A mobile app for the treatment of female mixed and urgency incontinence: a cost-effectiveness analysis in Sweden

Introduction and hypothesis

A previous randomized controlled trial (RCT) demonstrated that the app Tät II, for self-management of mixed urinary incontinence (MUI) and urgency urinary incontinence (UUI), yielded significant, clinically relevant improvements in symptom severity and quality of life (QoL) compared with a control group. We aimed to assess the cost-effectiveness of Tät II.

Methods

A cost–utility analysis with a 1-year societal perspective was carried out, comparing Tät II with an information app. Data were collected alongside an RCT: 122 community-dwelling women aged ≥18 years with MUI or UUI ≥2 times/week were randomized to 3 months of Tät II treatment focused on pelvic floor muscle training (PFMT) and bladder training (BT; n = 60), or to an information app (n = 62). Self-assessed data from validated questionnaires were collected at baseline and at 3-month and 1-year follow-ups. Costs for assessment, treatment delivery, incontinence aids, laundry, and time for PFMT and BT were included. We calculated quality-adjusted life-years (QALYs) using the International Consultation on Incontinence Modular Questionnaire Lower Urinary Tract Symptoms Quality of Life. The incremental cost-effectiveness ratio (ICER) between the groups was our primary outcome. Sensitivity analyses were performed.

Results

The mean age was 58.3 (SD = 9.6) years. Annual overall costs were €738.42 in the treatment group and €605.82 in the control group; annual QALY gains were 0.0152 and 0.0037 respectively. The base case ICER was €11,770.52; ICERs in the sensitivity analyses ranged from €−9,303.78 to €22,307.67.

Conclusions

The app Tät II is a cost-effective treatment method for women with MUI and UUI.

Epidemiology and emm types of invasive group A streptococcal infections in Finland, 2008-2013

Invasive Streptococcus pyogenes (group A streptococcus, GAS) infections are a major global cause of morbidity and mortality. We analysed the surveillance data on invasive GAS and the microbiological characteristics of corresponding isolates to assess the incidence and emm type distribution of invasive GAS infections in Finland. Cases defined as patients with isolations of blood and cerebrospinal fluid S. pyogenes are mandatorily notified to the National Infectious Disease Registry and sent to the national reference laboratory for emm typing. Antimicrobial data were collected through the network including all clinical microbiology laboratories. Pulsed-field gel electrophoresis (PFGE) analysis was performed to assess clonality. In total, 1165 cases of invasive GAS were reported in Finland during 2008-2013; the median age was 52 years (range, 0-100) and 54% were male. The overall day 7 case fatality rate was 5.1% (59 cases). The average annual incidence was 3.6 cases per 100,000 population. A total of 1122 invasive GAS isolates (96%) were analysed by emm typing; 72 different emm types were identified, of which emm28 (297 isolates, 26%), emm89 (193 isolates, 12%) and emm1 (132 isolates, 12%) were the most common types. During 2008-2013, an increase of erythromycin resistance (1.9% to 8.7%) and clindamycin (0.9% to 9.2%) was observed. This resistance increase was in parallel with the introduction of a novel clone emm33 into Finland. The overall incidence of invasive GAS infections remained stable over the study period in Finland. We identified clonal spread of macrolide-resistant invasive emm33 GAS type, highlighting the importance of molecular surveillance.

Clindamycin resistant emm33 Streptococcus pyogenes emerged among invasive infections in Helsinki metropolitan area, Finland, 2012 to 2013

Binary file ES_Abstracts_Final_ECDC.txt matches

Endogenous gas formation of carbon dioxide used for wound flooding--an experimental study with implications regarding gas microembolism during cardiopulmonary bypass

BACKGROUND

Gas microembolisation is an identified risk in cardiac surgery. Flooding the wound with carbon dioxide is a method proposed to reduce this problem. The high solubility of carbon dioxide is beneficial, but may also cause problems. The gas solubility diminishes at warming and endogenous bubbles are formed when cold blood saturated with carbon dioxide is returned by cardiotomy suction.

METHODS

The release of endogenous gas was measured at high resolution in an experimental digital model. A medium (water or blood) was incubated and equilibrated with gas (100% carbon dioxide or air) at a low temperature (10 °C or 23 °C). The temperature was increased to 37 °C and the gas release was measured, at rest and at fluid motion.

RESULTS

The amount of carbon dioxide released at warming was substantial for both water and blood (both p=0.005). The effect was more pronounced when the temperature differential increased (p=0.005). However, blood and water differed in these terms: with water, the release of carbon-dioxide started instantly at warming; with blood, carbon dioxide remained dissolved and was released at fluid motion. When blood was warmed from 10 °C to 37 °C, the gas release corresponded to 44.4% (40.6/46.5) of the medium volume (median with quartile range).

CONCLUSION

Gas dissolved in a medium becomes released at warming, as confirmed here. Blood exposed to carbon dioxide became heavily oversaturated at warming, with the gas instantly released at fluid motion. The amount of contained gas increased with a higher temperature differential. Our study has relevance to wound flushing, using carbon dioxide, in cardiac surgery. The clinical consequences of these findings remain to be answered.

A prediction of the renal and cardiovascular efficacy of aliskiren in ALTITUDE using short-term changes in multiple risk markers

INTRODUCTION

We recently developed and validated in existing trials a novel algorithm (PRE score) to predict long-term drug efficacy based on short-term (month-6) drug-induced changes in multiple risk markers. To show the value of the PRE score for ongoing and planned clinical trials, we here report the predicted long-term cardio-renal efficacy of aliskiren in type 2 diabetes, which was investigated in the ALTITUDE trial, but unknown at the time this study was conducted.

METHODS

We established the relation between multiple risk markers and cardio-renal endpoints (as defined in ALTITUDE) using a background database from past clinical trials. The short-term effect of aliskiren on multiple risk markers was taken from the AVOID trial. A PRE score was developed by multivariate Cox analysis in the background population and was then applied to the baseline and month-6 measurements of the aliskiren treatment arm of the AVOID trial to predict cardio-renal risk. The net risk difference at these time-points, after correction for placebo effects, was taken to indicate the estimated long-term cardio-renal risk change.

RESULTS

Based on the PRE score, we predicted that aliskiren treatment in ALTITUDE would confer a relative risk change of -7.9% (95% CI -2.5 to -13.4) for the cardio-renal endpoint, a risk change of -5.1% (-1.2 to -9.0) for the CV endpoint and a non-significant risk change of -19.9% (-42.1 to +2.1) for the renal endpoint.

CONCLUSIONS

PRE score estimations suggested that aliskiren has only a marginal additive protective effect on cardio-renal endpoints. These predictions were validated by the results of the ALTITUDE trial, confirming the potential of the PRE score to prospectively predict drug efficacy on cardio-renal outcomes.

A cathepsin-cleavage site between the adenovirus capsid protein IX and a tumor-targeting ligand improves targeted transduction

Human adenoviruses have a great potential as anticancer agents. One strategy to improve their tumor-cell specificity and anti-tumor efficacy is to include tumor-specific targeting ligands in the viral capsid. This can be achieved by fusion of polypeptide-targeting ligands with the minor capsid protein IX. Previous research suggested that protein IX-mediated targeting is limited by inefficient release of protein IX-fused ligands from their cognate receptors in the endosome. This thwarts endosomal escape of the virus particles. Here we describe that the targeted transduction of tumor cells is augmented by a cathepsin-cleavage site between the protein IX anchor and the HER2/neu-binding ZH Affibody molecule as ligand. The cathepsin-cleavage site did not interfere with virus production and incorporation of the Affibody molecules in the virus capsid. Virus particles harboring the cleavable protein IX-ligand fusion in their capsid transduced the HER2/neu-positive SKOV-3 ovarian carcinoma cells with increased efficiency in monolayer cultures, three-dimensional spheroid cultures and in SKOV-3 tumors grown on the chorioallantoic membrane of embryonated chicken eggs. These data show that inclusion of a cathepsin-cleavage sequence between protein IX and a high-affinity targeting ligand enhances targeted transduction. This modification further augments the applicability of protein IX as an anchor for coupling tumor-targeting ligands.

A transductionally retargeted adenoviral vector for virotherapy of Her2/neu-expressing prostate cancer

The efficacy of adenovirus (Ad)-based gene therapy of solid tumors, such as prostate cancer, is limited. One of the many problems is that the virus infects many different cell types in the body, resulting in high toxicity, whereas the target cancer cells are often less prone to wild-type Ad infection. Our aim was to develop genetically de- and retargeted Ad vectors to reduce off-target effects and increase target infection for prostate cancer. We have previously reported an Ad5 vector specific for the cancer-associated receptor Her2/neu, created by inserting Her2/neu-reactive Affibody(®) molecules (ZH) into the HI loop of a coxsackievirus and adenovirus receptor binding-ablated fiber (Ad[ZH/1]). In addition to virus retargeting to Her2/neu, this virus was further modified from wild-type Ad by changing the RGD motif in the penton base to EGD and by substitution of the KKTK motif in the third shaft repeat to RKSK, resulting in the vector Ad[ZH/3]. The ZH-containing vectors could be produced to high titers and were specific for their target, resulting in efficient infection and killing of Her2/neu-positive androgen-dependent PC346C prostate cancer cells in vitro. Here we show that the oncolytic Ad[ZH/3] vector significantly prolonged survival time and reduced serum prostate-specific antigen levels in an orthotopic prostate tumor model in nude mice to the same extent as wild-type Ad5. Our results show that Her2/neu targeting using Ad-based vectors for prostate cancer is feasible and may serve as a basis for the development of gene therapy of human prostate cancer as well as other Her2/neu-expressing cancers.

Detection of Streptococcus pneumoniae carriage by the Binax NOW test with nasal and nasopharyngeal swabs in young children

The rapid detection of carriage of Streptococcus pneumoniae could assist in the management of pneumococcal infection, such as acute otitis media. We evaluated the reliability of the Binax NOW test in the exclusion and detection of pneumococcal carriage by nasal samples from 139 children and using nasopharyngeal samples from 250 children (aged 6-35 months) with respiratory infection with or without acute otitis media. The Binax NOW test results were compared with culture-based detection of carriage of S. pneumoniae. The Binax NOW test from the nasal samples had a sensitivity of 95%, a specificity of 78%, and the positive and negative predictive values were 83 and 93%, respectively; and for the nasopharyngeal samples the corresponding numbers were 88%, 95%, 96%, and 87%. When rapid knowledge of the carriage status of S. pneumoniae is needed, the Binax NOW test is a reliable method for the exclusion of carriage using nasal sampling, and in the detection of carriage using nasopharyngeal sampling.

Serum uric acid is associated with new-onset diabetes in hypertensive patients with left ventricular hypertrophy: The LIFE Study

BACKGROUND

It is unclear whether serum uric acid (SUA) is associated with development of new-onset diabetes (NOD) in patients with hypertension and left ventricular hypertrophy (LVH). The aim of the present investigation was to test the hypothesis that SUA predicts development of NOD in these patients.

METHODS

In the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, a double-masked, parallel-group design, 9,193 patients with hypertension and electrocardiographic LVH were randomized to losartan- or atenolol-based antihypertensive treatment and followed for a mean of 4.9 years. At baseline, 7,489 patients with available SUA measurements did not have diabetes mellitus and were thus at risk of its development during the study. We used Cox regression analyses to investigate whether SUA predicted development of NOD.

RESULTS

NOD developed in 522 of 7,489 patients. The association between baseline SUA and development of NOD was significant (hazard ratio (HR) 1.29 per s.d. (1.3 mg/dl), 95% confidence interval (CI) 1.18-1.42, P < 0.001) after adjustment for treatment with losartan vs. atenolol, baseline serum glucose, urinary albumin/creatinine ratio, estimated glomerular filtration rate and Framingham risk score, time-varying systolic and diastolic blood pressure, and time-varying LVH by Cornell voltage-duration product and Sokolow-Lyon voltage. In parallel analyses, baseline quartiles of SUA were significantly associated with increasing NOD (HR 1.28, 95% CI 1.18-1.40, P < 0.001). Time-varying SUA was also associated with NOD (HR 1.10 per s.d. [1.3 mg/dl], 95% CI 1.02-1.19, P = 0.015).

CONCLUSION

Our analysis suggests that SUA is an independent risk marker for NOD in hypertensive patients with LVH.

Both high and low blood pressures risk indicators of death in middle-aged males. Isotonic regression of blood pressure on age applied to data from a 13-year prospective study

This study was performed to investigate whether a moderately sized population of men (n = 954) living in a geographically defined area could be utilized and give valid results in a 13-year prospective study regarding mortality as a function of blood pressure. Isotonic regression of blood pressure on age was used to define groups of men with low, medium, and high blood pressure. Men aged 40-69 years in both extreme groups showed an excess death risk in comparison with those in the medium group. Thus, mortality appeared to be a U-shaped function of blood pressure in this age group. The mortality ratios of the low and high blood pressure groups vis-à-vis the medium group were higher during the first than during the second half of the observation period. Chronic diseases at the time of the initial examination were more common among men who died in the lowest blood pressure group than among those who died in the medium group. In males aged 70-99 years, blood pressure appeared to be of less importance as a risk indicator of death.

Parental obesity combined with hypertension--an indicator of excess risk of hypertension in offspring. A case-control study in a Swedish primary care district

A case-control study was performed to estimate the excess risk of hypertension in a defined population. The study comprised 121 hypertensive patients, aged 40-59 years, and 138 non-hypertensive controls selected from the same primary care district. Parental obesity combined with hypertension proved to be a stronger risk indicator of hypertension in offspring than parental hypertension itself. Other risk indicators were obesity, hypertension in siblings and a positive family history of myocardial infarction. In order to study the size of the problem we estimated the prevalence of hypertension and borderline hypertension in the district. Patients with these diagnoses amounted to about one fourth of the middle-aged population in the district. More than 80% of the hypertensives had been diagnosed before this study, but only about 20% of the borderline hypertensives were previously known.

Low prevalence of abdominal aortic aneurysm in hypertensive patients. A population-based study

The prevalence of abdominal aortic aneurysms (AAA) was estimated by ultrasonography in hypertensives in the age group 50-70 years in geographically defined population. Only one case of AAA was found among 245 patients. This rather unexpected result implies a probability of less than 5% that the true prevalence of AAA is as high as 2% in hypertensives. Our population-based study indicates a lower prevalence than earlier studies based on necropsies and is an example of research cooperation between primary health care and specialized hospital care.

Utility of a population-based case-control study model with a limited number of patients in estimating risks of hypertension

A population-based case-control study of the risks of hypertension was carried out in a primary care district where data on all patients have been registered in out- and in-patient computer schemes and where extensive studies and treatment programs regarding blood pressure have been performed for more than a decade. The results of the study, which comprised a limited number of patients, accord with those of more extensive and prospective studies. The hypertensives had high risks of developing myocardial infarction and stroke even though they were treated according to internationally accepted norms regarding blood pressure. The estimated population-attributable risk of hypertension in men was 30% with regard to myocardial infarction and 68% with regard to stroke. Smoking and hypertension were found to be independent risk indicators of myocardial infarction in men and hypertension was a strong risk indicator of stroke. Thus, a case-control study carried out in this way in a primary care district gives valid results regarding the efficacy of an antihypertensive treatment program and may therefore serve as a model for future studies in primary health care.

High risk of cerebro-cardiovascular morbidity in well treated male hypertensives. A retrospective study of 40-59-year-old hypertensives in a Swedish primary care district

In a retrospective study of 121 hypertensives aged 40-59 years in comparison with 138 controls selected from the population in the same primary care district, male hypertensives had a high odds ratio of cerebro-cardiovascular (CCV) diseases even when their blood pressure had been well treated. The estimated odds ratio (corrected for small numbers) was 13.7 (2.5-76.7). In female hypertensives there was a trend towards more CCV diseases than in their controls. Although the hypertensives' blood pressure was reduced in accordance with what has been internationally accepted, their values were still at least 10-11 mmHg higher than those of the controls. A reduction of this magnitude may be accomplished by (further) weight reduction and, probably, intervention with factors linked to obesity. This may be one way to reduce the excess risk in hypertensives.

Economic evaluation of nursing practices: a review of literature

BACKGROUND

The importance of cost-effectiveness of nursing practices and its influence on prioritizations has been discussed in literature. It is, however, unclear to what extent health economic analysis has been used in the area of nursing.

AIM

The aim of this paper was to investigate how studies of nursing practices apply economic evaluations.

METHODS

A literature review was conducted that included studies through August 2007. The search was performed using Medline, CINAHL, PsycINFO, Econlit, DARE, HTA, NHS EED, Cochrane reviews and clinical trials with a search term connected to nursing and health economics. Protocols were used in the screening procedure and the result is reported in a descriptive form.

RESULTS

The search identified 115 studies published between 1984 and August 2007. Studies were found in the following nursing practices: provision of support and treatment (n = 17); assessing suffering/well-being (n = 1); preventing or treating ill health (n = 53); and organization of individual care (n = 44). In 22% of all studies, the authors explicitly presented the health economic method used. In 25% of all studies, the perspective of the economic analysis was explicitly stated and a large variability in cost was considered in the analysis. In 82 studies, the authors reported cost-effective intervention.

CONCLUSIONS

Although economic evaluation of nursing practice has increased, it is still a rather small area. According to the items elucidated in this study, further methodological improvement is needed to evaluate the economics of nursing.

Suppressor cell activity in a male infant with T-and B-lymphocyte dysfunction treated with thymosin

A male infant with bilateral iris coloboma who had had repeated infections and malabsorption was studied. The levels of total lymphocytes and of T and B cells were normal or high, but IgA became undectable and IgG low, whereas IgM was normal. His lymphocytes did not respond to phytohemagglutinin (PHA), concanavalin A, pokeweed mitogen (PWM) or in mixed lymphocyte reactions (MLR), nor did they respond in vitro when thymosin was included in the test systems. He was skin-test-negative, even to dinitrochlorobenzene. His crudely isolated T lymphocytes and the supernatant of his PHA-stimulated lymphocytes inhibit the response of normal lymphocytes to PHA, PWM, and in MLR. During thymosin treatment skin test and lymphocyte reactivity to mitogen remained negative. He became faintly positive in MLR, and the suppressor activity in the supernatant of his PHA-stimulated lymphocytes no longer inhibited the response of normal lymphocytes to PHA, PWM, or in MLR. In parallel with thymosin treatment he showed quite marked clinical improvement.

The value of caries preventive care among 19-year olds using the contingent valuation method within a cost-benefit approach

OBJECTIVES

The aim of this study was to explore adolescents with high and no caries experience and their preferences for caries preventive dental care. Their willingness-to-pay (WTP) for preventive dental care was elicited using the contingent valuation method (CVM) within a cost-benefit approach.

METHODS

Eighty-two individuals (19-year olds) agreed to participate in an exploratory case-control study. Thirty individuals with high caries experience formed the test group. The control group consisted of 52 individuals with no caries experience, selected randomly from a caries-free population. Using personal questionnaires in combination with the CVM, we elicited respondents' WTP for preventive dental care. The data were used to: (a) compare WTP between study groups, and (b) calculate net social benefit (NSB) in cost-benefit analysis (CBA).

RESULTS

The result shows a mean yearly WTP for the high- and low-risk group of 1405 SEK and 1087 SEK (7.70 SEK = US$1; July 2005), respectively. Two variables were associated with the differences between the groups: caries risk (i.e. group designation) and housing. Using these WTP values, the CBA showed positive NSB values for both study groups.

CONCLUSIONS

Through use of the CVM, 19-year olds' WTP for caries preventive measures was elicited. An NSB >0 was found, which means that benefits exceeded the costs for prevention. Despite the small sample size and restriction to one Swedish county, the results indicate that the methods used in this study are suitable for further testing and analyses.

A Pilot Study of the Use of Oral Health-Related Quality of Life Measures as an Outcome for Analysing the Impact of Caries Disease among Swedish 19-Year-Olds

OBJECTIVES

To be useful as a supplement for health economic evaluations in caries preventive care, the oral health-related quality of life (OHRQOL) measures must be able to discriminate for caries disease. The aim of this study was therefore to explore whether any differences existed in perceived OHRQOL among adolescents with either high or no caries experience.

METHODS

Eighty-two individuals (all 19-year-olds) agreed to participate in a pilot exploratory case-control study. Thirty individuals with high caries experience formed the test group. The control group consisted of 52 individuals with no caries experience, selected randomly from a caries-free population. OHRQOL scores were collected for analysis through personal interviews using two OHRQOL measures, the Child Perceptions Questionnaire (CPQ(11-14)) and Oral Health Impact Profile-14 (OHIP-14).

RESULTS

The OHRQOL measures used were not able to discriminate between young adults with high and no caries risk experience with respect to perceived OHRQOL. Despite a consistently higher impact score for the test group throughout the overall and subscale scores, the differences were not statistically significant except for one of the subscale scores, oral symptoms.

CONCLUSIONS

This study indicates that the prevalence and incidence of caries must be seen as too low in Sweden to have major influence on young adults' perceived OHRQOL and well-being. Therefore, the usefulness of OHRQOL measures in supplementing outcome measurement in health economic evaluations, particularly those that focus on caries preventive strategies, must be questioned.

Adenovirus 5 vector genetically re-targeted by an Affibody molecule with specificity for tumor antigen HER2/neu

In order to use adenovirus (Ad) type 5 (Ad5) for cancer gene therapy, Ad needs to be de-targeted from its native receptors and re-targeted to a tumor antigen. A limiting factor for this has been to find a ligand that (i) binds a relevant target, (ii) is able to fold correctly in the reducing environment of the cytoplasm and (iii) when incorporated at an optimal position on the virion results in a virus with a low physical particle to plaque-forming units ratio to diminish the viral load to be administered to a future patient. Here, we present a solution to these problems by producing a genetically re-targeted Ad with a tandem repeat of the HER2/neu reactive Affibody molecule (ZH) in the HI-loop of a Coxsackie B virus and Ad receptor (CAR) binding ablated fiber genetically modified to contain sequences for flexible linkers between the ZH and the knob sequences. ZH is an Affibody molecule specific for the extracellular domain of human epidermal growth factor receptor 2 (HER2/neu) that is overexpressed in inter alia breast and ovarian carcinomas. The virus presented here exhibits near wild-type growth characteristics, infects cells via HER2/neu instead of CAR and represents an important step toward the development of genetically re-targeted adenoviruses with clinical relevance.

Decreased immune reactivity towards a knobless, affibody-targeted adenovirus type 5 vector

In this study, a prototype Adenovirus type 5 (Ad5) vector deleted of the fiber knob domain and carrying an Affibody molecule as the targeting ligand showed decreased susceptibility to human pre-existing antibodies. This vector, Ad5/R7-Z(taq)Z(taq), has short fibers carrying seven shaft repeats, a non-native trimerization signal and an affibody molecule (Z(taq)) reactive to Taq polymerase. Ad5/R7-Z(taq)Z(taq) could be specifically targeted to 293 cells stably expressing membrane-bound anti-Z(taq) idiotypic affibody called Z(ztaq) (293Z(ztaq)). Sera from 50 blood donors were analyzed for neutralization activity (NA) against the parental Ad5/Fiwt vector and knobless Ad5/R7-Z(taq)Z(taq) on 293Z(ztaq) cells. Twenty-three sera had NA titers (> or =1:64) against Ad5/Fiwt (46%) and only two against Ad5/R7-Z(taq)Z(taq) (4%). Characterization of sera with NA titers showed that the knob domain is one of the targets of the antibodies. Neutralization assays using sera pre-adsorbed on knob and hexon proteins showed that the NA of the sera was carried mainly by anti-knob and anti-hexon antibodies, but in certain sera the anti-hexon antibodies represent the major population of the neutralizing antibodies (NAbs). Our results suggested that a combination of knob deletion and hexon switching could be an effective strategy for Ad vectors to better evade the anti-Ad NAbs.

Tumor cell targeted gene delivery by adenovirus 5 vectors carrying knobless fibers with antibody-binding domains

Most human carcinoma cell lines lack the high-affinity receptors for adenovirus serotype 5 (Ad5) at their surface and are nonpermissive to Ad5. We therefore tested the efficiency of retargeting Ad5 to alternative cellular receptors via immunoglobulin (Ig)-binding domains inserted at the extremity of short-shafted, knobless fibers. The two recombinant Ad5's constructed, Ad5/R7-Z(wt)-Z(wt) and Ad5/R7-C2-C2, carried tandem Ig-binding domains from Staphylococcal protein A (abbreviated Z(wt)) and from Streptococcal protein G (C2), respectively. Both viruses bound their specific Ig isotypes with the expected affinity. They transduced human carcinoma cells independently of the CAR pathway, via cell surface receptors targeted by specific monoclonal antibodies, that is, EGF-R on A549, HT29 and SW1116, HER-2/neu on SK-OV-3 and SK-BR-3, CA242 (epitope recognized by the monoclonal antibody C242) antigen on HT29 and SW1116, and PSMA (prostate-specific membrane antigen) expressed on HEK-293 cells, respectively. However, Colo201 and Colo205 cells were neither transduced by targeting CA242 or EGF-R nor were LNCaP cells transduced by targeting PSMA. Our results suggested that one given surface receptor could mediate transduction of certain cells but not others, indicating that factors and steps other than cell surface expression and virus-receptor interaction are additional determinants of Ad5-mediated transduction of tumor cells. Using penton base RGD mutants, we found that one of these limiting steps was virus endocytosis.

Cost-effectiveness of different caries preventive measures in a high-risk population of Swedish adolescents

OBJECTIVES

A total of 3373 12-year-olds agreed to participate in an intervention study evaluating different caries preventive measures. The study, titled 'Evaluation of caries preventive measures', was performed between 1995 and 1999 at 26 dental health clinics throughout Sweden. At the start of the study, the subjects were classified as individuals at high or low risk of developing caries. The high-risk group consisted of 1165 subjects. The children in the high-risk group were randomly assigned to one of four preventive programs. The programs represent a step-wise increase in fluoride content, contact with dental personnel and cost. The aim of the present cost-effectiveness analysis (CEA) study performed from a societal perspective is to compare costs and consequences of caries preventive programs in a caries high-risk population. By 'costs' is meant both treatment costs and costs contributed by the patient and the patient's family. Costs contributed by patients and their families consist of out-of-pocket expenses, transportation costs, and time. Conclusions are that it is important to consider the perspective from which a study is carried out. Costs contributed by the patient and the patient's family have a high impact on total costs for children and younger adolescents but decrease with time as the adolescents get older. The present study shows an incremental cost-effectiveness of 2043 SEK (8.54 SEK = 1 US dollar, December 1999) per averted decayed enamel and dentine missing and filled surface (DeMFS), of which treatment costs represent 1337 SEK using the unit cost for a nurse. This means a yearly cost of approximately 334 SEK.

Nutrient intake and iron status of urban poor and rural poor without access to rice fields are affected by the emerging economic crisis: the case of pregnant Indonesian women

OBJECTIVE

We evaluated the adequacy of nutrient intake in comparison with the Indonesian Estimated Average Requirement (EARs) among pregnant Indonesian women and explain the short-term effect of economic crisis on nutrient intake and iron status.

DESIGN

Cross-sectional study.

SETTING

Purworejo District, Central Java, located 60 km west of Yogyakarta Province, Indonesia.

SUBJECTS

During the period from 1996 to 1998, up to six 24 h recalls were performed during the second trimester of pregnancy among 450 women. Nutrient intake and iron status was evaluated in relation to date of data collection relative to the economic crisis that emerged in August 1997. A computer program (Inafood) was developed to calculate nutrient intake.

RESULTS

: Forty percent of the pregnant women were at risk of inadequate intake of energy and protein, and 70% were at risk of inadequate intake of vitamin A, calcium and iron even before the crisis. Our results also demonstrate an effect of short-term economic crisis on nutrient intake and iron status. When the crisis emerged, urban poor experienced a decrease in intake of most nutrients. During the crisis, rich women experienced a significant decrease in fat (P<0.05). Negative changes in fat density during crisis were experienced by the rich and the rural, poor, and access to rice field subgroups (P<0.01). A significant increase in carbohydrate densities was seen for the rich and rural, poor, and access to rice fields groups (P<0.05). Urban poor experienced decreased serum ferritin concentration (P<0.05), whereas rich women experienced a significant increase (P<0.05).

CONCLUSIONS

Urban poor and rural poor landless women were most directly affected by the emerging economic crisis.

Genetic modification of adenovirus 5 tropism by a novel class of ligands based on a three-helix bundle scaffold derived from staphylococcal protein A

The use of adenovirus (Ad) as an efficient and versatile vector for in vivo tumor therapy requires the modulation of its cellular tropism. We previously developed a method to genetically alter the tropism of Ad5 fibers by replacing the fiber knob domain by an extrinsic trimerization motif and a new cellular ligand. However, fibers carrying complex ligands such as single-chain antibody fragments did not assemble into functional pentons in vitro in the presence of penton base, and failed to be rescued into infectious virions because of their inability to fold correctly within the cytoplasm of Ad-infected cells. Here we show that the coding sequence for a disulfide bond-independent three-helix bundle scaffold Z, derived from domain B of Staphylococcal protein A and capable of binding to the Fc portion of immunoglobulin (Ig) G1, could be incorporated into modified knobless Ad fiber gene constructs with seven shaft repeats. These fiber gene constructs could be rescued into viable virions that were demonstrated to enter 293 cells engineered for IgG Fc surface expression but not unmodified 293 cells, via a mechanism that could be specifically blocked with soluble Fc target protein. However, the tropism modified viruses showed a slightly impaired cellular entry and a lower infectivity than wildtype (WT) virus. In addition, we generated recombinant fibers containing an IgA binding Affibody ligand, derived from combinatorial specificity-engineering of the Z domain scaffold. Such fiber constructs also showed the expected target specific binding, indicating that the affibody protein class is ideally suited for genetic engineering of Ad tropism.

Energy intake during economic crisis depends on initial wealth and access to rice fields: the case of pregnant Indonesian women

Starting in August 1997, Indonesia experienced a radical and rapid deterioration in its economy. Between 1996 and 1998, dietary intake during the second trimester was measured in 450 pregnant women in Purworejo, Central Java, Indonesia. Using six 24 h recalls we describe the consequences of the economic crisis on the energy intake of pregnant Indonesian women. Depending on the date of data collection, women were grouped into 'before crisis', 'transition' and 'during crisis'. Mean energy intake among groups was compared using ANOVA and Student's t-test. All groups of pregnant women already had a mean energy intake before the emerging crisis that was lower than the Indonesian recommended dietary allowances (RDA). Nevertheless, energy intake differed significantly among women with different education levels (P = 0.00) and from different socio-economic groups (P = 0.00). 'During transition', a significant decrease in energy intake was experienced by urban poor women (P = 0.01). Poor women with access to rice fields had a higher rice consumption than other groups throughout the period. Our results most likely reflect the effect of higher rice price on income and welfare. 'During crisis', energy intake improved among vulnerable groups, perhaps reflecting government intervention.

Insulin (GIK) improves central mixed and hepatic venous oxygenation in clinical cardiac surgery

OBJECTIVE

Insulin is a vasodilating agent and it was hypothesized that insulin (GIK) could improve systemic and regional oxygenation in cardiac surgery with cardiopulmonary bypass (CPB). Two questions were addressed: 1) Does insulin improve central mixed and hepatic venous oxygenation during CPB? and 2) Does this treatment reduce systemic levels of the proinflammatory mediators C3a and IL-6?

DESIGN

Prospective, randomized, controlled study at a university hospital. Thirty patients were included and 16 of these received an infusion of insulin, glucose and potassium (GIK) using an euglycemic clamp technique. The insulin infusion was started during hypothermia, 15 min before rewarming. Blood gases and hemodynamic parameters were measured during hypothermia (before the insulin infusion was started), during rewarming at 35 degrees C, and 30 min after CPB was discontinued. Inflammatory markers were measured: preoperatively, during hypothermia and 2 h after CPB.

RESULTS

GIK was associated with reduced systemic vascular resistance (p = 0.02 vs the control group), higher bypass pump flow (p = 0.001). higher central mixed oxygen saturation (p = 0.036) and oxygen tension (p = 0.001) and higher hepatic venous oxygen saturation (p = 0.04) and oxygen tension (p = 0.006). C3a and IL-6 increased during surgery in both groups but there were no differences between the groups.

CONCLUSION

1) GIK infusion improved central mixed and hepatic venous oxygenation in patients undergoing heart surgery. 2) During the conditions of this study, this had no effect on the proinflammatory mediators C3a and IL-6.

Evaluation of the QALY model for analysis of cost-effectiveness of eating training after stroke

New methods developed and insights gained in research are of increasing significance in health care and the question is which services and methods are to be implemented. If eating training after stroke is to be implemented it must be given priority in relation to other measures. Otherwise there is a risk that patients with eating difficulties after stroke will be fed by personnel or permanently receive nourishment via tube. This may lead to expensive measures or costs for the tube feeding as well as costs for the personnel needed for feeding, and patients' well-being will be reduced if they do not have the opportunity to eat as independently as possible. Economic analyses should not guide the priorities to be made, but can be one of several bases for resource allocation. The estimation of cost-effectiveness must, however, be made by means of a method which in its ethical foundation is in line with nursing and the Swedish Government Bill for guiding priorities in health care. The aim of this paper is to discuss the ethical foundation of nursing care and the ethical principles proposed by the Swedish Government Bill for guiding priorities in health care and the model of Quality Adjusted Life Years (QALYs) related to eating training after stroke. The findings showed that there was a considerable difference in the ways health and health maximization were discussed in the QALY model and in specific nursing care. There are two aspects underpinning the QALY model that are not in line with either the ethical foundations of nursing or the principles proposed by the Swedish Government Bill for guiding priorities in health care. However, a new method called Equity Adjusted Life Years (EQALYs) can be a tool for evaluation in specific nursing care. Cost per EQALY is based on a compromise between initial severity of disease and treatment effect that is very close to the distribution rule applied in specific nursing care. In conclusion it is obvious that cost per EQALY, a balance between health maximization and severity of disease and treatment effects, can be a tool for the evaluation of eating training after stroke.

A cost-benefit analysis of the community-based injury prevention programme in Motala, Sweden--a WHO Safe Community

The objective in this study was to calculate costs and benefits caused by a safe community injury prevention programme in Motala, Sweden. The study design was a quasi-experimental evaluation involving an intervention population and a non-random control population. All injuries were recorded before and after an intervention programme. The presented calculations show that costs of injuries in a societal perspective decreased from 116 million Swedish Crowns (SEK) to 96 million SEK, while the cost for the intervention was estimated at approximately 10 million SEK. Thus, the safe community injury prevention programme in Motala should be judged as cost-effective.

Genetic retargeting of adenovirus: novel strategy employing "deknobbing" of the fiber

For efficient and versatile use of adenovirus (Ad) as an in vivo gene therapy vector, modulation of the viral tropism is highly desirable. In this study, a novel method to genetically alter the Ad fiber tropism is described. The knob and the last 15 shaft repeats of the fiber gene were deleted and replaced with an external trimerization motif and a new cell-binding ligand, in this case the integrin-binding motif RGD. The corresponding recombinant fiber retained the basic biological functions of the natural fiber, i.e., trimerization, nuclear import, penton formation, and ligand binding. The recombinant fiber bound to integrins but failed to react with antiknob antibody. For virus production, the recombinant fiber gene was rescued into the Ad genome at the exact position of the wild-type (WT) fiber to make use of the native regulation of fiber expression. The recombinant virus Ad5/FibR7-RGD yielded plaques on 293 cells, but the spread through the monolayer was two to three times delayed compared to WT, and the ratio of infectious to physical particles was 20 times lower. Studies on virus tropism showed that Ad5/FibR7-RGD was able to infect cells which did not express the coxsackie-adenovirus receptor (CAR), but did express integrins. Ad5/FibR7-RGD virus infectivity was unchanged in the presence of antiknob antibody, which neutralized the WT virus. Ad5/FibR7-RGD virus showed an expanded tropism, which is useful when gene transfer to cells not expressing CAR is needed. The described method should also make possible the construction of Ad genetically retargeted via ligands other than RGD.

What is the "golden standard" for assessing population-based interventions?--problems of dilution bias

OBJECTIVES

To identify different types of dilution bias in population-based interventions and to suggest measures for handling these methodological problems.

DESIGN

Literature review plus analysis of data from a population-based intervention against cardiovascular disease in a Swedish municipality.

MAIN RESULTS

The effects of an intervention on mortality and morbidity were much more diluted by non-intervening factors, dissemination to areas outside the intervention area, social diffusion, population mobility and time than by using intermediate outcome measures.

CONCLUSIONS

Theoretically, changes in scientifically well documented risk factors, for example, intermediate outcome measures, should be preferred to using morbidity or mortality as outcome measures.

Is skeletal muscle luxury perfusion the main hemodynamic effect of high-dose insulin in cardiac surgery?

Insulin, in combination with glucose and potassium (GIK), can be used in heart surgery to improve hemodynamic performance. This study evaluates the role of skeletal muscle vasodilation in hemodynamic effects of high-dose GIK therapy early after coronary surgery. Thirty-three male patients undergoing coronary artery bypass grafting were included in a prospective, randomized and controlled study. Eleven patients received infusions of mixed amino acids (11.4 g) and insulin solution (225 IU insulin, glucose with the glucose clamp technique, and potassium), 11 patients received infusions of mixed amino acids (11.4 g) and 11 patients served as control subjects. During combined insulin and amino acid infusion, cardiac output increased by 13+/-3% (+0.6+/-0.2 L x min(-1)) and systemic vascular resistance decreased by 24+/-3% (-320+/-46 dyn x s x cm(-5)). The changes differed from those in the control group (CO: -0.2+/-0.1 L x min(-1), p < 0.05; SVR: +136+/-42 dyn x s x cm(-5), p < 0.05). Changes in skeletal muscle perfusion and leg vascular resistance did not differ significantly among the groups. At most, changes in leg blood flow could explain 40% of the changes in cardiac output. Skeletal muscle luxury perfusion is not the main hemodynamic effect of high-dose insulin in the early postoperative period after coronary surgery.

Cost-minimisation analysis of three conservative treatment programmes in 180 patients sick-listed for acute low-back pain

OBJECTIVE

To perform a cost-minimization analysis of three conservative treatment regimes for acute low-back pain (LBP).

DESIGN

A prospective randomized clinical trial. Patients were assigned at random to one of three treatment programmes: General Practitioner Programme (GPP-) controls, Manual Therapy Programme (MTP) or Intensive Training Programme (ITP).

SETTING

Primary care and physiotherapists in Stockholm, Sweden.

PATIENTS

180 patients sick-listed for acute LBP.

MAIN OUTCOME MEASURES

Direct, indirect and total costs for three treatment programmes.

RESULTS

The direct costs for treatment were lowest in the GPP group -- 2744 Swedish crowns (SEK) per patient. More patients in the MTP and ITP underwent operations for disk hernia and radiological investigations than in the GPP. Indirect costs, defined as sick-leave for LBP represent about 90% of the total cost.

CONCLUSIONS

With respect to total costs, the findings were similar between the three treatment programmes. The GPP had the lowest direct costs. It is not possible to conclude which treatment programme is to be recommended as a least cost alternative. The strong effect of indirect costs on the total cost stresses that further studies should focus on methods of shortening sick-leave.

Being in the world of the suffering patient: a challenge to nursing ethics

Ethics in caring is what we actually make explicit through our approach and how we invite the suffering patient into a caring relationship. This phenomenological study investigates suffering and health and how this presupposes a deeper reflection on ethics in caring. The aim was to try to discover, describe and understand how patients experience their life situation three years after undergoing surgery. The theoretical approach is based on central aspects of Eriksson's caritative theory (i.e. the view of the person as body, soul and spirit). The informants were four women and four men aged between 55 and 77 years. The empirical material revealed suffering that was connected with both illness and life. Suffering involves experiences of grief, loneliness and struggling. Health implies a yearning for something beyond the current life situation, a yearning to experience some meaning in life. This leads to an awareness of unplumbed possibilities. Understanding the experiences of individual patients demands of us, as both researchers and nurses, to act, seeking after the scientific truth (i.e. a deeper reflection of the ontological, epistemological and methodological questions). The idea of responsibility helps us to interpret and meet the innermost desires of suffering patients in their true presence. Caritative caring ethics means 'being there', confirming patients' absolute dignity; it is a manifestation of the love that 'just exists'. Compassion requires an inner disposition to go with others to the places where they are weak, vulnerable, lonely and broken. An ontology of caring provides both a starting point and a context for reflection about ethics and the ethical life.

Cost-effectiveness analysis with defined budget: how to distribute resources for the prevention of cardiovascular disease?

The aim of the study was to undertake cost-effectiveness calculations subject to a defined budget. The setting chosen was the prevention of cardiovascular disease (CVD) by means of three intervention programmes in a Swedish county council. The population in the county was divided into subgroups according to risk level. For each subgroup the cost per years of life saved was calculated, as well as the annual budget claims. The budget available was defined as present direct cost in the programmes. The calculations resulted in a programming solution showing the optimal distribution of resources between the programmes. Also a league table was constructed and the cut-off value for a 'acceptable' cost-effectiveness was shown. The conclusion that can be drawn is that a combination of internationally published intervention results and local data regarding epidemiology and resource improves the accuracy and usefulness of cost-effectiveness ratios. However, the model presented is a first attempt containing only three interventions: the planned next phase is to integrate more interventions in the model.

The importance of ethics in the clinical supervision of nursing students

This article investigates whether or not an ethical attitude manifests itself in the clinical supervision of nursing students. The data consist of 57 narratives written by nursing students, which were subjected to latent content analysis. The interpretation represents a caring science perspective based on Eriksson's 'caring ethics'. The results showed that some students received good supervision, while others felt hurt and humiliated. The students were of the opinion that they should feel welcome, be allowed to take responsibility and be treated as individuals by their supervisors. Supervision can take a form such that the ethical element comes to the fore in the conduct of the students as well as of their supervisor. Both the students' and the supervisor's disposition permeates all the questions, actions and reflections that form part of supervision, which could help to bring students' ethical sense to maturity.

[Cost-effectiveness analysis of cardiovascular disease prevention: a graded list as aid to the rational distribution of resources]

In a study designed to compare the cost-effectiveness of three cardiovascular disease prevention programmes, subject to a defined budget, a population was subgrouped according to risk levels. Cost per year of life saved and annual budget expenditure were calculated for each subgroup. Budget expenditure was defined in terms of current direct costs. A ranked list was constructed, and the cut-off level of 'acceptable' cost-effectiveness elicited.

[Modified cost-benefit analysis takes equity into consideration. Treatment of brain tumors is more cost-effective than hip replacement]

As health care resources are held to be insufficient to permit free choice of available treatment options, prioritizing is necessary. A precondition of careful prioritizing is comprehensive knowledge of the consequences, both for the patient and the community, of adopting each of the available options in a given case. A tool used in setting priorities is cost-benefit analysis, based on the utilitarian principle of health maximisation. However, it is evident from findings in recent studies that equity is widely considered a factor which ought to be included in the analysis. The article presents a method for correcting the variable, quality-adjusted life years (QALY), by introducing an equity factor, yielding a new variable, equity-adjusted QALY (EQALY). Use of the method is illustrated by comparison of the cost-effectiveness of two procedures, hip replacement and the treatment of malignant glioma, and showing how priority ranking of the two procedures is reversed if the EQALY variable is used instead of QALY.

Urogenital symptoms in women aged 50-59 years. Women's Health in Lund Area (WHILSA) Study Group

Problems related to the urogenital tract are common in elderly women. Control of micturition is often impeded and questionnaire-based studies have reported a prevalence of poor control of micturition in about 30% of postmenopausal women. In an ongoing cohort comprising women born between 1935 and 1945, an interim analysis was performed in 1800 women based on an interview and questionnaire. The prevalence of urinary incontinence was found to be 33%, which is in accordance with previous reports. The main difference between the interview and the questionnaire was that the interview could take into account intensity as well as intermittence of symptoms. There were no differences between premenopausal women and postmenopausal women using or not using hormone replacement therapy. In agreement with earlier studies, we found poorer control of micturition in parous women. A higher percentage of incontinence was also found in women who had lost more than 5 kg in body weight during the preceding 5 years. In addition, women with a family history of diabetes were more prone to complaints of incontinence. Of the 155 women who had a family history of diabetes, 66 were incontinent (p < 0.01). It was also found that women who were incontinent were more often on regular surveillance for various diseases, using more medications regularly and had been hospitalized during the last 5 years more often than women who were continent. There were no differences in smoking habits. The present results imply that urinary incontinence in women is of a complicated origin and that the hormonal situation plays a minor role for this socially handicapping symptom.

How many lives is equity worth? A proposal for equity adjusted years of life saved

STUDY OBJECTIVE

To present a formula for equity adjusted years of life saved (EYLS).

DESIGN

A mailed questionnaire. The survey participants were given a scenario describing a trade off between a health maximization programme and a programme that is less efficient, but eliminates social inequalities.

SETTING

Swedish politicians responsible for health care in the county councils.

PARTICIPANTS

A sample of 449 Swedish politicians responsible for health care in the county councils.

MAIN RESULTS

The principle of health maximization was rejected. Under certain conditions, the Swedish politicians are prepared to sacrifice 15 of 100 preventable deaths to achieve equity. Based on the results a formula for EYLS is presented.

CONCLUSIONS

An equity adjusted formula for years of life saved has been proposed, but must be developed and revised according to each country's specific conditions and value premises. In the future, such formulas could serve the purpose of incorporating explicit considerations of equity into cost effectiveness analyses.

On the measurement of the nation's equity adjusted health

The aim of this article is to show a method for measuring the nation's equity-adjusted health. In order to estimate what the 'nation's health function' looks like, data from a survey sent to a sample of Swedish politicians were used. The results from the survey can be interpreted as a measure of inequity aversion, and this was applied to data on healthy years (HY) for males in different social groups for the period 1975-1990. The mean of healthy years increased during the period 1986-1990 by 1.09% while equity adjusted healthy years (HY(EDE)) dropped by -1.78%. The nation's health has decreased in spite of the fact that the individual's health has increased.

Alcohol advice in primary health care--is it a wise use of resources?

Many attempts to calculate costs caused by the use of alcohol in accordance with the cost-of-illness method have been reported in the literature. However, in a decision-making perspective and with a focus on what possible interventions to undertake, cost-benefit or cost-effectiveness studies are more useful. In this study the cost-effectiveness of advice aimed at reducing 'heavy' drinking to 'moderate' drinking is calculated. Results from controlled trials, showing the short-range effects of advice, are combined with observations from long-term epidemiological studies showing the association between alcohol consumption and total mortality. This study shows that advice from primary health care staff has a potential to be a very cost-effective means of intervention. The crucial point seems to be the number of people that makes durable changes in consumption. If about 1% make lasting changes a brief intervention is relatively cost-effective (20,000 ECU/YLS), and if about 10% change resources will be saved in health care. Important effects such as increased quality of life and decreasing production losses are not taken into account.

Reproducibility of mental stress-induced myocardial ischemia in the Psychophysiological Investigations of Myocardial Ischemia (PIMI)

OBJECTIVE

Many patients with coronary artery disease (CAD) develop myocardial ischemia in response to mental stress. This has been documented both in the natural environment and in the laboratory. However, the reproducibility of laboratory mental stress-induced ischemia has not been investigated.

METHOD

Sixty patients with documented CAD and a positive exercise stress test discontinued cardiac medications and underwent two standardized mental stress tests (a timed Stroop Color-Word test and a public speaking task) in a nuclear cardiology laboratory (Visit 1), and repeated this procedure between 2 and 8 weeks later (Visit 2). Measurements of cardiovascular function and neurohormonal responses were obtained throughout testing, and mood state was assessed before and after testing.

RESULTS

Sixty-eight percent of the 56 patients with detailed radionuclide data from both visits had consistent responses (ie, ischemia either present during both sessions or absent during both) to the Stroop task (kappa = .29, p = .03), 61% had consistent responses to the speech task (kappa = .20, p = .12), and 60% had consistent responses when ischemia was considered present if it occurred during either the Stroop test, the speech task, or both, and absent if it did not occur during either task (kappa = .22, p = .07). Hemodynamic and neuroendocrine responses to the tests were moderately reproducible.

CONCLUSIONS

We conclude that two popular laboratory tests for mental stress-induced myocardial ischemia are modestly reproducible. The relatively low reproducibility is probably influenced by uncertainties in detecting relatively small changes in wall motion, habituation of the patient to repeated exposure to psychological stressors, and physiological differences in threshold for ischemia on different days of testing.