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Bevan G, Nazer B. Exercise and arrhythmogenic cardiomyopathy: all things in moderation. Heart 2023:heartjnl-2023-322453. [PMID: 36914249 DOI: 10.1136/heartjnl-2023-322453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Graham Bevan
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Babak Nazer
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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Bevan G, Pandey A, Griggs S, Dalton JE, Zidar D, Patel S, Khan SU, Nasir K, Rajagopalan S, Al-Kindi S. Neighborhood-level Social Vulnerability and Prevalence of Cardiovascular Risk Factors and Coronary Heart Disease. Curr Probl Cardiol 2022:101182. [PMID: 35354074 PMCID: PMC9875801 DOI: 10.1016/j.cpcardiol.2022.101182] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/22/2022] [Indexed: 01/27/2023]
Abstract
Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). The social vulnerability index (SVI) is an estimate of a neighborhood's potential for deleterious outcomes when faced with natural disasters or disease outbreaks. We sought to investigate the association of the SVI with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We linked census tract SVI with prevalence of census tract CVD risk factors (smoking, high cholesterol, diabetes, high blood pressure, low physical activity and obesity), and prevalence of CHD obtained from the behavioral risk factor surveillance system. We evaluated the association between SVI, its sub-scales, CVD risk factors and CHD prevalence using linear regression. Among 72,173 census tracts, prevalence of all cardiovascular risk factors increased linearly with SVI. A higher SVI was associated with a higher CHD prevalence (R2 = 0.17, P < 0.0001). The relationship between SVI and CHD was stronger when accounting for census-tract median age (R2 = 0.57, P < 0.0001). A multivariable linear regression model including 4 SVI themes separately explained considerably more variation in CHD prevalence than the composite SVI alone (50.0% vs 17.3%). Socioeconomic status and household composition and disability were the SVI themes most closely associated with cardiovascular risk factors and CHD prevalence. In the United States, social vulnerability can explain significant portion of geographic variation in CHD, and its risk factors. Neighborhoods with high social vulnerability are at disproportionately increased risk of CHD and its risk factors. Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). We investigated the association of social vulnerability index (SVI) with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We show that cardiovascular risk factors and CHD were more common with higher SVI. A multivariable linear regression model including 4 SVI themes separately explained considerably more variation in CHD prevalence than the composite SVI alone (50.0% vs 17.3%). Socioeconomic status and household composition and/or disability were the SVI themes most closely associated with cardiovascular risk factors and CHD prevalence.
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Affiliation(s)
- Graham Bevan
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland OH.,School of Medicine, Case Western Reserve University, Cleveland, OH
| | | | - Stephanie Griggs
- Frances Payne Bolton School of Nursing, Case Western Reserve University
| | - Jarrod E. Dalton
- Frances Payne Bolton School of Nursing, Case Western Reserve University
| | - David Zidar
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland OH.,School of Medicine, Case Western Reserve University, Cleveland, OH,Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Shivani Patel
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH
| | - Safi U Khan
- Hubert Department of Global Health ∣ Rollins School of Public Health, Emory University, Atlanta, GA
| | - Khurram Nasir
- Hubert Department of Global Health ∣ Rollins School of Public Health, Emory University, Atlanta, GA
| | - Sanjay Rajagopalan
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland OH.,School of Medicine, Case Western Reserve University, Cleveland, OH,Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Sadeer Al-Kindi
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland OH.,School of Medicine, Case Western Reserve University, Cleveland, OH,Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
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Dong T, Bevan G, Zidar DA, Achirica MC, Nasir K, Rashid I, Rajagopalan S, Al-Kindi S. Soluble Tumor Necrosis Factor Receptor 1 is Associated With Cardiovascular Risk in Persons With Coronary Artery Calcium Score of Zero. Pathog Immun 2022; 6:135-148. [PMID: 34988343 PMCID: PMC8714175 DOI: 10.20411/pai.v6i2.477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/27/2021] [Indexed: 01/02/2023] Open
Abstract
Background: A coronary artery calcium (CAC) score of zero confers a low but nonzero risk of atherosclerotic cardiovascular events (CVD) in asymptomatic patient populations, and additional risk stratification is needed to guide preventive interventions. Soluble tumor necrosis factor receptors (sTNFR-1 and sTNFR-2) are shed in the context of TNF-alpha signaling and systemic inflammation, which play a role in atherosclerosis and plaque instability. We hypothesized that serum sTNFR-1 concentrations may aid in cardiovascular risk stratification among asymptomatic patients with a CAC score of zero. Methods: We included all participants with CAC=0 and baseline sTNFR-1 measurements from the prospective cohort Multi-Ethnic Study of Atherosclerosis (MESA). The primary outcome was a composite CVD event (myocardial infarction, stroke, coronary revascularization, cardiovascular death). Results: The study included 1471 participants (mean age 57.6 years, 64% female), with measured baseline sTNFR-1 ranging from 603 pg/mL to 5544 pg/mL (mean 1294 pg/mL ±378.8 pg/mL). Over a median follow-up of 8.5 years, 37 participants (2.5%) experienced a CVD event. In multivariable analyses adjusted for Framingham Score, doubling of sTNFR-1 was associated with a 3-fold increase in the hazards of CVD (HR 3.0, 95% CI: 1.48-6.09, P = 0.002), which remained significant after adjusting for traditional CVD risk factors individually (HR 2.29; 95% CI: 1.04-5.06, P=0.04). Doubling of sTNFR-1 was also associated with progression of CAC >100, adjusted for age (OR 2.84, 95% CI: 1.33-6.03, P=0.007). Conclusions: sTNFR-1 concentrations are associated with more CVD events in participants with a CAC score of zero. Utilizing sTNFR-1 measurements may improve cardiovascular risk stratification and guide primary prevention in otherwise low-risk individuals.
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Affiliation(s)
- Tony Dong
- Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Graham Bevan
- Department of Medicine, University Hospitals, Cleveland, Ohio
| | - David A Zidar
- Department of Medicine, University Hospitals, Cleveland, Ohio.,Louis Stokes Cleveland Veterans Affairs Hospital, Cleveland, Ohio.,School of Medicine, Case Western Reserve University, Cleveland, Ohio.,Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | | | | | - Imran Rashid
- Department of Medicine, University Hospitals, Cleveland, Ohio.,Louis Stokes Cleveland Veterans Affairs Hospital, Cleveland, Ohio.,Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | - Sanjay Rajagopalan
- Department of Medicine, University Hospitals, Cleveland, Ohio.,Louis Stokes Cleveland Veterans Affairs Hospital, Cleveland, Ohio.,Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | - Sadeer Al-Kindi
- Department of Medicine, University Hospitals, Cleveland, Ohio.,Louis Stokes Cleveland Veterans Affairs Hospital, Cleveland, Ohio.,Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
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Palanivel R, Vinayachandran V, Biswal S, Deiuliis JA, Padmanabhan R, Park B, Gangwar RS, Durieux JC, Ebreo Cara EA, Das L, Bevan G, Fayad ZA, Tawakol A, Jain MK, Rao S, Rajagopalan S. Exposure to Air Pollution Disrupts Circadian Rhythm through Alterations in Chromatin Dynamics. iScience 2020; 23:101728. [PMID: 33241196 PMCID: PMC7672280 DOI: 10.1016/j.isci.2020.101728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/21/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022] Open
Abstract
Particulate matter ≤2.5μm (PM2.5) air pollution is a leading environmental risk factor contributing disproportionately to the global burden of non-communicable disease. We compared impact of chronic exposure to PM2.5 alone, or with light at night exposure (LL) on metabolism. PM2.5 induced peripheral insulin resistance, circadian rhythm (CR) dysfunction, and metabolic and brown adipose tissue (BAT) dysfunction, akin to LL (with no additive interaction between PM2.5 and LL). Transcriptomic analysis of liver and BAT revealed widespread but unique alterations in CR genes, with evidence for differentially accessible promoters and enhancers of CR genes in response to PM2.5 by ATAC-seq. The histone deacetylases 2, 3, and 4 were downregulated with PM2.5 exposure, with increased promoter occupancy by the histone acetyltransferase p300 as evidenced by ChIP-seq. These findings suggest a previously unrecognized role of PM2.5 in promoting CR disruption and metabolic dysfunction through epigenetic regulation of circadian targets. Air pollution disrupts the circadian rhythm (CR) similar to light at night Dysregulated circadian genes result in insulin resistance and metabolic diseases PM2.5 alters chromatin structure of circadian genes at regulatory regions PM2.5 alters chromatin structure by recruiting histone acetyl transferase (HAT), p300
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Affiliation(s)
- Rengasamy Palanivel
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Vinesh Vinayachandran
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Shyam Biswal
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Jeffrey A Deiuliis
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Roshan Padmanabhan
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bongsoo Park
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Roopesh Singh Gangwar
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Jared C Durieux
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Elaine Ann Ebreo Cara
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Lopa Das
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Graham Bevan
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed Tawakol
- Cardiology Division and Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mukesh K Jain
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Sujata Rao
- Department of Ophthalmic Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Ophthalmology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Sanjay Rajagopalan
- Cardiovascular Research Institute, Department of Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA
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Bevan G, Al-Kindi S. EPIDEMIOLOGY AND TRENDS OF AORTIC STENOSIS MORTALITY IN THE UNITED STATES (1999-2016). J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32578-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kohli M, McDonnell S, Bevan G, Riska SM, Costello BA, Longenbach S, Dronca RS, Moynihan TJ, Pitot HC, Quevedo F, Cerhan JR. Association of germ-line genetic variation in the NK3 homeobox 1 gene with overall survival in advanced-stage castrate-resistant prostate cancer (CRPC). J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.6_suppl.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
75 Background: We investigated the association of germline variation in ten candidate genes important in prostate cancer biology (NKX3-1, JAK2, SLCO2B1, STAT3, CYP19A1, HSD17B4, TRMT11, PRMT3, HSD17B12, NCOA4) with overall survival (OS) in a cohort of metastatic CRPC stage patients. Methods: Patients (N=497) were enrolled at the time of androgen deprivation therapy failure for D2 stage prostate cancer. Candidate genes were selected from the literature and pilot studies. Genes were tagged using SNPs from HapMap with minor allele frequency (MAF) of >5% and r2≥0.8. DNA was extracted from peripheral blood and genotyped using Illumina Veracode platform. The primary endpoint was OS, defined as time from development of CRPC to death. Principle components analysis was used for gene-levels tests. To account for multiple testing we calculated the false discovery rate (FDR). For SNP level results we estimated per allele (ordinal model) hazard ratios (HR) and 95% confidence intervals (CI) using Cox regression and adjusted for age and Gleason score (GS). Results: We successfully genotyped 60 SNPs (from 10 genes) in 497 Caucasian subjects. The median age of the CRPC cohort was 71 years (range 43,93). The GS distribution was 51% subjects with GS≥8; 32% with GS7 and 17% with GS<7. After a median follow up of 2.1 years (IQ range: 1.2-3.6), 297 subjects had died. In unadjusted gene level analyses, NKX3-1 (p=0.04; FDR=0.03) was associated with OS. After adjusting for age and GS the result remained significant (p=0.03). Two of the 5 genotyped SNPs in this gene were associated with OS after adjustment for age and GS: rs10503733 (dominant model p=0.03, HR=0.77; 95 CI=0.60-0.98; A>C; MAF = 0.22) and rs7005368 (dominant model p=0.05, HR=1.38, 95CI=1.0-1.92; G>A; MAF=0.07). Both SNPs are in Hardy Weinberg Equilibrium and in complete LD (D'=1), although r2 is low (r2=0.025) due to different allele frequencies. Conclusions: Variation in the homeobox NKX-1 gene, a prostate specific tumor suppressor gene involved in prostate development and carcinogenesis is significantly associated with OS in CRPC after accounting for age and GS. Further validation is needed to develop these as prognostic biomarkers.
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Marsh M, Rawluk N, Nguyen H, Bevan G, Schreiner L. SU-E-I-22: Non-Clinical Applications for Cobalt-60 Cone Beam CT Imaging. Med Phys 2011. [DOI: 10.1118/1.3611595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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11
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Baxter K, Stoddart H, Bevan G. Evidence-based medicine: a conflict between rigour and reality. Prim Health Care Res Dev 2001. [DOI: 10.1191/146342301670156272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
The World Bank's Global Burden of Disease Study pioneered the use of Disability Adjusted Life Years (DALYs). In this paper we distinguish between the total and the "avoidable" burden of disease. We identify different ways of measuring DALYs: incidence-based DALYs are appropriate where the means of reducing the burden of disease is by prevention; prevalence-based DALYs are appropriate when a disease cannot be prevented but effective treatment is available. The methods of estimating each are explained and we describe how we have applied these methods to seven causes of death and disability in the South and West Region. We discuss the relevance of this work for monitoring the health of populations and deciding how best to use scarce resources to improve health.
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Affiliation(s)
- S Hollinghurst
- LSE Health, London School of Economics and Political Science, UK.
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13
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Affiliation(s)
- G Bevan
- Department of Operational Research, London School of Economics and Political Science, London WC2A 2AE.
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Abstract
STUDY OBJECTIVE To determine the relative costs of prostheses and factors associated with changes in these cost rankings. DESIGN AND SETTING Economic model using published data. MAIN RESULTS The main cost drivers are current costs and revision rates. Expected revision costs are a small proportion of the expected total costs. There are few competitors to the "gold standard" Charnley in terms of total expected costs over 20 years. There is no monetary advantage in using higher cost prostheses in older patients even if they were to have lower revision rates. There may be a monetary case for using prostheses with higher costs and lower revision rates in younger patients. CONCLUSIONS The most cost effective prosthesis in older patients is the Stanmore. The Charnley, Exeter Polished and Muller Straight Stem are marginally more costly than the Stanmore. The study inevitably lacks good data on survival for newer prostheses. This does not affect the ability to make choices for older patients. Data are needed, however, on survival of cemented prostheses for younger patients.
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Affiliation(s)
- K Baxter
- Department of Social Medicine, University of Bristol
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Clack GB, Bevan G, Eddleston AL. Service increment for teaching (SIFT): a review of its origins, development and current role in supporting undergraduate medical education in England and Wales. Med Educ 1999; 33:350-358. [PMID: 10336770 DOI: 10.1046/j.1365-2923.1999.00310.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVES To describe the ways in which total resources available for the Service Increment for Teaching (SIFT) have been determined and related to numbers of undergraduate medical students; and the development and current arrangements for allocating SIFT to the providers of service support for teaching. DESIGN The derivation of SIFT from excess costs of teaching hospitals over general hospitals is described. The official principles of organizing SIFT to reimburse the service costs of teaching undergraduate medical students are explained. The crucial development that is examined is the change from SIFT being a global subsidy to being related to educational contracts. This development has facilitated both the specification of standards and innovative uses of SIFT. These are illustrated with examples. SETTING Hospital and Community Health Services and Primary Care in the National Health Service (NHS) in England and Wales. SUBJECTS Medical students. RESULTS There is often confusion caused by SIFT being intended to cover the service costs of teaching but not having been derived in this way. This causes problems in deciding what providers should be paid through contracts for teaching of different kinds. CONCLUSIONS The new contractual basis has enabled medical schools to use contracts to improve the clinical teaching of undergraduate medical students in the NHS. These developments may offer useful models for other countries.
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Affiliation(s)
- G B Clack
- School of Education, King's and St Thomas' School of Medicine, London, UK
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Kendall JM, Bevan G, Clancy MJ. Point of care testing in the accident and emergency department: a cost analysis and exploration of financial incentives to use the technology within the hospital. J Health Serv Res Policy 1999; 4:33-8. [PMID: 10345564 DOI: 10.1177/135581969900400109] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT). METHODS Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process. RESULTS For the supplemental option, current arrangements cost 68,466 Pounds in total per year; average costs per test were 5.53 Pounds (venous in the central laboratory) and 3.60 Pounds (arterial on the ITU). Introducing POCT would increase total hospital costs by 35,929 Pounds, and average costs per test would be 5.32 Pounds (venous) and 4.28 Pounds (arterial). For the replacement option, current arrangements cost 132,630 Pounds in total, and average cost per test (for all tests) was 4.06 Pounds. Introducing POCT would make hospital savings ranging from 8332 Pounds to 20,000 Pounds, and average cost per test would be 3.78 Pounds. CONCLUSIONS Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially 'profitable' for the A&E department, but would result in higher expenditure for the hospital as a whole.
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Affiliation(s)
- J M Kendall
- Department of Accident and Emergency Medicine, Bristol Royal Infirmary, UK
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17
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Fidler HM, El-Jabbour JN, Bevan G. Endoscopic resection of large polypoid leiomyoma: case study. Endoscopy 1998; 30:740. [PMID: 9865570 DOI: 10.1055/s-2007-1001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Faulkner A, Kennedy LG, Baxter K, Donovan J, Wilkinson M, Bevan G. Effectiveness of hip prostheses in primary total hip replacement: a critical review of evidence and an economic model. Health Technol Assess 1998; 2:1-133. [PMID: 9728294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
MESH Headings
- Arthritis, Rheumatoid/economics
- Arthritis, Rheumatoid/surgery
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/methods
- Biocompatible Materials
- Costs and Cost Analysis
- Female
- Fractures, Bone/etiology
- Hip Prosthesis/adverse effects
- Hip Prosthesis/economics
- Humans
- Male
- Models, Economic
- Osteoarthritis, Hip/economics
- Osteoarthritis, Hip/surgery
- Pain/etiology
- Prognosis
- Prosthesis Design
- Prosthesis Failure
- Randomized Controlled Trials as Topic
- Technology Assessment, Biomedical
- Weight-Bearing
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Affiliation(s)
- A Faulkner
- Department of Social Medicine, University of Bristol
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Bevan G. Allocating the WHO's resources rationally. One cheer for the who's proposed changes in regional budgets? BMJ 1998; 316:1403-4. [PMID: 9572745 PMCID: PMC1113112 DOI: 10.1136/bmj.316.7142.1403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Affiliation(s)
- G Bevan
- Department of Operational Research, London School of Economics and Political Science
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Affiliation(s)
- N Mays
- King's Fund Policy Institute, London
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Abstract
The National Health Service (NHS) market led to problems in funding research and development (R&D). The current policy is to resolve these by funding R&D through a national levy on purchasers. The policy does not, however, address the underlying problem that evidence produced by R&D is largely irrelevant to purchasers. The consequences of this policy are likely to be that purchasing will have limited impact in securing health gain most effectively, the progress and impact of R&D will be impaired, and its funding will remain insecure. If R&D and purchasing were integrated each could become more effective. This integration can be fostered through developing the regulation of purchasers and providers within the NHS market.
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Affiliation(s)
- S F Gray
- South and West Regional Health Authority, Bristol
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Abstract
BACKGROUND Health Authorities seeking to make appropriate investments in health care require information about the nature of the burden of disease in their populations. The World Bank instrument called DALY-Disability Adjusted Life Year-has been used in the South and West Region to measure this burden. METHOD The burden of disease caused by a selection of diseases has been calculated using DALYs, which combine premature mortality and disability. An estimate of the total burden has been estimated by ICD chapter. RESULTS Premature mortality accounts for 52 per cent of the burden of disease and disability 48 per cent. Mental illness, for which its DALY value is largely derived from disability not premature mortality, contributes the third largest component of the total burden, after heart disease and cancer. DISCUSSION DALYs can be calculated using UK data, and, with an appreciation of the theoretical issues which surround the calculations, can be used to describe the burden of disease in a population. Although designed to assist investment decisions in developing countries, the DALY is likely to be valuable in established market economies.
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Affiliation(s)
- C Bowie
- Wessex Institute of Health Research & Development, Highcroft, Winchester
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Bachmann MO, Bevan G. Determining the size of a total purchasing site to manage the financial risks of rare costly referrals: computer simulation model. BMJ 1996; 313:1054-7. [PMID: 8898599 PMCID: PMC2352382 DOI: 10.1136/bmj.313.7064.1054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To estimate the financial risks of 15 categories of rare costly referrals for total purchasing sites of different population sizes. DESIGN Computer simulation of 100 fund years assuming Poisson distribution of referrals. SETTING British general practices that have opted to become total purchasing sites. Referral rates and price estimates were supplied by South and West Devon Health Commission. MAIN OUTCOME MEASURES Variation in referral costs to purchasers in relation to size of risk pool (person years at risk). RESULTS Random variation in referral costs increased as the size of the risk pool decreased. Variation increased greatly below 30,000 person years. The mean simulated cost of the referral categories considered was 2.8% of total NHS hospital and community service costs, and the maximum simulated cost for 7000 person years was 6.8%. Simulated variation was robust to assumption about prices and referral rates for specific types of referral. CONCLUSION Rare costly referrals seem unlikely to bankrupt total purchasing sites. The management of risk is not in itself justification for total purchasing to be based in several general practices in order to generate large populations. There are other ways of managing risk. Sites can easily explore options by simulations using local referral rates and prices.
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Affiliation(s)
- M O Bachmann
- Department of Social Medicine, University of Bristol
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Buckley D, Fahey T, Bevan G. The prevalence and direct costs of pre-immunization testing for hepatitis A in general practice. Br J Gen Pract 1996; 46:541-2. [PMID: 8917876 PMCID: PMC1239752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Two hundred and twenty patients in one general practice travelling to destinations where immunization against hepatitis A virus (HAV) is recommended were tested for their HAV immune status before immunization. Age-specific prevalence of prior immunity to HAV was estimated. The relative costs of pre-immunization testing and immediate immunization were compared. The most cost-effective testing method for this practice was found to be total population testing prior to immunization with HAV vaccine. Individual general practices can estimate the optimal age at which to commence testing for HAV in their own practice population.
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Affiliation(s)
- D Buckley
- Department of Social Medicine, University of Bristol
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26
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Abstract
BACKGROUND In the US Medicare programme, hospitals are paid directly by activity. To provide incentives for efficiency, the US Federal Government has sought objective measures of inpatients' need for resources. In the UK National Health Service, resources are allocated for acute hospital services as part of a global budget to purchasers, who then contract with hospitals. To provide equity in resource allocation, the Department of Health in England, has sought objective measures of populations' need for resources. METHODS Examination of policy and technology that has used variations in utilization of resources to derive objective measures of efficiency and equity. RESULTS The technology of developing empirical measures of resources needed by patients has lacked information on outcomes, which is vital for measures of efficiency. The technology of developing empirical measures of resources needed by populations has relied on aggregate data. Analyses of specific procedures and conditions consistently find that these variations are explained by differences in medical practice and not by need. CONCLUSIONS There is scope for multidisciplinary research to explain small area variations for specific procedures and conditions in resources used by populations. It seems unlikely, however, that governments will be interested in findings from this research.
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Affiliation(s)
- G Bevan
- Department of Social Medicine, University of Bristol, UK
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Abstract
National allocation of resources to regional health authorities and by them to districts is now determined by a weighted capitation formula. The national formula was derived from regression analysis, with hospital utilisation as an index of need for health care--a method which has fundamental limitations. This paper argues that the search for an empirically based resource allocation formula of high precision in the name of promotion of equity is largely fruitless given the impossibility of measuring the true need for, and costs of, providing health care, especially with the limited data available. The inclusion of measures of social deprivation is also poorly thought out. The availability of data from the 1991 census, which included a question regarding long-standing illness, together with the intention of the Department of Health to review the weighted capitation formula using this information may stimulate much work but little light. It is essential that the impact of resource allocation formulas is justifiable on grounds other than the composition of any particular formula.
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Affiliation(s)
- T A Sheldon
- Centre for Health Economics, University of York, Heslington
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28
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Affiliation(s)
- G B Clack
- King's College School of Medicine and Dentistry, London
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29
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Bevan G, France G, Taroni F. Dolce vita. Health Serv J 1992; 102:20-3. [PMID: 10117200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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30
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Bevan G. Trapped in the health market. Health Serv J 1989; 99:790-1. [PMID: 10293967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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31
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Abstract
The Government's white-paper Working for Patients proposes introducing a system in which publicly financed resources for hospital and community health services will be distributed to districts and general practitioners with practice budgets for them to choose between competing providers from both the public and private sectors. The NHS Management Board in 1986 observed that such a system would be costly and impractical and would require careful pilot work in situations where its benefits are likely to outweight its costs. This paper shows that there is no reason for changing that judgement.
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Affiliation(s)
- G Bevan
- Department of Community Medicine, United Medical School of Guys Hospital, London
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32
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Bevan G. Medical research. Br Med J (Clin Res Ed) 1988; 296:1672. [PMID: 3135071 PMCID: PMC2546202 DOI: 10.1136/bmj.296.6637.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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33
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Affiliation(s)
- G Bevan
- Department of Community Medicine, United Medical School, Guy's Hospital, London
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34
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Bevan G, Charlton J. Making access to health care more equal. West J Med 1987. [DOI: 10.1136/bmj.295.6609.1349-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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35
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Abstract
The review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board has considered the method used to account for cross boundary flows between health authorities. There is no consensus on how this should be done subregionally, as it raises the unresolved problem of the best method of estimating the size of catchment populations. Different methods produce different population sizes when the admission rates of individuals living in different districts vary. The National Health Service/Department of Health and Social Security acute services working group on performance indicators recently considered the assumptions made by different methods in terms of admission thresholds set by hospital clinicians. More complicated methods of assessing catchment areas seem to offer little advantage over the simplest method, but none of the methods answer the underlying questions of what truly determines admission rates and whether higher admission rates are better than lower ones. Empirical research into variations in admission rates and their relation to outcomes is important for determining the fair allocation of resources in future.
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Affiliation(s)
- G Bevan
- Department of Community Medicine, United Medical School of Guy's Hospital, St Thomas's Campus, London
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36
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Abstract
One issue of interest to the current review of the Resource Allocation Working Party (RAWP) formula is the extra service costs associated with medical teaching. RAWP intended the medical service increment for teaching (SIFT) to cover these costs. Although it is not possible to assess from the methods used to derive the SIFT rate whether it is or is not overgenerous for its intended purpose, the "excellence" elements of teaching hospitals tend to be protected. The financial problems of the teaching hospitals are more likely to be due to the relatively high use of services by local residents. But cutting services of London teaching hospitals to bring this use down to equitable levels may impair their capacity to train medical students.
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Affiliation(s)
- G Bevan
- Department of Community Medicine, United Medical School of Guy's Hospital, St Thomas's Campus, London
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37
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Abstract
Accounting for the cross boundary flows of residents from one health authority treated by another has been considered by the review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board. A common concern is that the approximate costs used are unfair to those authorities (typically those with teaching hospitals) that are likely to treat more complex cases. This paper argues that when spending exceeds the target allowance for acute services this is more likely to be due to district residents using services at a high rate than to inadequate compensation for inflows. Districts where residents make a high use of services are often those where there are large flows across district boundaries. Since authorities cannot control outflows there is little they can do to reduce their residents' high use of services. Furthermore, curious financial incentives can be inferred for clinicians in these districts if they were to take effective action to bring their district's spending to target levels. These problems are discussed to illuminate problems of accounting for cross boundary flows that alternatives to current practice must resolve.
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Affiliation(s)
- G Bevan
- Department of Community Medicine, United Medical School, Guy's Hospital, London
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38
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Abstract
The Resource Allocation Working Party (RAWP) recognised the need to consider both health authority and primary care services in achieving its objective. RAWP and the subsequent Advisory Group on Resource Allocation (AGRA) found (but did not publish) considerable variation in resources used by both services but could not find a clear relation between them. Statistics provided by the DHSS were used to compare spending by 80 area health authorities in 1980-1 with expenditure per head on general medical services by their corresponding family practitioner committees. There was considerable variation in the provision of resources for both services and no clear relation between the variations in spending on each service. Only 40 of the 80 areas had both health authority and family practitioner committee spending levels within 10% of "target." Subregional inequalities in resources tend to be related to variations in admission rates, which in turn are related to general practitioners' referral behaviour. These results emphasise the importance of finding out more about inequalities in the provision of general medical services and their relation to the use of hospital services. They also suggest that RAWP's aim of equality of opportunity of access to health care resources may be achieved only if general medical services are brought into the equation as well.
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Affiliation(s)
- G Bevan
- Department of Community Medicine, United Medical School, St Thomas's Campus, London
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39
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Bevan G. A Doctor in Saudi Arabia. Postgrad Med J 1986. [DOI: 10.1136/pgmj.62.731.899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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40
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Sanderson H, Craig M, Winyard G, Bevan G. Using diagnosis-related groups in the NHS. Community Med 1986; 8:37-46. [PMID: 3084165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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41
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Bevan G, Beech R, Craig M. Resource allocation. Alternatives to RAWP. Health Soc Serv J 1985; 95:1098-9. [PMID: 10273767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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43
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Bevan G, Brazier J. Moving resources. Subregional RAWP--Hobson's choice? Health Soc Serv J 1985; 95:1064-5. [PMID: 10273762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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44
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Barbara JA, Howell DR, Contreras M, Tedder RS, Briggs M, Sanderson PJ, Wood J, Bevan G. Indications for hepatitis B immunoglobulin for neonates of HBsAg carrier mothers. Br Med J (Clin Res Ed) 1984; 289:880. [PMID: 6434124 PMCID: PMC1443422 DOI: 10.1136/bmj.289.6449.880] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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45
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Bevan G. First-line management training-does it work? Nurs Times 1982; 78:1487. [PMID: 6923235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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46
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Greenstone M, Hartley B, Gabriel R, Bevan G. Acute nephrotic syndrome with reversible renal failure after phenylbutazone. Br Med J (Clin Res Ed) 1981; 282:950-1. [PMID: 6781669 PMCID: PMC1504829 DOI: 10.1136/bmj.282.6268.950-a] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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47
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Abstract
A sample of 16 patients had pentagastrin stimulation studies performed before starting a 12 week course of cimetidine, and again 12 hours after completing the course. Basal and pentagastrin stimulated intrinsic factor secretion was assayed in 13 patients. There was no significant difference in the pattern of secretion after 12 weeks' treatment with cimetidine. The basal and peak acid outputs of all 16 patients were measured. No significant difference was found in the pattern of acid secretion after treatment. It appears that parietal cell secretory function is restored to normal within 12 hours of discontinuing a prolonged course of cimetidine.
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48
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49
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Vaughan-Neil EF, Ardeman S, Bevan G, Blakeman AC, Jenkins WJ. Post-transfusion purpura associated with unusual platelet antibody (anti-Pl-B1). Br Med J 1975; 1:436-7. [PMID: 1115962 PMCID: PMC1672388 DOI: 10.1136/bmj.1.5955.436] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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50
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Abstract
Mean and peak jejunal bile salt concentrations during digestion of a standard fat meal were found to be significantly lower in six Puerto Rican patients with untreated tropical sprue, all of whom had steatorrhoea, than in six asymptomatic subjects who had normal fat absorption. Bile salt pool size and turnover time did not differ significantly in the two groups.It is suggested that bile salt concentrations may be reduced in the proximal small intestine of patients with tropical sprue as a result of excessive dilution by intestinal fluid. The finding of low bile salt concentrations in two asymptomatic subjects indicates that bile salt lack alone may not be sufficient to produce steatorrhoea.
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