A multinational economic evaluation of rhDNase in the treatment of cystic fibrosis

Economic evaluations of pharmaceuticals are increasingly being conducted in conjunction with randomized phase III clinical trials to meet the demand for pharmacoeconomic data when new products are launched. While the need for such data is often global, the trials in which relevant information may be collected are often conducted in only one or a limited number of countries. A critical issue is how data from pivotal clinical trials in one setting can serve as the basis for pharmacoeconomic evaluations in others. We address this issue and report on four economic evaluations that we undertook in conjunction with a recent U.S. phase III clinical trial of recombinant human deoxyribonuclease (rhDNase), which is used to improve pulmonary function in patients with cystic fibrosis (CF). The objective of these evaluations was to estimate the potential impact of rhDNase therapy in France, Germany, Italy, and the United Kingdom on the direct costs of medical care for the treatment of respiratory tract infections (RTIs) in patients with CF. Analyses of economic impact were undertaken both with and without adjustment for differences in practice patterns between the United States and the countries of interest. Our findings suggest that rhDNase therapy may reduce the cost of RTI-related care by between US$600 and US$1,100 over a 24-week period; the cost of rhDNase is not included in these figures, as a price was unavailable when our analyses were undertaken. Despite methodologic challenges, economic evaluations that meet the information needs of decision makers in diverse countries can nonetheless be undertaken in conjunction with phase III clinical trials.

Hepatitis B immunisation among invasive cardiologists: poor compliance with United Kingdom guidelines

OBJECTIVES

To assess the compliance of invasive cardiologists in the United Kingdom with recently accepted national guidelines on the protection of health care workers and patients from hepatitis B. To determine levels of awareness of the infectivity and prevalence of the virus and current attitudes towards screening of patients before cardiac catheterisation and surgery.

DESIGN

Anonymous postal survey by questionnaire from the University Hospital of Wales, Cardiff. The questionnaire established the respondent's position, knowledge of hepatitis B, current immunological state, and policy towards the routine screening of patients for hepatitis B carriage.

PARTICIPANTS

All British cardiologists of consultant or senior registrar grade involved in invasive procedures.

RESULTS

The response rate was 78% (211/271). 20% of respondents had never been vaccinated against hepatitis B and about a third of those vaccinated had not complied correctly with the recommended immunisation regimen. There was little uniformity in practices for screening patients for hepatitis B carriage before invasive procedures, and the level of knowledge concerning the prevalence of hepatitis B and the risks of inoculation was poor.

CONCLUSIONS

Invasive cardiologists are at high risk of inoculation with hepatitis B. Nationally agreed guidelines are designed to protect both medical staff and patients against the risk of infection but currently they are ill heeded.

A closer look at gender and distress among the never married

This study examines the relationship between gender and distress among a sample of never married and married individuals aged 18-64 years from the 1987-88 National Survey of Families and Households. The hypothesis that singlehood benefits women more than men in terms of economic and psychosocial resources, which then translate into lower levels of distress, was not completely supported. In general, single women and men appear more similar than different in resources, although gender differences in distress vary by age. The importance of recognizing conceptual distinctions among the single is discussed.

Ubiquitin-positive achromatic neurons in corticobasal degeneration

A 66-year-old woman presented with an alien limb syndrome without dementia. The course of her illness was unremitting and at autopsy 6 years later her diagnosis was confirmed as corticobasal degeneration without Alzheimer-type pathology. Although the presence of ballooned achromatic cortical neurons and cell loss from the substantia nigra distinguishes such patients, the site and density of achromatic neurons has not previously been quantified. We show that immunohistochemistry for the cell stress protein ubiquitin selectively stains these achromatic neurons, whereas they do not stain for abnormally phosphorylated tau protein. Phosphorylated neurofilament antibodies recognise both ballooned and non-ballooned neurons. In this case, high densities of ubiquitin-positive ballooned neurons were found in frontal cortical regions with the highest densities in layers V and VI of the anterior cingulate cortex. In addition, high densities of ubiquitin-positive ballooned neurons were found in the insular cortex, claustrum and amygdala. These results confirm past reports of frontal pathology, but show that there is also considerable pathology in insular and parahippocampal cortical regions and some subcortical regions. Our findings suggest that the distribution and staining characteristics of ballooned neurons in corticobasal degeneration may help to differentiate these cases pathologically, while the absence of dementia appears to be an important clinical criterion.

Perceptual problems in thyroid eye disease

Graves' disease affects the individual in many significant ways, but perhaps the most immediately obvious is its effect on the eyes. The author explores how exophthalmus and proptosis associated with the disease can create not only physical and perceptual difficulties for the patient, but also complicated problems with social interaction, self-image and psychological functioning.

Health care experiences of Vietnamese families in Nottingham

There is a dearth of information on the health needs of Vietnamese refugees in Britain. In May 1993, a structured interview survey was undertaken to determine the health care experiences and health-related behaviour of Vietnamese adults living in Nottingham Health District. One hundred and thirty-five adults (66 women) were successfully interviewed in Vietnamese or Cantonese, from 71 to 77 eligible households. Levels of English usage were extremely low, and between 27% and 69% of respondents reported considerable difficulty during the various stages of a consultation with their general practitioner. Data on breast screening services suggested a pattern of low uptake, and the prevalence of male smoking was estimated to be 47%. These results suggest that Vietnamese communities suffer high levels of disadvantage in their use of primary care services; remedial action is required.

Economic evaluation of standard heparin and enoxaparin for prophylaxis against deep vein thrombosis in elective hip surgery

Deep vein thrombosis (DVT) is a common complication in patients undergoing elective hip surgery. Because of the associated risk of pulmonary embolism, prophylaxis with standard (unfractionated) heparin is becoming increasingly important. Recent clinical trials have shown a low molecular weight form of heparin, enoxaparin, to be more effective than standard heparin in preventing DVT, but the new drug is also more expensive. Data on clinical effectiveness and cost were combined in an economic evaluation of the two regimens. It was found that prophylaxis with enoxaparin would be expected to lead to a net saving of 20 pounds per patient. The economic results are sensitive to the costs of enoxaparin, the costs of drug administration and the probability of false clinical diagnosis of DVT or pulmonary embolism.

The cost of treatment for post-herpetic neuralgia in the UK

Post-herpetic neuralgia (PHN) following acute shingles caused by the herpes simplex virus is a painful and often disabling condition. Treatment of the condition can involve a range of drug therapies. In addition, patients with continuing pain may make several visits to general practitioners and hospital outpatient departments. The costs of treatment for these patients may be substantial. The main objective of this study was to estimate the costs and consequences to the UK National Health Service (NHS) of the treatment of PHN following shingles, and the effect of the condition on patients' lives in terms of pain and time off usual activities such as work. The lifetime direct treatment costs of a cohort of people from onset of PHN to resolution of the disease or death were calculated. These costs were estimated from data on the type and quantity of health resources used, and the unit costs or prices of those resources. This study has shown that PHN can be a costly consequence of acute shingles. For patients attending a tertiary referral centre the lifetime cost was 770 British pounds sterling. For a 1-year incidence cohort of people with shingles in the UK, the lifetime costs of treating PHN are between 4.8 million British pounds sterling (incidence of 21 000 people) and 17.9 million British pounds sterling (incidence of 78 200 people). Efforts are needed to reduce the incidence or severity of PHN.(ABSTRACT TRUNCATED AT 250 WORDS)

Development rates of some pre-adult stages in blowflies with reference to low temperatures

Duration of some pre-adult stages of Calliphora vicina Robineau-Desvoidy, C.alpina Zett., C. vomitoria Linn., Phormia terraenovae R.-D. and Lucilia sericata Meig. were determined at 3.5-26 degrees C, in the context of use of these insects in forensic estimates of post-mortem intervals. Egg development in C. vicina occurs down to at least 3.5 degrees C, larval growth to 4 degrees C and puparial formation, development and perfect adult emergence to 5 degrees C. Growth curves by successive weighing of individual larvae showed specific differences in rates of development of the above species at constant temperatures. Alternating temperatures for 12h periods (such as 10 degrees C and 20 degrees C) to simulate diurnal changes, usually, but not at all temperature pairs tested, caused acceleration of growth relative to the corresponding constant temperature (15 degrees C in the above case), in C. vomitoria, P. terraenovae and L. sericata, but usually caused retardation of larval growth in C. vicina. In this species, larvae as single individuals on beef liver in small tubes grew on average at the same rates as those (50-100 larvae) growing communally. All species showed variation in larval growth between individuals, more marked in C. vicina, and slower-growing larvae showed increased unexplained mortality. Because of this and to avoid complication by fast-growing larvae from later laid egg batches on a carcass, growth curves given are those of mean weights of the heaviest 25% (upper quartile) of groups of 40-90 feeding larvae.(ABSTRACT TRUNCATED AT 250 WORDS)

Current status of economic appraisal of health technology in the European Community: report of the network. The EC Network on the Methodology of Economic Appraisal of Health Technology

The use of economic evaluation to assess the costs and consequences of health care technologies has steadily increased in recent years. However, little is known about the influence economic studies have on health care decision makers or policy at local and national level. This paper reports the results of a survey of economic evaluations in EC countries to identify the impact of the results on decision and policy making in health care. Health service researchers in 10 EC countries were identified and asked to participate in the survey. The researchers were asked to locate economic evaluations in their country and complete a standardised questionnaire for each study. The criteria for inclusion in the survey were first, the studies should have been started or reported since 1987, second, the evaluations should include a comparison of the cost and consequences of the technologies assessed and finally, the appraisals should include a comparison of alternative health care technologies or programmes. A total of 66 studies which met the survey criteria were reported. Of these, 27% were thought to have influenced health care decision makers or policy. The results suggested that method of dissemination, source of funding and purpose of the study may be important determinants of whether an economic evaluation will be used in health care policy or decision making. The results of the survey suggest that economic evaluation currently has a relatively low impact on health care policy or decision making.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of hypothalamic neuropeptide Y gene expression in body weight regulation

Hypothalamic neuropeptide Y (NPY) may be involved in the hyperphagia that follows food deprivation associated with significant weight loss. However, it is unclear whether NPY is involved in body weight regulation under more physiological circumstances. Consequently, we measured body weight, food intake, arcuate nucleus (ARC) NPY mRNA, serum glucose, and insulin in male Wistar rats after 48 h of food deprivation and various refeeding protocols. Food deprivation produced a twofold increase in NPY mRNA, whereas 3 days of ad libitum refeeding returned body weight and NPY mRNA to control. If hyperphagia was prevented for 5 days during refeeding, then neither body weight nor NPY mRNA normalized. There were strong negative correlations between ARC NPY mRNA and both loss of body weight and serum insulin levels. These data suggest that hypothalamic NPY gene expression plays a role in control of body weight under physiological conditions. The data further suggest that NPY mRNA may be decreased by peripheral insulin levels.

Vasculitic neuropathy

Patients with vasculitic neuropathy may present with either mononeuritis multiplex, or a symmetrical or asymmetrical sensorimotor neuropathy. In those patients whose neuropathy is part of a systemic vasculitis the neuropathy can be expected to improve leaving only mild or moderate functional disability. Nevertheless, the long-term outlook for such patients is poor with a 5-year survival of around 50% with most excess deaths being due to vascular disease. The prognosis in non-systemic vasculitic neuropathy is almost certainly substantially better than this. Treatment of vasculitic neuropathy should be based on diagnosis by tissue biopsy, usually of nerve, and early use of aggressive immunosuppression.

Brave new world?

Arguments in favour of embryo research Prevention of congenital defects. Reduction in number of miscarriages. Better understanding of infertility. Arguments against embryo research Morally unacceptable to take potential human life. The 14-day limit on research is arbitrary. Fears about the creation of 'superspecies' and 'designer babies'. Fear of embryo 'trade' in which embryos are bought and sold.

Economic evaluation of lenograstim for prophylaxis of chemotherapy-induced neutropenia in patients with small cell lung cancer

The impact of lenograstim, recombinant human granulocyte colony-stimulating factor, on healthcare costs was evaluated on the basis of the results of a clinical trial of the drug in patients receiving VICE (vincristine, ifosfamide, carboplatin and etoposide) chemotherapy for small cell lung cancer (SCLC). The use of lenograstim resulted in a significant (p < 0.03) increase in the cumulative chemotherapy dose intensity (125% with lenograstim vs 118% without). Lenograstim was found to have no significant impact on the use of healthcare resources for administration of chemotherapy, chemotherapy-induced neutropenia, and associated infections. The cost of healthcare for the lenograstim group (excluding lenograstim acquisition costs) was 700 pounds higher per patient than that for the group not treated with lenograstim (95% CI -930 pounds to 2300 pounds). The use of lenograstim to intensify the chemotherapy dose is likely to increase the costs of treatment for SCLC. However, any increased costs need to be balanced against the potential cost savings associated with the possible long term benefits resulting from chemotherapy dose intensification.

The target of ammonia action in dictyostelium

The weak base ammonia is implicated in a number of key processes in Dictyostelium development, notably aggregation and culmination. To determine its intracellular site of action, we compared its biological potency with that of other weak bases. All the bases inhibited these developmental processes effectively, but differed manyfold in potency in accordance with their activity in dissipating pH gradients, as measured by in vivo 31P NMR with pH-sensitive phosphonate probes. These results indicate that weak bases influence development by raising the pH of an intracellular acidic compartment.

The pulmonary response to sublethal thoracic irradiation in the rat

An animal model of radiation-induced lung disease was established using male Wistar rats given sublethal bilateral thoracic irradiation (15 Gy). The rats were studied for up to 20 weeks and compared to sham-irradiated controls. Three distinct syndromes were identified. Two weeks after irradiation there was an increase in wet lung weight without an increase in dry lung weight. Interstitial edema was confirmed ultrastructurally, but aside from minor abnormalities of endothelial cells, both capillary and alveolar basement membranes were intact and there was no alveolar protein leak. At 4 weeks after irradiation, there was an abrupt increase in both wet and dry lung weights, as well as intra-alveolar macrophages, lymphocytes, polymorphs, and protein. These changes persisted for periods of up to 8 weeks. Electron microscopy at 4 weeks revealed prominent interstitial edema and severe endothelial cell damage. There was patchy thickening of the cytoplasm of type I cells as well as some cells which appeared to be transforming from type II to type I cells, suggesting previous epithelial denudation. Mast cell density increased in perivascular and peribronchial areas from 4 weeks, and this and parenchymal mast cell density peaked at 7 weeks. The total collagen content of the lungs (determined biochemically) rose by up to 50% above control values from 5 weeks after irradiation, the bulk of the increase having occurred by 12 weeks. Further increases up to 20 weeks were similar to that seen in growing control animals. Collagen deposition (as defined by electron microscopy and Picrosirius polarization) was prominent in peribronchial and perivascular areas in all animals, but in alveolar walls it was increased severalfold above controls by 20 weeks after irradiation. In summary, this model provides sequential changes of interstitial edema, alveolitis, and interstitial fibrosis which can be studied independently. The temporal relationship between the appearance of mast cells and increased collagen deposition supports the hypothesis that mast cells are intimately related to the development of fibrosis.

The effect of steroids on radiation-induced lung disease in the rat

We have used a model of bilateral radiation-induced lung disease in the rat to study the effects of corticosteroids. This model is characterized by interstitial edema at 2 weeks after radiotherapy followed by florid alveolitis with an alveolar protein leak which peaks at 4 weeks. Mast cell density peaks at 7 weeks, and there is a progressive increase in lung collagen (fibrosis) from 5 to 20 weeks. Intraperitoneal corticosteroids or saline were given at the time of irradiation or sham irradiation (protocol 1), every second day during weeks 3 and 4 (protocol 2), or three times weekly during weeks 3 to 8 (protocol 3). In protocol 1, steroids protected the lung from interstitial edema at 2 weeks, delayed the alveolitis without reducing its intensity, and significantly reduced the alveolar protein leak. However, radiation fibrosis was not reduced at 20 weeks. Longer steroid administration (protocol 2) suppressed the alveolar protein leak and delayed and significantly reduced the severity of the inflammatory cell response. Although the tissue mast cell and fibrotic responses were suppressed during and for at least 3 weeks after steroids, the ultimate fibrotic reaction was the same in both irradiated groups. In protocol 3, steroids suppressed the alveolitis and delayed the rise in tissue mast cell density, but did not affect the fibrotic response at 20 weeks. These studies suggest that steroids can suppress the alveolitis provided they are used throughout the period of alveolitis. Although they also delay the tissue mast cell response to radiation, the ultimate fibrosis is not altered. This provides further evidence for the dissociation of alveolitis and fibrosis after lung irradiation and has potential implications for management of radiation-induced lung disease in humans.

Identification, synthesis and properties of 5-(aziridin-1-yl)-2-nitro-4-nitrosobenzamide, a novel DNA crosslinking agent derived from CB1954

5-(Aziridin-1-yl)-4-hydroxylamino-2-nitrobenzamide, the active form of 5-(aziridin-1-yl)-2,4-dinitrobenzamide (CB1954), can react spontaneously with oxygen, and in aqueous solution yields 5-(aziridin-1-yl)-2-nitro-4-nitrosobenzamide and hydrogen peroxide. Mild biological reducing agents such as NAD(P)H, reduced thiols and ascorbic acid rapidly re-reduced the nitroso compound to the hydroxylamine. Both compounds were equally efficient at inducing cytotoxicity and DNA interstrand crosslinking in cells when exposed in phosphate-buffered saline (PBS). Neither agent was capable of inducing cross-links in isolated DNA. When acetyl coenzyme A was included in the incubation, crosslink formation was seen with the hydroxylamine, but not with the nitroso compound. Thus, the nitroso compound is acting as a prodrug for the hydroxylamine, and needs to be reduced to this compound to exert its cytotoxic effects. In vivo anti-tumour tests showed that neither compound was effective in its own right. This may be due to the rapid reduction of the nitroso to the hydroxylamine, and the reaction of the hydroxylamine with serum proteins. The chemical synthesis of the 5-(aziridin-1-yl)-2-nitro-4-nitrosobenzamide, and an improved synthesis of 5-(aziridin-1-yl)-4-hydroxylamino-2-nitrobenzamide is described. These results emphasize the potential efficacy of the in situ activation of prodrugs such as CB1954 either by endogenous enzymes such as DT diaphorase, or by antibody directed enzyme prodrug therapy (ADEPT).

Discharge properties of single motor units in patients with spinal cord injuries

To study neurophysiological correlates of spastic paresis, we analyzed the discharge pattern of single motor units (SMUs) during sustained voluntary contraction from muscles weakened by spinal cord injury (SCI) and from muscles of near normal strength just at or above the level of injury. The average firing rate of SMUs was reduced in patients' biceps brachii and tibialis anterior muscles compared with controls, but not in the triceps brachii. Floating serial correlation coefficients obtained from successive interdischarge intervals were significantly more positive in patients than in controls in all three muscles. One statistical measure of regularity of discharge, akin to a coefficient of variation, was best able to differentiate patient and control SMUs. Increased discharge variability in muscles just above the level of injury suggested that subtle effects of traumatic SCIs were more extended than was clinically apparent. Although consistent statistical differences could be measured, these changes were not specific to SCI, nor were all SMUs equally affected.

Portable system for quantifying motor abnormalities in Parkinson's disease

In order to quantify motor disabilities in Parkinson's disease (PD), we designed a compact, portable, neurophysiological system based upon a personal computer to measure tremor, bradykinesia, and muscle tone. Tremor was detected by solid state accelerometers and translated into a digital signal. The system displayed the root mean square displacements and frequency distribution of the tremor in the horizontal and vertical planes, along with a reconstructed graphic image of the displacement. Bradykinesia was measured using a panel that detects release and depression of switches in response to auditory and visual signals; the system calculated subjects' reaction times and movement times in milliseconds. Tone at the elbow was measured by strapping the upper extremity to a lightweight low-friction cradle and then passively moving the cradle with an instrumented handle. Signals representing torque and arm angle were processed by the computer and displayed in real time on the screen with stiffness as a mean slope in Nm/degree. In clinical tests, quantitative measures of tremor, movement time and rigidity were significantly abnormal in PD patients compared to control subjects. We conclude that this system is a convenient and accurate method to quantitate important aspects of the parkinsonian syndrome, and may be applied to quantitate other movement disorders.

Rectal methohexital for sedation of children during imaging procedures

OBJECTIVE

Brevital (methohexital), administered as a solution per rectum, provides safe, rapid, and effective sedation for induction of surgical anesthesia. This study was undertaken to evaluate rectal Brevital as a sedative for children undergoing imaging procedures.

MATERIALS AND METHODS

In a review of patients' records, we found that, during a 1-year period, 190 children from 1 month to 14 years old were sedated for CT or MR imaging. Sedation was required for 94 CT and 96 MR imaging studies. Rectal Brevital was used in 102 patients (mean age, 25 +/- 2 months), and oral chloral hydrate was used in 88 (mean age, 28 +/- 3 months).

RESULTS

Sleep was achieved in 81% of patients who received Brevital and in 80% of those who received chloral hydrate. Induction time was shorter (p = .0001) with Brevital (9 +/- 1 min) than with chloral hydrate (28 +/- 2 min). The mean duration of sleep was 46 min with Brevital and 66 min with chloral hydrate (p = .0001). Brevital provided adequate sedation in 89 (87%) of 102 imaging studies, and chloral hydrate did so in 73 (83%) of 88 studies. No cardiorespiratory complications or allergic reactions occurred with either drug. Significantly fewer patients were discharged fully awake and alert after sedation with chloral hydrate than with Brevital (p < .002). Children sedated with chloral hydrate also required a longer period of observation in the radiology department (p < .04).

CONCLUSION

We conclude that rectal Brevital produces sedation of adequate duration for most imaging procedures in children. Ease of administration, wide margin of safety, rapid and pleasant induction, and short recovery time make this drug a favorable alternative to other commonly used sedatives.

Variation in firing order of human soleus motoneurons during voluntary and reflex activation

The activation of motoneurons in a muscle pool is said to proceed as an ordered array in response to both dorsal root stimulation and voluntary activation, with small motoneurons being recruited before larger ones. We have examined 19 voluntarily recruited soleus motor units in 5 normal subjects and found that in 18 cases, the lowest threshold motor unit recruited by slowly increasing 'tonic' voluntary activity was different from the lowest threshold unit recruited by electrical stimulation of the tibial nerve in the popliteal fossa (phasic Hoffman reflex). The initially recruited voluntary units were, however, part of the pool influenced by the stimulated afferents because, during tonic activation, the timing of their discharge could be shown to be altered by electrical stimulation at a lower intensity than that required for H recruitment at rest. These findings suggest that the pool of soleus motoneurons responding to the voluntary command "tonically plantar flex your ankle" differs somewhat, in order of activation, from the pool responding to phasic stimulation of the largest diameter fibers in the tibial nerve, perhaps because of inhomogeneities in the distribution of descending or segmental inputs to the soleus motoneuron pool. Whether this partitioning is functional or a reflection of minor, random variations in synaptic density remains to be determined.

Recumbent tic

A 59-year-old man with a 30-year history of an unusual movement disorder characterised by involuntary axial spasms that occur only in recumbency is described. Clinical and electrophysiological evidence suggest that this disorder is best characterised as a simple tic of unusual form. We have coined the term "recumbent tic" to describe this disorder.

An active covalently linked dimer of human interferon-gamma. Subunit orientation in the native protein

We have constructed and expressed a covalently linked head to tail dimer of human interferon-gamma (IFN-gamma) in which two monomers are joined head to tail via a rigid peptide hinge using genetic engineering techniques. The hinge was derived from the human immunoglobin IgA1 sequence (Hallewell, R.A., Laria, I., Tabrizi, A., Carlin, G., Getzoff, E.D., Tainer, J.A., Cousens, L.S., and Mullenbach, G.T. (1989) J. Biol. Chem. 264, 5260-5268). Analysis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis shows that the polypeptide produced by this construction migrates as a 30,000 polypeptide species. The protein elutes as a single species by molecular sieve chromatography under native conditions. The covalently linked dimer exhibits one-half the antiviral activity of native dimeric IFN-gamma; receptor binding assays show the covalently linked dimer binds to the IFN-gamma receptor with one-half the avidity of native IFN-gamma. This difference is not due to conformational differences between the two molecules, as the aromatic region of the NMR spectrum of the purified covalently linked dimer is identical with that of the wild type protein. From these data, we suggest that human IFN-gamma associates in a head to tail dimer in its active configuration. Regions of IFN-gamma are contiguous with the amino and carboxyl termini and are obscured by the hinge peptide in the covalently linked dimer. Our studies demonstrate that these regions may be important for receptor-ligand interaction.

Confidants and companions: choices in later life

This study examines and compares the correlates of considering each of the following as a confidant or a companion: spouse, children, siblings, other relatives, friends. Using a Canadian sample of 400 respondents aged 65 and over, we found evidence of substitution among the previously married and childless; more extensive ties to children and more intimate ties to friends among women; the importance of geographic proximity to children for confiding and companionship, and to siblings for confiding; the relevance of family size to confiding in siblings; and the precariousness of friendship as one reaches very old age. Predictors of who serve as confidants and as companions are similar, but important differences emerge. We compared our results to those of studies in Australia and the United States and to an earlier analysis of network composition and concluded that the confiding and companionate relations of older persons are best understood by combining the results of relationship-specific and network composition analyses.

The economics of femorocrural reconstruction for critical leg ischemia with and without autologous vein

It is well established that primary arterial reconstruction, even to crural vessels, is cheaper than amputation. Reintervention increases expenditure and may produce mean costs exceeding those of primary amputation. Furthermore, secondary amputation may eventually become necessary. Femorocrural grafts have the highest average "reconstruction policy" cost (i.e., primary procedure and all further operations necessary during follow-up). We must therefore seek support for this potentially expensive form of treatment. In conjunction with health economists we have compared the average policy cost of 130 reconstructions with grafts exceeding 70 cm in length (89 vein grafts, 41 polytetrafluoroethylene grafts with a distal vein collar) with 67 vascular amputations, at mean follow-up of 3 years. One-month mortality rate after reconstruction was less than 1% but was 10% after amputation. At 3 years, however, 20% of both groups were dead. Overall 3-year patency is 65% (72% for vein grafts, 48% for polytetrafluoroethylene grafts). Ninety-seven percent of irreversible graft occlusions resulted in amputation in these patients. After autologous vein grafting reintervention, our follow-up showed increased mean costs from $6898 to $15,024 per patient. After prosthetic grafting, the higher reintervention rate increased from $6898 to $20,416. These mean costs remained less than amputation, reintervention, and additional mobility costs, which amounted to a mean of $21,726 per patient. Important differences in outcome were observed: 70% of patients undergoing amputation were confined to the home compared with only 9% of patients undergoing reconstruction; 30% of patients undergoing amputation were confined to bed or had to use a wheelchair compared with 1% of patients undergoing reconstruction.

Correlates of using mental health services: implications of using alternative definitions

BACKGROUND

Studies using varying definitions of mental health visits result in widely divergent estimates. This analysis examines the stability of a predictive model using three varying definitions based on provider type, diagnosis, psychotherapy, and psychotropic medication use.

METHODS

Interview and questionnaire data and claims records from the RAND Health Insurance Experiment are used to test these models among 3138 enrollees.

RESULTS

Estimates of visits, and factors associated with them, are highly sensitive to definitions. Depression was the only symptom/life situation variable, and education the only sociodemographic measure, predictive across all three models. Risk indicators such as suicide thoughts and drinking problems were only significant for the traditional (mental health specialty) model. While patients within the traditional model definition were significantly younger than other enrollees, those within the model using the most expansive definition were significantly older. Varying the definition also led to different results in respect to experimental manipulations, geographic sites and some specific types of comorbidity.

CONCLUSIONS

A reasonable definition, consistent with medical standards, requires, at least, a mental health diagnostic judgment and some form of psychotherapeutic or drug treatment. Studies of the content of mental health care are needed.

The evaluation of NIMROD, a community-based service for people with mental handicap: revenue costs

The cost implications of moving from a system of services for people with mental handicaps centred on large institutions to a network of community-based services are not precisely known. The provision of the NIMROD service in a part of Cardiff, with its aim not only to meet the residential needs of adults comprehensively by providing a number of houses in the community but also to develop a support service to people living in their family home, gave an opportunity to investigate and report the revenue costs of a number of service elements with respect to a defined total population. The residential costs of intensively staffed houses in 1986-87, varying in size from two to six places, were found to range between pounds 16,473 and pounds 23,319 per person per year. With the addition of community support costs, such as the provision of day services, the total costs of care per resident averaged pounds 21,708; range, pounds 18,883-pounds 26,009. These compared to the total costs in a minimally staffed house of pounds 9,678 per resident. The costs of community support services for people living in their family homes averaged pounds 5,614 inclusive of DSS benefits, of which pounds 1,743 was accounted for by the NIMROD domiciliary support service, office base and administrative overheads. The residential costs reported were compared to other cost data in the literature. The study supports previous conclusions that there is little evidence of diseconomy attached to small scale per se but that the way staffing levels and therefore staff costs are determined is critical. No evidence was found in this study to link greater cost to better quality.

Warning signals for malnutrition in the elderly

Aging and disability are often assumed to coexist in Western society. Nevertheless, most elderly people live in noninstitutional settings. Monitoring and improving the nutritional integrity of the elderly could play a part in helping them remain healthy and independent. A community-based approach to the prevention of malnutrition in elderly people has been developed. This approach teaches warning signals for malnutrition to care providers who are in contact with elderly men and women. Care providers learn to recognize a group of circumstances (warning signals) that could have a negative impact on an elderly person's nutritional status. Examples of risk factors are given, and the interplay between risk factors and warning signals is discussed as well as their combined application. Practical steps for simple intervention are suggested. The dietitian is the nutrition educator and coordinator of this service.

Vasculitic neuropathy. A clinical and pathological study

The clinical, electrophysiological and pathological features and prognosis of 34 patients with peripheral neuropathy caused by necrotizing vasculitis were evaluated. The causes included polyarteritis nodosa and its Churg-Strauss variant, rheumatoid arthritis, undifferentiated connective tissue disease, Wegener's granulomatosis, primary Sjögren's disease, and chronic lymphocytic leukaemia with cryoglobulinaemia; 2 patients had no evidence of systemic vasculitis. Mononeuritis multiplex was the most common clinical manifestation, followed by asymmetrical polyneuropathy and distal symmetrical polyneuropathy. Pain was a frequent symptom. Nerve conduction studies were abnormal in all cases, and in 3 patients there was conduction block or severe slowing of motor conduction. Necrotizing vasculitis was present in sural nerve biopsies of most cases, and severe active axonal degeneration was a dominant feature. Immunofluorescent staining of blood vessels for immunoglobulin, C3 and fibrinogen was positive in all cases in which it was performed, even when there was no cellular infiltration. All patients were treated with prednisone alone or in combination with other immunosuppressive agents, or with plasmapheresis. Long-term follow-up studies demonstrated that although the peripheral neuropathy usually improved and caused only mild to moderate functional disability, the long-term prognosis of the systemic disease was poor with a 5-yr survival of only 37%.

HIV prevalence and risk behaviours for HIV transmission in South Australian prisons

During the latter half of 1989, HIV prevalence in South Australian prisoners was 1.4%. The prevalence of HIV infection across the prison system did not change significantly during 1989 but there was clustering of HIV-infected prisoners in some prisons. Almost half the prisoners from all of the South Australian prisons agreed to participate in our studies, from which we estimate that about 42% of prisoners engage in risk behaviours at least once while incarcerated. Prisoners estimated that 36% of all prisoners inject drugs intravenously at some stage during their stay and that 12% engage in anal intercourse at least once. Interviews with former prisoners who had a history of intravenous drug use revealed that about half had injected themselves while in prison, 60% shared needles and most did not clean shared needles adequately. Most of these prisoners injected themselves once a month or less frequently. The conditions for spread of HIV within the prison system exist but at the current prevalence of infection, transmission can be expected to be infrequent. The opportunity exists now to improve and expand preventive measures.

Economic analysis alongside clinical trials. Revisiting the methodological issues

Controlled clinical trials are recognized as the best source of data on the efficacy of health care interventions and technologies. Because economic evaluation is dependent on the quality of the underlying medical evidence, clinical trials have increasingly been viewed as a natural vehicle for economic analysis. However, the closer integration of economic and clinical research raises many methodological issues. This paper discusses these issues in trial design, collection of resource use data, collection of outcome data, and interpretation and extrapolation of results. Some guidelines are suggested for economic analysts wishing to undertake evaluations alongside clinical trials.

Adverse effects of aspirin, acetaminophen, and ibuprofen on immune function, viral shedding, and clinical status in rhinovirus-infected volunteers

A double-blind, placebo-controlled trial was conducted to study the effects of over-the-counter analgesic/antipyretic medications on virus shedding, immune response, and clinical status in the common cold. Sixty healthy volunteers were challenged intranasally with rhinovirus type 2 and randomized to one of four treatment arms: aspirin, acetaminophen, ibuprofen, or placebo. Fifty-six volunteers were successfully infected and shed virus on at least 4 days after challenge. Virus shedding, antibody levels, clinical symptoms and signs, and blood leukocyte levels were carefully monitored. Use of aspirin and acetaminophen was associated with suppression of serum neutralizing antibody response (P less than .05 vs. placebo) and increased nasal symptoms and signs (P less than .05 vs. placebo). A concomitant rise in circulating monocytes suggested that the suppression of antibody response may be mediated through drug effects on monocytes and/or mononuclear phagocytes. There were no significant differences in viral shedding among the four groups, but a trend toward longer duration of virus shedding was observed in the aspirin and acetaminophen groups.

Economic evaluation of gastric ulcer prophylaxis in patients with arthritis receiving non-steroidal anti-inflammatory drugs

This study assesses the economic benefits of misoprostol in the prophylaxis of gastric ulcers larger than 0.3 cm in patients with osteoarthritis receiving non-steroidal anti-inflammatory drugs. Independent epidemiological data were obtained for patients in Scotland and the West Midlands. Co-diagnosis of arthritis with gastric ulcer recorded in the routine data was substantially less (4% Scotland, 10% West Midlands) than the 21% found at case review. These data were combined with cost and patient management data in a decision analysis model to explore whether prophylactic use of misoprostol altered substantially the average cost of managing gastric ulcer. Using conservative assumptions and a daily dose of 400 micrograms, cost savings per patient to the National Health Service of 5-8 pounds over a 3-month period are expected in the groups of patients studied, while at the 800 micrograms dose there would be a net cost of 23-25 pounds. Sensitivity analysis showed that under many assumptions misoprostol is expected to be cost saving or cost neutral.

Confidants and companions in later life: the place of family and friends

Responses from a sample of 400 older persons were used to determine the relative importance of various family members (spouse, children, siblings, other relatives) and friends in the confidant and companion networks of later life. Significant differences exist among older persons (based on gender, marital status, and availability of children) in the salience of these ties as confidants and companions. There are also major differences in the configuration of the confidant vs companion networks. These variations are discussed in the context of the hierarchical-compensation, task specificity, and functional specificity of relationships models of support. The findings demonstrate that a distinction regarding availability of kin must be made among those who never had a particular kin tie (e.g., the childless and single), those who have lost a previous tie (e.g., the widowed), and those whose tie lives far away.

Mental effort and elaboration: effects of accessibility and instruction

The present study examined the effects of accessibility to relevant schematic knowledge for elaboration in the associative learning of noun pairs. Fifth-grade participants performed two simultaneous tasks--associative learning and finger tapping--so that the mental effort demands of elaborating pairs that varied in accessibility could be estimated. The mental effort expended during the creation of sentence elaborations was greater for inaccessible pairs than accessible pairs. This accessibility difference was not observed when subjects were provided with the pair members in sentences. These findings confirm information-processing analyses of the elaboration process and support a knowledge-base interpretation of developmental differences in elaboration effort.