Τhe current paper examines the relationship between per capita health care expenditures, per capita CO₂ emissions, and per capita gross domestic product (GDP) in G7 countries. At the beginning, we examine the cross-sectional dependence and the slope homogeneity between the countries. Then, the second-generation unit root test is applied using the Pesaran, CIPS (2007) test, while for the cointegration test, the Westerlund (Oxford Bulletin of Economics and Statistics 69(6):709-748, 2007) test was applied. The long -run panel cointegration coefficients were analyzed with the augmented mean group (AMG) estimators, which allow the cross-sectional dependence and heterogeneity. Finally, the test by Dumitrescu and Hurlin (Economic Modelling 29(4):1450-1460, 2012) was used in order to check for causality taking into account the heterogeneity and cross-sectional dependence on panel data. The preliminary analyses show that variables are cross-sectional-dependant and heterogenous and are first-order stationary. Cointegration test by Westerlund (Oxford Bulletin of Economics and Statistics 69(6):709-748, 2007) which allows heterogeneity and cross-sectional dependence show that there is a stable and long-run relationship between variables. Moreover, the long-run coefficients which were estimated with the AMG approach are found to be statistically significant and positive for the GDP per capita, and negative in the case of greenhouse gas emissions per capita. Finally, causality test by Dumitrescu and Hurlin (Economic Modelling 29(4):1450-1460, 2012) revealed a unilateral causality from greenhouse gas emissions per capita towards health expenditure per capita for all G7 countries.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet

Background: Rotator cuff-related shoulder pain is very common, but there is uncertainty regarding which modes of exercise delivery are optimal and the long-term benefits of corticosteroid injections.Objectives: To assess the clinical effectiveness and cost-effectiveness of progressive exercise compared with best-practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.Design: This was a pragmatic multicentre superiority randomised controlled trial (with a 2 × 2 factorial design).Setting: Twenty NHS primary care-based musculoskeletal and related physiotherapy services.Participants: Adults aged ≥ 18 years with a new episode of rotator cuff-related shoulder pain in the previous 6 months.Interventions: A total of 708 participants were randomised (March 2017–May 2019) by a centralised computer-generated 1 : 1 : 1 : 1 allocation ratio to one of four interventions: (1) progressive exercise (n = 174) (six or fewer physiotherapy sessions), (2) best-practice advice (n = 174) (one physiotherapy session), (3) corticosteroid injection then progressive exercise (n = 182) (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (n = 178) (one physiotherapy session).Main outcome measures: The primary outcome was Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes included SPADI subdomains, the EuroQol 5 Dimensions, five-level version, sleep disturbance, fear avoidance, pain self-efficacy, return to activity, Global Impression of Treatment and health resource use. Outcomes were collected by postal questionnaires at 8 weeks and at 6 and 12 months. A within-trial economic evaluation was also conducted. The primary analysis was intention to treat.Results: Participants had a mean age of 55.5 (standard deviation 13.1) years and 49.3% were female. The mean baseline SPADI score was 54.1 (standard deviation 18.5). Follow-up rates were 91% at 8 weeks and 87% at 6 and 12 months. There was an overall improvement in SPADI score from baseline in each group over time. Over 12 months, there was no evidence of a difference in the SPADI scores between the progressive exercise intervention and the best-practice advice intervention in shoulder pain and function (adjusted mean difference between groups over 12 months –0.66, 99% confidence interval –4.52 to 3.20). There was also no difference in SPADI scores between the progressive exercise intervention and best-practice advice intervention when analysed at the 8-week and 6- and 12-month time points. Injection resulted in improvement in shoulder pain and function at 8 weeks compared with no injection (adjusted mean difference –5.64, 99% confidence interval –9.93 to –1.35), but not when analysed over 12 months (adjusted mean difference –1.11, 99% confidence interval –4.47 to 2.26), or at 6 and 12 months. There were no serious adverse events. In the base-case analysis, adding injection to best-practice advice gained 0.021 quality-adjusted life-years (p = 0.184) and increased the cost by £10 per participant (p = 0.747). Progressive exercise alone was £52 (p = 0.247) more expensive per participant than best-practice advice, and gained 0.019 QALYs (p = 0.220). At a ceiling ratio of £20,000 per quality-adjusted life-year, injection plus best-practice advice had a 54.93% probability of being the most cost-effective treatment.Limitations: Participants and physiotherapists were not blinded to group allocation. Twelve-month follow-up may be insufficient for identifying all safety concerns.Conclusions: Progressive exercise was not superior to a best-practice advice session with a physiotherapist. Subacromial corticosteroid injection improved shoulder pain and function, but provided only modest short-term benefit. Best-practice advice in combination with corticosteroid injection was expected to be most cost-effective, although there was substantial uncertainty.Future work: Longer-term follow-up, including any serious adverse effects of corticosteroid injection.Trial registration: Current Controlled Trials ISRCTN16539266 and EudraCT 2016-002991-28.Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 25, No. 48. See the NIHR Journals Library website for further project information.

In academic discussions about how to achieve sustainable growth in the world, it is stated that this is not possible without spending on research and development and innovative activities so that countries can maintain their competitiveness in the global environment. The EU has defined strategies that consider innovation as a key element for stimulating growth and creatung employment. In this context, this study examines the relationship between R&D expenditures and the global innovation index in the scope of EU countries. A PVAR model and annual data from 2007 to 2020 were used for the relationship between research expenditures and growth in the innovation of EU countries. We first examined the cross-sectional and cross-country homogeneity of slopes. The second-generation unit root test was then applied using the Pesaran CIPS (2007) test, and the ARDL panel model was applied to test for cointegration. Causal analyses with the panel ARDL model and the error correction model were applied to determine the relationships of the variables and their direction. For the long-term dynamic effects between variables, an impulse response function (IRF) was used, and for the degree of the effect between R&D expenditures and the global innovation index, variance decomposition was used. The results of this paper reveal a long-term positive significant relationship between R&D spending and the global innovation index, whereas in the short-term, this relationship is negative. Furthermore, the causality results of the error correction ARDL model show unidirectional short-run and long-run causality from research and development to the global innovation index in EU countries. Finally, this paper enhances the understanding of the relationship between research and development spending and the global innovation index in EU countries.

Background: The best treatment for fractures of the distal tibia remains controversial. Most of these fractures require surgical fixation, but the outcomes are unpredictable and complications are common.Objectives: To assess disability, quality of life, complications and resource use in patients treated with intramedullary (IM) nail fixation versus locking plate fixation in the 12 months following a fracture of the distal tibia.Design: This was a multicentre randomised trial.Setting: The trial was conducted in 28 UK acute trauma centres from April 2013 to final follow-up in February 2017.Participants: In total, 321 adult patients were recruited. Participants were excluded if they had open fractures, fractures involving the ankle joint, contraindication to nailing or inability to complete questionnaires.Interventions: IM nail fixation (n = 161), in which a metal rod is inserted into the hollow centre of the tibia, versus locking plate fixation (n = 160), in which a plate is attached to the surface of the tibia with fixed-angle screws.Main outcome measures: The primary outcome measure was the Disability Rating Index (DRI) score, which ranges from 0 points (no disability) to 100 points (complete disability), at 6 months with a minimum clinically important difference of 8 points. The DRI score was also collected at 3 and 12 months. The secondary outcomes were the Olerud–Molander Ankle Score (OMAS), quality of life as measured using EuroQol-5 Dimensions (EQ-5D), complications such as infection, and further surgery. Resource use was collected to inform the health economic evaluation.Results: Participants had a mean age of 45 years (standard deviation 16.2 years), were predominantly male (61%, 197/321) and had experienced traumatic injury after a fall (69%, 223/321). There was no statistically significant difference in DRI score at 6 months [IM nail fixation group, mean 29.8 points, 95% confidence interval (CI) 26.1 to 33.7 points; locking plate group, mean 33.8 points, 95% CI 29.7 to 37.9 points; adjusted difference, 4.0 points, 95% CI –1.0 to 9.0 points;p = 0.11]. There was a statistically significant difference in DRI score at 3 months in favour of IM nail fixation (IM nail fixation group, mean 44.2 points, 95% CI 40.8 to 47.6 points; locking plate group, mean 52.6 points, 95% CI 49.3 to 55.9 points; adjusted difference 8.8 points, 95% CI 4.3 to 13.2 points;p < 0.001), but not at 12 months (IM nail fixation group, mean 23.1 points, 95% CI 18.9 to 27.2 points; locking plate group, 24.0 points, 95% CI 19.7 to 28.3 points; adjusted difference 1.9 points, 95% CI –3.2 to 6.9 points;p = 0.47). Secondary outcomes showed the same pattern, including a statistically significant difference in mean OMAS and EQ-5D scores at 3 and 6 months in favour of IM nail fixation. There were no statistically significant differences in complications, including the number of postoperative infections (13% in the locking plate group and 9% in the IM nail fixation group). Further surgery was more common in the locking plate group (12% in locking plate group and 8% in IM nail fixation group at 12 months). The economic evaluation showed that IM nail fixation provided a slightly higher quality of life in the 12 months after injury and at lower cost and, therefore, it was cost-effective compared with locking plate fixation. The probability of cost-effectiveness for IM nail fixation exceeded 90%, regardless of the value of the cost-effectiveness threshold.Limitations: As wound dressings after surgery are clearly visible, it was not possible to blind the patients to their treatment allocation. This evidence does not apply to intra-articular (pilon) fractures of the distal tibia.Conclusions: Among adults with an acute fracture of the distal tibia who were randomised to IM nail fixation or locking plate fixation, there were similar disability ratings at 6 months. However, recovery across all outcomes was faster in the IM nail fixation group and costs were lower.Future work: The potential benefit of IM nail fixation in several other fractures requires investigation. Research is also required into the role of adjuvant treatment and different rehabilitation strategies to accelerate recovery following a fracture of the tibia and other long-bone fractures in the lower limb. The patients in this trial will remain in longer-term follow-up.Trial registration: Current Controlled Trials ISRCTN99771224 and UKCRN 13761.Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 22, No. 25. See the NIHR Journals Library website for further project information.

Surgery for nail bed injuries in children is common. One of the key surgical decisions is whether to replace the nail plate following nail bed repair. The aim of this RCT was to assess the clinical effectiveness and cost-effectiveness of nail bed repair with fingernail replacement/substitution compared with repair without fingernail replacement. A two-arm 1 : 1 parallel-group open multicentre superiority RCT was performed across 20 secondary-care hospitals in the UK. The co-primary outcomes were surgical-site infection at around 7 days after surgery and cosmetic appearance summary score at a minimum of 4 months. Some 451 children presenting with a suspected nail bed injury were recruited between July 2018 and July 2019; 224 were allocated to the nail-discarded arm, and 227 to the nail-replaced arm. There was no difference in the number of surgical-site infections at around 7 days between the two interventions or in cosmetic appearance. The mean total healthcare cost over the 4 months after surgery was €84 (95 per cent c.i. 34 to 140) lower for the nail-discarded arm than the nail-replaced arm (P < 0.001). After nail bed repair, discarding the fingernail was associated with similar rates of infection and cosmesis ratings as replacement of the finger nail, but was cost saving. Registration number: ISRCTN44551796 (http://www.controlled-trials.com).