Severe disorders of the mother-infant relationship: definitions and frequency

We assessed the frequency of severe disorders of the mother-infant relationship in over 200 mothers referred to services in Birmingham and Christchurch, all of whom were interviewed using the Birmingham Interview for Maternal Mental Health. 10.6% had established rejection and 14.6% threatened rejection of their infants. 28.6% had various degrees of pathological anger, which was severe in 8.3%. Rejection was strongly associated with unwanted pregnancy and lack of interaction with the foetus.

The Postpartum Bonding Questionnaire: a validation

This is a validation of a self-rating questionnaire designed to detect disorders of the mother-infant relationship. 125 subjects filled in the questionnaire, and were also interviewed using the 5(th) Edition of the Birmingham Interview for Maternal Mental Health. On the basis of these interviews and the case records, we made consensus diagnoses of various forms and degrees of mother infant relationship disorder, according to criteria published in this paper. We calculated specificity, sensitivity and positive predictive value of the four scale scores generated by the questionnaire. Scale 1 (a general factor) had a sensitivity of 0.82 for all mother-infant relationship disorders. Scale 2 (rejection and pathological anger) had a sensitivity of 0.88 for rejection of the infant, but only 0.67 for severe anger. The performance of scale 3 (infant-focused anxiety) was unsatisfactory. Scale 4 (incipient abuse) selected only a few mothers, but was of some value in identifying those at high risk of child abuse. Revision of the thresholds can improve sensitivity, especially of scale 2, where a cut-off point of 12 = normal, 13 = high better identifies mothers with threatened rejection. These new cut-off points would need validation in another sample.

Adherence to antiretroviral therapy and its impact on clinical outcome in HIV-infected patients

We analyse data on patient adherence to prescribed regimens and surrogate markers of clinical outcome for 168 human immunodeficiency virus infected patients treated with antiretroviral therapy. Data on patient adherence consisted of dose-timing measurements collected for an average of 12 months per patient via electronic monitoring of bottle opening events. We first discuss how such data can be presented to highlight suboptimal adherence patterns and between-patient differences, before introducing two novel methods by which such data can be statistically modelled. Correlations between adherence and subsequent measures of viral load and CD4+T-cell counts are then evaluated. We show that summary measures of short-term adherence, which incorporate pharmacokinetic and pharmacodynamic data on the monitored regimen, predict suboptimal trends in viral load and CD4+T-cell counts better than measures based on adherence data alone.

Video capsule endoscopy in peutz-jeghers syndrome: a blinded comparison with barium follow-through for detection of small-bowel polyps

BACKGROUND AND STUDY AIMS

Video capsule endoscopy has shown promise for the surveillance of significant small-bowel polyps in patients with Peutz-Jeghers syndrome. In this study the yield of significant small-bowel polyps by capsule endoscopy was compared to the yield of these polyps by barium follow-through in adults with Peutz-Jeghers syndrome.

PATIENTS AND METHODS

A total of 19 adults with Peutz-Jeghers syndrome who were undergoing surveillance underwent both capsule endoscopy and barium follow-through examinations, and the number of small-bowel polyps of at least 1 cm in diameter that were detected was recorded for each method. The two methods were assessed in terms of comfort and convenience for the patients and their preferred future surveillance method, using a questionnaire.

RESULTS

Capsule endoscopy detected a median of four significant small-bowel polyps while barium follow-through detected a median of one (P = 0.008). There was a trend towards more participants having at least one significant small-bowel polyp detected by capsule endoscopy than was the case with barium follow-through, though capsule endoscopy seemed to be less reliable for accurate sizing of polyps that were at the limit of clinical significance. Most participants expressed a preference for capsule endoscopy for future surveillance.

CONCLUSIONS

Capsule endoscopy should replace barium follow-through for the surveillance of small-bowel polyps in adults with Peutz-Jeghers syndrome, but the findings of this study should be interpreted with caution until a more reliable means of sizing polyps by capsule endoscopy is available.

Systematic review of the safety of electrosurgery for tonsillectomy

In the meta-analysis models, compared with cold steel dissection with ties/packs haemostasis (reference technique): * Bipolar diathermy dissection and haemostasis was associated with statistically significant lower odds of primary haemorrhage (OR 0.13, 95% CrI 0.03 to 0.51), including primary haemorrhage requiring return to theatre (OR 0.002, 95% CrI <0.001 to 0.26). * Coblation was associated with statistically significant higher odds of secondary haemorrhage requiring return to theatre (OR 33.82, 95% CrI 1.25 to 5676.00). * Monopolar and bipolar diathermy dissection and haemostasis (OR 4.12, 95% CrI 1.12 to 14.67; OR 2.86, 95% CrI 1.12 to 8.02, respectively), coblation (OR 3.75, 95% CrI 1.29 to 12.12), and cold steel dissection with monopolar or bipolar diathermy haemostasis (OR 4.83, 95% CrI 1.56 to 15.95; OR 9.18, 95% CrI 3.09 to 30.53, respectively) were all associated with statistically significant higher odds of secondary haemorrhage. * In deciding which technique to employ, factors to consider include patient characteristics, the underlying risk of primary or secondary haemorrhage, which is regarded as likely to be more serious, and the clinical significance of the observed differences in haemorrhage rates across techniques.

Seroprevalence of IgG antibodies to SARS-coronavirus in asymptomatic or subclinical population groups

We systematically reviewed the current understanding of human population immunity against SARS-CoV in different groups, settings and geography. Our meta-analysis, which included all identified studies except those on wild animal handlers, yielded an overall seroprevalence of 0.10% [95% confidence interval (CI) 0.02-0.18]. Health-care workers and others who had close contact with SARS patients had a slightly higher degree of seroconversion (0.23%, 95% CI 0.02-0.45) compared to healthy blood donors, others from the general community or non-SARS patients recruited from the health-care setting (0.16%, 95% CI 0-0.37). When analysed by the two broad classes of testing procedures, it is clear that serial confirmatory test protocols resulted in a much lower estimate (0.050%, 95% CI 0-0.15) than single test protocols (0.20%, 95% CI 0.06-0.34). Potential epidemiological and laboratory pitfalls are also discussed as they may give rise to false or inconsistent results in measuring the seroprevalence of IgG antibodies to SARS-CoV.

Methods for estimating the case fatality ratio for a novel, emerging infectious disease

During the course of an epidemic of a potentially fatal disease, it is important that the case fatality ratio be well estimated. The authors propose a novel method for doing so based on the Kaplan-Meier survival procedure, jointly considering two outcomes (death and recovery), and evaluate its performance by using data from the 2003 epidemic of severe acute respiratory syndrome in Hong Kong, People's Republic of China. They compare this estimate obtained at various points in the epidemic with the case fatality ratio eventually observed; with two commonly quoted, naïve estimates derived from cumulative incidence and mortality statistics at single time points; and with estimates in which a parametric mixture model is used. They demonstrate the importance of patient characteristics regarding outcome by analyzing subgroups defined by age at admission to the hospital.

Interventions to improve outpatient referrals from primary care to secondary care

BACKGROUND

The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.

OBJECTIVES

To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.

SEARCH STRATEGY

We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Three studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices and requiring a second 'in-house' opinion prior to referral), all of which were effective. Five studies (six comparisons) evaluated financial interventions. Two studies evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.

AUTHORS' CONCLUSIONS

There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation

OBJECTIVES

To determine whether laparoscopic methods are more effective and cost-effective than open mesh methods of inguinal hernia repair, and then whether laparoscopic transabdominal preperitoneal (TAPP) repair is more effective and cost-effective than laparoscopic totally extraperitoneal (TEP).

DATA SOURCES

Electronic databases. Conference proceedings. Manufacturers' submissions to the National Institute for Clinical Excellence (NICE) were reviewed.

REVIEW METHODS

Selected studies were rigorously assessed. Dichotomous outcome data were combined using the relative risk method and continuous outcomes were combined using the Mantel-Haenszel weighted mean difference method. Time to return to usual activities was described using hazard ratios derived from individual patient data reanalysis. A review of economic evaluations undertaken by NICE in 2001 was updated and an economic evaluation was performed. The estimation of cost-effectiveness focused on the comparison of laparoscopic repair with open flat mesh. A Markov model incorporating the data from the systematic review was used to estimate cost-effectiveness for a time horizon up to 25 years.

RESULTS

Thirty-seven randomised control trials (RCTs) and quasi-RCTs met the inclusion criteria on effectiveness. Fourteen studies were included in the review of economic evaluations. Laparoscopic repair was associated with a faster return to usual activities and less persisting pain and numbness. There also appeared to be fewer cases of wound/superficial infection and haematoma. However, operation times are longer and there appears to be a higher rate of serious complications in respect of visceral (especially bladder) injuries. Mesh infection is very uncommon with similar rates noted between the surgical approaches. There is no apparent difference in the rate of hernia recurrence. Laparoscopic repair was more costly to the health service than open repair, with an estimated extra cost from studies conducted in the UK of about 300-350 pounds per patient. The point estimates of cost provided by the economic model also suggest that the laparoscopic techniques are more costly (approximately 100-200 pounds more per patient after 5 years). From the review of economic evaluations, the estimates of incremental cost per additional day at usual activities were between 86 pounds and 130 pounds. Where productivity costs were included, they eliminated the cost differential between laparoscopic and open repair. Additional analysis incorporating new trial evidence suggested that TEP was associated with significantly more recurrences than open mesh but these data did not greatly influence cost-effectiveness.

CONCLUSIONS

For the management of unilateral hernias, the base-case analysis and most of the sensitivity analysis suggest that open flat mesh is the least costly option but provides less quality adjusted life years (QALYs) than TEP or TAPP. TEP is likely to dominate TAPP (on average TEP is estimated to be less costly and more effective). It is likely that, for management of symptomatic bilateral hernias, laparoscopic repair would be more cost-effective as differences in operation time (a key cost driver) may be reduced and differences in convalescence time are more marked (hence QALYs will increase) for laparoscopic compared with open mesh repair. When possible repair of contralateral occult hernias is taken into account, TEP repair is most likely to be considered cost-effective at threshold values for the cost per additional QALY above 20,000 pounds. The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. This may, for some people, reduce any loss of income. For the NHS, increased use of laparoscopic repair would lead to an increased requirement for training and the risk of serious complications may be higher. Chronic pain should now be addressed prospectively using standard definitions and allowing assessment of the degree of pain. More evidence is required on the loss of utility caused by persisting pain and numbness, as well as serious complications resulting from minor surgery. Prospective population-based registries of new surgical procedures may be the best way to address this, as a complement to randomised trials assessing effectiveness. Further research relating to whether the balance of advantages and disadvantages changes when hernias are recurrent or bilateral is also required as current data are limited. Methodologically sound RCTs are needed to consider the relative merits and risks of TAPP and TEP. Further methodological research is required into the complexity of laparoscopic groin hernia repair and the improvement of performance that accompanies experience.

Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review

BACKGROUND

The choice of approach to the laparoscopic repair of inguinal hernia is controversial. There is a scarcity of data comparing the laparoscopic transabdominal preperitoneal (TAPP) approach with the laparoscopic totally extraperitoneal (TEP) approach, and questions remain about their relative merits and risks.

METHODS

Electronic databases were searched to identify reports of trials comparing laparoscopic TAPP with laparoscopic TEP. In addition, selected conference proceedings were hand-searched, websites consulted, reference lists of all included papers were scanned, and experts contacted for other potentially eligible reports. All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic TAPP with laparoscopic TEP for inguinal hernia repair were eligible for inclusion. Large non-randomised prospective studies were also eligible for inclusion to provide further comparative evidence of complications and serious adverse events. Two reviewers independently extracted data and assessed study quality. Statistical analyses were performed using the fixed effects model and the results expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI).

RESULTS

The search identified one RCT which reported no statistically significant difference between TAPP and TEP when considering duration of operation, haematoma, length of stay, time to return to usual activities, and recurrence. The eight non-randomised studies suggest that TAPP is associated with higher rates of port-site hernias and visceral injuries whilst there appear to be more conversions with TEP. Vascular injuries and deep/mesh infections were rare and there was no obvious difference between the groups. No studies reporting economic evidence were identified.

CONCLUSIONS

There is insufficient data to allow conclusions to be drawn about the relative effectiveness of TEP compared with TAPP. Efforts should be made to start and complete adequately-powered randomised controlled trials (RCTs), which compare the different methods of laparoscopic repair.

Grasp size and accuracy of approach in reaching

In reaching for an object in the environment, it has been suggested that movement components concerned with transport of the hand toward the object and those related to grasping the object are organized and executed independently. An experiment is reported that demonstrates people adjust grasp aperture to compensate for factors affecting transport error. Grasp aperture was found to be greater in reaching movements performed faster than normal, and grasp aperture was also found to be wider when reaching with the eyes closed. In both cases, transport was spatially less accurate. It is argued that, in advance of movement, formation of grasp is planned to take into account not only the perceived characteristics of the object but, also, internalized information based on past experience about the likely accuracy of the transport component.

Systematic review of sacral nerve stimulation for faecal incontinence and constipation

BACKGROUND AND METHOD

This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies).

RESULTS

From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off.

CONCLUSION

SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.

Certification of multiple sclerosis nurses: an international perspective

The Multiple Sclerosis Nursing International Certification Board was formed as a special initiative of the International Organization of Multiple Sclerosis Nurses (IOMSN). The aim was to develop a certification examination for MS nursing practice. This certification should achieve the vision of the IOMSN and unite MS nurses worldwide through standard practices. Such practices are based on common knowledge and skills, and tasks that encourage the best outcome for the nurse-patient collaborative relationship. Certification allows recognition of an individual nurse's skill level, establishes a standard for all nurses treating patients with MS, improves patient care, and also benefits the neurological community. The Multiple Sclerosis Certified Nurse is revolutionary, as certification is an international effort to enhance and standardize MS care and develop MS nurse professionalism across borders.

Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction

OBJECTIVES

To assess the effectiveness and cost-effectiveness of single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction (MI).

DATA SOURCES

Major electronic databases.

REVIEW METHODS

Two reviewers independently extracted data and assessed study quality. A decision tree model was used to model the diagnosis decision and a Markov model was developed for the management of patients with suspected coronary artery disease. Costs for the treatments and interventions within strategies were derived from the literature and expressed in 2001-02 pounds sterling. Quality-adjusted life-year (QALY) weights for the different Markov model states were also obtained from the literature.

RESULTS

Twenty-one diagnostic and 46 prognostic studies were included, plus two studies comparing SPECT with electrocardiography (ECG)-gated SPECT and one study comparing SPECT with attenuation-corrected SPECT. The diagnostic values of SPECT were generally higher than those of stress ECG, indicating that SPECT provided a better diagnostic performance. SPECT also provided higher positive and lower negative likelihood ratios than stress ECG but heterogeneity was evident among studies. The subgroup of studies including patients with previous MI tended to report a better diagnostic performance for SPECT than stress ECG, but there were too few studies to assess this reliably. The extent and size of the perfusion defect, and whether reversible or fixed, were important factors in predicting future cardiac events such as cardiac death or non-fatal MI. SPECT may be able to identify lower risk patients for whom coronary angiography (CA) might be avoided. Normal SPECT scans were associated with a benign prognosis and the option of medical rather than invasive management. Four studies of patients post-MI reported SPECT to be valuable in stratifying patients into at-risk groups for further cardiac events. The two studies comparing SPECT with ECG-gated SPECT, one diagnostic and the other prognostic, found in favour of gated SPECT. The study comparing SPECT with attenuation-corrected SPECT reported the latter to be more accurate. The systematic review of economic evaluations indicated that strategies involving SPECT were likely either to be dominant or to produce more QALYs at an acceptable cost. There was less agreement about which of the strategies involving SPECT was optimal. The model suggested that, for low prevalence, the incremental cost per unit of output (true positives diagnosed, accurate diagnosis, QALY) for the move from stress ECG-SPECT-CA and from stress ECG-CA to SPECT-CA might be considered worthwhile. Even after allowing for different values for sensitivity or specificity, the least costly and least effective strategy was stress ECG-SPECT-CA. The sensitivity analysis suggested that the cost-effectiveness of SPECT-CA improved if it was assumed that SPECT results allowed for the adoption of a management strategy without recourse to CA. As the time horizon reduced, the incremental cost per QALY increased (as the cost of initial diagnosis and treatment were not offset by survival and quality of life gains).

CONCLUSIONS

There was a considerable variability in terms of measurement of outcomes, management, setting and patient characteristics, however the direction of evidence tended to favour SPECT in terms of test sensitivity, although these conclusions are based on a relatively small number of diagnostic studies. SPECT, in a variety of settings and patient populations, provided valuable independent and incremental prognostic information to that provided by stress ECG and/or CA that helped to risk-stratify patients and influence the way in which their condition was managed. However, all of the prognostic studies were observational studies and may be biased by unknown confounding factors. Although the ECG-gated and attenuation-corrected SPECT findings seem promising, it is difficult to draw conclusions from so few studies. Further research is needed on the effectiveness and cost-effectiveness, diagnostically and prognostically, of (a) gated and attenuation-corrected SPECT compared with standard SPECT, (b) standard SPECT compared with stress echocardiography and (c) the uncertainty surrounding the results presented in the cost-effectiveness analysis.

Effectiveness and efficiency of guideline dissemination and implementation strategies

OBJECTIVES

To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.

DATA SOURCES

MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group.

REVIEW METHODS

Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.

RESULTS

In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources.

CONCLUSIONS

There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

Changes in pharyngeal corticobulbar excitability and swallowing behavior after oral stimulation

Faucial pillar (FP) stimulation is commonly used in swallowing rehabilitation, yet its physiological basis remains uncertain. We investigated the effects of intraoral FP stimulation on human corticobulbar excitability and swallowing behavior, to explore the possibility of a central mechanism for functional change. In 10 healthy subjects, corticobulbar projections to pharynx were investigated with transcranial magnetic stimulation, via intraluminal electrodes, before and up to 1 h after 10 min of electrical FP stimulation with three frequencies (0.2, 1, and 5 Hz) or sham and peripheral (median nerve) stimulation. In a second study, swallowing behavior was assessed with videofluoroscopy before and after FP stimulation. FP stimulation at 5 Hz inhibited the corticobulbar projection (-14 +/- 6%, P < 0.02) and lengthened swallow response time (+114 +/- 24%, P = 0.02). By comparison, FP stimulation at 0.2 Hz facilitated this projection (+60 +/- 28%, P < 0.04), without enhancing swallowing behavior. Neither 1-Hz, sham, nor median nerve stimulation altered excitability. Thus changes in corticobulbar excitability to FP stimulation are frequency dependent with implications for the treatment for neurogenic swallowing dysfunction.

Radiation hybrid map, physical map, and low-pass genomic sequence of the canine prcd region on CFA9 and comparative mapping with the syntenic region on human chromosome 17

Progressive rod-cone degeneration (prcd) is a canine retinal disease that maps to the centromeric end of CFA9 in a region of synteny with the distal part of HSA17q. As such, prcd has been postulated as the only animal model of RP17, a human retinitis pigmentosa locus that maps to 17q22. In an effort to establish more detailed regions of synteny between dog CFA9 and the HSA17q-ter region, we created a robust gene-enriched CFA9-RH08(3000) map with 34 gene-based markers and 12 microsatellites, with the highest resolution and number of markers for the centromeric end of CFA9. Furthermore, we built an approximately 1.5-Mb physical map containing both GRB2 and GALK1, genes so far identified by meiotic linkage analysis as being closest to the prcd locus, and generated about 1.2 Mb low-pass (3.2x) canine sequence. Canine to human comparative sequence analysis identified 49 transcripts that had been previously mapped to the HSA17q25 region. The generated low-pass canine sequence was annotated with a working draft of human sequence from HSA17q25, and we used this scaffold to order and orient the canine sequence against human. This order and orientation are preliminary, as high-throughput genomic sequencing of HSA17q-ter has not been fully completed.

Quantification of intrinsic residual viral replication in treated HIV-infected patients

The intrinsic rate of viral replication in HIV-infected patients treated with antiretroviral combination therapy is estimated by using a mathematical model of viral dynamics. This intrinsic replication is found to be episodic, varying considerably in quantity between patients (even among those achieving long-term undetectable levels of viremia) and is always reduced by increasing the potency of the antiviral drug regimen. The analysis reveals that even in conditions of perfect patient adherence and drug penetration a substantial level of residual viral replication is expected. The rate of evolution in the viral quasispecies, and thus also the probability of new drug-resistant viral strains being created, is proportional to the total amount of residual viral replication. Under most circumstances, the viral population continues to turn over rapidly during therapy, albeit at a much reduced level.

Caregivers' utilization of health services: results from the Medicare Alzheimer's Disease Demonstration, Illinois site

OBJECTIVES

The purpose of this study is to examine the effect of the Medicare Alzheimer's Disease Demonstration and Evaluation (MADDE) conducted in Illinois on the use of health services and Medicare expenditures by caregivers of persons with dementia.

DESIGN

Prospective randomized clinical trial.

SETTING

The MADDE (1989-1994), Illinois site.

PARTICIPANTS

A cohort of 412 Medicare-eligible caregivers of persons with dementia.

MEASUREMENTS

Medicare claims files provided data on the number of hospitalizations, hospital bed days, emergency department visits, and total Medicare Part A expenditures.

RESULTS

After adjustment for baseline variables, the caregivers in the treatment group, when compared with those in the comparison group, had a lower likelihood of any hospitalization during the study period (odds ratio 0.58 (95% confidence interval (CI)=0.35-0.97), P= .037) and a reduced, but not significant, likelihood of emergency department use (odds ratio 0.66 (95% CI=0.40-1.08), P= .095). For those who were hospitalized, there were no significant differences between the treatment and comparison group caregivers in the number of hospitalizations, hospital length of stay, or Medicare payments.

CONCLUSION

These results suggest that enhanced chronic illness case management directed at persons with dementia and their caregivers can reduce the need for acute hospital care.