Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective

Abstract

Objectives: Atrial fibrillation (AF) is the most common arrhythmia and a major marker of ischemic stroke risk. Early detection is crucial and, once diagnosed, anticoagulation therapy can be initiated to reduce stroke risk. The aim of this study was to assess the cost-effectiveness of employing an insertable cardiac monitor (ICM), BIOMONITOR, for the detection of AF compared to standard of care (SoC) ECG and Holter monitoring in patients with cryptogenic stroke, that is, stroke of unknown origin and where paroxysmal, silent AF is suspected.

Materials and methods: A Markov model was developed which consisted of five main health states reflecting the potential lifetime evolution of the AF disease: post cryptogenic stroke (index event), subsequent mild, moderate and severe stroke, and death. Sub-states were included to track a patient’s AF diagnostic status and the use of antiplatelet or anticoagulant therapy. AF detection was assumed to result in a treatment switch from aspirin to anticoagulants, except among those with a history of major bleeding. Detection yield and accuracy, clinical actions and treatment effects were derived from the literature and validated by an expert clinician. All relevant costs from a US Medicare perspective were included.

Results and conclusions: An ICM-based strategy was associated with a reduction of 37 secondary ischemic strokes per 1000 patients monitored compared with SoC. Total per-patient costs with an ICM were higher (US$90,052 vs. US$85,157) although stroke-related costs were reduced. The use of an ICM was associated with a base-case incremental cost-effectiveness ratio of US$18,487 per life year gained compared with SoC and US$25,098 per quality-adjusted life year gained, below established willingness-to-pay thresholds. The conclusions were found to be robust over a range of input values. From a US Medicare perspective the use of a BIOMONITOR ICM represents a cost-effective diagnostic strategy for patients with cryptogenic stroke and suspected AF.     

The Political Economy of Argentina's Debacle

In this paper I argue that political economy considerations and, in particular, the identity of the reformers, are central to understanding the Argentine crisis that culminated in sovereign default in January 2002. During the 1990s, the main political parties remained attached to populism, and no strong party emerged at the center of the political spectrum. This had two effects in the reform process. First, it severely deteriorated it (efficiency, corruption), reducing the support of the population. Second, when a series of shocks hit the economy the anti‐reform camp tried to undo most reforms, and thus convey a message to the population about the “right” model of the world.     

Estimation of the Natural Unemployment Rate in the Russian Federation, 1994–2004

To specify the problem of unemployment in Russia, we estimate the natural rate of unemployment by consecutively estimating the optimal size of the labour force and the optimal employment. For estimation of the optimal values we used a modified Hodrick–Prescott filter technique. The results show that the natural rate of unemployment in Russia during 1994–97 was stable around 13–13.5% and decreased to 7.1% by mid-2004. Moreover, before 1998 the actual unemployment was significantly lower than the natural rate and today practically equals it.     

International law as a moral theory of state territory?

Current states face challenges from other states and secessionist movements, and no moral theory exists to evaluate these conflicting claims. One step towards a theory is to evaluate international law on territory, specifically as articulated through decolonisation. I argue that international law does not provide a plausible moral theory of territory because the principles of territorial integrity and uti possidetis cannot coherently coexist with the principle of self‐determination. I suggest that philosophers must choose between viewing territory as an expression of national self or as a property right, or else develop a third view from sources beyond current international law.     

Leave the Lemons at Home: Towards a Political Ecology of Border Space

This paper presents a political ecology approach to the study of borders through consideration of a lemon's travels in contemporary North American border space. Following discussion of recent work on the dynamic, multi-scalar, and process-based character of modern borders, I suggest that such critical approaches could be usefully augmented by drawing on ideas about socio-material networks advanced by Bruno Latour. By adopting a political ecology framework, border scholars would be able to consider more fully the materiality of borders and bordering processes. Through the example of the lemon, I demonstrate that in constructing the fruit as a particular socio-material artifact that embodies multiple threats to US national space, it and its carrier become implicated in the regulation of political-economic and geopolitical networks that are seemingly far removed from the object of concern.     

‘Wiped From the Map of the World’? Zanzibar,Critical Geopolitics and Language

This essay uses the case of Zanzibar in its complicated relationship with the United Republic of Tanzania (of which it is a part) as a lens on debates in political geography on empirical and conceptual approaches to critical geopolitics. We test the veracity of a multi-faceted critical geopolitics in the contemporary public contestation of Zanzibar's place in the United Republic from 2008–2012. We analyze Tanzanian media, the speech acts of Tanzanian leaders, and the key events and processes related to what is termed the ‘Zanzibar problem’ during the selected years, to make two points about a critical geopolitics approach: to strengthen critical geopolitics by broadening the analysis of language to engage political acts and languages beyond the Global North; and taking ‘subaltern geopolitics’ more seriously via engagement with critical geopolitical voices on discourses, events and processes from the Global South.     

Watching out for regional separatism in the Russian far East: Ideological cueing of territorial security,economic incentives and cultural identity

Why has regional separatism failed to materialise in the post‐Soviet Russian Far East despite the region's remoteness from Russia's European heartland, its proximity to the Pacific Rim economies, the decline of economic support from Moscow, and a ‘frontier’ culture of resistance to Moscow's rule? Focusing on political developments in Primorskii Krai ‐ the key frontier province in the Russian Far East ‐ the study finds that territorial security, economic incentives, and cultural identity affect proclivities for regional separatism selectively, depending on ideological and institutional constraints in which centre‐periphery relations are embedded. In the absence of ideological commitments and enforceable institutional rales and norms, centre‐periphery conflicts devolve into economic bargaining and rule‐manipulation by elites for quick material gains. The changing ideological context amidst post‐Soviet institutional transition in Russia provide the most consistent explanation of conflict dynamic between Primorskii Krai's leaders and Moscow, of the non‐emergence of regional separatism, and of gross economic mismanagement of the province.     

A spatial analysis of R&D: the role of industry proximity

This paper employs individual firm data in order to check the existence of industry-spatial effects alongside other microeconomic determinants of R&D investment. Spatial proximity is defined by a measure of firms’ industry distance based on trade intensity between sectors. The spatial model specified here refers to the combined spatial-autoregressive model with autoregressive disturbances. In modelling the outcome for each location as dependent on a weighted average of the outcomes of other locations, outcomes are determined simultaneously. The results of the spatial estimation suggest that in their R&D decision firms benefit from spillovers originating from neighbouring industries.     

Measuring Socio-Economic GENDER Inequality: Toward an Alternative to the UNDP Gender-Related Development Index

This paper assesses the United Nations Development Program’s (UNDP) Gender-Related Development Index (GDI). Although the GDI has increased attention on gender equality in human development, it suffers from several limitations. A major problem is that it conflates relative gender equality with absolute levels of human development and thus gives no information on comparative gender inequality among countries. Using the same indicators as the GDI, the paper constructs a Relative Status of Women (RSW) index, which demonstrates how using a measure of gender equality that abstracts from levels of development results in very different country rankings. However, the RSW is not an ideal measure of gender inequality. The GDI indicators are not the most appropriate ones for measuring gender inequality and hence both the RSW and the GDI have limited validity. The paper concludes by offering a conceptual framework that provides the basis for an alternative measure of gender inequality.