A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers

OBJECTIVES

To review the evidence for different models of community-based respite care for frail older people and their carers, where the participant group included older people with frailty, disability, cancer or dementia. Where data permitted, subgroups of carers and care recipients, for whom respite care is particularly effective or cost-effective, were to be identified.

DATA SOURCES

Major databases were searched from 1980 to March 2005. Ongoing and recently completed research databases were searched in July 2005.

REVIEW METHODS

Data from relevant studies were extracted and quality assessed. The possible effects of study quality on the effectiveness data and review findings were discussed. Where sufficient clinically and statistically similar data were available, data were pooled using appropriate statistical techniques.

RESULTS

Twenty-two primary studies were included. Most of the evidence came from North America, with a minority of effectiveness and economic studies based in the UK. Types of service studied included day care, host family, in-home, institutional and video respite. Effectiveness evidence suggests that the consequences of respite upon carers and care recipients are generally small, with better controlled studies finding modest benefits only for certain subgroups. However, many studies report high levels of carer satisfaction. No reliable evidence was found that respite can delay entry to residential care or that respite adversely affects care recipients. Randomisation validity in the included randomised studies was sometimes unclear. Studies reported many different outcome measures, and all of the quasi-experimental and uncontrolled studies had methodological weaknesses. The descriptions of the studies did not provide sufficient detail of the methods of data collection or analysis, and the studies failed to describe adequately the groups of study participants. In some studies, only evidence to support respite care services was presented, rather than a balanced view of the services. Only five economic evaluations of respite care services were found, all of which compared day care with usual care and only one study was undertaken in the UK. Day care tended to be associated with higher costs and either similar or a slight increase in benefits, relative to usual care. The economic evaluations were based on two randomised and three quasi-experimental studies, all of which were included in the effectiveness analysis. The majority of studies assessed health and social service use and cost, but inadequate reporting limits the potential for exploring applicability to the UK setting. No study included generic health-related quality of life measures, making cost-effectiveness comparisons with other healthcare programmes difficult. One study used sensitivity analysis to explore the robustness of the findings.

CONCLUSIONS

The literature review provides some evidence that respite for carers of frail elderly people may have a small positive effect upon carers in terms of burden and mental or physical health. Carers were generally very satisfied with respite. No reliable evidence was found that respite either benefits or adversely affects care recipients, or that it delays entry to residential care. Economic evidence suggests that day care is at least as costly as usual care. Pilot studies are needed to inform full-scale studies of respite in the UK.

Area-Power Efficient VLSI Implementation of Multichannel DWT for Data Compression in Implantable Neuroprosthetics

Time-frequency domain signal processing of neural recordings, from high-density microelectrode arrays implanted in the cortex, is highly desired to ease the bandwidth bottleneck associated with data transfer to extra-cranial processing units. Because of its energy compactness features, discrete wavelet transform (DWT) has been shown to provide efficient data compression for neural records without compromising the information content. This paper describes an area-power minimized hardware implementation of the lifting scheme for multilevel, multichannel DWT with quantized filter coefficients and integer computation. Performance tradeoffs and key design decisions for implantable neuroprosthetics are presented. A 32-channel 4-level version of the circuit has been custom designed in 0.18-mum CMOS and occupies only 0.22 mm(2) area and consumes 76 muW of power, making it highly suitable for implantable neural interface applications requiring wireless data transfer.

Etanercept and efalizumab for the treatment of psoriasis: a systematic review

OBJECTIVES

To evaluate the clinical effectiveness, safety, tolerability and cost-effectiveness of etanercept and efalizumab for the treatment of moderate to severe chronic plaque psoriasis.

DATA SOURCES

Major electronic databases and several Internet resources were searched up to April 2004.

REVIEW METHODS

Systematic reviews were undertaken of the efficacy, safety and economic reviews of etanercept and efalizumab. An existing systematic review of the efficacy and safety of other treatments was also updated. Economic models supplied by the manufacturers of etanercept and efalizumab were critiqued. An economic model was then developed of etanercept and efalizumab in the treatment of moderate to severe chronic plaque psoriasis.

RESULTS

The review of the clinical evidence identified a total of 39 published and three unpublished studies: eight randomised controlled trials (RCTs) of the efficacy of etanercept (three trials) and efalizumab (five); 10 studies of the adverse effects of the interventions; and 24 RCTs of the efficacy of the other treatments for moderate to severe psoriasis. The trials of the efficacy of the interventions were all double-blind and placebo-controlled trials and generally of good quality, but three of the five efalizumab trials were poorly reported. A total of 1347 patients were included in the etanercept trials and 2963 in the efalizumab trials. Data on the efficacy of etanercept 25 mg twice a week for 12 weeks were available from three RCTs. On average, active treatment resulted in 62% of patients achieving a Psoriasis Area and Severity Index (PASI) 50, 33% achieving a PASI 75, 11% achieving a PASI 90 and 40% were assessed as clear or almost clear. These figures are not adjusted for changes relative to placebo. Improvement in quality of life as assessed by mean percentage change in Dermatology Life Quality Index (DLQI) was around 59% with etanercept 25 mg twice a week compared with 9% with placebo, and all mean differences that could be calculated were statistically significantly in favour of etanercept. Data on the efficacy of etanercept 50 mg twice a week for 12 weeks were available from two RCTs. Across the two trials, the proportion of patients achieving PASI 50, 75 and 90 was 76, 49 and 21%, respectively; the pooled relative risks were all statistically significantly in favour of etanercept. The findings for mean PASI after treatment, mean percentage change in PASI from baseline and mean percentage change in DLQI also demonstrated the efficacy of etanercept treatment. Evidence from one RCT indicates that the response to etanercept is maintained post-treatment, at least in the medium term, and data from uncontrolled follow-up phases reflect and extend these findings. Efalizumab at a dose of 1 mg/kg once a week subcutaneously was studied in five RCTs. Across these trials, 12 weeks of active treatment resulted in an average of 55% of patients achieving PASI 50, 27% PASI 75, 4.3% PASI 90 and 27% clear or minimal psoriasis status. These figures are not adjusted for changes relative to placebo. There is no evidence from RCTs that the response to efalizumab 1 mg/kg once a week is maintained when treatment continues beyond 12 weeks, and long-term follow-up data relate to a range of doses and are poorly reported and so cannot be used to draw even tentative conclusions regarding the long-term efficacy of efalizumab. Uncontrolled data from trial follow-up suggest that time to relapse may be around 60 days. No data indicating the existence or absence of any rebound in psoriasis after discontinuation of efalizumab were identified. There is no evidence relating to the efficacy of efalizumab upon retreatment. A mixed treatment comparison analysis found a higher response rate in terms of PASI 50, 75 and 90 with etanercept than with efalizumab. Injection site reactions appear to be the most common adverse effects of etanercept. Overall, etanercept appears to be well tolerated in short- and long-term use, although many of the long-term data are not from patients with psoriasis. Headache, chills and, to a lesser extent, nausea, myalgia, pain and fever are the common adverse events associated with efalizumab. Overall, withdrawal rates due to adverse events are low. Longer term data for efalizumab are not readily available for evaluation, but the adverse events data up to 3 years appear to reflect those over 12 weeks and to remain stable. Unfortunately, few data for serious infections and serious adverse events with efalizumab are available. For the primary analysis comparing etanercept, efalizumab and supportive care, the results of the York Model suggest that the biological therapies would only be cost-effective for all patients with moderate to severe psoriasis if the NHS were willing to pay over pound 60,000 per QALY gained. In patients with poor baseline quality of life (fourth quartile DLQI), efalizumab, etanercept 25 mg (intermittent), etanercept 25 mg (continuous) and etanercept 50 mg (intermittent) would be cost-effective as part of a treatment sequence if the NHS were willing to pay pound 45,000, pound 35,000, pound 45,000 and pound 65,000 per QALY gained, respectively. In patients who are also at high risk of inpatient hospitalisation (21 days per annum), these therapies would be cost-effective as part of a sequence as long as the NHS were willingness to pay pound 25,000, pound 20,000, pound 25,000 and pound 45,000 per QALY gained, respectively. As part of a secondary analysis including a wider range of systemic therapies as comparators, the York Model found that it would only be cost-effective to use etanercept and efalizumab in a sequence after methotrexate, ciclosporin and Fumaderm.

CONCLUSIONS

Clinical trial data indicate that both etanercept and efalizumab are efficacious in patients who are eligible for systemic therapy, but the economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients with poor baseline QoL and who are at risk of hospitalisation. Efficacy trials conducted in the specific population for which etanercept and efalizumab are licensed are required, as are long-term comparisons of etanercept and efalizumab with other treatments for moderate to severe psoriasis. Long-term efficacy trials and safety/tolerability data for patients treated with etanercept or efalizumab are required, as are trials on the response of specific subtypes of psoriasis to different drugs. Research on the rate of inpatient hospitalisation in patients with moderate to severe psoriasis is warranted, and the effect of treatment on this rate.

Undetectable salivary testosterone in young women with premature ovarian failure

BACKGROUND

The extent of androgen deficiency in young women with premature ovarian failure (POF) is unclear.

AIM

Cross-sectional study of androgen status in young women with POF.

PATIENTS

Twenty women with POF: six had Turner syndrome (group A); eight had iatrogenic POF either secondary to bilateral oophorectomy or treatment of malignancy (group B); and six had idiopathic POF (group C). The median age was 30.5 years (range 19-39); in groups B and C the median duration of ovarian failure was 10.0 years (range 1-35).

METHODS

After a 2-month wash-out period without sex steroid replacement (SSR), serum testosterone (T), androstenedione (A4), dehydroepiandrosterone (DHEAS), SHBG, salivary testosterone (SalT) and the free androgen index [FAI = (serum T/SHBG) x 100] were measured.

RESULTS

Median serum A4 was 4.6 nmol/l (10th, 90th centiles, 3.6, 5.1) and DHEAS was 3.2 micromol/l (10th, 90th centiles, 2.3, 9.3). Although median serum T was relatively low at 1.4 nmol/l (10th, 90th centiles, 1.1, 1.7), median SHBG was also low at 34 nmol/l (10th, 90th centiles 22.2, 67.5) and the median calculated FAI was within the normal range at 3.7 (10th, 90th centiles, 2.3, 7.0). However, SalT was undetectable in almost all subjects in the three groups of POF.

CONCLUSIONS

Serum T and SHBG are relatively low in young women with POF and their FAI is therefore within the normal range. However, SalT, which measures free testosterone, is consistently low to undetectable in these young women with POF. The reliability of the FAI as a marker of androgen deficiency remains questionable.

Use of case fatality and readmission measures to compare hospital performance in gynaecology

OBJECTIVE

To identify suitable outcome measures for comparing gynaecology performance between hospitals.

DESIGN

Analysis of routinely collected statistics.

SETTING

England. POPULATION A total of 1.45 million gynaecology admissions in 1999/2001.

METHODS

The database used was a linked file of English NHS hospital admission statistics and death certificate data. Case fatality rates (CFRs)and emergency readmission (ERA) rates were calculated for different components of gynaecology workload. Funnel plots, using age-sex standardised measures, were displayed to compare the outcomes.

MAIN OUTCOME MEASURES

CFRs and ERA rates.

RESULTS

The CFR within 30 days after admission for patients with cancer was 5.1%. These patients accounted for only 3% of all the admissions but for 73% of all 30-day deaths. All other 30-day CFRs were extremely low-below 0.5%. The 30-day ERA rates ranged from 1.8% after day case care to 17.4% after emergency admissions for people who did not have an operation. Funnel plots showed considerable variation between hospitals for ERA after day case care but not after elective abdominal hysterectomy.

CONCLUSIONS

There are no measures of mortality that could be used routinely and meaningfully to compare the performance of gynaecology units. We suggest that two suitable comparative measures of outcome, derivable from routine hospital statistics, are 30-day ERA rates after day case admissions and after elective abdominal hysterectomy, excluding those records with a cancer diagnosis. These measures are relatively homogeneous with respect to their likely rates of adverse events and have sufficient numbers to produce potentially useful comparative results.

Role of viral replication in extrahepatic syndromes related to hepatitis B virus infection

Approximately 20% of patients with hepatitis B virus (HBV) infection may experience extrahepatic disease. These manifestations include a viral prodrome with a serum sickness-like syndrome, polyarteritis nodosa, glomerulonephritis, as well as various neurological and dermatologic diseases amongst other manifestations. The viral pathogenesis is not well understood and has been difficult to study due to the lack of an animal model of HBV-related extrahepatic disease. Deposition of immune complexes and activation of the complement cascade has been most widely studied. However, circulating immune complexes are physiologic and occur more frequently than extrahepatic disease. Also, HBV-related extrahepatic syndromes occur in the absence of immune complex formation. Several studies support the notion that HBV replication in extrahepatic tissues may also precipitate disease but extrahepatic replication has commonly been observed without any apparent cytopathic or immune related tissue damage. It is clear that suppression of viral replication with antiviral therapy or spontaneous viral clearance positively correlates with resolution of extrahepatic disease. The use of continuous immunosuppressive therapy has largely been abandoned with the advent of robust antiviral strategies to manage disease. These data support the notion that a combination of factors including inadequate clearance immune complexes and viral replication in extrahepatic tissues play an important role in the pathogenesis. This conceptual framework is potentially significant as it emphasizes the importance of antiviral treatment in the management of extrahepatic disease.

Clinical effectiveness, tolerability and cost-effectiveness of newer drugs for epilepsy in adults: a systematic review and economic evaluation

OBJECTIVES

To examine the clinical effectiveness, tolerability and cost-effectiveness of gabapentin (GBP), lamotrigine (LTG), levetiracetam (LEV), oxcarbazepine (OXC), tiagabine (TGB), topiramate (TPM) and vigabatrin (VGB) for epilepsy in adults.

DATA SOURCES

Electronic databases. Internet resources. Pharmaceutical company submissions.

REVIEW METHODS

Selected studies were screened and quality assessed. Separate analyses assessed clinical effectiveness, serious, rare and long-term adverse events and cost-effectiveness. An integrated economic analysis incorporating information on costs and effects of newer and older antiepileptic drugs (AEDs) was performed to give direct comparisons of long-term costs and benefits.

RESULTS

A total of 212 studies were included in the review. All included systematic reviews were Cochrane reviews and of good quality. The quality of randomised controlled trials (RCTs) was variable. Assessment was hampered by poor reporting of methods of randomisation, allocation concealment and blinding. Few of the non-randomised studies were of good quality. The main weakness of the economic evaluations was inappropriate use of the cost-minimisation design. The included systematic reviews reported that newer AEDs were effective as adjunctive therapy compared to placebo. For newer versus older drugs, data were available for all three monotherapy AEDs, although data for OXC and TPM were limited. There was limited, poor-quality evidence of a significant improvement in cognitive function with LTG and OXC compared with older AEDs. However, there were no consistent statistically significant differences in other clinical outcomes, including proportion of seizure-free patients. No studies assessed effectiveness of AEDs in people with intellectual disabilities or in pregnant women. There was very little evidence to assess the effectiveness of AEDs in the elderly; no significant differences were found between LTG and carbamazepine monotherapy. Sixty-seven RCTs compared adjunctive therapy with placebo, older AEDs or other newer AEDs. For newer AEDs versus placebo, a trend was observed in favour of newer drugs, and there was evidence of statistically significant differences in proportion of responders favouring newer drugs. However, it was not possible to assess long-term effectiveness. Most trials were conducted in patients with partial seizures. For newer AEDs versus older drugs, there was no evidence to assess the effectiveness of LEV, LTG or OXC, and evidence for other newer drugs was limited to single studies. Trials only included patients with partial seizures and follow-up was relatively short. There was no evidence to assess effectiveness of adjunctive LEV, OXC or TPM versus other newer drugs, and there were no time to event or cognitive data. No studies assessed the effectiveness of adjunctive AEDs in the elderly or pregnant women. There was some evidence from one study (GBP versus LTG) that both drugs have some beneficial effect on behaviour in people with learning disabilities. Eighty RCTs reported the incidence of adverse events. There was no consistent or convincing evidence to draw any conclusions concerning relative safety and tolerability of newer AEDs compared with each other, older AEDs or placebo. The integrated economic analysis for monotherapy for newly diagnosed patients with partial seizures showed that older AEDs were more likely to be cost-effective, although there was considerable uncertainty in these results. The integrated analysis suggested that newer AEDs used as adjunctive therapy for refractory patients with partial seizures were more effective and more costly than continuing with existing treatment alone. Combination therapy, involving new AEDs, may be cost-effective at a threshold willingness to pay per quality-adjusted life year (QALY) greater than 20,000 pounds, depending on patients' previous treatment history. There was, again, considerable uncertainty in these results. There were few data available to determine effectiveness of treatments for patients with generalised seizures. LTG and VPA showed similar health benefits when used as monotherapy. VPA was less costly and was likely to be cost-effective. The analysis indicated that TPM might be cost-effective when used as an adjunctive therapy, with an estimated incremental cost-effectiveness ratio of 34,500 pounds compared with continuing current treatment alone.

CONCLUSIONS

There was little good-quality evidence from clinical trials to support the use of newer monotherapy or adjunctive therapy AEDs over older drugs, or to support the use of one newer AED in preference to another. In general, data relating to clinical effectiveness, safety and tolerability failed to demonstrate consistent and statistically significant differences between the drugs. The exception was comparisons between newer adjunctive AEDs and placebo, where significant differences favoured newer AEDs. However, trials often had relatively short-term treatment durations and often failed to limit recruitment to either partial or generalised onset seizures, thus limiting the applicability of the data. Newer AEDs, used as monotherapy, may be cost-effective for the treatment of patients who have experienced adverse events with older AEDs, who have failed to respond to the older drugs, or where such drugs are contraindicated. The integrated economic analysis also suggested that newer AEDs used as adjunctive therapy may be cost-effective compared with the continuing current treatment alone given a QALY of about 20,000 pounds. There is a need for more direct comparisons of the different AEDs within clinical trials, considering different treatment sequences within both monotherapy and adjunctive therapy. Length of follow-up also needs to be considered. Trials are needed that recruit patients with either partial or generalised seizures; that investigate effectiveness and cost-effectiveness in patients with generalised onset seizures and that investigate effectiveness in specific populations of epilepsy patients, as well as studies evaluating cognitive outcomes to use more stringent testing protocols and to adopt a more consistent approach in assessing outcomes. Further research is also required to assess the quality of life within trials of epilepsy therapy using preference-based measures of outcomes that generate cost-effectiveness data. Future RCTs should use CONSORT guidelines; and observational data to provide information on the use of AEDs in actual practice, including details of treatment sequences and doses.

Dementia care provision in rural Scotland: service users' and carers' experiences

There has been global neglect of service users' and carers' experiences of dementia care provision in rural areas. The present paper draws on a qualitative study of service provision for people with dementia and their carers in remote and rural Scotland. It draws on interviews with 15 people with dementia and 16 carers to explore their views about health and social dementia care service provision in rural Scotland. A further 14 carers of people with dementia participated in one of three focus groups. The paper discusses perceived gaps in services as well as positive aspects of dementia service provision which service users attribute to living in a rural area. The important issues this raises for the development of dementia care provision in rural areas are briefly discussed.

Molecular mechanisms of membrane polarity in renal epithelial cells

Exciting discoveries in the last decade have cast light onto the fundamental mechanisms that underlie polarized trafficking in epithelial cells. It is now clear that epithelial cell membrane asymmetry is achieved by a combination of intracellular sorting operations, vectorial delivery mechanisms and plasmalemma-specific fusion and retention processes. Several well-defined signals that specify polarized segregation, sorting, or retention processes have, now, been described in a number of proteins. The intracellular machineries that decode and act on these signals are beginning to be described. In addition, the nature of the molecules that associate with intracellular trafficking vesicles to coordinate polarized delivery, tethering, docking, and fusion are also becoming understood. Combined with direct visualization of polarized sorting processes with new technologies in live-cell fluorescent microscopy, new and surprising insights into these once-elusive trafficking processes are emerging. Here we provide a review of these recent advances within an historically relevant context.

Aboriginal perspective on middle ear disease in the arid zone of Western Australia

OBJECTIVES

To explore perceptions, knowledge and experience of otitis media (OM) and barriers to compliance with treatment among Aboriginal people of the Kalgoorlie-Boulder area, Western Australia.

METHODS

This qualitative applied research study is based on a holistic design. We conducted structured interviews with three community focus groups, 56 key informants, and 22 mothers of babies known to have suffered from OM. Written records of interviews were checked with participants. The three sources of data enabled comparison and verification of results.

RESULTS

People were concerned about serious consequences of OM, especially deafness and learning difficulties. Since early disease may have no localizing symptoms, not surprisingly, people had limited understanding of the aetiology of OM and were often only aware of disease once ear discharge was visible. Nevertheless, they usually sought treatment for non-specific symptoms. Competing demands in people's daily lives and the unpleasant, intensive nature of treatment result in families becoming resigned to a child's chronic ear discharge. Someone other than the biological mother within the extended family may be responsible for administering treatments. Half the carers thought passive smoking may predispose children to OM and 70% suggested clearing the nasal passages to prevent OM. Results of surgery were viewed positively but specialist services were not always readily accessible.

CONCLUSIONS

Since responsibility for treatment may not lie with the biological mother, awareness campaigns must target the entire community. As early OM may be asymptomatic, health personnel should be encouraged to do otoscopy on all children with non-specific symptoms.

Flumazenil does not affect intracortical motor excitability in humans: a transcranial magnetic stimulation study

OBJECTIVE

The motor cortex may be subject to tonic inhibitory drive. One inhibitory mechanism is supported by activity at benzodiazepine (BZP) receptors. In this study we investigate whether or not the BZP antagonist, flumazenil, increases cortical motor excitability in humans.

METHODS

Eight healthy subjects received a 1 mg intravenous (i.v.) loading dose of flumazenil followed by a 0.5 mg i.v. infusion over the next 30 min. Before, during, and 1 h after flumazenil infusion, we measured cortical motor excitability using transcranial magnetic stimulation (TMS). This included resting motor threshold (rMT), paired-pulse measurements of intracortical inhibition and facilitation (ICI and ICF), recruitment curve (RC), and silent period (SP). We also measured F response and compound muscle action potential (CMAP) with peripheral nerve stimulation. The study was carried out using a randomized, double-blind crossover design controlled with a saline infusion.

RESULTS

None of the measures of cortical or peripheral excitability were significantly affected by drug administration.

CONCLUSIONS

Our findings suggest that flumazenil has no effect on cortical motor excitability in normal humans.

SIGNIFICANCE

There does not appear to be any tonic activity at benzodiazepine receptors in the normal resting human motor cortex.

Evaluation of food safety education for consumers

Traditionally, nutrition educators have used a fairly global approach to teach food safety by teaching a broad range of safe food handling behaviors in the expectation that this will lead to the avoidance of foodborne illness. This approach can be confusing and lead to evaluation data that are difficult to interpret. This article suggests that food safety education and evaluation in the future be organized around five behavioral constructs: practice personal hygiene, cook foods adequately, avoid cross-contamination, keep foods at safe temperatures, and avoid food from unsafe sources. These five constructs are derived from data on actual outbreaks and estimated incidences of foodborne illness. Research is needed to establish reliable and valid evaluation measures for these five behavioral constructs. Evaluation instruments can be tailored to fit specific education programs. If evaluation instruments focus on these five behavior areas, the result will be meaningful evaluation data that can be more easily summarized across food safety education programs for consumers.

Referrals to a secondary care dental clinic for anxious adult patients: implications for treatment

OBJECTIVES

This study aimed to determine the methods suggested by general dental practitioners for management of patients with dental anxiety whom they refer to a dental hospital setting, the treatment modalities eventually used with such patients and the relationship between patients previous sedation experience and the current referral.

METHODS

Consecutive referral letters (n = 125) for management of patients with dental anxiety over a 16 month period were analysed for content, including reason for referral and suggested treatment modalities. Patient records were also examined for previous sedation experience.

RESULTS

From 115 referrals eligible for analysis, the dentists requested management of anxiety using pharmacological methods in 113 referrals with only two referrals mentioning psychologically-based treatments. In secondary care, 29% of the adult referrals opted for dental treatment using psychological techniques alone.

CONCLUSIONS

In spite of the efficacy of psychological treatments for dental anxiety, primary and secondary care dentists appear not to be suggesting or promoting their use for patients with dental anxiety. Further research into the availablility of, and barriers to accessing the full range of services for those with dental anxiety, including patient perspectives, needs to be undertaken.

Viral induction of type 2 diabetes and autoimmune liver disease

Cross-sectional studies performed worldwide have shown that hepatitis C virus (HCV) infection is linked with type 2 diabetes, but these endocrine and liver diseases have an insidious onset, and it has been difficult to establish that patients acquire HCV infection before the development of diabetes. It is likely that investigations in small animal models or in vitro systems will be required to determine whether a causal relationship of HCV infection and the development of diabetes can be established. We have developed an in vitro model to study the viral induction of primary biliary cirrhosis (PBC) based on the phenotype of the diseased biliary epithelial cells. PBC patients make antimitochondrial antibodies and also express proteins reactive to these antibodies on their biliary epithelium. In coculture studies we have found that normal biliary epithelial cells develop the phenotypic manifestation of PBC in vitro specifically when cultivated with lymph nodes from PBC patients and not with relevant liver disease control subjects. We have also cloned a novel human retrovirus from a PBC biliary epithelium cDNA library and confirmed that the development of the PBC phenotype in vitro coincides with the presence of this virus. In clinical trials using antiretroviral therapy, we have observed a reversal of ductopenia as well as improvements in histology and hepatic biochemistry in patients with PBC. As Koch's postulates are not readily applicable to chronic diseases, we have used cocultivation viral transmission model in vitro and antimicrobial clinical studies in vivo to help establish a causal relationship with a retrovirus infection and the phenotypic manifestation of disease.

Hemophilic pseudotumor of the chest

We report the progressive imaging findings of a case of hemophilic pseudotumor of the chest, not previously described. The pseudotumor, although originally extrapleural, has gradually enlarged and eroded into a bronchus, producing a bronchopleural fistula.

Visual and visuospatial development in young children with Williams syndrome

This study investigated the relation between sensory visual problems and the severity of visuospatial difficulties in a large group of young children with Williams' syndrome (WS). A questionnaire describing visual and associated problems was completed by the families of 108 children with WS and detailed follow-up assessments were conducted, including visual, spatial, motor, visuocognitive, and linguistic tests of 73 of these children (mean age 7 years 3 months; 40 males, 73 females). Children with WS showed a much higher incidence of common paediatric sensory vision problems (strabismus, visual acuity loss, amblyopia, reduced stereopsis) than normally developing children. It was found that delays with respect to age normative values increased with age on all tests. No significant correlation was found between the presence of a visual deficit and the severity of the visuospatial problems, suggesting that the difficulties children with WS have in understanding spatial arrangements are not simply a result of their earlier sensory visual problems. Results confirm the dissociation between visuospatial and language abilities in children with WS, and support the neurobiological model of a split between ventral and dorsal stream processing of visual information with a generalized deficit in dorsal stream processing in young children with WS.

Autoimmune liver disease. Current standards, future directions

The diagnosis and management of autoimmune hepatitis continues to evolve as new diagnostic tests and new therapies are added to the armamentarium. Also encouraging are the advances in the understanding of the human immune system and its involvement in the origin and course of auto immune diseases in general and in the variants of autoimmune liver disease. Promising changes are expected in the next few years as new medications become available to the practicing hepatologist. New immune tests may allow therapies to be customized to patients, and antiviral therapies may also eventually be used in the management of this autoimmune liver diseases.

Food safety education: what should we be teaching to consumers?

Food safety education is most effective when messages are targeted toward changing behaviors most likely to result in foodborne illness. The five major control factors for pathogens are personal hygiene, adequate cooking, avoiding cross-contamination, keeping food at safe temperatures, and avoiding foods from unsafe sources. Pathogens associated with poor personal hygiene have the highest incidence and costs. Inadequate cooking and cross-contamination have lower incidence. Keeping food at safe temperatures and unsafe food sources have the lowest incidence, although costs per case are sometimes very high. We recommend that consumer food safety educators primarily focus on hand washing, adequate cooking, and avoiding cross-contamination. Secondary messages should focus on keeping food at safe temperatures and avoiding food from an unsafe source. Evaluation tools are needed to evaluate self-reported behavior changes. The evaluation questions must focus on salient behaviors that are most likely to result in foodborne illnesses and must withstand rigorous standards of reliability and validity.