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Quaife M, Medley GF, Jit M, Drake T, Asaria M, van Baal P, Baltussen R, Bollinger L, Bozzani F, Brady O, Broekhuizen H, Chalkidou K, Chi YL, Dowdy DW, Griffin S, Haghparast-Bidgoli H, Hallett T, Hauck K, Hollingsworth TD, McQuaid CF, Menzies NA, Merritt MW, Mirelman A, Morton A, Ruiz FJ, Siapka M, Skordis J, Tediosi F, Walker P, White RG, Winskill P, Vassall A, Gomez GB. Considering equity in priority setting using transmission models: Recommendations and data needs. Epidemics 2022; 41:100648. [PMID: 36343495 PMCID: PMC9623400 DOI: 10.1016/j.epidem.2022.100648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity. METHODS We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations. RESULTS We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration. CONCLUSIONS Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.
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Affiliation(s)
- M. Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - GF Medley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - M. Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - T. Drake
- Center for Global Development in Europe (CGD Europe), UK
| | - M. Asaria
- LSE Health, London School of Economics, UK
| | - P. van Baal
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands
| | - R. Baltussen
- Nijmegen International Center for Health Systems Research and Education, Radboudmc, the Netherlands
| | | | - F. Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - O. Brady
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - H. Broekhuizen
- Centre for Space, Place, and Society, Wageningen University and Research, Netherlands
| | - K. Chalkidou
- International Decision Support Initiative, Imperial College London, UK
| | - Y.-L. Chi
- International Decision Support Initiative, Imperial College London, UK
| | - DW Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, USA
| | - S. Griffin
- Centre for Health Economics, University of York, UK
| | - H. Haghparast-Bidgoli
- Institute for Global Health, Centre for Global Health Economics, University College London, UK
| | - T. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, UK
| | - K. Hauck
- Department of Infectious Disease Epidemiology, Imperial College London, UK
| | - TD Hollingsworth
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, UK
| | - CF McQuaid
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - NA Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, USA
| | - MW Merritt
- Johns Hopkins Berman Institute of Bioethics and Department of International Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - A. Mirelman
- Centre for Health Economics, University of York, UK
| | - A. Morton
- Department of Management Science, University of Strathclyde, UK
| | - FJ Ruiz
- International Decision Support Initiative, Imperial College London, UK
| | - M. Siapka
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK,Impact Elipsis, Greece
| | - J. Skordis
- Institute for Global Health, Centre for Global Health Economics, University College London, UK
| | - F. Tediosi
- Swiss Tropical and Public Health Institute and Universität Basel, Switzerland
| | - P. Walker
- Department of Infectious Disease Epidemiology, Imperial College London, UK
| | - RG White
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - P. Winskill
- Department of Infectious Disease Epidemiology, Imperial College London, UK
| | - A. Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK,Correspondence to: London School of Hygiene and Tropical Medicine, 15 – 17 Tavistock Place, London WC1H 9SH, UK
| | - GB Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
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Boniol M, Siyam A, Desai S, Gurung S, Mirelman A, Nair TS, Diallo K, Campbell J. Estimating the health workforce requirements and costing to reach 70% COVID-19 vaccination coverage by mid-2022: a modelling study and global estimates. BMJ Open 2022; 12:e063059. [PMID: 37574719 PMCID: PMC9361754 DOI: 10.1136/bmjopen-2022-063059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/07/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The implementation of COVID-19 vaccination globally poses unprecedented stress to health systems particularly for countries with persisting health workforce shortages prior the pandemic. The present paper estimates the workforce requirement to reach 70% COVID-19 vaccination coverage in all countries by mid-2022 using service target-based estimation. METHODS Health workforce data from National Health Workforce Accounts and vaccination coverage reported to WHO as of January 2022 were used. Workload parameters were used to estimate the number of health workers needed with a service target-based approach, the gap and the scale-up required partially accounting for countries' challenges, as well as the associated costs in human resources. RESULTS As of 1 January 2022, only 34 countries achieved 70% COVID-19 vaccination coverage and 61 countries covered less than a quarter of their population. This analysis showed that 1 831 000 health workers working full time would be needed to reach a global coverage of 70% COVID-19 vaccination by mid-2022. To avoid severe disruptions to health system, 744 000 additional health workers should be added to domestic resources mostly (77%) in low-income countries. In a sensitivity analysis, allowing for vaccination over 12 months instead of 6 months would decrease the scale-up to 476 000 health workers. The costing for the employment of these 744 000 additional health workers is estimated to be US$2.5 billion. In addition to such a massive scale-up, it is estimated that 29 countries would have needed to redeploy more than 20% of their domestic workforce, placing them at serious risk of not achieving the mid-year target. CONCLUSION Reaching 70% global coverage with COVID-19 vaccination by mid-2022 requires extraordinary efforts not before witnessed in the history of immunisation programmes. COVID-19 vaccination programmes should receive rapid and sustainable investment in health workforce.
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Affiliation(s)
- Mathieu Boniol
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - Amani Siyam
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - Shalini Desai
- Immunization, Vaccines & Biologicals Department, World Health Organization, Geneva, Switzerland
| | - Santosh Gurung
- Immunization, Vaccines & Biologicals Department, World Health Organization, Geneva, Switzerland
| | - Andrew Mirelman
- Health System Governance and Financing Department, World Health Organization, Geneva, Switzerland
| | | | - Khassoum Diallo
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - James Campbell
- Health Workforce Department, World Health Organization, Geneva, Switzerland
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Assad M, Galperin I, Giladi N, Mirelman A, Hausdorff JM, Maidan I. Disease severity and prefrontal cortex activation during obstacle negotiation among patients with Parkinson's disease: Is it all as expected? Parkinsonism Relat Disord 2022; 101:20-26. [PMID: 35759913 DOI: 10.1016/j.parkreldis.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/09/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous reports indicate that patients with Parkinson's disease (PD) activate the prefrontal cortex (PFC) during complex activities such as obstacle negotiation to compensate for impaired motor function. However, the influence of disease severity on PFC activation has not been systematically evaluated. Here, we examined the effects of disease severity on PFC activation during obstacle negotiation. METHODS 74 patients with PD (age 68.26 ± 7.54 yrs; 62.2% men) were divided into three groups based on Hoehn and Yahr stages. All patients walked along an obstacle course while negotiating anticipated and unanticipated obstacles (long/low available response time) at heights of 50 mm and 100 mm. PFC activation was measured using functional near-infrared spectroscopy (fNIRS) and was compared between groups and tasks using mixed model analyses. RESULTS Participants with more advanced PD (i.e., Hoehn & Yahr 3) had higher PFC activation levels when negotiating anticipated obstacles, compared to participants with milder PD (i.e., Hoehn & Yahr 1, 2) (p < 0.001). Moreover, higher LEDD correlated with higher prefrontal activation during the higher anticipated obstacle. In contrast, during the negotiation of unanticipated obstacles, the differences in PFC activation were not associated with disease severity in a linear manner. CONCLUSIONS The present study suggests that with increased disease severity, patients with PD rely more on the PFC when negotiating anticipated obstacles, perhaps to compensate for attention and motor deficits. These findings support the role of cognition in fall risk and the need to improve attention and cognition in fall prevention programs, especially among patients with more advanced disease.
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Affiliation(s)
- M Assad
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - I Galperin
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - N Giladi
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - A Mirelman
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - J M Hausdorff
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel; Rush Alzheimer's Disease Center and Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - I Maidan
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
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Kreif N, Mirelman A, Suhrcke M, Buitrago G, Moreno-Serra R. The impact of civil conflict on child health: Evidence from Colombia. Econ Hum Biol 2022; 44:101074. [PMID: 34839051 DOI: 10.1016/j.ehb.2021.101074] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 06/28/2021] [Accepted: 10/20/2021] [Indexed: 05/24/2023]
Abstract
Internal armed conflicts have become more common and more physically destructive since the mid-20th century, with devastating consequences for health and development in low- and middle-income countries. This paper investigates the causal impacts of the long-term internal conflict on child health in Colombia, following an identification strategy based on the temporal and geographic variation of conflict intensity. We estimate the effect of different levels of conflict intensity on height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height z-scores among children under five years old, and explore the underlying potential mechanisms, through maternal health behavior and health care utilization. We find a harmful effect of exposure to conflict violence in utero and in early childhood for HAZ and WAZ, in the full sample and even more strongly in the rural sample, yet these estimates are smaller than those found for shorter term conflicts. The underlying pathways appear to operate around the time of the pregnancy and birth (in the form of maternal alcohol use, use of antenatal care and skilled birth attendance), rather than during the post-birth period (via breastfeeding or vaccination), and the impacts accumulate over the childhood. The most adverse impacts of conflict violence on child health and utilization of maternal healthcare were observed in municipalities which suffered from intermittent presence of armed groups.
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Affiliation(s)
- Noémi Kreif
- Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK.
| | - Andrew Mirelman
- Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK; Luxembourg Institute of Socio-economic Research, 11 Porte des Sciences, 4366 Esch-sur-Alzette, Luxembourg
| | - Giancarlo Buitrago
- Clinical Research Institute, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogota, DC, Colombia
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Love-Koh J, Mirelman A, Suhrcke M. Equity and economic evaluation of system-level health interventions: A case study of Brazil's Family Health Program. Health Policy Plan 2021; 36:229-238. [PMID: 33386400 DOI: 10.1093/heapol/czaa181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 11/14/2022] Open
Abstract
Distributional economic evaluation estimates the value for money of health interventions in terms of population health and health equity impacts. When applied to interventions delivered at the population and health system-level interventions (PSIs) instead of clinical interventions, additional practical and methodological challenges arise. Using the example of the Programme Saúde da Familia (PSF) in Brazil, a community-level primary care system intervention, we seek to illustrate these challenges and provide potential solutions. We use a distributional cost-effectiveness analysis (DCEA) approach to evaluate the impact of the PSF on population health and between-state health inequalities in Brazil. Data on baseline health status, disease prevalence and PSF effectiveness are extracted from the literature and incorporated into a Markov model to estimate the long-term impacts in terms of disability-adjusted life years. The inequality and average health impacts are analysed simultaneously using health-related social welfare functions. Uncertainty is computed using Monte Carlo simulation. The DCEA encountered several challenges in the context of PSIs. Non-randomized, quasi-experimental methods may not be powered to identify treatment effect heterogeneity estimates to inform a decision model. PSIs are more likely to be funded from multiple public sector budgets, complicating the calculation of health opportunity costs. We estimate a cost-per-disability-adjusted life years of funding the PSF of $2640. Net benefits were positive across the likely range of intervention cost. Social welfare analysis indicates that, compared to gains in average health, changes in health inequalities accounted for a small proportion of the total welfare improvement, even at high levels of social inequality aversion. Evidence on the population health and health equity impacts of PSIs can be incorporated into economic evaluation methods, although with additional complexity and assumptions. The case study results indicate that the PSF is likely to be cost-effective but that the inequality impacts are small and highly uncertain.
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Affiliation(s)
- James Love-Koh
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK
| | - Andrew Mirelman
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK.,Health Systems Governance and Financing, Universal Health Coverage and Life Course, WHO, Geneva, Switzerland
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK.,Luxembourg Institute of Socio-Economic Research 11, Porte des Sciences L-4366 Esch-sur-Alzette Luxemburg
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6
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Stacey N, Mirelman A, Kreif N, Suhrcke M, Hofman K, Edoka I. Facility standards and the quality of public sector primary care: Evidence from South Africa's "Ideal Clinics" program. Health Econ 2021; 30:1543-1558. [PMID: 33728741 DOI: 10.1002/hec.4228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Primary healthcare systems are central to achieving universal healthcare coverage. However, in many low- and middle-income country settings, primary care quality is challenged by inadequate facility infrastructure and equipment, limited human resources, and poor provider process. We study the effects of a recent large-scale quality improvement policy in South Africa, the Ideal Clinics Realization and Maintenance Program (ICRMP). The ICRMP introduced a set of standards for facilities and a quality improvement process involving manuals, district-based support, and external assessment. Exploiting differential prioritization of facilities for the ICRMP's quality improvement process, we apply differences-in-differences methods to identify the effects of the program's efforts on standards scores and primary care quality indicators over the first 12 months of implementation. We find large and statistically significant increases in standards scores, but mixed effects on care outcomes-a small magnitude improvement in early antenatal care usage, null effects on childhood immunization and cervical cancer screening, and small negative effect of human immunodeficiency virus (HIV) care. While the ICRMP process has led to significant improvements in facilities' satisfaction of the program's standards, we were unable to detect meaningful change in care quality indicators.
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Affiliation(s)
- Nicholas Stacey
- Department of Health Policy, London School of Economics and Political Science, London, UK
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Noemi Kreif
- Centre for Health Economics, University of York, York, UK
| | - Marc Suhrcke
- Centre for Health Economics, University of York, York, UK
- Luxembourg Institute of Socio-economic Research, Luxembourg
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ijeoma Edoka
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Tan-Torres Edejer T, Hanssen O, Mirelman A, Verboom P, Lolong G, Watson OJ, Boulanger LL, Soucat A. Projected health-care resource needs for an effective response to COVID-19 in 73 low-income and middle-income countries: a modelling study. Lancet Glob Health 2020; 8:e1372-e1379. [PMID: 32918872 PMCID: PMC7480983 DOI: 10.1016/s2214-109x(20)30383-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Since WHO declared the COVID-19 pandemic a Public Health Emergency of International Concern, more than 20 million cases have been reported, as of Aug 24, 2020. This study aimed to identify what the additional health-care costs of a strategic preparedness and response plan (SPRP) would be if current transmission levels are maintained in a status quo scenario, or under scenarios where transmission is increased or decreased by 50%. METHODS The number of COVID-19 cases was projected for 73 low-income and middle-income countries for each of the three scenarios for both 4-week and 12-week timeframes, starting from June 26, 2020. An input-based approach was used to estimate the additional health-care costs associated with human resources, commodities, and capital inputs that would be accrued in implementing the SPRP. FINDINGS The total cost estimate for the COVID-19 response in the status quo scenario was US$52·45 billion over 4 weeks, at $8·60 per capita. For the decreased or increased transmission scenarios, the totals were $33·08 billion and $61·92 billion, respectively. Costs would triple under the status quo and increased transmission scenarios at 12 weeks. The costs of the decreased transmission scenario over 12 weeks was equivalent to the cost of the status quo scenario at 4 weeks. By percentage of the overall cost, case management (54%), maintaining essential services (21%), rapid response and case investigation (14%), and infection prevention and control (9%) were the main cost drivers. INTERPRETATION The sizeable costs of a COVID-19 response in the health sector will escalate, particularly if transmission increases. Instituting early and comprehensive measures to limit the further spread of the virus will conserve resources and sustain the response. FUNDING WHO, and UK Foreign Commonwealth and Development Office.
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Affiliation(s)
- Tessa Tan-Torres Edejer
- Health Systems Governance and Financing, Universal Health Coverage and Life Course, WHO, Geneva, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel Switzerland.
| | | | - Andrew Mirelman
- Health Systems Governance and Financing, Universal Health Coverage and Life Course, WHO, Geneva, Switzerland
| | | | - Glenn Lolong
- Health Emergencies Preparedness and Response, WHO, Geneva, Switzerland
| | - Oliver John Watson
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | - Agnès Soucat
- Health Systems Governance and Financing, Universal Health Coverage and Life Course, WHO, Geneva, Switzerland
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Sharon T, Kurz I, Bernad-Elazari H, Shustak S, Galperin I, Giladi N, Mirelman A, Hausdorff JM, Maidan I. Which obstacle attributes place additional demands on higher-level cognitive function in patients with Parkinson's disease? Parkinsonism Relat Disord 2020; 78:178-183. [PMID: 32927415 DOI: 10.1016/j.parkreldis.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 06/11/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous reports show that patients with Parkinson's disease (PD) rely on prefrontal activation to compensate for impaired motor function during complex activities such as obstacle negotiation. However, the influence of the properties of the obstacles on prefrontal activation has not been systematically evaluated. Here, we examined the effects of obstacle height and anticipation time on prefrontal activation in patients with PD and older adults. METHODS 34 patients with PD (age: 67.4 ± 5.7 years; 14 women) and 26 older adults (age: 71.3 ± 8.9 years; 11 women) walked in an obstacle course while negotiating anticipated and unanticipated obstacles (long/short available time response, ART) at heights of 50 mm and 100 mm. Prefrontal activation was measured using functional Near-Infrared Spectroscopy (fNIRS); obstacle negotiation performance was measured using Kinect cameras. RESULTS PD patients showed greater increases in prefrontal activation during and after obstacle crossing compared to the older adults (p < 0.001). Obstacle height affected prefrontal activity only when crossing anticipated obstacles (ARTxheight interaction, p = 0.011), in which case higher obstacles were accompanied by higher prefrontal activity. PD patients showed higher levels of activation during unanticipated obstacles, compared to older adults (groupXART: p = 0.015). Different correlations between prefrontal activation and obstacle negotiation strategies were observed in patients and controls. CONCLUSIONS These results point to the use of prefrontal activation as a compensatory mechanism in PD. Moreover, the higher activation observed when negotiating more challenging obstacles suggests that there is greater reliance on cognitive resources in these demanding situations that may contribute to the higher risk of falls in PD patients.
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Affiliation(s)
- T Sharon
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - I Kurz
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - H Bernad-Elazari
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel
| | - S Shustak
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel
| | - I Galperin
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel
| | - N Giladi
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - A Mirelman
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - J M Hausdorff
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Rush Alzheimer's Disease Center and Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - I Maidan
- Laboratory of Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
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9
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Hsieh KL, Mirelman A, Shema-Shiratzky S, Galperin I, Regev K, Shen S, Schmitz-Hübsch T, Karni A, Paul F, Devos H, Sosnoff JJ, Hausdorff JM. A multi-modal virtual reality treadmill intervention for enhancing mobility and cognitive function in people with multiple sclerosis: Protocol for a randomized controlled trial. Contemp Clin Trials 2020; 97:106122. [PMID: 32858229 DOI: 10.1016/j.cct.2020.106122] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/25/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gait and cognitive impairments are common in individuals with Multiple Sclerosis (MS) and can interfere with everyday function. Those with MS have difficulties executing cognitive tasks and walking simultaneously, a reflection of dual-task interference. Therefore, dual-task training may improve functional ambulation. Additionally, using technology such as virtual reality can provide personalized rehabilitation while mimicking real-world environments. The purpose of this randomized controlled trial is to establish the benefits of a combined cognitive-motor virtual reality training on MS symptoms compared to conventional treadmill training. METHODS This study will be a single-blinded, two arm RCT with a six-week intervention period. 144 people with MS will be randomized into a treadmill training alone group or treadmill training with virtual reality group. Both groups will receive 18 sessions of training while walking on a treadmill, with the virtual reality group receiving feedback from the virtual system. Primary outcome measures include dual-task gait speed and information processing speed, which will be measured prior to training, one-week post-training, and three months following training. DISCUSSION This study will provide insight into the ability of a multi-modal cognitive-motor intervention to reduce dual-task cost and to enhance information processing speed in those with MS. This is one of the first studies that is powered to understand whether targeted dual-task training can improve MS symptoms and increase functional ambulation. We anticipate that those in the virtual reality group will have a significantly greater increase in dual-task gait speed and information processing speed than those achieved via treadmill training alone.
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Affiliation(s)
- K L Hsieh
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA; Illinois Multiple Sclerosis Research Collaborative, Interdisciplinary Health Science Institute, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - A Mirelman
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Shema-Shiratzky
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - I Galperin
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - K Regev
- Neuroimmunology and Multiple Sclerosis Unit of the Neurology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - S Shen
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - T Schmitz-Hübsch
- NeuroCure, Charité - Universitaetsmedizin Berlin, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - A Karni
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Neuroimmunology and Multiple Sclerosis Unit of the Neurology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - F Paul
- NeuroCure, Charité - Universitaetsmedizin Berlin, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitaetsmedizin Berlin, Berlin, Germany; Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - H Devos
- Laboratory for Advanced Rehabilitation Research in Simulation, Department of Physical Therapy and Rehabilitation Science, School of Health Professions, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - J J Sosnoff
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA; Illinois Multiple Sclerosis Research Collaborative, Interdisciplinary Health Science Institute, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - J M Hausdorff
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Rush Alzheimer's Disease Center and Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Garcia MM, Azevedo PS, Mirelman A, Safatle LP, Iunes R, Bennie MC, Godman B, Guerra Junior AA. Funding and Service Organization to Achieve Universal Health Coverage for Medicines: An Economic Evaluation of the Best Investment and Service Organization for the Brazilian Scenario. Front Pharmacol 2020; 11:370. [PMID: 32351382 PMCID: PMC7175689 DOI: 10.3389/fphar.2020.00370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/11/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There are many health benefits since 31 years after the foundation of the National Health Service (NHS) in Brazil, especially the increase in life expectancy. However, family-income inequalities, insufficient funding, and suboptimal private sector-public sector collaboration are still areas for improvement. The efforts of Brazil to achieve universal health coverage (UHC) for medicines have resulted in increased public financing of medicines and their availability, reducing avoidable hospitalization and mortality. However, lack of access to medicines still remains. Due to historical reasons, pharmaceutical service organization in developing countries may have important differences from high-income countries. In some cases, developing countries finance and promote medicine access by using the public infrastructure of health care/medical units as dispensing sites and cover all costs of medicines dispensed. In contrast, many high-income countries use private community pharmacies and cover the costs of medicines dispensed plus a fee, which includes all logistic costs. In this study, we will undertake an economic evaluation to understand the funding needs of the Brazilian NHS to reduce inequalities in access to medicines through adopting a pharmaceutical service organization similar to that seen in many high-income countries with hiring/accrediting private pharmacies. METHODS We performed an economic evaluation of a model to provide access to medicines within public funds based on a decision tree model with two alternative scenarios public pharmacies (NHS, state-owned facilities) versus private pharmacies (NHS, agreements). The analysis assumed the perspective of the NHS. We identified the types of resources consumed, the amount, and costs in both scenarios. We also performed a budget impact forecast to estimate the incremental funding required to reduce inequalities in access to essential medicines in Brazil. FINDINGS The model without rebates for medicines estimated an incremental cost of US$3.1 billion in purchasing power parity (PPP) but with an increase in the average availability of medicines from 65% to 90% for citizens across the country irrespective of family income. This amount places the NHS in a very good position to negotiate extensive rebates without the need for external reference pricing for government purchases. Forecast scenarios above 35% rebates place the alternative of hiring private pharmacies as dominant. Higher rebate rates are feasible and may lead to savings of more than US$1.3 billion per year (30%). The impact of incremental funding is related to medicine access improvement of 25% in the second year when paying by dispensing fee. The estimate of the incremental budget in five years would be US$4.8 billion PPP. We have yet to explore the potential reduction in hospital and outpatient costs, as well as in lawsuits, with increased availability with the yearly expenses for these at US$9 billion and US$1.4 billion PPP respectively in 2017. INTERPRETATION The results of the economic evaluation demonstrate potential savings for the NHS and society. Achieving UHC for medicines reduces household expenses with health costs, health litigation, outpatient care, hospitalization, and mortality. An optimal private sector-public sector collaboration model with private community pharmacy accreditation is economically dominant with a feasible medicine price negotiation. The results show the potential to improve access to medicines by 25% for all income classes. This is most beneficial to the poorest families, whose medicines account for 76% of their total health expenses, with potential savings of lives and public resources.
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Affiliation(s)
- Marina Morgado Garcia
- Department of Social Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Collaborating Centre for Health Technology Assessment and Excellence (CCATES), Belo Horizonte, Brazil
| | - Pamela Santos Azevedo
- Department of Social Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Collaborating Centre for Health Technology Assessment and Excellence (CCATES), Belo Horizonte, Brazil
| | - Andrew Mirelman
- Centre for Health Economics, University of York, York, United Kingdom
| | - Leandro Pinheiro Safatle
- Department of Medicines Market Regulation - Brazilian Health Regulatory Agency (ANVISA), Brasília, Brazil
| | | | - Marion Clark Bennie
- Department of Pharmacoepidemiology, University of Strathclyde, Glasgow, United Kingdom
| | - Brian Godman
- Department of Pharmacoepidemiology, University of Strathclyde, Glasgow, United Kingdom
- Management School, University of Liverpool, Liverpool, United Kingdom
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Augusto Afonso Guerra Junior
- Department of Social Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Collaborating Centre for Health Technology Assessment and Excellence (CCATES), Belo Horizonte, Brazil
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11
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Baltussen R, Marsh K, Thokala P, Diaby V, Castro H, Cleemput I, Garau M, Iskrov G, Olyaeemanesh A, Mirelman A, Mobinizadeh M, Morton A, Tringali M, van Til J, Valentim J, Wagner M, Youngkong S, Zah V, Toll A, Jansen M, Bijlmakers L, Oortwijn W, Broekhuizen H. Multicriteria Decision Analysis to Support Health Technology Assessment Agencies: Benefits, Limitations, and the Way Forward. Value Health 2019; 22:1283-1288. [PMID: 31708065 DOI: 10.1016/j.jval.2019.06.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Recent years have witnessed an increased interest in the use of multicriteria decision analysis (MCDA) to support health technology assessment (HTA) agencies for setting healthcare priorities. However, its implementation to date has been criticized for being "entirely mechanistic," ignoring opportunity costs, and not following best practice guidelines. This article provides guidance on the use of MCDA in this context. METHODS The present study was based on a systematic review and consensus development. We developed a typology of MCDA studies and good implementation practice. We reviewed 36 studies over the period 1990 to 2018 on their compliance with good practice and developed recommendations. We reached consensus among authors over the course of several review rounds. RESULTS We identified 3 MCDA study types: qualitative MCDA, quantitative MCDA, and MCDA with decision rules. The types perform differently in terms of quality, consistency, and transparency of recommendations on healthcare priorities. We advise HTA agencies to always include a deliberative component. Agencies should, at a minimum, undertake qualitative MCDA. The use of quantitative MCDA has additional benefits but also poses design challenges. MCDA with decision rules, used by HTA agencies in The Netherlands and the United Kingdom and typically referred to as structured deliberation, has the potential to further improve the formulation of recommendations but has not yet been subjected to broad experimentation and evaluation. CONCLUSION MCDA holds large potential to support HTA agencies in setting healthcare priorities, but its implementation needs to be improved.
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Affiliation(s)
- Rob Baltussen
- Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | | | - Vakaramoko Diaby
- Florida Agricultural and Mechanical University, Tallahassee, FL, USA
| | | | | | | | - Georgi Iskrov
- Medical University of Plovdiv, Plovdiv, Bulgaria; Institute for Rare Diseases, Plovdiv, Bulgaria
| | | | | | | | - Alec Morton
- University of Strathclyde, Glasgow, Scotland
| | | | | | | | | | | | | | - Agnes Toll
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten Jansen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leon Bijlmakers
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wija Oortwijn
- Radboud University Medical Center, Nijmegen, The Netherlands
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12
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Maidan I, Patashov D, Shustak S, Fahoum F, Gazit E, Shapiro B, Levy A, Sosnik R, Giladi N, Hausdorff JM, Mirelman A. A new approach to quantifying the EEG during walking: Initial evidence of gait related potentials and their changes with aging and dual tasking. Exp Gerontol 2019; 126:110709. [PMID: 31449852 DOI: 10.1016/j.exger.2019.110709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND The electroencephalogram (EEG) can be a useful tool to investigate the neurophysiology of gait during walking. Our aims were to develop an approach that identify and quantify event related potentials (ERPs) during a gait cycle and to examine the effects of aging and dual tasking on these gait related potentials (GRPs). METHODS 10 young and 10 older adults walked on a treadmill while wearing a wireless 20-channels EEG and accelerometers on the ankles. Each heel strike extracted from the accelerometers was used as an event to which the electrical brain activity pattern was locked. The subjects performed usual and dual task walking that included an auditory oddball task. GRPs amplitude and latency were computed, and a new measure referred to as Amplitude Pattern Consistency (APC) was developed to quantify the consistency of these GRP amplitudes within a gait cycle. The results were compared between and within groups using linear mixed model analysis. RESULTS The electrical pattern during a gait cycle consisted of two main positive GRPs. Differences in these GRPs between young and older adults were observed in Pz and Cz. In Pz, older adults had higher GRPs amplitude (p = 0.006, p = 0.010), and in Cz lower APC (p = 0.025). Alterations were also observed between the walking tasks. Both groups showed shorter latency during oddball walking compared to usual walking in Cz (p = 0.040). In addition, the APC in Cz was correlated with gait speed (r = 0.599, p = 0.011) in all subjects and with stride time variability in the older adults (r = -0.703, p = 0.023). CONCLUSIONS This study is the first to define specific gait related potentials within a gait cycle using novel methods for quantifying waveforms. Our findings show the potential of this approach to be applied broadly to study the EEG during gait in a variety of contexts. The observed changes in GRPs with aging and walking task and the relationship between GRPs and gait may suggest the neurophysiologic foundation for studying walking and for developing new approaches for improving gait.
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Affiliation(s)
- I Maidan
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
| | - D Patashov
- Faculty of Engineering, Holon Institute of Technology, Holon, Israel; Faculty of Sciences, Holon Institute of Technology, Holon, Israel
| | - S Shustak
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - F Fahoum
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - E Gazit
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - B Shapiro
- Faculty of Engineering, Holon Institute of Technology, Holon, Israel
| | - A Levy
- Faculty of Engineering, Holon Institute of Technology, Holon, Israel
| | - R Sosnik
- Faculty of Engineering, Holon Institute of Technology, Holon, Israel
| | - N Giladi
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - J M Hausdorff
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Rush Alzheimer's Disease Center and Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - A Mirelman
- Laboratory for Early Markers of Neurodegeneration, Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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13
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Hausdorff J, Geffen N, Gazit E, Dawe R, Mirelman A, Curran T, Buchman A. THINKING ABOUT WALKING: A NEW APPROACH TO QUANTIFYING GAIT INITIATION USING A WEARABLE SENSOR. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - N Geffen
- Tel Aviv Sourasky Medical Center
| | - E Gazit
- Tel Aviv Sourasky Medical Center
| | - R Dawe
- Rush University Medical Center, Chicago, IL USA
| | - A Mirelman
- Tel Aviv Medical Center, Tel Aviv University
| | - T Curran
- Rush University Medical Center, Chicago, IL USA
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14
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Maidan I, Eyal S, Kurz I, Geffen N, Gazit E, Ravid L, Giladi N, Mirelman A, Hausdorff JM. Age-associated changes in obstacle negotiation strategies: Does size and timing matter? Gait Posture 2018; 59:242-247. [PMID: 29096267 DOI: 10.1016/j.gaitpost.2017.10.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/24/2017] [Accepted: 10/21/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Tripping over an obstacle is one of the most common causes of falls among older adults. However, the effects of aging, obstacle height and anticipation time on negotiation strategies have not been systematically evaluated. METHODS Twenty older adults (ages: 77.7±3.4years; 50% women) and twenty young adults (age: 29.3±3.8years; 50% women) walked through an obstacle course while negotiating anticipated and unanticipated obstacles at heights of 25mm and 75mm. Kinect cameras captured the: (1) distance of the subject's trailing foot before the obstacles, (2) distance of the leading foot after the obstacles, (3) clearance of the leading foot above the obstacles, and (4) clearance of the trailing foot above the obstacles. Linear-mix models assessed changes between groups and conditions. RESULTS Older adults placed their leading foot closer to the obstacle after landing, compared to young adults (p<0.001). This pattern was enhanced in high obstacles (group*height interaction, p=0.033). Older adults had lower clearance over the obstacles, compared to young adults (p=0.007). This was more pronounced during unanticipated obstacles (group*ART interaction, p=0.003). The distance of the leading foot and clearance of the trailing foot after the obstacles were correlated with motor, cognitive, and functional abilities. CONCLUSIONS These findings suggest that there are age-related changes in obstacle crossing strategies that are dependent on the specific characteristics of the obstacle. The results have important implications for clinical practice, suggesting that functional exercise should include obstacle negotiation training with variable practice of height and available response times. Further studies are needed to better understand the effects of motor and cognitive abilities.
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Affiliation(s)
- I Maidan
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel.
| | - S Eyal
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - I Kurz
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel; Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - N Geffen
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel
| | - E Gazit
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel
| | - L Ravid
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel
| | - N Giladi
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel; Sagol School of Neuroscience, Tel Aviv University, Israel; Sieratzki Chair in Neurology Tel Aviv University, Israel; Department of Neurology and Neurosurgery, Sackler School of Medicine, Tel Aviv University, Israel
| | - A Mirelman
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel; Sagol School of Neuroscience, Tel Aviv University, Israel; Department of Neurology and Neurosurgery, Sackler School of Medicine, Tel Aviv University, Israel; Laboratory of Early Markers of Neurodegeneration; Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - J M Hausdorff
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel; Sagol School of Neuroscience, Tel Aviv University, Israel; Rush Alzheimer's Disease Center and Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
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15
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Eyal S, Kurz I, Mirelman A, Maidan I, Giladi N, Hausdorff J. AGE-ASSOCIATED FACTORS CONTRIBUTING TO OBSTACLE NEGOTIATION ABILITIES: NOT ALL IS AS EXPECTED. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S. Eyal
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
| | - I. Kurz
- Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel,
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
| | - A. Mirelman
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
- Department of Neurology, Tel Aviv University, Tel Aviv, Israel
| | - I. Maidan
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
| | - N. Giladi
- Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
- Department of Neurology, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel,
| | - J.M. Hausdorff
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel,
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Mirelman A, Rochester L, Olde Rikkert M, Bloem B, Giladi N, Nieuwboer A, Hausdorff J. TREADMILL TRAINING WITH VIRTUAL REALITY TO REDUCE FALLS AMONG OLDER ADULTS: RCT RESULTS. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.5026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A. Mirelman
- Center for the study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
- Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - L. Rochester
- Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom,
| | - M. Olde Rikkert
- Department of Geriatric Medicine and Neurology, Radboud University Medical Center; Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands,
- Radboud umc Alzheimer Centre, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands,
| | - B.R. Bloem
- Department of Geriatric Medicine and Neurology, Radboud University Medical Center; Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands,
- Radboud umc Alzheimer Centre, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands,
| | - N. Giladi
- Center for the study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
- Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel,
| | - A. Nieuwboer
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - J.M. Hausdorff
- Center for the study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel,
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
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Hausdorff J, Maidan I, Mirelman A. GAIT AND COGNITIVE IMPAIRMENT SHARE COMMON MECHANISMS. BRAIN FUNCTIONAL (FNIRS) STUDIES. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.3664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J.M. Hausdorff
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
- Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel,
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel,
| | - I. Maidan
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel,
| | - A. Mirelman
- Center for the Study of Movement, Cognition, and Mobility, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel,
- Department of Neurology, Tel Aviv University, Tel-Aviv, Israel
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Ozawa S, Clark S, Portnoy A, Grewal S, Stack ML, Sinha A, Mirelman A, Franklin H, Friberg IK, Tam Y, Walker N, Clark A, Ferrari M, Suraratdecha C, Sweet S, Goldie SJ, Garske T, Li M, Hansen PM, Johnson HL, Walker D. Estimated economic impact of vaccinations in 73 low- and middle-income countries, 2001-2020. Bull World Health Organ 2017; 95:629-638. [PMID: 28867843 PMCID: PMC5578376 DOI: 10.2471/blt.16.178475] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 05/31/2017] [Accepted: 06/02/2017] [Indexed: 12/30/2022] Open
Abstract
Objective To estimate the economic impact likely to be achieved by efforts to vaccinate against 10 vaccine-preventable diseases between 2001 and 2020 in 73 low- and middle-income countries largely supported by Gavi, the Vaccine Alliance. Methods We used health impact models to estimate the economic impact of achieving forecasted coverages for vaccination against Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, rotavirus, rubella, Streptococcus pneumoniae and yellow fever. In comparison with no vaccination, we modelled the costs – expressed in 2010 United States dollars (US$) – of averted treatment, transportation costs, productivity losses of caregivers and productivity losses due to disability and death. We used the value-of-a-life-year method to estimate the broader economic and social value of living longer, in better health, as a result of immunization. Findings We estimated that, in the 73 countries, vaccinations given between 2001 and 2020 will avert over 20 million deaths and save US$ 350 billion in cost of illness. The deaths and disability prevented by vaccinations given during the two decades will result in estimated lifelong productivity gains totalling US$ 330 billion and US$ 9 billion, respectively. Over the lifetimes of the vaccinated cohorts, the same vaccinations will save an estimated US$ 5 billion in treatment costs. The broader economic and social value of these vaccinations is estimated at US$ 820 billion. Conclusion By preventing significant costs and potentially increasing economic productivity among some of the world’s poorest countries, the impact of immunization goes well beyond health.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB # 7574, Beard Hall 115H, Chapel Hill, North Carolina, 27599, United States of America (USA)
| | - Samantha Clark
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Allison Portnoy
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA
| | - Simrun Grewal
- Department of Pharmacy, University of Washington, Seattle, USA
| | | | - Anushua Sinha
- Department of Preventive Medicine and Community Health, Rutgers New Jersey Medical School, Newark, USA
| | - Andrew Mirelman
- Centre for Health Economics, University of York, York, England
| | - Heather Franklin
- Department of Preventive Medicine and Community Health, Rutgers New Jersey Medical School, Newark, USA
| | - Ingrid K Friberg
- Department of Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Yvonne Tam
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Andrew Clark
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, England
| | - Matthew Ferrari
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, USA
| | | | - Steven Sweet
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, USA
| | - Sue J Goldie
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, USA
| | - Tini Garske
- MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, England
| | - Michelle Li
- Gavi, the Vaccine Alliance, Geneva, Switzerland
| | - Peter M Hansen
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
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Mirelman A. Economic evaluation of diabetes prevention: informing global health implementation decisions. Lancet Diabetes Endocrinol 2016; 4:879-880. [PMID: 27717765 DOI: 10.1016/s2213-8587(16)30289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 11/21/2022]
Affiliation(s)
- Andrew Mirelman
- Centre for Health Economics, University of York, York YO10 5DD, UK.
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Maidan I, Rosenberg-Katz K, Jacob Y, Giladi N, Deutsch JE, Hausdorff JM, Mirelman A. Altered brain activation in complex walking conditions in patients with Parkinson's disease. Parkinsonism Relat Disord 2016; 25:91-6. [PMID: 26861167 DOI: 10.1016/j.parkreldis.2016.01.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Behavioral studies suggest that deficits in cognitive domains and sensory-motor processes associated with Parkinson's disease (PD) impair the ability to walk in complex environments. However, the neural correlates of locomotion in complex environments are still unclear. METHODS Twenty healthy older adults (mean age 69.7 ± 1.3 yrs) and 20 patients with PD (mean age 72.9 ± 1.6 yrs; disease duration: 6.8 ± 1.3 yrs; UPDRSIII: 29.8 ± 2.4) were asked to imagine themselves walking while in the MRI scanner. Three imagined walking tasks, i.e., usual walking, obstacle negotiation, and navigation were performed. Watching the same virtual scenes without imagining walking served as control tasks. Whole brain analyses were used. RESULTS Compared to usual walking, both groups had increased activation during obstacle negotiation in middle occipital gyrus (MOG) (pFWEcorr<0.001), middle frontal gyrus (MFG) (pFWEcorr<0.005), and cerebellum (pFWEcorr<0.001). Healthy older adults had higher activation in precuneus and MOG (pFWEcorr<0.023) during navigation, while no differences were observed in patients with PD. Between group comparisons revealed that patients with PD had a significantly higher activation in usual walking and obstacle negotiation (pFWEcorr<0.039) while during navigation task, healthy older adults had higher activation (pFWEcorr<0.047). CONCLUSIONS Patients with PD require greater activation during imagined usual walking and obstacle negotiation than healthy older adults. This increased activation may reflect a compensatory attempt to overcome inefficient neural activation in patients with PD. This increased activation may reduce the functional reserve needed during more demanding tasks such as during navigation which may contribute to the high prevalence of falls and dual tasking difficulties among patients with PD.
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Affiliation(s)
- I Maidan
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; Rivers Lab, Department of Rehabilitation and Movement Science, Rutgers Biomedical and Health Sciences, Newark, USA
| | - K Rosenberg-Katz
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Y Jacob
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - N Giladi
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - J E Deutsch
- Rivers Lab, Department of Rehabilitation and Movement Science, Rutgers Biomedical and Health Sciences, Newark, USA
| | - J M Hausdorff
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - A Mirelman
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Israel.
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Gan-Or Z, Amshalom I, Bar-Shira A, Gana-Weisz M, Mirelman A, Marder K, Bressman S, Giladi N, Orr-Urtreger A. The Alzheimer disease BIN1 locus as a modifier of GBA-associated Parkinson disease. J Neurol 2015; 262:2443-7. [PMID: 26233692 DOI: 10.1007/s00415-015-7868-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/28/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
GBA mutations are among the most common genetic risk factors for Parkinson disease (PD) worldwide. We aimed to identify genetic modifiers of the age at onset (AAO) in GBA-associated PD. The study included a genome-wide discovery phase, including a cohort of 79 patients with the GBA p.N370S mutation, and candidate validation and replication analyses of 8 SNPs in patients with mild (n = 113) and severe (n = 41) GBA mutations. Genotyping was performed using the Affymetrix human SNP 6.0 array and TaqMan assays. In the genome-wide phase, none of the SNPs passed the genome-wide significance threshold. Eight SNPs were selected for further analysis from the top hits. In all GBA-associated PD patients (n = 153), the BIN1 rs13403026 minor allele was associated with an older AAO (12.4 ± 5.9 years later, p = 0.0001), compared to patients homozygous for the major allele. Furthermore, the AAO was 10.7 ± 6.8 years later in patients with mild GBA mutations, (p = 0.005, validation group), and 17.1 ± 2.5 years later in patients with severe GBA mutations (p = 0.01, replication). Our results suggest that alterations in the BIN1 locus, previously associated with Alzheimer disease, may modify the AAO of GBA-associated PD. More studies in other populations are required to examine the role of BIN1-related variants in GBA-associated PD.
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Affiliation(s)
- Z Gan-Or
- The Genetic Institute, Tel Aviv Sourasky Medical Center, Weizmann Street, 64239, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Haim Levanon, 69978, Tel Aviv, Israel
| | - I Amshalom
- The Genetic Institute, Tel Aviv Sourasky Medical Center, Weizmann Street, 64239, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Haim Levanon, 69978, Tel Aviv, Israel
| | - A Bar-Shira
- The Genetic Institute, Tel Aviv Sourasky Medical Center, Weizmann Street, 64239, Tel Aviv, Israel
| | - M Gana-Weisz
- The Genetic Institute, Tel Aviv Sourasky Medical Center, Weizmann Street, 64239, Tel Aviv, Israel
| | - A Mirelman
- Movement Disorders Unit, Department of Neurology, Parkinson Center, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel
| | - K Marder
- Department of Neurology, Columbia Presbyterian Medical Center, Columbia University, West 168th Street, New York, NY, 10032, USA
| | - S Bressman
- Department of Neurology, Beth Israel Medical Center, Union Square East, New York, NY, 10003, USA
| | - N Giladi
- Movement Disorders Unit, Department of Neurology, Parkinson Center, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Haim Levanon, 69978, Tel Aviv, Israel
| | - A Orr-Urtreger
- The Genetic Institute, Tel Aviv Sourasky Medical Center, Weizmann Street, 64239, Tel Aviv, Israel. .,The Sackler Faculty of Medicine, Tel-Aviv University, Haim Levanon, 69978, Tel Aviv, Israel.
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Ben Assayag E, Shenhar-Tsarfaty S, Kliper E, Hallevi H, Shopin L, Bornstein N, Korczyn A, Mike A, Giladi N, Mirelman A, Weiss A, Hausdorff J. Balance and gait measures as predictors of cognitive function in post-stroke patients. J Neurol Sci 2013. [DOI: 10.1016/j.jns.2013.07.971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ozawa S, Mirelman A, Stack ML, Walker DG, Levine OS. Cost-effectiveness and economic benefits of vaccines in low- and middle-income countries: a systematic review. Vaccine 2012; 31:96-108. [PMID: 23142307 DOI: 10.1016/j.vaccine.2012.10.103] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 10/19/2012] [Accepted: 10/26/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Public health interventions that prevent mortality and morbidity have greatly increased over the past decade. Immunization is one of these preventive interventions, with a potential to bring economic benefits beyond just health benefits. While vaccines are considered to be a cost-effective public health intervention, implementation has become increasingly challenging. As vaccine costs rise and competing priorities increase, economic evidence is likely to play an increasingly important role in vaccination decisions. METHODS To assist policy decisions today and potential investments in the future, we provide a systematic review of the literature on the cost-effectiveness and economic benefits of vaccines in low- and middle-income countries from 2000 to 2010. The review identified 108 relevant articles from 51 countries spanning 23 vaccines from three major electronic databases (Pubmed, Embase and Econlit). RESULTS Among the 44 articles that reported costs per disability-adjusted life year (DALY) averted, vaccines cost less than or equal to $100 per DALY averted in 23 articles (52%). Vaccines cost less than $500 per DALY averted in 34 articles (77%), and less than $1000 per DALY averted in 38 articles (86%) in one of the scenarios. 24 articles (22%) examined broad level economic benefits of vaccines such as greater future wage-earning capacity and cost savings from averting disease outbreaks. 60 articles (56%) gathered data from a primary source. There were little data on long-term and societal economic benefits such as morbidity-related productivity gains, averting catastrophic health expenditures, growth in gross domestic product (GDP), and economic implications of demographic changes resulting from vaccination. CONCLUSIONS This review documents the available evidence and shows that vaccination in low- and middle-income countries brings important economic benefits. The cost-effectiveness studies reviewed suggest to policy makers that vaccines are an efficient investment. This review further highlights key gaps in the available literature that would benefit from additional research, especially in the area of evaluating the broader economic benefits of vaccination in the developing world.
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Affiliation(s)
- Sachiko Ozawa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States.
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24
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Nieuwhof F, Reelick M, Rikkert MO, Mirelman A, Hausdorff J, Claassen J. Wireless fNIRS for neuroimaging during dual task walking and obstacle negotiation in the elderly: Feasible, reliable and valid? Eur Geriatr Med 2012. [DOI: 10.1016/j.eurger.2012.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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25
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Mirelman A, Mentzakis E, Kinter E, Paolucci F, Fordham R, Ozawa S, Ferraz M, Baltussen R, Niessen LW. Decision-making criteria among national policymakers in five countries: a discrete choice experiment eliciting relative preferences for equity and efficiency. Value Health 2012; 15:534-539. [PMID: 22583464 DOI: 10.1016/j.jval.2012.04.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Worldwide, there is a need for formalization of the priority setting processes in health. Recent research has used the term multicriteria decision analysis for methods that systematically include preferences for both equity and efficiency. The present study compares decision-makers' preferences at the country level for a set of equity and efficiency criteria according to a multicriteria decision analysis framework. METHODS Discrete choice experiments were conducted for Brazil, Cuba, Nepal, Norway, and Uganda. By using standardized methods, we elicited preferences for intervention attributes using a individual choice questionnaire. A multinomial logistic regression was applied to estimate the coefficients for all single-policy criteria, per country. Attributes were assigned to an equity group or to an efficiency group. After testing for scale variance, predicted probabilities for interventions with both types of attributes were compared across countries. RESULTS The Norway and Nepal groups showed considerable preferences for efficiency criteria over equity criteria with percent change in respective predicted sum probabilities of [10%, -84%] and [6%, -79%]. Brazil and Uganda also showed preference for the efficiency criteria though less convincingly ([-34%, -93%], [-18%, -63%], respectively). The Cuban group showed the strongest preferences with equity attributes dominating efficiency ([-52%, 213%]). CONCLUSIONS Group preferences of policymakers show explicit but varying trade-offs of efficiency and equity in these diverse settings. This multicriteria decision analysis approach, using discrete choice experiments, indicates that systematic setting of health priorities is possible across a variety of countries. It may be a valuable tool to guide health reform initiatives.
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Affiliation(s)
- Andrew Mirelman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Defechereux T, Paolucci F, Mirelman A, Youngkong S, Botten G, Hagen TP, Niessen LW. Health care priority setting in Norway a multicriteria decision analysis. BMC Health Serv Res 2012; 12:39. [PMID: 22335815 PMCID: PMC3312861 DOI: 10.1186/1472-6963-12-39] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Accepted: 02/15/2012] [Indexed: 11/22/2022] Open
Abstract
Background Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles. Methods In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas. Results The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health. Conclusions Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions.
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Affiliation(s)
- Thierry Defechereux
- Department of International Health, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, USA.
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Thaler A, Mirelman A, Simon E, Orr-Urtreger A, Gurevich T, Giladi N. 3.029 SUBTLE DIFFERENCES IN COGNITIVE FUNCTION OF HEALTHY G2019S LRRK2 MUTATION CARRIERS. Parkinsonism Relat Disord 2012. [DOI: 10.1016/s1353-8020(11)70765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mirelman A, Peruzzi A, Gazit E, Giladi N, Hausdorff J, Plotnik M. 1.303 MEASURING ARM SWING DURING GAIT IN PATIENTS WITH PARKINSON'S DISEASE USING WEARABLE SENSORS – A FEASIBILITY STUDY. Parkinsonism Relat Disord 2012. [DOI: 10.1016/s1353-8020(11)70361-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Mirelman A, Thaler A, Gurevich T, Shkedy A, Shira AB, Orr-Urtreger A, Giladi N. 3.054 THE PREVALENCE OF CANCER IN PATIENTS WITH PARKINSON'S DISEASE WHO ARE CARRIERS OF THE G2019S MUTATION IN THE LRRK2 GENE. Parkinsonism Relat Disord 2012. [DOI: 10.1016/s1353-8020(11)70790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Curran K, Njeuhmeli E, Mirelman A, Dickson K, Adamu T, Cherutich P, Mahler H, Fimbo B, Mavuso TK, Albertini J, Fitzgerald L, Bock N, Reed J, Castor D, Stanton D. Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa. PLoS Med 2011; 8:e1001129. [PMID: 22140364 PMCID: PMC3226463 DOI: 10.1371/journal.pmed.1001129] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Voluntary medical male circumcision (VMMC) reduces female-to-male HIV transmission by approximately 60%; modeling suggests that scaling up VMMC to 80% of men 15- to 49-years-old within five years would avert over 3.3 million new HIV infections in 14 high priority countries/regions in southern and eastern Africa by 2025 and would require 20.33 million circumcisions. However, the shortage of health professionals in these countries must be addressed to reach these proposed coverage levels. To identify human resource approaches that are being used to improve VMMC volume and efficiency, we looked at previous literature and conducted a program review. We identified surgical efficiencies, non-surgical efficiencies, task shifting, task sharing, temporary redeployment of public sector staff during VMMC campaign periods, expansion of the health workforce through recruitment of unemployed, recently retired, newly graduating, or on-leave health care workers, and the use of volunteer medical staff from other countries as approaches that address human resource constraints. Case studies from Kenya, Tanzania, and Swaziland illustrate several innovative responses to human resource challenges. Although the shortage of skilled personnel remains a major challenge to the rapid scale-up of VMMC in the 14 African priority countries/regions, health programs throughout the region may be able to replicate or adapt these approaches to scale up VMMC for public health impact.
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Ozawa S, Stack ML, Bishai DM, Mirelman A, Friberg IK, Niessen L, Walker DG, Levine OS. During the 'decade of vaccines,' the lives of 6.4 million children valued at $231 billion could be saved. Health Aff (Millwood) 2011; 30:1010-20. [PMID: 21653951 DOI: 10.1377/hlthaff.2011.0381] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Governments constantly face the challenge of determining how much they should spend to prevent premature deaths and suffering in their populations. In this article we explore the benefits of expanding the delivery of life-saving vaccines in seventy-two low- and middle-income countries, which we estimate would prevent the deaths of 6.4 million children between 2011 and 2020. We present the economic benefits of vaccines by using a "value of statistical life" approach, which is based on individuals' perceptions regarding the trade-off between income and increased risk of mortality. Our analysis shows that the vaccine expansion described above corresponds to $231 billion (uncertainty range: $116-$614 billion) in the value of statistical lives saved. This analysis complements results from analyses based on other techniques and is the first of its kind for immunizations in the world's poorest countries. It highlights the major economic benefits made possible by improving vaccine coverage.
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Affiliation(s)
- Sachiko Ozawa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Stack ML, Ozawa S, Bishai DM, Mirelman A, Tam Y, Niessen L, Walker DG, Levine OS. Estimated Economic Benefits During The ‘Decade Of Vaccines’ Include Treatment Savings, Gains In Labor Productivity. Health Aff (Millwood) 2011; 30:1021-8. [DOI: 10.1377/hlthaff.2011.0382] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Meghan L. Stack
- Meghan L. Stack ( ) is a research associate in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Sachiko Ozawa
- Sachiko Ozawa is an assistant scientist in the Department of International Health at the Bloomberg School
| | - David M. Bishai
- David M. Bishai is a professor in the Department of Population, Family, and Reproductive Health at the Bloomberg School
| | - Andrew Mirelman
- Andrew Mirelman is a doctoral candidate in the Department of International Health at the Bloomberg School
| | - Yvonne Tam
- Yvonne Tam is a research associate in the Department of International Health at the Bloomberg School
| | - Louis Niessen
- Louis Niessen is an associate professor in the Department of International Health at the Bloomberg School
| | - Damian G. Walker
- Damian G. Walker is a senior program officer, Global Health, at the Bill & Melinda Gates Foundation, in Seattle, Washington
| | - Orin S. Levine
- Orin S. Levine is an associate professor in the Department of International Health at the Bloomberg School
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Nicolai S, Mirelman A, Herman T, Zijlstra A, Mancini M, Becker C, Lindemann U, Berg D, Maetzler W. Improvement of balance after audio-biofeedback. A 6-week intervention study in patients with progressive supranuclear palsy. Z Gerontol Geriatr 2011; 43:224-8. [PMID: 20814797 DOI: 10.1007/s00391-010-0125-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Progressive supranuclear palsy (PSP) is a neurodegenerative disease with no sufficient treatment options to date. The most devastating symptom is the loss of balance with consecutive falls. Based on the observation that postural control improved in patients with vestibular dysfunction after audio-biofeedback training, we tested the effects of this training in PSP patients. Eight PSP patients were included into an uncontrolled 6-week intervention trial. The focus of the training was the improvement of posture and dynamic balance by using audio-biofeedback. The device was well accepted. No adverse events occurred. A significant improvement in the Berg Balance Scale was observed (T2 vs. T1, p=0.016), which remained significant at the 4-week follow-up (T3 vs. T1, p=0.008). Significant improvement of the Parkinson's disease questionnaire was demonstrated. No significant changes were found in the Timed Up-and-Go Test, the Five Chair Rise Test, and in specific clinical scales. To our knowledge, the present study is the first to demonstrate that audio-biofeedback training with PSP patients is associated with improvements of balance and psychosocial aspects.
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Affiliation(s)
- S Nicolai
- Clinic for Geriatric Rehabilitation, Robert-Bosch-Hospital, Auerbachstr. 110, 70376 Stuttgart.
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Mirelman A, Maidan I, Herman T, Deutsch JE, Giladi N, Hausdorff JM. Virtual Reality for Gait Training: Can It Induce Motor Learning to Enhance Complex Walking and Reduce Fall Risk in Patients With Parkinson's Disease? J Gerontol A Biol Sci Med Sci 2010; 66:234-40. [DOI: 10.1093/gerona/glq201] [Citation(s) in RCA: 253] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nicolai S, Zijlstra A, Mirelman A, Herman T, Maetzler W, Becker C. 251 EFFECT OF AUDIO-BIOFEEDBACK ON BALANCE AND GAIT IN PSP PATIENTS – A 6 WEEKS PILOT STUDY. Parkinsonism Relat Disord 2010. [DOI: 10.1016/s1353-8020(10)70252-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mirelman A, Maidan I, Jacobs A, Mirelman D, Giladi N, Hausdorff J. 294 VIRTUAL REALITY FOR GAIT TRAINING IN PARKINSON'S DISEASE: A FEASIBILITY STUDY. Parkinsonism Relat Disord 2010. [DOI: 10.1016/s1353-8020(10)70295-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Maidan I, Plotnik M, Mirelman A, Weiss A, Giladi N, Hausdorff J. 136 DOES HEART RATE CHANGE WITH FREEZING OF GAIT IN PATIENTS WITH PARKINSON'S DISEASE? Parkinsonism Relat Disord 2010. [DOI: 10.1016/s1353-8020(10)70137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sidransky E, Nalls MA, Aasly JO, Aharon-Peretz J, Annesi G, Barbosa ER, Bar-Shira A, Berg D, Bras J, Brice A, Chen CM, Clark LN, Condroyer C, De Marco EV, Dürr A, Eblan MJ, Fahn S, Farrer MJ, Fung HC, Gan-Or Z, Gasser T, Gershoni-Baruch R, Giladi N, Griffith A, Gurevich T, Januario C, Kropp P, Lang AE, Lee-Chen GJ, Lesage S, Marder K, Mata IF, Mirelman A, Mitsui J, Mizuta I, Nicoletti G, Oliveira C, Ottman R, Orr-Urtreger A, Pereira LV, Quattrone A, Rogaeva E, Rolfs A, Rosenbaum H, Rozenberg R, Samii A, Samaddar T, Schulte C, Sharma M, Singleton A, Spitz M, Tan EK, Tayebi N, Toda T, Troiano AR, Tsuji S, Wittstock M, Wolfsberg TG, Wu YR, Zabetian CP, Zhao Y, Ziegler SG. Multicenter analysis of glucocerebrosidase mutations in Parkinson's disease. N Engl J Med 2009; 361:1651-61. [PMID: 19846850 PMCID: PMC2856322 DOI: 10.1056/nejmoa0901281] [Citation(s) in RCA: 1464] [Impact Index Per Article: 97.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent studies indicate an increased frequency of mutations in the gene encoding glucocerebrosidase (GBA), a deficiency of which causes Gaucher's disease, among patients with Parkinson's disease. We aimed to ascertain the frequency of GBA mutations in an ethnically diverse group of patients with Parkinson's disease. METHODS Sixteen centers participated in our international, collaborative study: five from the Americas, six from Europe, two from Israel, and three from Asia. Each center genotyped a standard DNA panel to permit comparison of the genotyping results across centers. Genotypes and phenotypic data from a total of 5691 patients with Parkinson's disease (780 Ashkenazi Jews) and 4898 controls (387 Ashkenazi Jews) were analyzed, with multivariate logistic-regression models and the Mantel-Haenszel procedure used to estimate odds ratios across centers. RESULTS All 16 centers could detect two GBA mutations, L444P and N370S. Among Ashkenazi Jewish subjects, either mutation was found in 15% of patients and 3% of controls, and among non-Ashkenazi Jewish subjects, either mutation was found in 3% of patients and less than 1% of controls. GBA was fully sequenced for 1883 non-Ashkenazi Jewish patients, and mutations were identified in 7%, showing that limited mutation screening can miss half the mutant alleles. The odds ratio for any GBA mutation in patients versus controls was 5.43 across centers. As compared with patients who did not carry a GBA mutation, those with a GBA mutation presented earlier with the disease, were more likely to have affected relatives, and were more likely to have atypical clinical manifestations. CONCLUSIONS Data collected from 16 centers demonstrate that there is a strong association between GBA mutations and Parkinson's disease.
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Affiliation(s)
- E Sidransky
- Section on Molecular Neurogenetics, Medical Genetics Branch, NHGRI, National Institutes of Health, Bethesda, MD 20892-3708, USA.
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Gan-Or Z, Bar-Shira A, Mirelman A, Gurevich T, Kedmi M, Giladi N, Orr-Urtreger A. LRRK2 and GBA mutations differentially affect the initial presentation of Parkinson disease. Neurogenetics 2009; 11:121-5. [DOI: 10.1007/s10048-009-0198-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Accepted: 05/06/2009] [Indexed: 12/17/2022]
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Aerts MB, Synhaeve NE, Mirelman A, Bloem BR, Giladi N, Hausdorff JM. Is heart rate variability related to gait impairment in patients with Parkinson's disease? A pilot study. Parkinsonism Relat Disord 2009; 15:712-5. [PMID: 19329349 DOI: 10.1016/j.parkreldis.2009.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2008] [Revised: 02/07/2009] [Accepted: 03/01/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Impairments in gait and autonomic function are common in patients with Parkinson's disease (PD). These are likely independent symptoms, based on different etiologic mechanisms. However, a few recent reports have observed an association between motor function, in particular gait impairment, and autonomic function in PD. In those studies, the Unified Parkinson's Disease Rating Scale (UPDRS) was used to evaluate gait and motor function. The present study was performed to further examine this putative relationship using quantitative measures of autonomic function and gait in order to shed light on the underlying pathophysiology of these symptoms. METHODS Nine healthy young, 15 healthy elderly and 18 PD patients were studied. Heart rate variability (HRV) measures were collected during rest. Gait speed, swing time and swing time variability were measured during a 1-min walk at comfortable speed. The motor portion of the UPDRS was also evaluated in all subjects. RESULTS HRV values were highest in the young adults, intermediate in the healthy elderly controls, and lowest in the PD patients. Gait measures tended to deteriorate with age and were significantly worse in the PD patients, compared to the elderly controls. HRV was not correlated with any measure of gait performance (p>0.129) nor with the UPDRS-motor score (p>0.147). DISCUSSION AND CONCLUSIONS The present findings support the idea that gait and autonomic function impairments co-exist in PD, but their etiology is based on distinct pathophysiological pathways, with minimal overlap.
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Affiliation(s)
- M B Aerts
- Department of Neurology, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Abstract
Several approaches have been developed and implemented to use virtual reality for rehabilitation of walking for people poststroke. The purpose of this article is to compare and contrast these approaches by describing the virtual reality technology and evaluating the evidence to support its use. Early findings are encouraging but await verification, refinement, and extension.
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Affiliation(s)
- J E Deutsch
- Rivers Lab, UMDNJ-SHRP, Newark, New Jersey, USA
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Eilat S, Avramovitch D, Rabinkov A, Mirelman A, Battler A, Eldar M, Vered Z. Allicin. DRUG FUTURE 1996. [DOI: 10.1358/dof.1996.021.11.380761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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