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Impact of hysterectomy on analgesic, psychoactive and neuroactive drug use in women with endometriosis: nationwide cohort study. BJOG 2020; 128:846-855. [PMID: 32804432 PMCID: PMC7984057 DOI: 10.1111/1471-0528.16469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 12/17/2022]
Abstract
Objective To evaluate how hysterectomy affects the prescription of analgesic, psychotropic and neuroactive drugs in women with endometriosis using population‐based nationwide registers. Design Nationwide cohort study. Setting Swedish national registers, from 1 January 2009 to 31 December 2018. Population Women with benign disease undergoing a total hysterectomy during the 4‐year period of 2012–2015. Women with endometriosis (n = 1074) were identified and compared with women who did not have endometriosis (n = 10 890). Methods Prospectively collected data from two population‐based registers were linked: the Swedish National Quality Register of Gynaecological Surgery and the Swedish National Drug Register. Multivariate logistic regression was used as the main statistical method. Main outcome measures Changes in drug prescription over time for 3 years prior to and 3 years after hysterectomy. Results The frequency of prescription of analgesics was higher in women with endometriosis compared with women without endometriosis (OR 2.2, 95% CI 1.7–2.9). Among women with endometriosis, the prescription of analgesics (OR 1.0, 95% CI 0.8–1.2) did not decrease 3 years after hysterectomy compared with the 3 years prior to surgery. There was also a significantly higher rate of prescription of psychoactive (OR 1.6, 95% CI 1.4–2.0) and neuroactive drugs (OR 1.9, 95% CI 1.3–2.7) in the long term postoperatively. Conclusions In women undergoing hysterectomy, endometriosis was associated with a higher prescription rate of analgesics. In the endometriosis group the prescription of analgesic, psychoactive and neuroactive drugs did not decrease when comparing prescription rates for the 3 years prior to and the 3 years after surgery. Tweetable abstract In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy. In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy.
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Die TIDieR Checkliste und Anleitung – ein Instrument für eine verbesserte Interventionsbeschreibung und Replikation. DAS GESUNDHEITSWESEN 2018; 78:e174. [DOI: 10.1055/s-0037-1600948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sleep in Schizophrenic Patients: Discrepancy Between Self-reported Versus Recorded Sleep. Eur Psychiatry 2015. [DOI: 10.1016/s0924-9338(15)30731-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Choosing Important Health Outcomes For Comparative Effectiveness Research: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2014; 17:A435. [PMID: 27201147 DOI: 10.1016/j.jval.2014.08.1118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study. Health Technol Assess 2014; 17:i-xiv, 1-307. [PMID: 23834998 DOI: 10.3310/hta17280] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. DESIGN Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis. SETTING Eleven primary-care practices: eight in Birmingham and three in Lambeth. PARTICIPANTS Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs. MAIN OUTCOME MEASURES Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) 'fatty liver' not associated with the above; and (4) the absence of detectable disease. RESULTS Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of 'fatty liver' was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change. CONCLUSIONS Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of 'fatty' liver. Abnormal LFTs and 'fatty' liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat. FUTURE WORK RECOMMENDATIONS (1) the cases of 'fatty liver' and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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A meta-analysis of echocardiographic measurements of the left heart for the development of normative reference ranges in a large international cohort: the EchoNoRMAL study. Eur Heart J Cardiovasc Imaging 2013; 15:341-8. [DOI: 10.1093/ehjci/jet240] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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229 * MAJOR AND UNEXPLAINED VARIATIONS IN ELECTIVE CORONARY REVASCULARIZATION PRACTICES IN ENGLAND. Interact Cardiovasc Thorac Surg 2013. [DOI: 10.1093/icvts/ivt372.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Towards best reporting practices for clinical pharmacology trials. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Association between gestational diabetes mellitus and subsequent overactive bladder among premenopausal female twins. BJOG 2013; 120:1289-95. [DOI: 10.1111/1471-0528.12253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2013] [Indexed: 01/27/2023]
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Different fatty acid pattern in breast milk of obese compared to normal-weight mothers. Prostaglandins Leukot Essent Fatty Acids 2013; 88:211-7. [PMID: 23273824 DOI: 10.1016/j.plefa.2012.11.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The aim of this study was to investigate the fatty acid (FA) pattern in breast milk of obese mothers and their neonates' plasma compared to those of normal weight mothers. PATIENTS AND METHODS This was an observational study of 41 obese and 41 normal weight pregnant women. Twenty-nine obese women participating in a weight reduction program were investigated for comparison. FAs were analyzed in breast milk collected at 3 and 10 days and one and two months postnatally and in infant's plasma 3 days after birth. RESULTS AND CONCLUSIONS The concentration of long-chain n-3 FA were lower and the ratio n-6/n-3 FA higher in neonates and in consecutive samples of breast milk of obese mothers compared to normal weight mothers. The obese mothers that participated in an intervention program with general dietary advice had FA concentrations approaching that of the normal-weight mothers. The study indicates importance of dietary advice in pregnancy.
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O677 OVERACTIVE BLADDER SYNDROME IN WOMEN WITH GESTATIONAL DIABETES. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)61107-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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W299 RISK OF OBSTETRIC ANAL SPHINCTER LACERATIONS AMONG OBESE WOMEN. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)62022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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P2-12-03: A Prospective Study of the Prognostic Implications of Being a BRCA1 Carrier for Young Onset Breast Cancer Patients. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p2-12-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
BRCA1 gene carriers frequently develop triple negative breast cancer (TNBC) at young ages. Retrospective studies have reached conflicting conclusions about the prognostic implications of breast cancer diagnosed on a background of a constitutional BRCA1 gene mutation. Many studies have the disadvantages of retrospective design and small numbers or both. The Prospective study of Outcomes in Sporadic versus Hereditary breast cancer (POSH) recruited 3024 patients diagnosed before 41 years of age and treated for breast cancer in the UK between 2000 and 2007 (protocol published: Eccles et al BMC Cancer 2008).
Aim: To investigate the effect of family history and BRCA1 gene mutation status on breast cancer survival in women aged younger than 41 years at diagnosis.
Methods: Cases in which the primary tumour pathology report was not available (2.8% of total) were excluded from this analysis. A completed family history questionnaire was available for 2907 cases (99% of total). The primary end point for this analysis was the development of distant metastases from breast cancer. All patients were younger than the starting age for screening in the UK except for known gene carriers of which there were only 8 in total, the remainder of identified gene carriers were tested after cancer diagnosis or as part of this study. Over 90% of patients received adjuvant or neoadjuvant chemotherapy with over 90% of these receiving an anthracycline based regimen. Kaplan Meier survival analysis and log rank test were used to assess survival differences.
Results: 2937 patients were included in the analysis. Mean and median age at diagnosis was 36 years and the cohort was followed prospectively for a mean and median follow up time of 50 months. Overall distant disease free survival in the whole cohort was only 75% at 5 years. The effect of family history on presentation was explored. Patients who reported a first or second degree relative with breast cancer presented with smaller tumours (20mm compared to 22.5mm, p= 0.006) but no difference in axillary nodal status (p=0.2605). Survival was however significantly better comparing the 499 patients who reported a family history of breast cancer compared with the rest of the cohort (p=0.0164). 539 patients had been tested for mutations in the BRCA1/2 genes and 176 high risk gene BRCA1/BRCA2 carriers were identified. We compared 118 patients with a known BRCA1 gene mutation (almost all diagnosed after the cancer) to the 465 patients with confirmed TNBC (p=0.0118). Survival was significantly better in the BRCA1 carriers (p=0.0118). After excluding 29 gene carriers whose primary tumour showed any of ER, HER2 or PR as positive, the same improved survival trend was seen although significant at the 10% level (p=0.07).
Conclusion: This prospective study indicates that BRCA1 gene carriers clearly do not have a worse prognosis when compared to triple negative breast cancers or young onset breast cancer overall and these early follow up data indicate an improved outlook in gene carriers.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-03.
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Bevorzugte Report Items für systematische Übersichten und Meta-Analysen: Das PRISMA-Statement. Dtsch Med Wochenschr 2011. [DOI: 10.1055/s-0031-1272982] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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CONSORT 2010: Aktualisierte Leitlinie für Berichte randomisierter Studien im Parallelgruppen-Design. Dtsch Med Wochenschr 2011. [DOI: 10.1055/s-0031-1272983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
OBJECTIVES To assess the effect of coffee and tea consumption on symptoms of urinary incontinence. DESIGN Population-based study. SETTING The Swedish Twin Register. POPULATION In 2005, all twins born between 1959 and 1985 in Sweden (n = 42,852) were invited to participate in a web-based survey to screen for common complex diseases and common exposures. The present study was limited to female twins with information about at least one urinary symptoms and coffee and tea consumption (n = 14,031). MAIN OUTCOME MEASURE The association between coffee and tea consumption and urinary incontinence, as well as nocturia, was estimated as odds ratios (ORs) with 95% confidence intervals. RESULTS Women with a high coffee intake were at lower risk of any urinary incontinence (OR 0.78, 95% CI 0.64-0.98) compared with women not drinking coffee. Coffee intake and incontinence subtypes showed no significant associations whereas high tea consumption was specifically associated with a risk for overactive bladder (OR 1.34, 95% CI 11.07-1.67) and nocturia (OR 1.18, 95% CI 1.01-1.38). Results from co-twin control analysis suggested that the associations observed in logistic regression were mainly the result of familial effects. CONCLUSIONS This study suggests that coffee and tea consumption has a limited effect on urinary incontinence symptoms. Familial and genetic effects may have confounded the associations observed in previous studies.
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Abstract
Abstract
Background
Diverticulitis is a risk factor for fistula formation but little is known about the influence of hysterectomy in this association. A population-based nationwide matched cohort study was performed to determine the risk of fistula formation in hysterectomized women with, and without, diverticulitis.
Methods
Women who had a hysterectomy between 1973 and 2003, and a matched control cohort, were identified from the Swedish Inpatient Register. Incidence of diverticulitis and fistula surgery was determined by cross-linkage to the Register, and risk was estimated using a Cox regression model.
Results
In a cohort of 168 563 hysterectomized and 614 682 non-hysterectomized women (mean follow-up 11·0 and 11·5 years respectively), there were 14 051 cases of diverticulitis and 851 fistulas. Compared with women who had neither hysterectomy nor diverticulitis, the risk of fistula surgery increased fourfold in hysterectomized women without diverticulitis (hazard ratio (HR) 4·0 (95 per cent confidence interval (c.i.) 3·5 to 4·7)), sevenfold in non-hysterectomized women with diverticulitis (HR 7·6 (4·8 to 12·1)) and 25-fold in hysterectomized women with diverticulitis (HR 25·2 (15·5 to 41·2)).
Conclusion
Diverticulitis, and to a lesser extent hysterectomy, is strongly associated with the risk of fistula formation. Hysterectomized women with diverticulitis have the highest risk of developing surgically managed fistula.
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Abstract
OBJECTIVE To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up. DESIGN Randomised controlled trial. SETTING University hospital in Sweden. POPULATION A total of 165 women diagnosed with a third- to fourth-degree perineal tear. METHODS The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up. MAIN OUTCOME MEASURES Anal incontinence measured by the validated Pescatori incontinence score. RESULTS A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces. CONCLUSION Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.
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Abstract
BACKGROUND There is controversy over whether patients presenting with a primary attack of acute diverticulitis at a younger age are more prone to complications and recurrence than older patients. METHODS A review, including postal questionnaires, was undertaken of 234 patients who had a primary episode of acute diverticulitis. The diagnosis was confirmed by computed tomography (CT) and/or pathology report. The mean length of follow-up was 30 (range 16-45) months. RESULTS In 58 patients aged 50 years or less no differences in fever or white blood cell count were found in comparison with findings in 176 patients aged above 50 years. The rate of severe diverticulitis observed with CT was lower in the younger patients (2 versus 11.9 per cent; P = 0.025). Surgical management during the first admission was undertaken less commonly in younger patients (2 versus 6.8 per cent; P = 0.271). Rates of subsequent events (recurrent diverticulitis and/or further surgery) during follow-up were higher in younger patients (25 versus 19.5 per cent), but this was not significant (P = 0.423). A type II error cannot be excluded. CONCLUSION First episodes of acute diverticulitis were not more aggressive in patients aged 50 years or less. Recurrence rates were slightly higher than in older patients.
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Abstract
OBJECTIVE To assess the impact on sexual function attributed to lower urinary tract dysfunction in a female obese population. DESIGN We performed a case-control study based on the registry of a university hospital obesity unit. A consecutive sample of women with body mass index(BMI) >or=30 (obese) was randomly matched by age, gender and residential county to control subjects using the computerized Register of the Total Population. Data were collected by a self-reported postal survey including the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). RESULTS The questionnaire was completed and returned by 279/446 patients (62%) and 430/892 control subjects (48%). Obese women reported significantly lesser satisfaction with their sexual life, more frequent symptoms of urinary incontinence at intercourse, more often fear of urine leakage at intercourse, a higher tendency toward avoiding intercourse and more frequent feelings of guilt and disgust during intercourse (P<0.001). While considering sexual function in a subset of women with urge or stress urinary incontinence, the overall PISQ-12 scores were significantly lower in obese women compared to their age-matched nonobese controls for both the conditions (P<0.001). In an adjusted multivariate analysis, a BMI >30 was independently associated with a significantly increased risk for sexual dysfunction (odds ratio (OR) 1.8; 95% confidence interval (CI) 1.1-2.9), as were symptoms of urge or stress urinary incontinence (OR, 2.0; 95% CI, 1.3-3.1 and OR, 2.6; 95% CI, 1.7-4.0), respectively. CONCLUSION Urge and stress urinary incontinences are more common and have greater impact on sexual function in obese women.
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Efficacy of Selective Serotonin Reuptake Inhibitors (SSRIS) compared to placebo in obsessive compulsive disorder in adults. Eur Psychiatry 2008. [DOI: 10.1016/j.eurpsy.2008.01.387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev 2008; 2008:CD001765. [PMID: 18253995 PMCID: PMC7025764 DOI: 10.1002/14651858.cd001765.pub3] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Obsessive compulsive disorder is a common and disabling disorder. A significant proportion of patients manifest a chronic course. Individual randomised controlled trials (RCTs) have shown that selective serotonin re-uptake inhibitors (SSRIs) are effective in this condition. Previous systematic reviews or meta-analyses summarising the evidence are methodologically problematic or limited in the scope of their analysis. OBJECTIVES To examine the efficacy and adverse effects of serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD) in adults. SEARCH STRATEGY CCDANCTR-Studies and CCDANCTR-References were searched on 12/11/2007. Reference lists were checked. Experts in the field were contacted. SELECTION CRITERIA All RCTs and quasi-RCTs examining the efficacy of SSRIs compared with placebo for OCD in adults were eligible for inclusion. DATA COLLECTION AND ANALYSIS Selection of studies and data extraction were carried out by two review authors independently, and quality assessment of studies was undertaken. Data analysis was conducted using Review Manager software. Summary measures were produced using the weighted mean difference (WMD) for continuous data and relative risk (RR) for dichotomous data, with 95% confidence intervals (CI). SSRIs were examined as an overall group of drugs, and as individual drugs. MAIN RESULTS Seventeen studies were included in the review, involving 3097 participants. Based on all 17 studies, SSRIs as a group were more effective than placebo in reducing the symptoms of OCD between 6 and 13 weeks post-treatment, measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS) (WMD -3.21, 95% CI -3.84 to -2.57). The WMD for individual SSRI drugs were similar and not statistically different. Based on 13 studies (2697 participants), SSRIs were more effective than placebo in achieving clinical response at post-treatment (RR 1.84, 95% CI 1.56 to 2.17). The pooled RR was shown to be similar between individual SSRI drugs. Although reported adverse effects data were more limited, with few exceptions, the overall and individual adverse effects for the different SSRIs were always worse than for placebo and, in the majority of cases, the difference was statistically significant. Nausea, headache and insomnia were always reported amongst the most common adverse effects in trials of each of the drugs. AUTHORS' CONCLUSIONS SSRIs are more effective than placebo for OCD, at least in the short-term, although there are differences between the adverse effects of individual SSRI drugs. The longer term efficacy and tolerability of different SSRI drugs for OCD has yet to be established.
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Cost-effectiveness of using prognostic information to select women with breast cancer for adjuvant systemic therapy. Health Technol Assess 2007; 10:iii-iv, ix-xi, 1-204. [PMID: 16959170 DOI: 10.3310/hta10340] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To investigate the cost-effectiveness of using prognostic information to identify patients with breast cancer who should receive adjuvant therapy. DATA SOURCES Electronic databases from 1980 through to February 2002. A survey of clinical practice in UK cancer centres and units. Large retrospective dataset containing data on prognostic factors, treatments and outcomes for women with early breast cancer treated in Oxford. REVIEW METHODS Between six and nine databases were searched by an information expert. Evidence-based methods were used to review and select those studies and the quality of each included paper was assessed using standard assessment tools reported in the literature or piloted and developed for this study. A survey of clinical practice in UK cancer centres and units was carried out to ensure that conclusions drawn from the report could be implemented. These data, along with the information gathered in the systematic reviews, informed the methodological approach adopted for the health economic modelling. An illustrative framework was developed for incorporating patient-level prediction within a health economic decision model. This framework was applied to a large retrospective dataset containing data on prognostic factors, treatments and outcomes for women with early breast cancer treated in Oxford. The data were used to estimate directly a parametric regression-based risk equation, from which a prognostic index was developed, and prognosis-specific estimates of the baseline breast cancer hazard could be observed. Published estimates of treatment effects, health service treatment costs and utilities were used to construct a decision analytic framework around this risk equation, thus enabling simulation of the effectiveness and cost-effectiveness of adjuvant therapy for all possible combinations of prognostic factors included in the model. RESULTS The lack of good-quality systematic reviews and well-conducted studies of prognostic factors in breast cancer is a striking finding. There are no registers of studies of prognostic factors or of reviews of prognostic studies. Many of the reviews used weak methods, primary studies are similar with poor methodology and reporting of results. In addition, there is much variation in patient populations, assay methods, analysis of results, definitions used and reporting of results. Most studies appear to be retrospective and some use inappropriate methods likely to inflate outcomes such as optimising cut points and failing to test the results in an independent population. Very few reviews used meta-analysis to conduct a pooled analysis and to provide an estimate of the average size of any association. Instead, most reviews relied on vote counting. Although many prognostic models for breast cancer have been published, remarkably few have been re-examined by independent groups in independent settings. The few validation studies have been carried out on ill-defined samples, sometimes of smaller size and short follow-up, and sometimes using different patient outcomes when validating a model. The evidence from the validation studies shows support for the prognostic value of the Nottingham Prognostic Index (NPI). No new prognostic factors have been shown to add substantially to those identified in the 1980s. Improvement of this index depends on finding factors that are as important as, but independent of, lymph node, stage and pathological grade. The NPI remains a useful clinical tool, although additional factors may enhance its use. We accepted that hormone receptor status (ER) for hormonal therapy such as tamoxifen and prediction of response to trastuzumab by HER2 did not require systematic review, as the mechanism of action of these drugs requires intact receptors. There was no clear evidence that other factors were useful predictors of response and survival. The survey confirmed pathological nodal status, tumour grade, tumour size and ER status as the most clinically important factors for consideration when selecting women with early breast cancer for adjuvant systemic therapy in the UK. The protocols revealed that although UK cancer centres appear to be using the same prognostic and predictive factors when selecting women to receive adjuvant therapy, much variation in clinical practice exists. Some centres use protocols based upon the NPI whereas others do not use a single index score. Within NPI and non-NPI users, between-centre variability exists in guidelines for women for whom the benefits are uncertain. Consensus amongst units appears to be greatest when selecting women for adjuvant hormone therapy with the decision based primarily upon ER or progesterone receptor status rather than combinations of a number of factors. Guidelines as to who should receive adjuvant chemotherapy, however, were found to be much less uniform. Searches of the literature revealed only five published papers that had previously examined the cost-effectiveness of using prognostic information for clinical decision-making. These studies were of varying quality and highlight the fact that economic evaluation in this area appears still to be in its infancy. By combining methodologies used in determining prognosis with those used in health economic evaluation, it was possible to illustrate an approach for simulating the effectiveness (survival and quality-adjusted survival) and the cost-effectiveness associated with the decision to treat individual women or groups of women with different prognostic characteristics. The model showed that effectiveness and cost-effectiveness of adjuvant systemic therapy have the potential to vary substantially depending upon prognosis. For some women therapy may prove very effective and cost-effective, whereas for others it may actually prove detrimental (i.e. the reductions in health-related quality of life outweigh any survival benefit). CONCLUSIONS Outputs from the framework constructed using the methods described here have the potential to be useful for clinicians, attempting to determine whether net benefits can be obtained from administering adjuvant therapy for any presenting woman; and also for policy makers, who must be able to determine the total costs and outcomes associated with different prognosis based treatment protocols as compared with more conventional treat all or treat none policies. A risk table format enabling clinicians to look up a patient's prognostic factors to determine the likely benefits (survival and quality-adjusted survival) from administering therapy may be helpful. For policy makers, it was demonstrated that the model's output could be used to evaluate the cost-effectiveness of different treatment protocols based upon prognostic information. The framework should also be valuable in evaluating the likely impact and cost-effectiveness of new potential prognostic factors and adjuvant therapies.
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Abstract
Abstract
Background
Preoperative radiotherapy improves local control and survival in rectal cancer, but there are few reports on long-term morbidity. The aims of this study were to compare long-term morbidity and quality of life in patients undergoing rectal cancer surgery with or without preoperative radiotherapy.
Methods
A total of 252 patients, randomized within the two Stockholm trials on preoperative radiotherapy in rectal cancer, were alive at a mean of 15 years after surgery. Some 139 of these patients were available for follow-up by questionnaires and clinical examination. Questionnaires regarding medical history and quality of life were completed by all patients. All patients had a clinical examination, and those without a stoma underwent rigid sigmoidoscopy.
Results
Overall, patients who had preoperative radiotherapy experienced significantly more late complications than those who did not (69 versus 43 per cent; P = 0·002). This morbidity consisted mainly of cardiovascular disease (35 versus 19 per cent; P = 0·032), faecal incontinence (12 of 21 versus 11 of 42 patients having anterior resection; P = 0·013) and urinary incontinence (45 versus 27 per cent; P = 0·023). No significant differences between groups were found for hip or pelvic fractures, small bowel obstruction or global quality of life.
Conclusion
Preoperative short-course, high-dose radiotherapy in patients with rectal cancer increases the risk of anal and urinary dysfunction, and may lead to increased cardiovascular morbidity, at long-term follow-up.
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Comparison of the maternal experience and duration of labour in two upright delivery positions-a randomised controlled trial. BJOG 2006; 113:165-70. [PMID: 16411993 DOI: 10.1111/j.1471-0528.2005.00824.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare two upright delivery positions at the second stage of labour in healthy primiparous women with regard to duration of the second stage of labour and maternal experience. DESIGN A randomised controlled trial. SETTING A county hospital delivery ward. SAMPLE Primiparous subjects (n=271) were randomly allocated to a kneeling (n=138) or a sitting (n=133) position during the second stage of labour. A postpartum questionnaire was answered by 264/271 women (97%) participating in the trial. METHODS Primiparous subjects were randomised to a kneeling or sitting delivery position during second stage of labour. Analysis was performed on an intention-to-treat basis. MAIN OUTCOME MEASURE Duration of the second stage of labour. RESULTS A comparison of the duration of the second stage of labour (kneeling 48.5 minutes+/-27.6 SD, sitting 41 minutes+/-23.4 SD) revealed no significant difference between the groups. A sitting position during the second stage of labour was associated with a higher level of delivery pain (P<0.01), a more frequent perception of the second stage as being long (P=0.002), less comfort for giving birth (P=0.03) and more frequent feelings of vulnerability (P=0.05) and exposure (P=0.02). There were no significant differences in the frequency of sphincter ruptures although a sitting position was associated with a higher degree of postpartum perineal pain (P<0.001) (Table 3). CONCLUSIONS Kneeling and sitting upright during the second stage of labour do not significantly differ from one another in duration of the second stage of labour. In healthy primiparous women, a kneeling position was associated with a more favourable maternal experience and less pain compared with a sitting position.
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Pelvic organ prolapse and urinary incontinence in women with surgically managed rectal prolapse: a population-based case-control study. Dis Colon Rectum 2006; 49:28-35. [PMID: 16273329 DOI: 10.1007/s10350-005-0217-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aimed to investigate the prevalence of genital prolapse surgery and urinary incontinence in female patients operated on for rectal prolapse compared with a matched control group without rectal prolapse. METHODS Fifty-two patients with a history of abdominal rectal prolapse surgery and 200 randomly selected age-matched and gender-matched control subjects without rectal prolapse received an extensive health care history survey. RESULTS Response rate in the patient group was 48 of 52 (92 percent) and 165 of 200 (82 percent) in the control group. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (odds ratio = 3.1; 95 percent confidence interval = 1.4-6.9) and vaginal wall prolapse (odds ratio = 3.2; 95 percent confidence interval = 1.3-7.8). Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (P < 0.01). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (P < 0.05). There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence. CONCLUSION Our results indicate a strong association between rectal and genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.
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Readmission to hospital 5 years after hysterectomy or endometrial resection in a national cohort study. Qual Saf Health Care 2005; 14:41-7. [PMID: 15692002 PMCID: PMC1743974 DOI: 10.1136/qshc.2004.010926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To investigate the readmission experience of a large national prospective cohort of women up to 5 years after undergoing either transcervical resection of the endometrium (TCRE) or hysterectomy to assess reasons for readmission and whether TCRE can be viewed as a definitive substitute for hysterectomy. DESIGN AND PARTICIPANTS Data are from the VALUE/MISTLETOE prospective national cohort studies of hysterectomy and TCRE respectively. 5294 women who underwent hysterectomy for dysfunctional uterine bleeding in 1994/5 and 4032 women who underwent TCRE in 1993/4 and who responded to postal questionnaires were included. Surgeons gathered operative details. Women completed postal follow up questionnaires at 3 and 5 years after surgery asking about readmission to hospital and reasons for readmission. Adjusted proportional hazard ratios were calculated for likelihood of readmission in each category comparing types of surgery. RESULTS 41.7% of women undergoing hysterectomy and 44.6% of women undergoing TCRE experienced one or more readmissions to hospital overall within 5 years (adjusted hazard ratio for all readmissions (AHR) 0.87 (95% confidence interval (CI) 0.80 to 0.95)). 12.6% of hysterectomy patients and 30.3% of TCRE patients were readmitted for gynaecological reasons (AHR 0.40 (95% CI 0.33 to 0.48)). Rates of readmission for gynaecological reasons were similar up to 6 months but were markedly reduced for hysterectomy compared with TCRE patients towards the end of the follow up period (AHR for readmission at 3-5 years 0.28 (95% CI 0.20 to 0.39)). CONCLUSIONS There are differences in the pattern of readmission to hospital after hysterectomy and TCRE for dysfunctional uterine bleeding. Women undergoing a hysterectomy are less likely to be readmitted to hospital up to 5 years after their operation overall, and are significantly less likely to be readmitted for reasons related to their operation, particularly for gynaecological reasons. Hysterectomy appears to be a more definitive operation. The different options for surgery for dysfunctional uterine bleeding are not interchangeable; they represent different patterns of care. Information should be available to women and practitioners to inform choices between these options.
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Das CONSORT Statement: Überarbeitete Empfehlungen zur Qualitätsverbesserung von Reports randomisierter Studien im Parallel-Design. Dtsch Med Wochenschr 2005. [DOI: 10.1055/s-2004-836117] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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A randomised phase II study of interferon alpha alone or in combination with thalidomide in metastatic renal cancer. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.4742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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The usefulness of ultrasound assessment of amniotic fluid in predicting adverse outcome in prolonged pregnancy: a prospective blinded observational study. BJOG 2003; 110:989-94. [PMID: 14592583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To determine whether a single ultrasound scan at or beyond 40 weeks of gestation to detect a single deepest pool of amniotic fluid <2 cm and amniotic fluid index (AFI) <5 cm is clinically useful in the prediction of subsequent adverse pregnancy outcome. DESIGN A prospective double blind cohort study. SETTING A university teaching hospital delivering approximately 6000 women annually. POPULATION One thousand and five hundred and eighty-four pregnant women at or beyond 40 weeks of gestation. METHODS Ultrasound assessment of liquor to detect the single deepest pool of amniotic fluid and derive the AFI at or after 40 weeks of gestation. MAIN OUTCOME MEASURES Perinatal death, meconium aspiration, birth asphyxia, intervention in labour for fetal distress, a cord arterial pH <7 and admission to the neonatal unit. RESULTS An AFI <5 cm but not a single deepest pool <2 cm was significantly associated with birth asphyxia or meconium aspiration. An AFI <5 cm was also significantly associated with caesarean section for fetal distress in labour, a cord arterial pH <7 at delivery and low Apgar scores. Despite there being a statistically significant association with adverse outcomes the sensitivity of AFI was low at 28.6%, 12% and 11.5% for major adverse outcome, fetal distress in labour or admission to the neonatal unit, respectively. CONCLUSIONS The AFI is superior to a measure of the single deepest pool as an assessment of the fetus at or after 40 weeks but has a poor sensitivity for adverse pregnancy outcome. Routine use is likely to lead to increased obstetric intervention without improvement in perinatal outcomes.
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The usefulness of ultrasound assessment of amniotic fluid in predicting adverse outcome in prolonged pregnancy: a prospective blinded observational study. BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02417.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Development of perfluorocarbon (PFC) primary standards for monitoring of emissions from aluminum production. FRESENIUS' JOURNAL OF ANALYTICAL CHEMISTRY 2001; 370:828-33. [PMID: 11569859 DOI: 10.1007/s002160100883] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An EPA Voluntary Aluminum Industrial Partnership (VAIP) program has been formed to help US primary producers focus on reducing the emissions of two perfluorocarbons (PFCs), tetrafluoromethane (CF4) and hexafluoroethane (C2F6), during the production of aluminum. To ensure comparability of measurements over space and time, traceability to national sources was desirable. Hence, the EPA approached the NIST to develop a suite of primary standards to cover a mole fraction (concentration) range of 0.1 to 1400 micromol mol(-1) for CF4 and 0.01 to 150 micromol mol(-1) of C2F6. A total of eight gravimetric PFC gas standards were prepared with relative expanded uncertainties of < or = 0.52% (approximately 95% confidence level). These primary standards were ultimately used to assign values to a series of secondary gas standards at three mole-fraction levels with relative expanded uncertainties ranging from +/- 0.7% to 5.3% (approximately 95% confidence level). This series of secondary standards was used within the aluminum industry to calibrate instruments used to make emission measurements. Assignment of values to the secondary standards was performed by use of gas chromatography with flame-ionization detection (GC-FID) and Fourier transform infrared spectrometry (FTIR). Real time pot-line and stack samples from a local aluminum plant were also obtained and sub-samples sent to each participating facility for analysis. The data generated from each facility were sent to NIST for analysis. The maximum difference between the NIST and individual facilities' values for the same sub-sample was +/- 26%.
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Confronting AIDS: human rights, law and social transformation. Health Hum Rights 2001; 5:149-79. [PMID: 11154527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
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Abstract
To comprehend the results of a randomized controlled trial (RCT), readers must understand its design, conduct, analysis, and interpretation. That goal can be achieved only through complete transparency from authors. Despite several decades of educational efforts, the reporting of RCTs needs improvement. Investigators and editors developed the original CONSORT (Consolidated Standards of Reporting Trials) statement to help authors improve reporting by using a checklist and flow diagram. The revised CONSORT statement presented in this article incorporates new evidence and addresses some criticisms of the original statement. The checklist items pertain to the content of the Title, Abstract, Introduction, Methods, Results, and Comment. The revised checklist includes 22 items selected because empirical evidence indicates that not reporting the information is associated with biased estimates of treatment effect or because the information is essential to judge the reliability or relevance of the findings. We intended the flow diagram to depict the passage of participants through an RCT. The revised flow diagram depicts information from 4 stages of a trial (enrollment, intervention allocation, follow-up, and analysis). The diagram explicitly includes the number of participants, according to each intervention group, included in the primary data analysis. Inclusion of these numbers allows the reader to judge whether the authors have performed an intention-to-treat analysis. In sum, the CONSORT statement is intended to improve the reporting of an RCT, enabling readers to understand a trial's conduct and to assess the validity of its results.
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Abstract
To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.
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Abstract
OBJECTIVE To examine the relationships among exposure to violence; tobacco, alcohol, and other substance use; depression; church attendance; and the use of violence among very young adolescents. METHODS An 86-item confidential questionnaire was administered to 722 sixth grade students (mean age = 11.9+/-0.8 years) attending 4 middle schools serving neighborhoods in and around public housing. RESULTS Boys had a higher mean violence scale score than girls (P < or =.0001), and students living in public housing had higher violence scale scores than other students (P< or =.0001). Self-reported use of violence was significantly associated with exposure to violence (r =.45); age (r =.28); frequency of church attendance (r = -.14); depression (r =.28); the probability of being alive at age 25 (r = -.09); the frequency of use of cigarettes (r =.39), alcohol (r =.37), and multiple substances (r =.38); and interest in a gang (r =.37). When all of these variables were analyzed with multiple linear regression, multiple substance use, exposure to violence, interest in a gang, male gender, cigarette smoking, and depression level accounted for 49.7% of the variation in the use of violence scale. CONCLUSION Recent multiple substance use and lifetime exposure to violence and victimization were the strongest correlates with the frequency that these youth reported using violence and carrying weapons.
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Rural economic development vs. tobacco control? Tensions underlying the use of tobacco settlement funds. J Public Health Policy 2000; 21:129-56. [PMID: 10881452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Some public health advocates in tobacco states, having reconsidered the impacts of the federal tobacco price-support program, have negotiated common tobacco regulatory policy stances with tobacco grower representatives. This paper describes the impact of this rapprochement on the state-level negotiations of Master Settlement Agreement funds. It argues that there are indeed two worthy public health goals: tobacco control and the economic viability of tobacco dependent communities (TDCs), but the immediacy of the threat to the latter, the political potency of tobacco growers, and growers' goal of maintaining tobacco as their farms' anchor bring severe risks to the tobacco control portion of Settlement funds. Among three competing philosophies of economic development for TDCs, none are well evaluated, and two potentially create endless demands on Settlement resources. Public health policy advocates are urged to participate in negotiations on TDC economic development and to forcefully advocate for adequate tobacco control resources.
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Understanding the diverse needs of the Medicare population: implications for Medicare reform. J Aging Soc Policy 2000; 10:25-50. [PMID: 10724769 DOI: 10.1300/j031v10n04_03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Meeting the health care needs of millions of elderly and disabled Americans is central to the debate over Medicare's future. Using data from a nationally representative survey of 3,309 beneficiaries, Medicare's most vulnerable beneficiaries were profiled, examining variations in coverage, satisfaction, access, and financial difficulties. A substantial portion of the Medicare population--two thirds--were found to have health problems or low incomes. The analysis found that about 40% of beneficiaries with incomes below the poverty level, in fair or poor health, or with ADL limitations, have difficulties paying their medical bills or getting needed health care. Medicare's disabled, under-65 beneficiaries are at even higher risk: nearly half (47%) have health care access problems or deal with financial hardship due to medical bills. The diverse needs and experiences of the Medicare population are underscored, providing new insights into the challenge of maintaining or improving protection for those with greatest need while assuring the long-term fiscal viability of the program.
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Specificity and function of immunogenic peptides from the 35-kilodalton protein of Mycobacterium leprae. Infect Immun 1999; 67:1501-4. [PMID: 10024600 PMCID: PMC96486 DOI: 10.1128/iai.67.3.1501-1504.1999] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We identified a T-cell determinant of the 35-kDa antigen of Mycobacterium leprae which is discriminatory against cross-sensitization by its closely related homologue in Mycobacterium avium. From synthetic peptides covering the entire sequence, those with the highest affinity and permissive binding to purified HLA-DR molecules were evaluated for the stimulation of proliferation of peripheral blood mononuclear cells (PBMCs) from leprosy patients and healthy sensitized controls. Responses to the peptide pair 206-224, differing by four residues between M. leprae and M. avium, involved both species-specific and cross-reactive T cells. Lymph node cell proliferation in HLA-DRB1*01 transgenic mice was reciprocally species specific, but only the response to the M. leprae peptide in the context of DR1 was immunodominant. Of the cytokines in human PBMC cultures, gamma interferon production was negligible, while interleukin 10 (IL-10) responses in both patients and controls were more pronounced. IL-10 was most frequently induced by the shared 241-255 peptide, indicating that environmental cross-sensitization may skew the response toward a potentially pathogenic cytokine phenotype.
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Conflict and consensus: HIV/AIDS and human rights in Asia and the Pacific. AIDS 1998; 12 Suppl B:S93-9. [PMID: 9679634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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University of California Commission on the Future of Medical Education. COST & QUALITY QUARTERLY JOURNAL : CQ 1998; 4:26-8. [PMID: 10178953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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