Economic evaluation and health care. What does it mean?

Ever since the concept of value for money in health care was introduced into the NHS, economic terms and jargon have become part of our everyday lives--but do we understand what the different types of economic evaluation all mean, particularly those that sound similar to the uninitiated? This article introduces readers to the purpose of economic evaluation, and briefly explains the differences between cost-minimisation analysis (used when the outcomes of the procedures being compared are the same); cost-effectiveness analysis (used when the outcomes may vary, but can be expressed in common natural units, such as mm Hg for treatments of hypertension); cost-utility analysis (used when outcomes do vary--for example, quality of life scales); and cost-benefit analysis (used when a monetary value is being placed on services received). Further articles will deal with each one in more detail.

The treatment of epiphora with balloon dacryocystoplasty

We examine a new treatment for epiphora: balloon dilatation of the nasolacrimal duct, or dacryocystoplasty. The procedure, which was performed as an out-patient procedure under local anaesthetic, was carried out on 20 patients with epiphora, 17 due to anatomical and 3 due to functional obstruction. There was an overall success rate of 60%, with complete relief of symptoms in 4 patients and a symptomatic improvement in another 8 (follow-up 2-9 months, mean 4.2 months). All patients tolerated the procedure well with minimal per-operative and post-operative discomfort. A higher success rate was seen in those patients with either a low anatomical or a functional obstruction. The procedure can be easily repeated and, if unsuccessful, still allows a dacryocystorhinostomy to be performed at a later date.

Blowing in the wind

Faced with healthcare demands that outstrip budgets, how do HAs prioritise services? Ray Robinson suggests four major inputs all purchasers should take into account.

Expressivity of the Manx gene in cats

New genetic data are presented which indicate that the assortment data for the mutant Manx gene, M, does not depart from normal expectation and does not enjoy a selective advantage at some stage of gametogenesis, as has been hypothesized. The variable expression of Manx taillessness is a remarkable and consistent feature of the Manx syndrome, encompassing the posterior skeleton, neural organization, and growth of soft tissues. The expression is partly genetic in origin, and the heritability is estimated to be in the region of h2 = 0.40 +/- 0.11.

Safety belt restraints and compartment intrusions in frontal and lateral motor vehicle crashes: mechanisms of injuries, complications, and acute care costs

A 3-year prospective study examined 76 frontal (F) and 45 lateral (L) motor vehicle crash (MVC) patients with regard to seatbelt restraint use and occupant compartment contact and intrusion injuries. These 121 MVC victims with multiple injuries (39 belted [B] and 82 non-belted [NB]), admitted to a level I trauma center, were studied by accident reconstruction and medical data analysis. They had a MVC mean impact velocity (delta V) of 30 +/- 11 mph and an injury Severity Score of 29 +/- 12. Proper restraint use reduced brain injury in F MVCs (30% FB vs. 47% FNB) but had no effect in L MVCs (63% LB vs. 30% FB [p < 0.06]). Belt use did not protect against lung, liver, spleen, pelvis, or lower extremity (LE) injury. These appeared to be more a function of crash direction, with LE injuries higher in F crashes (p < 0.04) and pelvis injuries (p < 0.001) higher in L crashes. In FB crashes, however, properly used safety restraints were the primary cause of bowel or colon injuries (p < 0.006). Belts did not prevent thoracic or abdominal solid organ injuries in L crashes. Contact-intrusions (CI) of the car occupant compartment in F crashes were the main cause of brain (A-pillar), lung and liver (steering wheel and instrument panel), and LE (toepan) injuries; but in L crashes, side-door CI caused lung, aorta, liver, and pelvic injuries. In contrast, contact-only (CO) injuries of the steering assembly were mainly responsible for injuries to the lung, heart, and liver in F crashes, and side-door CO for lung, liver, and spleen injuries in L crashes. Deaths and complications after injury were higher among F MVC occupants, or when delta V was > or = 30 mph. Hospital and professional costs reflect the complex care needed for victims of multiple injuries: FB, $99,000; FNB, $95,000; LB, $75,000; LNB, $79,000; total, $10.7 million. Present vehicle safety standards are not adequate, and structural design changes are needed to improve restraints and protect occupants from intrusion-related injuries.

H-ras-1 point mutations in soft tissue sarcomas

The H-ras-1 protooncogene is activated by single base substitutions occurring in either codon 12, 13, or 61. These mutations have been described with varying frequencies in several human tumor types. Since ras oncogenes were first discovered as the transforming sequences of Harvey and Kirsten murine sarcoma viruses (which also contain activating point mutations compared to the homologous cellular sequences), we wished to investigate the possibility that ras mutations might also occur in human sarcomas. We extracted DNA from six malignant fibrous histiocytomas (MFH), three embryonal rhabdomyosarcomas (ER), one alveolar rhabdomyosarcoma, one pleomorphic rhabdomyosarcoma, and one leiomyosarcoma. The DNA from regions flanking codons 12/13 and codon 61 was amplified by the polymerase chain reaction and sequenced with an automated DNA sequencer. As controls, we amplified and sequenced normal DNA (placenta) and DNA with known point mutations (T24 bladder carcinoma cells). We found three cases with mutations, all occurring in codon 12. One ER showed a G-to-T mutation in the second position of codon 12 (coding for valine instead of glycine). Two MFHs showed G-to-A mutations in the second position of codon 12 (coding for aspartic acid instead of glycine). Although a limited number of cases were sampled, we conclude that study of H-ras-1 mutations may be relevant to MFH and ER. Additional studies of N and K-ras mutations as well as more cases investigating H-ras will be required before we can ascertain the significance of ras mutations in the oncogenesis of human soft tissue sarcomas.

Microwave sterilization of polyethylene catheters for intermittent self-catheterization

A standard household 650 W microwave oven was used to sterilize polyethylene catheters of the type used for intermittent self-catheterization. The catheters were infected with Proteus sp. bacteria and microwaved at 650 W for periods of 2, 4, 6 and 8 minutes. The effect of microwaving was assessed by determining the resultant colony counts following catheter culture. It was determined that 6 minutes of microwaving were required to achieve sterility. It is suggested that use of a microwave oven is a reliable and cost-effective method of sterilizing polyethylene catheters for intermittent self-catheterization.

Follow-up study on premature infants with and without retinopathy of prematurity

The ocular complications in population of 131 premature infants, with and without retinopathy of prematurity (ROP) are reported. An increased incidence of strabismus (20% with ROP and 25% without ROP) and myopia (27.5% with ROP and 8.8% without ROP) was shown. Significant visual loss occurred in 10.7% overall, increasing to 35% with stage 3 disease and 100% with stage 4. With the increased survival rate of premature infants, the relevance to future management of this expanding group of young people is considered.

Moving ahead--community care in Gwent

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Evidence that oocyte maturation induced by an oncogenic ras-p21 protein and insulin is mediated by overlapping yet distinct mechanisms

We have recently shown that a peptide (residues 35-47) from a functional region of the ras p21 protein, thought to be involved in the binding of p21 to GTPase activating protein, the antibiotic azatyrosine, known to induce the ras-recision gene, and the selective protein kinase C inhibitor, CGP 41,251, all inhibit oncogenic p21 protein-induced maturation of oocytes in a dose-dependent manner. We now show that these three agents only partially inhibit insulin-induced oocyte maturation, known to be dependent on activation of cellular p21 protein. On the other hand, the anti-p21 protein antibody Y13-259 completely inhibits both insulin- and oncogenic p21 protein-induced maturation as does a tetrapeptide, CVIM, known to block the enzyme farnesyl transferase which covalently attaches the farnesyl moiety to the p21 protein allowing it to attach to the cell membrane. Our results suggest that while the oncogenic and insulin-activated normal p21 proteins share certain elements of their signal transduction pathways in common, these pathways diverge and allow for selective inhibition of the oncogenic pathway.

Azole therapy for trichosporonosis: clinical evaluation of eight patients, experimental therapy for murine infection, and review

We studied the in vivo antifungal activity of azoles in humans and in a murine model of disseminated trichosporonosis. Eight patients infected with Trichosporon species were treated with fluconazole, SCH 39304, or miconazole for 2-26 weeks. Four patients had fungemia, two patients had disseminated trichosporonosis, and one patient each had soft-tissue infection and cystitis. Response of trichosporonosis to azoles was seen in all eight patients, although one patient died with disseminated aspergillosis while still receiving SCH 39304. A literature review indicated that responses to ketoconazole or miconazole were noted in four patients with trichosporonosis. In the experimental infection, amphotericin B, SCH 39304, and fluconazole were effective in prolonging survival and reducing fungal counts in the kidneys of mice infected with a clinical strain of Trichosporon beigelii. Fluconazole but not amphotericin B prolonged survival of mice infected with a clinical strain of Trichosporon capitatum. We conclude that azoles represent effective therapy for infection with Trichosporon species.

Differential expression of proline-rich proteins in rabbit salivary glands

Salivary glands synthesize and secrete an unusual family of proline-rich proteins (PRPs) that can be broadly divided into acidic and basic PRPs. We studied the tissue-specific expression of these proteins in rabbits, using antibodies to rabbit acidic and basic PRPs as well as antibodies and cDNA probes to human PRPs. By immunoblotting, in vitro translation, and Northern blotting, basic PRPs could be readily detected in the parotid gland but were absent in other salivary glands. In contrast, synthesis in vitro of acidic PRPs was detected in parotid, sublingual, and submandibular glands. Ultrastructural localization with immunogold showed heavy labeling with antibodies to acidic PRPs of secretory granules of parotid acinar cells and sublingual serous demilune cells. Less intense labeling occurred in the seromucous acinar cells of the submandibular gland. With antibodies to basic PRPs, the labeling of the parotid gland was similar to that observed with antibodies to acidic PRPs, but there was only weak labeling of granules of a few sublingual demilune cells, and no labeling of the submandibular gland. These results demonstrate a variable pattern of distribution of acidic and basic PRPs in rabbit salivary glands. These animals are therefore well suited for study of differential tissue expression of PRPs.

Hypertensive retinopathy: a cause of decreased visual acuity in children

Hypertensive retinopathy may present atypically in children. Delays in diagnosis may result in permanent visual loss, as demonstrated in three cases we saw.

Choice of medical specialty: analysis of students' needs

The purposes of this study were to assess the career development needs of entering medical students as measured by the Medical Career Development Inventory and to examine gender differences in responses to the inventory. A total of 115 entering medical students (representing two entering classes) took the inventory two months prior to matriculation. Analysis suggested that this sample of entering students had formed a vocational identity and that they had evaluated the suitability and viability of a commitment to a physician's career. However, the participants had not formed a clear picture of their specialty interest and goals. No significant gender differences were indicated. A recommended career assistance workshop is presented as appropriate for these students' needs.

Cryotherapy for retinopathy of prematurity--a prospective study

Cryotherapy has been shown to reduce the unfavourable outcome in retinopathy of prematurity with stage 3 threshold disease by 50%. In a prospective study cryotherapy had a favourable outcome in 13 of 24 eyes with stage 3 threshold disease. The visual outcome, refraction, and complications of cryotherapy are discussed.