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Objectives The visual analogue scale (VAS) has been used in the context of health and healthcare for various purposes, for example, to measure pain and to provide a single-index measure of health-related quality of life (HRQoL). This scoping review aims to describe how the VAS has been used for health state valuation in the published literature. Methods The search was carried out in Medline, Web of Science and PsycInfo. The findings of the included articles were tabulated and presented descriptively using frequencies and proportions. Results The database search yielded 4856 unique articles, out of these, 308 were included. In 83% of the articles, the main purpose for using a VAS was to value health states. The two most common perspectives when valuing health states with a VAS were hypothetical (44%) and own health (34%). Some (n = 14) articles used the VAS in the context of economic evaluations, including calculating quality-adjusted life years (QALYs). A large variation in the design of the VAS was found, including the description of the lower and upper anchors. Advantages and disadvantages with using a VAS were mentioned in 14% of the included articles. Conclusion The VAS has been a common method for valuing health states, both as a stand-alone method and in combination with other valuation methods. Despite its widespread use, the design of the VAS has been inconsistent which makes comparison of results across studies challenging. Further research on the role of using the VAS in economic evaluations is warranted.

Objectives: There is a lack of consensus around the definition of delivery by cesarean section (CS) on maternal request, and clinical practice varies across and within countries. Previous economic evaluations have focused on specific populations and selected complications. Our aim was to evaluate the cost-effectiveness of CS on maternal request compared with planned vaginal birth in a Swedish context, based on a systematic review of benefits and drawbacks and national registry data on costs. Methods: We used the results from a systematic literature review of somatic risks for long-and short-term complications for mother and child, in which certainty was rated low, moderate, or high using the Grading of Recommendations Assessment, Development and Evaluation. Swedish national registry data were used for healthcare costs of delivery and complications. Utilities for long-term complications were based on a focused literature review. We constructed a decision tree and conducted separate analyses for primi-and multiparous women. Costs and effects were discounted by 3% and the time horizon was varied between 1 and 20 years. Results: Planned vaginal birth leads to lower healthcare costs and somatic health gains compared with elective CS without medical indication over up to 20 years. Although there is uncertainty around, for example, quality-of-life effects, results remain stable across sensitivity analyses. Conclusions: CS on maternal request leads to increased hospitalization costs in a Swedish setting, taking into account short -and long-term consequences for both mother and child. Future research needs to study the psychological consequences related to different delivery methods, costs in outpatient care, and productivity losses.

Purpose There is an increasing interest for using qualitative methods to investigate peoples’ cognitive process when asked to value health states. A standardised valuation protocol for the EQ-5D-Y-3L instrument was recently developed. Little is known regarding how people think, reason, and feel when asked to value health states for children. The aim was to explore how adolescents and adults perceive the task of valuing children’s health states using the standardised valuation protocol. Methods This was a qualitative study where adults (n = 10) and adolescents (n = 10) from the general population participated in individual video-interviews. Initially, participants reported their own health with the EQ-5D-3L instrument. Then they were asked to complete several valuations tasks for a 10-year-old child according to the standardised valuation protocol, followed by a semi-structured interview with open-ended questions to further explore participants’ perceptions. A qualitative content analysis was performed. Results The two main categories that emerged from the data were ‘Thoughts and feelings when valuing children’s health states’ and ‘Strategies when valuing children’s health states’. Participants expressed feeling doubt, awfulness and being reluctant to trade-off life years, and questioned who has the right to value health states for children. Experience and point of view were strategies participants used to complete the valuation tasks. Conclusion The findings from the present study can contribute to the understanding and interpretation of quantitative results where the standardised valuation protocol has been used to derive values for the EQ-5D-Y-3L. Furthermore, results of the study support the feasibility of including adolescents in valuation studies.

The Swedish Agency for Health Technology Assessment and Assessment of Social Services has evaluated quantitative and qualitative research regarding rehabilitation for persons with traumatic brain injury (TBI) through systematic reviews. The results indicate that specialized brain injury rehabilitation for persons with post-concussion symptoms after mild TBI results in improved health, when compared to usual care (results with low certainty according to GRADE). As few high-quality studies were identified, it was not possible to assess the effects of vocational rehabilitation, rehabilitation with case management/coordinator, residential living or specialized brain rehabilitation for persons with moderate to severe TBI. A synthesis of qualitative studies showed that persons with TBI experience insufficient coordination of health services and access to rehabilitation (results with low to moderate confidence according to CERQual).

The western spruce budworm (Choristoneura occidentalis Freeman = C. freemani (Razowski), Lepidoptera: Tortricidae) (WSB) is a recurrent defoliator of Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco) and other conifers in western North America. Repeated defoliation causes timber depletions, which often require control using pest management programs involving combinations of aerial sprays with biological controllers (Bacillus thuringiensis) and other tactics. Anticipating the recurrence cycle of this periodic defoliator is important for forest management planning, which needs to consider budworm-caused depletions in timber supply analyses, and for risk management and control. We studied the historical periodicity of outbreaks at the western edge of the insect’s distribution, on southern Vancouver Island, British Columbia, using the methods of dendrochronology applied to a living Douglas-fir chronology spanning 734 years (1281–2014 CE) and a floating chronology dating from 1863 to 1528 before the Common Era (BCE). To separate the growth fluctuations due to budworm defoliation from climatic fluctuations in the living chronology, we compared the temporal growth patterns of Douglas-fir with those of the non-budworm host western red cedar (Thuja plicata Donn ex D. Don), which is sympatric with Douglas-fir in this area. We concluded that before the 1930s, outbreaks were frequent, severe, and often spatially synchronized. Following the 1930s, periods of growth reductions indicative of outbreaks were present at the same frequency, but were less severe and not as synchronized as before. We provide evidence to suggest that periodic budworm disturbances on southern Vancouver Island have persisted through the centuries but that this regime has gradually shifted outside its historic range at about 1930. We concluded that although WSB is still present in this setting, population levels have not reached detectable outbreak levels for the last 90 years. We hypothesized that the absence of budworm outbreaks in the last 90 years is a response to the drastic ecosystem changes in this region caused by exploitation and fragmentation of the virgin forests, to possible changes in climate and to the accidental introduction of novel budworm predators into the ecosystem.

Introduction: To estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and Methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015. Results: A total of 382 patients (mean age: 54 years) participated in the Netherlands; 81% were below retirement age and of these, 31% were employed. Employment was inversely related to disease severity, and MS affected productivity at work for 82% of patients. Overall, 96% and 73% of patients experienced fatigue and cognitive difficulties, respectively, as a problem. Mean utility and annual costs were 0.744 and €23,100 at Expanded Disability Status Scale (EDSS) 0–3, 0.595 and €32,300 at EDSS 4–6.5, and 0.297 and €50,500 at EDSS 7–9. The mean cost of a relapse was estimated at €3000. Conclusion: This study provides current data on MS in the Netherlands that are important for the development of health policies and to estimate the value of current and future treatments.

Introduction: In order to estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of disability, from the societal perspective, in EUR (2015). Results: A total of 779 patients (mean age = 57 years) participated; 72% were below retirement age and of these, 36% were employed. Employment was related to disease severity, and MS affected productivity at work for 84% of patients. Overall, 96% and 72% of the patients experienced fatigue and cognition as a problem. Mean utility and annual costs were 0.735 and 11,400GBP at Expanded Disability Status Scale (EDSS) = 0–3, 0.534 and 22,700GBP at EDSS = 4–6.5, and 0.135 and 36,500GBP at EDSS = 7–9. The mean cost of a relapse was estimated at 790GBP. Conclusion: This study illustrates the burden of MS on UK patients and provides current data on MS that are important for development of health policies.

Introduction:In order to estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated.Objectives and Methods:This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015.Results:A total of 516 patients (mean age, 53 years) participated in Austria; 72% were below retirement age, and of these, 46% were employed. Employment was related to disability, and MS affected productivity at work for 77% of those working. Overall, 94% and 67% of patients experienced fatigue and cognition as a problem. Mean utility and total annual costs were 0.778 and 25,100€ at Expanded Disability Status Scale (EDSS) 0–3, 0.579 and 44,100€ at EDSS 4–6.5, and 0.244 and 73,800€ at EDSS 7–9. The mean cost of a relapse was estimated at 2563€.Conclusion:This study illustrates the burden of MS on Austrian patients and provides current data on MS that are important for development of health policies.

Background: To assess the value of management strategies in multiple sclerosis (MS), outcome data have to be combined with cost data. This requires that cost data be regularly updated. Objective and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting current data on resource consumption, work capacity and health-related quality of life (HRQoL). Descriptive analyses are presented by level of severity; costs are estimated in the societal perspective, in 2015 SEK. Results: A total of 1864 patients (mean age 56 years) participated in Sweden; 74% were below retirement age, and of these, 55% were employed. MS was reported to affect productivity at work in 78% of patients. Overall, 94% and 72% of patients felt that fatigue and cognition were a problem, respectively. The mean utility and costs were 0.757 and 244,000SEK at Expanded Disability Status Scale (EDSS) 0–3, 0.563 and 384,000SEK at EDSS 4–6.5 and 0.202 and 888,000SEK at EDSS 7–9, respectively. The average cost of a relapse was 36,900SEK. Conclusion: This study illustrates the burden of MS on Swedish patients and provides current data that are important for the development of health policies.

Introduction: To estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in CHF 2015. Results: A total of 721 patients (mean age 48 years) participated in Switzerland; 90% were below retirement age, and of these, 65% were employed. Employment was related to disease severity, and MS affected productivity at work for 69% of patients. Overall, 93% and 64% of patients experienced fatigue and cognition as a problem, respectively. The mean utility and annual costs were 0.799 and 29,600CHF at Expanded Disability Status Scale (EDSS) 0–3, 0.614 and 66,800CHF at EDSS 4–6.5 and 0.348 and 110,800CHF at EDSS 7–9, respectively. The mean cost of a relapse was estimated at 7600CHF. Conclusion: This study provides current data on MS in Switzerland that are important for development of health policies and to estimate the value of current and future treatments.

Introduction: This article describes the methods used to perform this large European-wide burden-of-illness study on multiple sclerosis (MS) using individual patient data. Methods: The study collected all MS-related resource consumption, workforce participation, prevalent disease symptoms and health-related quality of life (HRQoL). Patients were recruited by national patient associations and, after informed consent, completed a specific questionnaire either on-line or on paper. Analyses were performed by country as well as for the study overall. Costs were estimated from the societal perspective, using publicly available unit costs and reported in national currencies and in EUR 2015 adjusted for purchasing power parity. The results are reported by disease severity groups according to self-assessed Expanded Disability Status Scale (EDSS) (mild, moderate, severe) and by EDSS point to highlight the development of costs as disability progresses. Results: A total of 16,808 patients in 16 countries participated in the study: Austria, Belgium, Denmark, Czech Republic, France, Germany, Hungary, Italy, the Netherlands, Poland, Portugal, Russia, Spain, Sweden, Switzerland and the United Kingdom. Conclusion: This study, endorsed by the European Platform of MS Societies, provides up-to-date information on costs and expands the previously available information on HRQoL and symptoms.

Introduction: To estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption, work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of disability, from the societal perspective, in HUF 2015. Results: A total of 521 patients (mean age 47 years) participated; 85% were below retirement age, and of these, 47% were employed. Employment was related to disability and MS affected productivity at work for 82% of those working. Overall, 94% and 66% of patients experienced fatigue and cognitive difficulties as a problem, respectively. The mean utility and annual costs were 0.691 and 3,432,000HUF at Expanded Disability Status Scale (EDSS) 0–3, 0.491 and 5,262,000HUF at EDSS 4–6.5 and 0.076 and 6,235,000HUF at EDSS 7–9, respectively. The average cost of a relapse was estimated at 240,500HUF. Conclusion: This study illustrates the burden of MS on Hungarian patients and provides current data that are important for the development of health policies.

Introduction: In order to estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, in the societal perspective, in CZK 2015. Results: A total of 747 patients (mean age 47 years) participated; 86% were below retirement age and of these, 49% were employed. Employment was related to disease severity, and MS affected productivity at work for 82% of those working. Overall, 92% and 66% of patients experienced fatigue and cognitive difficulties as a problem. Mean utility and annual costs were 0.832 and 257,000CZK at Expanded Disability Status Scale (EDSS) 0–3, 0.530 and 425,500CZK at EDSS 4–6.5 and 0.141 and 489,000CZK at EDSS 7–9. The average cost of a relapse was estimated at 12,600CZK. Conclusion: This study provides current data on MS in the Czech Republic that are important for the development of health policies.

Introduction: In order to estimate the value of interventions in multiple sclerosis (MS) where lifetime costs and outcomes cannot be observed, outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption, work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015. Results: A total of 462 patients (mean age 43 years) participated in Spain; 96% were below retirement age and of these, 45% were employed. Employment was related to disability, and MS affected productivity at work for 72% of those working. Overall, 92% and 64% of patients experienced fatigue and cognitive difficulties as a problem, respectively. Mean utility and total annual costs were estimated at 0.772 and €20,600 at Expanded Disability Status Scale (EDSS) 0–3, 0.486 and €48,500 at EDSS 4–6.5 and 0.182 and €68,700 at EDSS 7–9, respectively. The mean cost of a relapse was €2050. Conclusion: This study illustrates the burden of MS on Spanish patients and provides current data that are important for development of health policies.

Background: To estimate the value of treatments in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with cost data. This, in turn, requires that cost data be regularly updated. Objectives and Methods: This study is part of a cross-sectional retrospective study in 16 countries collecting current data on resource consumption, work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in 2015 Danish Kronor (DKK). Results: A total of 830 patients (mean age of 54 years) participated; 78% were below retirement age and of these, 43% were employed. Employment was related to disease severity, and MS was felt to affect productivity at work by 73% of patients, most often through fatigue. Overall, 95% and 65% of patients felt that fatigue and cognition, respectively, were a problem. Mean utility and costs were 0.770 and 196,900DKK at Expanded Disability Status Scale (EDSS) 0–3, 0.619 and 287,300DKK at EDSS 4–6.5, and 0.302 and 533,250DKK at EDSS 7–9. The average cost of a relapse was estimated at 19,000DKK. Conclusion: This study illustrates the burden of MS on Danish patients and provides current data that are important for the development of health policies.

Whitebark pine (Pinus albicaulis Engelm.) is a widely distributed high-elevation species in western North America that is threatened primarily by an introduced disease and other disturbances. In British Columbia, this tree is a component of harvested forests, yet knowledge of post-harvest survivorship and factors that promote successful retention is lacking. Our objectives are to describe the temporal attrition of retained mature whitebark pine trees and to identify factors that likely influence survivorship during the critical initial post-harvest period. We assessed five separate harvest units in southeastern British Columbia. Dendrochronological investigation revealed that retained trees experienced high annual mortality rates (3–16%) across harvest sites during the initial five-year post-harvest period. By eight years post-harvest, retention survivorship ranged from 17–80%. After eight years post-harvest, mortality rates drastically declined. The preponderance of fallen stems oriented towards the northeast suggests that storm system events arriving from the Pacific Ocean are the most significant drivers of blowdown. We estimate that survivorship is positively associated with shorter tree heights and longer crown lengths, a lack of disease cankers, a greater presence of rodent wounding, and higher numbers of surrounding retained trees. We found little effect based on slope and aspect. As these trees are an endangered species, harvest operations should be practiced cautiously in associated forests. We recommend carefully selecting retention trees, ensuring an adequate number of neighbor trees, and orienting retention patches to avoid predominant storm wind directions.

Background There is limited information on drivers of utilities in patients with chronic heart failure (CHF). Objectives To analyze determinants of utility in CHF and drivers of change over 1 year in a large sample from clinical practice. Methods We included 5334 patients from the Swedish Heart Failure Registry with EuroQol five-dimensional questionnaire information available following inpatient or outpatient care during 2008 to 2010; 3495 had 1-year follow-up data. Utilities based on Swedish and UK value sets were derived. We applied ordinary least squares (OLS) and two-part models for utility at inclusion and OLS regression for change over 1 year, all with robust standard errors. We assessed the predictive accuracy of both models using cross-validation. Results Patients' mean age was 73 years, 65% were men, 19% had a left ventricular ejection fraction of 50% or more, 23% had 40% to 49%, 27% had 30% to 39%, and 31% had less than 30%. For both models and value sets, utility at inclusion was affected by sex, age, New York Heart Association class, ejection fraction, hemoglobin, blood pressure, lung disease, diabetes, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, nitrates, antiplatelets, and diuretics. The OLS model performed slightly better than did the two-part model on a population level and for capturing utility ranges. Change in utility over 1 year was influenced by age, sex, and (measured at inclusion) disease duration, New York Heart Association class, blood pressure, ischemic heart disease, lung disease, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and antiplatelets. Conclusions Utilities in CHF and their change over time are influenced by diverse demographic and clinical factors. Our findings can be used to target clinical interventions and for economic evaluations of new therapies.

Objectives To assess the association between fatigue, cognition, domains of the EuroQol five-dimensional questionnaire (EQ-5D-3L), disability, and utilities estimated with several Western European value sets in patients with multiple sclerosis (MS). Methods Data from a multinational, cross-sectional, observational study of patients with MS (N = 16,808) conducted in 16 European countries were used. Health-related quality of life data were collected through the EQ-5D-3L, and fatigue and cognitive difficulties were self-assessed on a 10-point visual analogue scale. Associations were assessed using Pearson correlation and multivariate regression model. Results Symptoms of fatigue and cognitive difficulties were present in 90% and 70% of patients at all levels of disability, respectively, and thus only weakly correlated to disability. Problems in the EQ-5D-3L domains were common even at mild disability levels. Mobility, usual activities, and pain issues were experienced by 80% to 90% of patients with moderate and high levels of disability. Mobility, usual activities, and self-care were strongly correlated to disability. Disability, MS type, fatigue, and cognition were associated with utility in regression models, although the coefficients of fatigue and cognition were small. Conclusions The strong relationship of disability with utility was confirmed. Despite this, fatigue and cognitive difficulties were associated with utility estimated with different European value sets.

Introduction: To estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, in the societal perspective, in EUR 2015. Results: A total of 491 patients (mean age 47 years) participated; 82% were below retirement age, and of these 56% were employed. Employment was related to disease severity, and MS affected productivity at work for 90% of patients. Overall, 95% and 67% of patients experienced fatigue and cognition as a problem, respectively. The mean utility and annual costs were 0.735 and €22,600 at Expanded Disability Status Scale (EDSS) 0–3, 0.500 and €38,100 at EDSS 4–6.5, and 0.337 and €48,100 at EDSS 7–9, respectively. The average cost of a relapse was estimated at €2300. Conclusion: This study provides current data on MS in France that are important for developments of health policies and to estimate the value of current and future treatments.

Background: In order to assess the value of management strategies in multiple sclerosis (MS), outcome data have to be combined with cost data. This, in turn, requires that cost data be regularly updated. Objective and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting current data on resource consumption, work capacity and health-related quality of life (HQoL). Descriptive analyses are presented by level of severity; costs are estimated in the societal perspective, in RUB 2015. Results: A total of 208 patients (mean age: 38.5 years) participated in the Russian study; 97% were below retirement age, and of these, 49% were employed. MS was reported to affect productivity at work in 63% of patients. Overall, 87% and 41% of patients felt that fatigue and cognition were a problem. The mean utility and costs were 0.769 and 578,000 RUB at Expanded Disability Status Scale (EDSS) 0–3, 0.509 and 826,000 RUB at EDSS 4–6.5, and 0.071 and 1,013,000 RUB at EDSS 7–9. The average cost of a relapse was 33,000 RUB. Conclusion: This study illustrates the burden of MS on Russian patients and provides current data that are important for developing health policies.

Introduction: In order to estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015. Results: A total of 1856 patients (mean age: 54 years) participated in Belgium; 66% were below retirement age, and of these, 44% were employed. Employment was related to disease severity, and MS affected productivity at work in 85% of the patients. Overall, 95% and 72% of the patients experienced fatigue and cognitive difficulties, respectively, as a problem. Mean utility and annual costs were 0.703 and €26,400 at Expanded Disability Status Scale (EDSS) 0–3, 0.478 and €45,300 at EDSS 4–6.5, and 0.193 and €62,000 at EDSS 7–9. The mean cost of a relapse was estimated to be €3000. Conclusion: This study provides current data on MS in Belgium that are important for development of health policies and for estimating the value of current and future treatments.

Introduction: To estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objectives and methods: This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015. Results: A total of 5475 patients (mean age 52 years) participated in Germany. In all, 84% were below retirement age, and of these, 51% were employed. Employment was related to disease severity, and MS affected productivity at work for 80% of patients. Overall, 96% and 78% of patients experienced fatigue and cognitive difficulties as a problem, respectively. The mean utility and total annual costs were 0.786 and 28,200€ at Expanded Disability Status Scale (EDSS) 0–3, 0.586 and €44,000 at EDSS 4–6.5 and 0.273 and €62,700 at EDSS 7–9, respectively. The mean cost of a relapse was estimated at €2500. Conclusion: This study provides current health economic data on MS in Germany that are important for the development of health policies and for estimating the value of the current and future treatments.

Background: In order to estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated. Objective and methods: This study is part of a cross-sectional retrospective study in 16 European countries collecting current data on resource consumption, work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in 2015 Polish Zloty (PLN). Results: A total of 411 MS patients (mean age = 40 years) participated in Poland; 94% were below retirement age, and of these, 59% were employed. Employment was related to disability, and MS affected productivity for 85% of those working. Overall, 97% and 71% of patients experienced fatigue and cognition as important problems, respectively. Mean utility and total annual costs were 0.686 and 48,700 PLN at Expanded Disability Status Scale (EDSS) 0–3, 0.521 and 59,200 PLN at EDSS 4–6.5 and 0.208 and 81,600 PLN at EDSS 7–9, respectively. The average cost of a relapse was 3,900 PLN. Conclusion: This study illustrates the burden of MS on Polish patients and provides current data that are important for developing health policies.

The western spruce budworm (WSB), Choristoneura occidentalis Freeman), a defoliator of conifers in western North America, causes severe timber losses to forests. In British Columbia, Canada, where the main species damaged is Douglas-fir, Pseudotsuga menziesii (Mirb.) Franco, outbreaks of C. occidentalis have been recorded since 1909. However, there is little information on the frequency of outbreaks of this defoliator for previous centuries. This information is needed to establish baselines defining the historic range of variability of this disturbance, to calculate potential depletions in timber supply from defoliation, and to refine forest management plans. Also, precise estimates of budworm recurrence are needed to assess potential ecosystem changes and possible departures from the historic range of this disturbance due to global warming. We used dendrochronology and time series analysis to determine past frequency of spruce budworm outbreaks in southern BC and found that, since the 1500s, outbreaks have been periodic, with a mean return interval of 28 years (95% Confidence Interval 21–35 years). No data was available before the 1500s. We found the number of outbreaks per century, since the 1800s, was fairly constant, with 3–4 outbreaks per century.

Introduction Although insulin is one of the most effective interventions for the treatment of type 2 diabetes, its disadvantages incur substantial medical cost. This study was designed to evaluate the medical costs of Swedish type 2 diabetic patients initiating insulin on top of metformin and/or sulfonylurea (SU), and to evaluate if costs before and after insulin initiation differ for patients where insulin is initiated above or below the recommended glycosylated hemoglobin (HbA1c) level (7.5%). Methods This was a register-based retrospective cohort study in which patients were identified from the Sörmland county council diabetes register. Patients being prescribed at least one prescription of metformin and/or SU from 2003 to 2010, and later prescribed insulin, were included. Results One hundred patients fulfilled the inclusion criteria and had at least 1 year of follow-up. The mean age was 61 years and 59% of patients were male. Mean time since diagnosis was 4.1 years, and since initiation of insulin was 2.2 years. The mean HbA1c level at index date was 8.0%. Total mean costs for the whole cohort were SEK 17,230 [standard deviation (SD) 17,228] the year before insulin initiation, and SEK 31,656 (SD 24,331) the year after insulin initiation (p

Introduction:In order to estimate the value of interventions in multiple sclerosis (MS) – where lifetime costs and outcomes cannot be observed – outcome data have to be combined with costs. This requires that cost data be regularly updated.Objectives and methods:This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption and work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015.Results:A total of 1010 patients (mean age = 45 years) participated in Italy. In total, 94% were below retirement age, and of these, 56% were employed. Employment was related to disability, and MS affected productivity at work in 77% of the patients. Overall, 96% and 65% of the patients experienced fatigue and cognitive difficulties as a problem, respectively. Mean utility and total annual costs were 0.735 and €22,900 at Expanded Disability Status Scale (EDSS) of 0–3, 0.534 and €40,100 at EDSS of 4–6.5, and 0.135 and €53,300 at EDSS of 7–9. The mean cost of a relapse was estimated to be €2600.Conclusion:This study illustrates the burden of MS on Italian patients and provides current data on MS that are important for the development of health policies.

Objective To estimate the cost-effectiveness of a new treatment (natalizumab) for multiple sclerosis (MS) compared with current standard therapy with disease-modifying drugs (DMDs) in Sweden. Methods A Markov model was constructed to illustrate disease progression based on functional disability (the Expanded Disability Status Scale (EDSS)). The effectiveness of natalizumab was based on a 2-year clinical trial in 942 patients (AFFIRM). The effectiveness of current DMDs was estimated from a matched sample of 512 patients in the Stockholm MS registry. Patients withdrawing from treatment were assumed to follow the disease course of 824 patients with relapsing–remitting disease at onset in the Ontario natural history cohort. Costs and utilities are based on a recent observational study in 1339 patients. All data sets were available at the patient level. Main results are presented from the societal perspective, over a 20-year time frame, in 2005 Euros (€1 = 9.25 SEK). Results In the base case, treatment with natalizumab was less expensive and more effective than treatment with current DMDs. When only healthcare costs were considered, the cost per quality-adjusted life year gained with natalizumab was €38 145. Results are sensitive only to the time horizon of the analysis and assumptions about effectiveness of natalizumab beyond the trial. Conclusions This cost-effectiveness analysis used registry data, cohort and observational studies to extrapolate the efficacy findings of natalizumab from the AFFIRM clinical trial to measure effectiveness in clinical practice. The analysis results suggest that for the population considered, natalizumab provides an additional health benefit at a similar cost to current DMDs from a societal perspective.

Objective To collect new primary data on community-based health utilities (time trade-off values) in different stages of mild cognitive impairment and dementia from a general population sample. Methods A cross-sectional study including 1,800 randomly selected members of the Swedish public aged 45–84 was performed through a postal survey; 42% response rate. The Clinical Dementia Rating scale was used for describing progressive stages of dementia in vignettes that were used in combination with time trade-off questions for valuing the perceived quality of life in these stages. Results The time-trade off values varied considerably across the progressive disease stages. The mean score was 0.82 for mild cognitive impairment, 0.62 for mild dementia, 0.40 for moderate dementia, and 0.25 for severe dementia. In multiple regression analyses, the scores were relatively insensitive to demographic factors like age, gender and self-assessed health. Conclusions The results showed that the average time trade-off values declined sharply from mild cognitive impairment to progressing stages of dementia. Since there are many methodological challenges involved in measuring health state utilities in mild cognitive impairment and dementia, more research that evaluates different methods would be welcome. Copyright © 2006 John Wiley & Sons, Ltd.

The objective of this observational study in nine European countries was to establish the current cost of MS at different levels of disease severity. The study used a prevalence-based bottom-up to estimate costs from a societal perspective. Patients were recruited via patient organizations and neurology centres and asked by mail to complete a detailed questionnaire concerning their resource consumption, work capacity, quality of life and current disease status. Resources included all health-care and social services, personal expenditures, informal care and temporary or definitive work absence. Quality of life was collected as utility and disease information collected related to functional capacity, relapses and fatigue. The data were analyzed separately for each country, using local unit costs but a fully standardized methodology. A total of 13 186 patients at all levels of disease severity participated in the survey, with an average response rate of around 40% (range 20-75%). This paper describes the methodology used for the study, while results are presented in the individual country reports.

This cost-of-illness analysis is based on information from 1.848 patients in Spain and is part of a Europe-wide study on the costs of multiple sclerosis. The objective was to analyze the costs and quality of life (QOL) related to the level of disease severity and progression. Patients were identified by the Asociación Española de Esclerosis Múltiple (AEDEM) and participated in the survey by answering a mail questionnaire (response rate 31.8%). In addition to details on the disease (type of disease, relapses, level of functional disability), the questionnaire asked for information on all resource consumption, medical, non-medical, work absence and informal care, as well as utility (QOL). The mean age of the cohort was 45 years, and only 5.5% of patients were 65 years of age or more. Approximately 36% of patients had mild disease (Expanded Disability Status Scale [EDSS] score of 0-3), 44.8% had moderate disease (EDSS score of 4-6.5) and 17.7% had severe disease (EDSS scoreor =7). The mean EDSS score in the sample was 4.5 (median 5.0), with a utility of 0.554. Costs and utility are highly correlated with disease severity. Workforce participation decreases from around 70% in early disease to less than 5% in the very late stages. Hospitalization is very infrequent in early disease, representing less than euro 1.300 per patient per year for patients at EDSS scores6, but increases steeply for patients at scoresor =7. Ambulatory care increases fivefold between early and late disease, while investments and services increase from basically no cost to just over euro 6.000 at EDSS scoresor =7. Productivity losses increase more than eightfold, and informal care increases from euro 593 at EDSS scores of 0-1 to nearly euro 34.228 at scores of 8-9. Hence, total mean costs per patient are driven by the distribution of the severity levels in the sample, increasing from euro 10.425 at EDSS scores of 0-1 to euro 45.264 at a score of 7, and euro 65.693 at scores of 8-9. The same is true for utility, which decreases from 0.865 to 0.084 as patients progress from the mildest to the most severe disability levels. However, the utility loss compared to the age- and gender-matched general population is high at all levels of the disease ( approximately 0.25 in patients below 30 years of age with an EDSS score of 2-3, and approximately 0.4 in patients over 60 years of age and a score ofor =6), leading to an estimated annual loss of 0.276 quality-adjusted life-year per patient. Relapses for patients with an EDSS score below 5 are associated with a cost of approximately euro 2.750 and a utility loss of 0.1 during the quarter in which they occur.

The authors propose a theoretical sequence for the psychological development of couples from narcissistic, autistic-contiguous and paranoid-schizoid levels to depressive position functioning. The authors illustrate their observations with vignettes from couple therapy with a husband and wife who are dealing with the impact of a third on their fragile relationship, initially in the form of their baby, subsequently his lover and lastly the couple therapist. They show how dealing with resistance and transference enables the couple to give up a shared manic defence, grieve together and move along the developmental levels to achieve a more satisfying reality. Copyright © 2004 Whurr Publishers Ltd.

Genetic factors influence susceptibility to multiple sclerosis but the responsible genes remain largely undefined, association with MHC class II alleles being the only established genetic feature of the disease. The Nordic countries have a high prevalence of multiple sclerosis, and to further explore the genetic background of the disease, we have carried out a genome-wide screen for linkage in 136 sibling-pairs with multiple sclerosis from Denmark, Finland, Norway and Sweden by typing 399 microsatellite markers. Seventeen regions where the lod score exceeds the nominal 5% significance threshold (0.7) were identified-1q11-24, 2q24-32, 3p26.3, 3q21.1, 4q12, 6p25.3, 6p21-22, 6q21, 9q34.3, 10p15, 10p12-13, 11p15.5, 12q21.3, 16p13.3, 17q25.3, 22q12-13 and Xp22.3. Although none of these regions reaches the level of genome-wide significance, the number observed exceeds the 10 that would be expected by chance alone. Our results significantly add to the growing body of linkage data relating to multiple sclerosis.