Health Economic Consequences Associated With COVID-19-Related Delay in Melanoma Diagnosis in Europe

Importance

The COVID-19 pandemic resulted in delayed access to medical care. Restrictions to health care specialists, staff shortages, and fear of SARS-CoV-2 infection led to interruptions in routine care, such as early melanoma detection; however, premature mortality and economic burden associated with this postponement have not been studied yet.

Objective

To determine the premature mortality and economic costs associated with suspended melanoma screenings during COVID-19 pandemic lockdowns by estimating the total burden of delayed melanoma diagnoses for Europe.

Design, Setting, and Participants

This multicenter economic evaluation used population-based data from patients aged at least 18 years with invasive primary cutaneous melanomas stages I to IV according to the American Joint Committee on Cancer (AJCC) seventh and eighth editions, including melanomas of unknown primary (T0). Data were collected from January 2017 to December 2021 in Switzerland and from January 2019 to December 2021 in Hungary. Data were used to develop an estimation of melanoma upstaging rates in AJCC stages, which was verified with peripandemic data. Years of life lost (YLL) were calculated and were, together with cost data, used for financial estimations. The total financial burden was assessed through direct and indirect treatment costs. Models were building using data from 50 072 patients aged 18 years and older with invasive primary cutaneous melanomas stages I to IV according to the AJCC seventh and eighth edition, including melanomas of unknown primary (T0) from 2 European tertiary centers. Data from European cancer registries included patient-based direct and indirect cost data, country-level economic indicators, melanoma incidence, and population rates per country. Data were analyzed from July 2021 to September 2022.

Exposure

COVID-19 lockdown-related delay of melanoma detection and consecutive public health and economic burden. As lockdown restrictions varied by country, lockdown scenario was defined as elimination of routine medical examinations and severely restricted access to follow-up examinations for at least 4 weeks.

Main Outcomes and Measures

Primary outcomes were the total burden of a delay in melanoma diagnosis during COVID-19 lockdown periods, measured using the direct (in US$) and indirect (calculated as YLL plus years lost due to disability [YLD] and disability-adjusted life-years [DALYs]) costs for Europe. Secondary outcomes included estimation of upstaging rate, estimated YLD, YLL, and DALY for each European country, absolute direct and indirect treatment costs per European country, proportion of the relative direct and indirect treatment costs for the countries, and European health expenditure.

Results

There were an estimated 111 464 (range, 52 454-295 051) YLL due to pandemic-associated delay in melanoma diagnosis in Europe, and estimated total additional costs were $7.65 (range, $3.60 to $20.25) billion. Indirect treatment costs were the main cost driver, accounting for 94.5% of total costs. Estimates for YLD in Europe resulted in 15 360 years for the 17% upstaging model, ranging from 7228 years (8% upstaging model) to 40 660 years (45% upstaging model). Together, YLL and YLD constitute the overall disease burden, ranging from 59 682 DALYs (8% upstaging model) to 335 711 DALYs (45% upstaging model), with 126 824 DALYs for the real-world 17% scenario.

Conclusions and Relevance

This economic analysis emphasizes the importance of continuing secondary skin cancer prevention measures during pandemics. Beyond the personal outcomes of a delayed melanoma diagnosis, the additional economic and public health consequences are underscored, emphasizing the need to include indirect economic costs in future decision-making processes. These estimates on DALYs and the associated financial losses complement previous studies highlighting the cost-effectiveness of screening for melanoma.

Clinical Indicators of Symptom Dimensions and Cognitive Ability in Schizophrenia

Introduction

Schizophrenia is a heterogeneous disorder and it is unknown what causes individual variability in symptoms and cognitive ability.

Objectives

To examine the association between nine clinical predictors measurable at the onset of schizophrenia and five phenotype dimensions: positive, negative (diminished expressivity), negative (motivation and pleasure), disorganised symptoms and cognitive ability.

Methods

852 participants (mean age 49 years old) with a diagnosis of schizophrenia or schizoaffective depression were included from the CardiffCOGS cross-sectional sample. Phenotype dimensions were created using confirmatory factor analysis and a 5-factor model. Associations were tested using linear regression, adjusting for age and sex. A Bonferroni correction was applied for (p<1.1x10^-3) for multiple testing.

Results

Age of onset of psychosis was significantly associated with positive symptoms (β=-0.18, p=4.0 x10^-6). Lower premorbid IQ was associated with diminished expressivity (β=-0.25, p= 7.0x10^-13), reduced motivation and pleasure (β=-0.23, p= 4.3x10^-11), disorganised symptoms (β=-0.14, p= 7.6x10^-5) and reduced cognition (β=0.54, p= 4.8x10^-77). Poor premorbid social adjustment held associations with all except positive. Developmental delay was associated with reduced cognition (β=-0.35, p= 4.3x10^-5). Cannabis use (year before onset), psychosocial stressors (within 6 months), childhood abuse and family history of schizophrenia held no associations.

Conclusions

Clinical indicators measurable at schizophrenia onset are associated with lifetime symptom variability. A younger psychosis onset is associated with more severe positive symptoms, suggesting possible age-targeted management. Pre-established links of lower premorbid IQ with poor premorbid social adjustment and negative symptom severity with cognition are strengthened. Further investigation could potentially improve diagnosis and guide treatment choice for aspects of schizophrenia with poor outcomes.

Disclosure

No significant relationships.

Swiss trade during the COVID-19 pandemic: an early appraisal

This study uses trade data from Switzerland's Federal Customs Administration to examine the impact of Covid-19 on international goods trade between January and July 2020. We show that Swiss trade during that period fell by 11% compared to 2019 and that the contraction following the "Federal Lockdown" in mid-March was considerably steeper than the Swiss trade collapse in the aftermath of the Lehman Brothers bankruptcy in September 2008. Examining cross-country variation in Covid-19 cases, the stringency of containment measures, and Swiss trade flows, we document that the pandemic adversely affected both the demand and supply side of foreign trade, while trade restrictions and exchange rate fluctuations played no major role behind the rapid decline of Swiss trade in the first half of 2020.

Tunable narrow-linewidth laser at 2 μm wavelength for gravitational wave detector research

We present and characterize a narrow-linewidth external-cavity diode laser at 2 μm, and show that it represents a low-cost, high-performance alternative to fiber lasers for research into 2 μm photonic technologies for next-generation gravitational-wave detectors. A linewidth of 20 kHz for a 10 ms integration time was measured without any active stabilization, with frequency noise of ∼ 15 Hz/Hz between 3 kHz and 100 kHz. This performance is suitable for the generation of quantum squeezed light, and we measure intensity noise comparable to that of master oscillators used in current gravitational wave interferometers. The laser wavelength is tunable over a 120 nm range, and both the frequency and intensity can be modulated at up to 10 MHz by modulating the diode current. These features also make it suitable for other emerging applications in the 2 μm wavelength region including gas sensing, optical communications and LIDAR.

How to improve threatened species management: An Australian perspective

Targeted threatened species management is a central component of efforts to prevent species extinction. Despite the development of a range of management frameworks to improve conservation outcomes over the past decade, threatened species management is still commonly characterised as ad hoc. Although there are notable successes, many management programs are ineffective, with relatively few species experiencing improvements in their conservation status. We identify underlying factors that commonly lead to ineffective and inefficient management. Drawing attention to some of the key challenges, and suggesting ways forward, may lead to improved management effectiveness and better conservation outcomes. We highlight six key areas where improvements are needed: 1) stakeholder engagement and communication; 2) fostering strong leadership and the development of achievable long-term goals; 3) knowledge of target species' biology and threats, particularly focusing on filling knowledge gaps that impede management, while noting that in many cases there will be a need for conservation management to proceed initially despite knowledge gaps; 4) setting objectives with measurable outcomes; 5) strategic monitoring to evaluate management effectiveness; and 6) greater accountability for species declines and failure to recover species to ensure timely action and guard against complacency. We demonstrate the importance of these six key areas by providing examples of innovative approaches leading to successful species management. We also discuss overarching factors outside the realm of management influence that can help or impede conservation success. Clear recognition of factors that make species' management more straightforward - or more challenging - is important for setting realistic management objectives, outlining strategic action, and prioritising resources. We also highlight the need to more clearly demonstrate the benefit of current investment, and communicate that the risk of under-investment is species extinctions. Together, improvements in conservation practice, along with increased resource allocation and re-evaluation of the prioritisation of competing interests that threaten species, will help enhance conservation outcomes for threatened species.

A way to reduce interference with Elliott traps

Elliott traps are widely used in Australia to capture small terrestrial mammals. However, in some situations non-target species disturb the traps, resulting in fewer traps being available for the target species. This situation occurred on Faure Island Wildlife Sanctuary (Western Australia) where boodies (burrowing bettongs) were disturbing the Elliott traps deployed to monitor populations of shark bay mice and western barred bandicoots. This note presents the method used to alleviate this problem on Faure Island but would be more widely applicable in other situations where Elliott traps are disturbed by animals other than the target species.

Effect of external stresses on protein conformation: a computer modelling study

The increasing use of digital technologies such as mobile phones has led to major health concerns about the effects of non-ionizing pulsed radiation exposure. We believe that the health implications of exposure to radiation cannot be fully understood without establishing the molecular mechanisms of biological effects of pulsed microwaves. We aim to establish methods for studying the molecular mechanisms of protein structural and energetic changes occurring due to external stresses related to non-ionizing radiation by using a combination of experimental and theoretical approaches. In this paper, we present the results from our fully atomistic simulation study of chemical and thermal stress response of a prototype protein, insulin. We performed a series of molecular dynamics simulations of insulin in solution under equilibrium conditions, under chemical stress (imitated by reducing the disulfide bonds in the protein molecule), and under short-lived thermal stress (imitated by increasing simulation temperature for up to 2 ns). The resultant protein conformational behaviour was analysed for various properties with the aim of establishing analysis routines for classification of protein unfolding pathways and associated molecular mechanisms.

Availability of nest hollows and breeding population size of eclectus parrots, Eclectus roratus, on Cape York Peninsula, Australia

The distribution of the Australian mainland endemic subspecies of the eclectus parrot, Eclectus roratus macgillivrayi, is currently confined to the lowland rainforests of the Iron–McIlwraith Ranges of eastern Cape York Peninsula. Females breed in large hollows in emergent rainforest trees that are readily visible from above. Aerial surveys were used to sample 58% of the rainforest (454 km2) of the Iron Range region to estimate the density of these nest trees. Corrections for overcounting bias (not all observed emergent trees were active nest trees) and undercounting bias (not all active nest trees were visible from the air) were made by ground-truthing over 70 trees. The tree count data were treated in two different ways, producing estimates of 417 (s.e. = 25) and 462 (s.e. = 31) nest trees for the Iron Range region. Long-term observational data on the number of eclectus parrots associated with each nest tree were used to estimate the population size of eclectus parrots at Iron Range: 538–596 breeding females, and 1059–1173 males. These results have three implications. First, this relatively low population estimate suggests that the Australian subspecies of eclectus parrots should be considered vulnerable to habitat loss or perturbation, especially in light of their complex social system, male-biased adult sex ratio, low breeding success and high variance in reproductive success among females. Second, the low density of nest trees suggests that eclectus parrots are absent from the rainforests of Lockerbie Scrub and the Jardine dunefields because these areas are too small. Finally, if eclectus parrots persisted in the Iron–McIlwraith region during the rainforest contractions of Pleistocene glacial maxima (e.g. 14 000–17 000 years ago), the refugium in this region must have been fairly substantial in order to support a viable population – probably larger than previously assumed.

Metallic orthopaedic implants and airport metal detectors

Airport security can detect in vivo metallic implants. We hypothesized that a soft tissue shield and fast transit through archway detectors would decrease implant detectability, whereas greater implant mass would increase detectability. Twelve patients with 8 orthopaedic implants in vivo and 60 trauma and arthroplasty implants in vitro were subjected to standard airport security measures at Stanstead Airport (British Airports Authority), including arch and standard and nonstandard hand-held detectors. Archway detectors failed to detect some implants; hand-held detectors detected almost all implants except an ankle arthroplasty. Positive archway detection was related to implant transit speed through the detection field. The implant mass consistently affected detection in stainless steel and titanium implants, and a 1-inch wax shield had no effect. Patients with metallic implants should prepare routinely with documentation of their implant before traveling through security ports.

Helper contributions in the cooperatively breeding laughing kookaburra: feeding young is no laughing matter

I studied the contributions of individuals to incubation and nestling feeding in a population of cooperatively breeding laughing kookaburras, Dacelo novaeguineae. In most cooperatively breeding birds where nest success is limited by nestling starvation, related helpers increase the overall level of provisioning to the nest, thus boosting the production of nondescendent kin. However, although partial brood loss is the largest cause of lost productivity in kookaburra nests, additional helpers failed to increase overall provisioning. Instead, all group members, but especially helpers, reduced their feeding contributions as group size increased. Breeders and helpers reduced the size of prey delivered, and helpers also reduced the number of feeding visits. An important benefit of helping in kookaburras may be to allow all group members to reduce their effort. Within groups, contributions to care depended on status, sex, group size and the brood size. Breeding males delivered the most food. Breeding females provisioned less than their partner, but their effort was comparable to that of male helpers. Female helpers contributed the least food. Incubation effort followed similar patterns. The relatedness of helpers to the brood had no impact on their provisioning. Across all group sizes, helpers generally brought larger items to the nest than breeders. Copyright 2000 The Association for the Study of Animal Behaviour.

Coalitions of relatives and reproductive skew in cooperatively breeding white-winged choughs

We used DNA fingerprinting to examine reproductive skew in cooperatively breeding white-winged choughs, Corcorax melanorhamphos, which live in groups of up to 20 individuals. Before a severe drought, groups that had been stable for multiple years were characterized by long-term monogamy involving a single breeding pair (high skew). After the drought, new groups formed from the amalgamation of multiple individuals and coalitions of relatives. At most one member of each faction succeeded in breeding, such that skew was dependent on the number of unrelated factions, and not group size. In the new groups, dominant males and females with supporting relatives were always successful. Whereas most females without support also gained breeding positions, many males without family support failed to breed. Thus subordinates gain indirect fitness by first helping related males to secure a breeding position, and then helping to raise their young. Our study demonstrates the advantage of operating in coalitions, and suggests that the acquisition of future allies may be a major benefit of helping behaviour in this species.

The cost of helping

Cooperative breeding in mammals, birds and fish has provided evolutionary biologists with a rich framework for studying the causes and consequences of group-based reproduction. Helping behaviour is especially enigmatic because it often entails an individual sacrificing personal reproduction while assisting others in their breeding attempts. The decision to help others to reproduce is affected by immediate and future costs analogous to those of direct reproduction, but these components of the equation have usually been neglected. Recent research suggests that the type of benefit sought could determine the extent of help given.