of PV. ResultsWe identified 165 relevant articles of which only 7 described testing various treatments for PV in RCTs. However, most data used to populate the decision model came from one RCT and one cohort study. Using base case of age of 45 years, we estimated a probability of survival at 10 and 20 years of 86% and 67% for ConsRxAsa versus 55% and 32% for allo-HCT (Fig). This translates into an average LE of 17.1 years for ConsRxAsa vs. 11.6 years for allo-HCT, respectively. Sensitivity analysis according to age, early transplant-related mortality, risk of bleeding or thrombosis did not affect the results. Adopting median age of 65 years and comparing reduced-intensity allo-HCT vs. ConsRxAsa, we found that the average LE was 8.6 years for allo-HCT vs. 12.5 in the conservative treatment arm. Again, conservative treatment remained superior under a wide range of assumptions. Conclusionsintegration of current best existing evidence into the decision model shows that conservative management of PV appears to provide a better survival compared to offering an allo-HCT in chronic phase of P. Vera. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Cost-Effectiveness Analysis of Intraoperative Radiation Therapy for Early-Stage Breast Cancer

Shortened courses of radiation therapy have been shown to be similarly effective to whole-breast external-beam radiation therapy (WB-EBRT) in terms of local control. We sought to analyze, from a societal perspective, the cost-effectiveness of two radiation strategies for early-stage invasive breast cancer: single-dose intraoperative radiation therapy (IORT) and the standard 6-week course of WB-EBRT. We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio over 10years. IORT single-dose intraoperative radiation therapy was the dominant, more cost-effective strategy, providing greater quality-adjusted life years at a decreased cost compared with 6-week WB-EBRT. The model was sensitive to health state utilities and recurrence rates, but not costs. IORT was either the preferred or dominant strategy across all sensitivity analyses. The two-way sensitivity analyses demonstrate the need to accurately determine utility values for the two forms of radiation treatment and to avoid indiscriminate use of IORT. With less cost and greater QALYs than WB-EBRT, IORT is the more valuable strategy. IORT offers a unique example of new technology that is less costly than the current standard of care option but offers similar efficacy. Even when considering the capital investment for the equipment ($425K, low when compared with the investments required for robotic surgery or high-dose-rate brachytherapy), which could be recouped after 3-4years conservatively, these results support IORT as a change in practice for treating early-stage invasive breast cancer.