Observing many researchers using the same data and hypothesis reveals a hidden universe of uncertainty

This study explores how researchers' analytical choices affect the reliability of scientific findings. Most discussions of reliability problems in science focus on systematic biases. We broaden the lens to emphasize the idiosyncrasy of conscious and unconscious decisions that researchers make during data analysis. We coordinated 161 researchers in 73 research teams and observed their research decisions as they used the same data to independently test the same prominent social science hypothesis: that greater immigration reduces support for social policies among the public. In this typical case of social science research, research teams reported both widely diverging numerical findings and substantive conclusions despite identical start conditions. Researchers' expertise, prior beliefs, and expectations barely predict the wide variation in research outcomes. More than 95% of the total variance in numerical results remains unexplained even after qualitative coding of all identifiable decisions in each team's workflow. This reveals a universe of uncertainty that remains hidden when considering a single study in isolation. The idiosyncratic nature of how researchers' results and conclusions varied is a previously underappreciated explanation for why many scientific hypotheses remain contested. These results call for greater epistemic humility and clarity in reporting scientific findings.

Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development

OBJECTIVE

Despite advancements in cancer treatment, racial disparities in breast cancer survival persist, with African American women experiencing lower survival rates and poorer quality of life than non-Hispanic White women. Using a social cognitive model of restorative well-being as a framework, this qualitative study sought: (a) to examine strength- and culture-related factors associated with African American female breast cancer survivors' cancer coping and post-treatment experiences and (b) to make recommendations for culturally sensitive intervention.

METHODS

Eight focus groups occurred with a total of 40 local African American breast cancer survivors. Focus groups were audiotaped and transcribed verbatim. Framework analyses were used to identify themes. NVivo qualitative analysis software-managed data.

RESULTS

Two major themes emerged from the focus group discussions: (a) God enables breast cancer survivorship and works every day in our lives and (b) the healthiest thing about us is that we are strong African American women. Recommendations for intervention planning and implementation were made towards intervention structure, content development and language framing in a local context.

CONCLUSION

Findings suggest a need for community-based participatory survivorship interventions that are culturally and spiritually consonant and peer-based. Such interventions may respond to the cancer-related and personal needs of the target population.

Thoroughbred fatality and associated jockey falls and injuries in races in New South Wales and the Australian Capital Territory, Australia: 2009-2014

Monitoring racehorse fatality and associated jockey falls provides benchmarks for intervention strategies. The aims of this study were to describe the incidence of and reasons for fatalities in Thoroughbred horses during flat races in the Australian Capital Territory and New South Wales (NSW), Australia, and to describe reported jockey falls and injuries associated with racehorse fatalities. A cohort study identified all racehorse fatalities reported through Racing NSW for the 2009-2010 to 2013-2014 racing seasons. Risks of racehorse fatality, fatal musculoskeletal injury, spontaneous death (as distinct from euthanasia) and racehorse fatality associated jockey falls and injuries were calculated using Poisson regression. A total of 167 horse fatalities were reported, with an overall incidence of 0.59 deaths/1000 starts. Forty-nine reasons for horse fatality were reported, although post-mortem examinations were conducted on only 52/165 (31.5%) horses. Musculoskeletal injury accounted for 144/167 (86.2%) fatalities, with an incidence of 0.52/1000 starts. Fractures comprised 96/167 (57.5%) fatalities, with the fetlock or proximal sesamoid bones being the most common fracture location, comprising 36/96 (37.5%) fractures. Only 22/166 (13.3%) racehorse fatalities were due to spontaneous death, representing an incidence of 0.08/1000 starts. A total of 50 racehorse fatality associated jockey falls were reported (incidence of 0.18/1000 starts), with 32 reported jockey injuries (incidence of 0.12/1000 starts). Most racehorse fatality associated jockey injuries occurred to the limbs (17/32, 53.1%), particularly the upper limb. The estimates for both horse fatality and associated jockey injury were comparable with previous estimates from other jurisdictions internationally.

Conquering racial disparities in perinatal outcomes

Infant mortality rate (IMR) is a reference indicator for societal health status. Trend analysis of IMR highlights 2 challenges to overcome in the United States: (1) US IMR is higher than most industrialized countries and (2) there are persistent racial/ethnic disparities in birth outcomes, especially for blacks. Racial/ethnic infant mortality disparities result from the complex interplay of adverse social, economic, and environmental exposures. In this article, racial/ethnic disparities are discussed, highlighting trends, the role of epigenetics in understanding mechanisms, key domains of community action planning, and programs and policies addressing the racial gaps in adverse birth outcomes.

Lipomodelling of the breast

Abstract #4149

Background: Lipomodelling is the autologous transfer of fat to correct congenital and post-surgical deformities. Recent improvements in technique have provided the opportunity for a greater volume of fat transfer thus increasing its potential application following surgery for benign and malignant breast disease.
 Materials & methods: After injecting a solution of local anaesthetic, normal saline and 1:106 adrenaline into donor sites in the abdomen and thighs, fat was aspirated with 3mm cannulae and centrifuged for 5 minutes. The fat was then re-injected into pre-marked areas in the breast using a 3mm injection cannula. Patients were followed up in a specialist breast clinic.
 Results: 23 patients (22 female, 1 male) were treated between November 2007 and May 2008. The mean age was 50.6 years (36-61).
 
 Prior to lipomodelling, volume deficit was observed in all patients. A visible depression was identified in 43.5% (n=10), significant flap atrophy in 21.7% (n=5), skin tethering in 21.7% (n=5) and implant rippling in 13% (n=3). Ten patients (43.5%) required lipomodelling to the upper pole, while in 7 patients (30.4%), the location was closely associated with the surgical scar.
 The average volume of fat harvested was 210.7 ml (85-510), and that injected per breast was 107.1 ml (45-206). Injections were stopped when slight overfilling was observed. Excessive tissue tension was avoided. Operative time varied between 45-100 minutes.
 During the first follow up visit, satisfactory results were recorded. 3 patients were booked for their second operation.
 Nine patients were seen at 3-4 months (second follow up visit). Two patients had clinical and radiological evidence of fat necrosis. One patient had marked volume resorption and numbness at the donor site. Eight patients had good volume retention. Two patients were booked for further lipomodelling at this stage.
 One patient had further lipomodelling five months after the first session, with satisfactory results, and is awaiting a third session.
 
 Discussion: Early results have shown satisfactory cosmetic outcome and patient satisfaction. The technical simplicity and autologous nature make lipomodelling an attractive option to both surgeon and patient. However it is not universally successful and further follow-up is required before the long term effects of the technique in cancer patients can be confirmed.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4149.

Phase II study of high-dose photon/proton radiotherapy in the management of spine sarcomas

PURPOSE

Radiotherapy (XRT) for spine sarcomas is constrained by spinal cord, nerve, and viscera tolerance. Negative surgical margins are uncommon; hence, doses of >or=66 Gy are recommended. A Phase II clinical trial evaluated high-dose photon/proton XRT for spine sarcomas.

METHODS AND MATERIALS

Eligible patients had nonmetastatic, thoracic, lumbar, and/or sacral spine/paraspinal sarcomas. Treatment included pre- and/or postoperative photon/proton XRT with or without radical resection; patients with osteosarcoma and Ewing's sarcoma received chemotherapy. Shrinking fields delivered 50.4 cobalt Gray equivalent (Gy RBE) to subclinical disease, 70.2 Gy RBE to microscopic disease in the tumor bed, and 77.4 Gy RBE to gross disease at 1.8 Gy RBE qd. Doses were reduced for radiosensitive histologies, concurrent chemoradiation, or when diabetes or autoimmune disease present. Spinal cord dose was limited to 63/54 Gy RBE to surface/center. Intraoperative boost doses of 7.5 to 10 Gy could be given by dural plaque.

RESULTS

A total of 50 patients (29 chordoma, 14 chondrosarcoma, 7 other) underwent gross total (n = 25) or subtotal (n = 12) resection or biopsy (n = 13). With 48 month median follow-up, 5-year actuarial local control, recurrence-free survival, and overall survival are: 78%, 63%, and 87% respectively. Two of 36 (5.6%) patients treated for primary versus 7/14 (50%) for recurrent tumor developed local recurrence (p < 0.001). Five patients developed late radiation-associated complications; no myelopathy developed but three sacral neuropathies appeared after 77.12 to 77.4 Gy RBE.

CONCLUSIONS

Local control with this treatment is high in patients radiated at the time of primary presentation. Spinal cord dose constraints appear to be safe. Sacral nerves receiving 77.12-77.4 Gy RBE are at risk for late toxicity.

Challenges and opportunities for HIV prevention and care: insights from focus groups of HIV-infected African American men

Given the inordinate burden of HIV illness borne by African American men, investigations of HIV prevention and care in this population are urgently needed. In this qualitative study, a sample of 20 HIV-infected African American men participated in two focus groups in which they exchanged experiences and ideas about living with HIV. They shared details about how they were personally impacted by HIV, and together they constructed a perspective on the larger societal context in which the HIV infection rate among African American men continues unabated. The men focused on growing complacency about HIV/AIDS in the United States, underfunding of supports and services, stigmas operative in African American communities, and differential care based on race, gender, and diagnosis. They saw opportunity in personal strategies that help individual men infected with HIV to take a more empowered stance to deal with the disease and improve their health but looked for changes undertaken by African Americans at the community level to make a real difference in the epidemic. Their vision included enhanced support for HIV prevention and care from influential community institutions like Black churches, more open dialogue about drugs and sexual behavior, and capacity-building for families whose members are HIV-infected or at risk for HIV.

Frequency and severity of tracheal wash hemosiderosis and association with underlying disease in 96 cats: 2002-2003

BACKGROUND

Hemosiderophages may be found in feline tracheal wash specimens in association with various disease conditions, including heart failure, trauma, infection, foreign body migration, lung lobe torsion, pulmonary embolism or infarction, neoplasia, and bleeding diathesis. Based on observations in our laboratory, we hypothesized that tracheal wash specimens from cats with asthma also frequently contain hemosiderophages, even in the absence of other known causes of pulmonary hemorrhage.

OBJECTIVES

The purpose of this study was to determine the frequency and severity of hemosiderosis in tracheal wash fluid from cats with various diseases, including asthma.

METHODS

Feline tracheal wash fluid specimens submitted for cytologic evaluation between March 2002 and August 2003 were included in the study. One hundred and one specimens from 96 cats were examined with both Wright's-Giemsa and Prussian blue stains. Cats were assigned to 6 disease categories: feline asthma, pneumonia, pulmonary neoplasia, rhinitis, heart disease, and other disorders. Based on the percentage of Prussian blue-positive macrophages, hemosiderosis was categorized as negative (0%), mild (<20%), moderate (21-50%), or marked (>50%).

RESULTS

The frequency of tracheal wash hemosiderosis in the study population was 63.5% (61/96); hemosiderosis was mild (29/96, 30.2%), moderate (22/96, 22.9%), or marked (10/96, 10.4%). Hemosiderosis was found in 85.7% (6/7) of cats with rhinitis, 78.6% (11/14) of cats with pulmonary neoplasia, 75.0% (27/36) of cats with asthma, 71.4% (5/7) of cats with primary or concurrent heart disease, 25.0% (5/20) of cats with pneumonia, and 66.7% (12/18) of cats with other disorders. In cats with asthma, hemosiderosis was usually mild to moderate and frequently was accompanied by increased eosinophils.

CONCLUSIONS

The results of this study confirm that hemosiderosis is a common finding in tracheal wash specimens collected from cats with diverse disease conditions, including feline asthma syndrome.

Prescription drug utilization following patient co-payment changes in Australia

In November 1990 major patient co-payment changes were introduced into the Pharmaceutical Benefits Scheme (PBS), which accounts for around 90% of all community prescriptions in Australia. Interrupted time series analyses were performed to assess the impact of these co-payment changes on the prescription levels of defined groups of 'discretionary' and 'essential' drugs for both the general community and for a subgroup comprising elderly returned servicemen and women. While the co-payment changes themselves had a significant immediate effect on lowering the use of both categories of drugs, the effects were substantially larger for the 'discretionary' groups in both cases. Notably there was a clear post-intervention trend for increased prescriptions of 'essential' drugs after the initial decline, which was not evident for the 'discretionary' drugs. The introduction of programmes to compensate high risk groups in Australia may have enabled the co-payment to become a more selective policy instrument than has been shown in other settings.

Late normal tissue sequelae in the second decade after high dose radiation therapy with combined photons and conformal protons for locally advanced prostate cancer

PURPOSE

We determined the long-term normal tissue effects of 77.4 Gy. delivered to the prostate in patients with locally advanced prostate cancer.

METHODS AND MATERIALS

Between 1976 and 1992, 167 men with stages T3 to 4 prostate cancer were treated on protocol with 50.4 Gy. photons at 1.8 Gy. per fraction using a 4-field box arrangement, followed by a conformal perineal proton boost of 27 Gy. (cobalt Gy. equivalent) in 11 fractions. The chart was reviewed and 39 of the 42 surviving patients were interviewed. Median followup was 13.1 years (range 7 to 23). Normal tissue morbidity was recorded using Radiation Therapy Oncology Group criteria and the late effects normal tissue scale.

RESULTS

The actuarial incidence of grade 2 or greater genitourinary morbidity was 59% at 15 years. However, these grade 2 or greater problems persisted to the time of the interview in only 7 of 39 cases. The actuarial incidence of grade 2 or greater hematuria was 21% at 5 years and 47% at 15. For grade 3 or greater hematuria the risk was 3% and 8% at 5 and 15 years, respectively. No patient required cystectomy but 1 required diversion for morbidity. Urethral stricture and urinary incontinence with pads needed developed in 4 and 3 men, respectively. This particular morbidity was strongly associated with previous or subsequent prostate surgery. The actuarial incidence of grade 2 or greater gastrointestinal morbidity was 13% at 5 and 15 years, while grade 1 rectal bleeding occurred in another 41%.

CONCLUSIONS

High dose conformal radiation to the prostate is followed by a high rate of low grade rectal bleeding but a low rate of grade 2 or higher gastrointestinal morbidity. This rate is stable and does not increase beyond 5 years. Genitourinary morbidity continues to develop well into the second decade after treatment, although high grade morbidity is uncommon. These findings do not suggest that the modern trend toward high dose prostate treatment with conformal techniques will result in a high incidence of serious and permanent late sequelae but it appears that hematuria will be common.

Impact of the Minimum Pricing Policy and introduction of brand (generic) substitution into the Pharmaceutical Benefits Scheme in Australia

PURPOSE

To describe the effects of introducing the Minimum Pricing Policy (MPP) and generic (brand) substitution in 1990 and 1994 respectively on the dispensing of Pharmaceutical Benefits Scheme (PBS) prescriptions both at the aggregate and individual patient level.

METHODS

The relative proportion of prescriptions with a brand premium and those at benchmark was examined 4 years after introduction of the MPP and again 5 years later after generic substitution by pharmacists was permitted. To determine the impact of a price signal at the individual level, case studies involving a patient tracking methodology were conducted on two drugs (fluoxetine and ranitidine) that received a brand premium.

RESULTS

From a zero base when the MPP was introduced in 1990, there were 5.4 million prescriptions (17%) dispensed for benchmark products 4 years later in 1994. At this stage generic (brand) substitution by pharmacists was then permitted and the market share of benchmark brands increased to 45% (25.2 million) by 1999. In the patient tracking studies, a significantly lower proportion of patients was still taking the premium brand of fluoxetine 3 months after the introduction of a price signal compared with patients taking paroxetine which did not have a generic competitor. This was also the case for the premium brand of ranitidine when compared to famotidine. The size of the price signal also had a marked effect on dispensing behaviour with the drug with the larger premium (fluoxetine) showing a significantly greater switch away from the premium brand to the benchmark product.

CONCLUSIONS

The introduction in 1990 of the Minimum Pricing Policy without allowing generic substitution had a relatively small impact on the selection of medicines within the Pharmaceutical Benefits Scheme. However the effect of generic substitution at the pharmacist level, which was introduced in December 1994, resulted in a marked increase in the percentage of eligible PBS items dispensed at benchmark. Case studies showed a larger premium resulted in a greater shift of patients from drugs with a brand premium to the benchmark alternative.

A cost-effectiveness approach to drug subsidy and pricing in Australia

The Australian government offers its citizens subsidies on a select list of pharmaceuticals. For a drug to qualify for inclusion on this list, its manufacturer must demonstrate that the drug is both clinically effective and cost-effective. In part, this measure, along with others, was introduced to improve clinical and economic outcomes. Although this evidence-based system has provided transparency and consistency in decision making about which drugs will be covered, it may not have contained the rate of increase in drug costs.

Co-prescribing of SSRIs and TCAs in Australia: how often does it occur and who is doing it?

AIMS

To determine the frequency with which the selective serotonin re-uptake inhibitor (SSRI) antidepressants are used as add-on therapy to the tricyclic antidepressants (TCA) rather than as replacement therapy.

METHODS

The data analysed were profiles of prescription records by date of supply to the patient. From within the national administrative dispensing claims database, the subset eligible for social security entitlements was identified as individuals by means of their coded permanent identification numbers (PINs). Following the initial supply of an SSRI in January 1996, the subsequent 6 months dispensing of SSRI and TCA antidepressants to these individuals was examined. The main outcome measure was the proportion of individuals to whom SSRIs and TCAs were dispensed concurrently, as an indirect measure of coprescription. In instances where a patient was receiving prescriptions for SSRIs and TCAs that had been written by the one doctor only, the major specialty of the doctor was investigated.

RESULTS

55 271 PINs were dispensed 63 865 SSRI prescriptions in January 1996 which represented over half (52%) of the total community SSRI prescriptions dispensed in that month. The number of these patients meeting the criteria for coprescription of SSRIs and TCAs over the next 6 months was 2773 (5%). The coprescribing instances were highest in Queensland and the prescribers most frequently involved had psychiatry major specialty codes.

CONCLUSIONS

Among SSRI users there is a cohort of patients who, within the same time frame, are receiving supplies of a TCA, the nonselective drug that the SSRIs were designed to replace. This is indirect evidence of probable coprescription. Such combination use is of uncertain clinical and cost effectiveness, and carries additional risks. The SSRIs were included on the subsidy list in Australia on the basis of reasonable cost effectiveness as monotherapy compared with the TCAs. Our data imply that for some patients, antidepressant prescribing is inconsistent with the basis on which government subsidy was approved.

Impact of increasing the re-supply interval on the seasonality of subsidised prescription use in Australia

OBJECTIVE

To evaluate the impact of increasing the minimum re-supply period for prescriptions on the Pharmaceutical Benefits Scheme (PBS) in November 1994. The intervention was designed to reduce the stockpiling of medicines used for chronic medical conditions under the PBS safety net.

METHODS

Interrupted times series regression analyses were performed on 114 months of PBS drug utilisation data from January 1991 to June 2000. These analyses assessed whether there had been a significant interaction between the onset of the intervention in November 1994 and the extreme levels of drug utilisation in the months of December (peak utilisation) and January (lowest utilisation) respectively. Both serial and 12-month lag autocorrelations were controlled for.

RESULTS

The onset of the intervention was associated with a significant reduction in the December peak in drug utilisation; after the introduction of the policy there were 1,150,196 fewer prescriptions on average for that month (95% CI 708,333-1,592,059). There was, however, no significant change in the low level of utilisation in January. The effect of the policy appears to be decreasing across successive post-intervention years, though the odds of a prescription being dispensed in December remained significantly lower in 1999 compared to each of the pre-intervention years (11% vs. 14%).

CONCLUSION

Analysis of the impact of increasing the re-supply period for PBS prescriptions showed that the magnitude of peak utilisation in December had been markedly reduced by the policy, though this effect appears to be decreasing over time. Continued monitoring and policy review is warranted in order to ensure that the initial effect of the intervention be maintained.

Recent trends in the use of antidepressant drugs in Australia, 1990-1998

OBJECTIVE

To determine the pattern of use of antidepressant drugs in the Australian community, 1990-1998, and to compare this with those of other developed countries.

DESIGN

Retrospective analyses of prescription and sales data, together with information about patient encounters for depression (from an ongoing survey of service provision by general practitioners) and population-based prevalence estimates for affective disorders (from community health surveys).

MAIN OUTCOME MEASURES

National and international consumption of antidepressants, expressed in defined daily doses (DDDs) per 1000 population per day. Changes in both the frequency of general practice patient encounters for depression and population-based prevalence estimates for affective disorders.

RESULTS

Dispensing of antidepressant prescriptions through community pharmacies in Australia increased from an estimated 12.4 DDDs/1000 population per day in 1990 (5.1 million prescriptions) to 35.7 DDDs/1000 population/day in 1998 (8.2 million prescriptions). There has been a rapid market uptake of the selective serotonin reuptake inhibitors (SSRIs), accompanied by a decrease of only 25% in the use of tricyclic antidepressants (TCAs). In 1998, the level of antidepressant use in Australia was similar to that of the United States, while the rate of increase in use between 1993 and 1998 was second only to that of Sweden. In Australia, depression has risen from the tenth most common problem managed in general practice in 1990-91 to the fourth in 1998-99, and the number of people reporting depression in the National Health Surveys (1995 v 1989-90) has almost doubled. Of the prescriptions dispensed in 1998 for antidepressant drugs subsidised by the Pharmaceutical Benefits Scheme, 85% were written by general practitioners, and 11.2% by psychiatrists.

CONCLUSIONS

As in most developed countries, antidepressant use increased between 1990 and 1998. The rapid market uptake of the new antidepressants, particularly SSRIs, is likely to have been driven by increased awareness of depression, together with availability and promotion of new therapies.

The effects in humans of rapid loss of body mass on a boxing-related task

The physiological effects of strategies for a rapid loss of body mass immediately before weighing-in for competition in weight-governed sports are unclear. This study examined the effects of a 3%-4% loss in body mass on a boxing-related task. Seven novice amateur boxers completed three 3 min rounds of simulated boxing on a prototype boxing ergometer in an euhydrated state (E-trial) and after exercise-induced thermal dehydration (D-trial). All subjects lost body mass following dehydration-mean body mass fell 3.8 (SD +/- 0.3)% [77.3 (SD +/- 11.3) to 74.4 (SD +/- 10.7) kg, P<0.001] - but changes in plasma volume (PV) were inconsistent. Four subjects suffered reductions in PV between 15% and 30%, one subject maintained his E-trial value and two recorded an increase. The D-trial mean PV value was 8.0 (SD +/- 17.2)% lower but this fall was not statistically significant (P>0.05). Analysis of D-trial boxing performance showed one subject maintained his performance over the two trials and a second improved 17.8%. A two-way ANOVA (condition x time) with repeated measures on both factors showed no significant main effect differences for condition (F1,6 = 3.93 P>0.05), time (F1.83,48 = 1.12, P>0.05) or interaction between them (F1.93,48, P>0.05). Furthermore, neither heart rate nor blood lactate responses in the boxing task differed between trials. These data were affected by the small sample. Power and effect size analysis using eta(2) procedure and removing the outlier data produced a mean fall in boxing performance of 26.8%. However, some subjects appeared able to resist the deleterious effects of a rapid loss of body mass prior to competition and further research is needed to explain the mechanisms under-pinning this ability.

Examining the adequacy of quantities available for subsidized antidepressant prescriptions in Australia

In Australia the Pharmaceutical Benefits Scheme (PBS), a national drug insurance plan, aims to provide around a month's therapy for medication used in chronic conditions. However, there are marked differences among the most commonly used antidepressants in the number of days supply represented by the PBS maximum quantity after adjustment for the defined daily dose (DDD). The DDD is the assumed adult daily dose for a drug and is a WHO drug utilization standard. Whereas the selective serotonin re-uptake inhibitors (SSRIs) and moclobemide largely provide around a month's supply at the DDD, most tricyclic antidepressant (TCA) items provide considerably less than this .A patient tracking study was conducted to determine the average length of time between prescription re-supplies for a number of tricyclic antidepressants and newer antidepressants as a means of measuring the efficiency of PBS supply for the different classes of antidepressant. The number of days between dispensings was similar for patients no matter whether they were taking TCAs, SSRIs or moclobemide, although for the older antidepressants presumably at a much lower prescribed daily dose than the DDD. Care needs to be taken when adjusting usage with the DDD/1000/day unit of measurement in cases where the DDD does not reflect the prescribed daily dose (PDD).

Compliance with restrictions on the subsidized use of proton pump inhibitors in Australia

AIMS

To determine among a cohort of patients newly dispensed a prescription for a proton pump inhibitor (PPI) the extent of prior use of other less expensive agents such as antacids and H2-receptor antagonists as evidence of a 'stepped care' approach to peptic ulcer and oesophageal disease.

METHODS

A retrospective drug utilization study was conducted within the Pharmaceutical Benefits Scheme (PBS) claims database in Australia. A cohort of social security recipients, who received approval for PPI supply in the month of October 1996, had no prior PPI approval in the previous 18 months and went on to have the drug dispensed, was assembled. This group of 'new PPI starters' was then examined for supply of less expensive prescription medicines to treat peptic ulcer and oesophageal disease in the 12 months prior to obtaining their PPI approval.

RESULTS

In a cohort of 4554 defined new PPI users, 1205 (26.5%) showed no use of H2-receptor antagonists, antacids, cisapride, cytoprotectants or antiregurgitants in the 12 month period prior to commencing the PPI. The major reason for use given by prescribers for PBS supply was 'severe refractory ulcerating oesophagitis'.

CONCLUSIONS

Subsidized supply is currently restricted on cost-effectiveness grounds to refractory peptic ulcer disease or severe oesophageal disease. Despite this, utilization and epidemiological data suggest that there is widespread leakage of use outside these indications particularly to less severe forms of oesophageal disease. This patient tracking study has shown within the PBS database that around a quarter of the patients are treated directly with a PPI without being prescribed less expensive agents at least in the preceding 12 months.

Risk and resiliency factors for violence

Research on human resiliency in the face of adversity has gained widespread currency in the study of the developmental outcomes for children exposed to multiple risk factors. This article reviews several of these studies from a multilevel perspective, with a view to documenting their contributions and limitations and what needs to be done in the future.

Use of lipid-lowering drugs from 1990 to 1994: an international comparison among Australia, Finland, Italy (Emilia Romagna Region), Norway and Sweden

OBJECTIVE

To compare the overall utilisation pattern of lipid-lowering drugs between 1990 and 1994 in Australia, Finland, Italy, Norway and Sweden as well as the pattern of use with respect to age and gender in Italy and Sweden.

METHODS

Data were retrieved from regulatory authorities in each country for the 5-year period and analysed according to the ATC/DDD methodology (Anatomical Therapeutic Chemical classification/Defined Daily Doses). Utilisation was calculated as the DDDs for 1000 inhabitants per day for all drugs of the ATC category B04 (serum lipid-reducing agents). Data from Sweden and Italy were also compared with respect to gender and age.

RESULTS

In 1994, Australia demonstrated the highest degree of utilisation (11.9 DDD) and the Nordic Countries the lowest (Sweden 5.6; Norway 4.9; Finland 4.0). In all countries except Italy, a steady increase was observed; in Italy, utilisation of these drugs reached a maximum in 1992 (11.5 DDD), but then underwent a reduction which was caused by restrictions in the reimbursement status in 1993 (10.4) and 1994 (6.7). Administration of statins increased in all countries, becoming the most used group of the B04 class. In 1988, the number of different drugs listed by each national health service ranged from 4 (Norway) to 16 (Italy); in 1994 it ranged from 6 (Norway) to 9 (Sweden). Analysis with respect to gender showed the opposite pattern in Sweden (males 4.6 and females 3.3 in 1992; 6.2 and 4.5, respectively, in 1994) than in Italy (males 10.8 and females 17.8 in 1992; 6.4 and 9.2, respectively, in 1994). Exposure was highest in people aged 60-69 years in both countries, followed by age group 50-59 in Sweden and 70-79 in Italy.

CONCLUSIONS

Large variations in the utilisation of lipid-lowering drugs exist between countries, with Australia and Italy much higher than others. Of the drugs in the ATC category B04, the use of statins predominates in all countries, but to varying degrees. The large difference in the degree of drug utilisation with respect to age and gender between Italy and Sweden suggests major deviations from evidence-based medicine.

Antibiotic use in the Australian community, 1990-1995

OBJECTIVE

To determine the pattern of antibiotic use in the Australian community, 1990-1995, and compare it with the pattern in other developed countries.

DESIGN

Survey of data from the national database on drugs dispensed in Australia (1990-1995), an international database on retail drug sales (1985-1994), and Australian prescriber surveys (1994, 1995).

MAIN OUTCOME MEASURES

National and international retail sales of oral antibiotics (defined daily doses [DDDs]/1000 population/day) and antibiotic prescriptions dispensed through community pharmacies by drug type; antibiotic prescribing profiles for common conditions.

RESULTS

Antibiotic use in Australia remained steady between 1990 and 1995, with an estimated 24.7 DDDs/1000 population/day dispensed through community pharmacies in 1990 and 24.8 DDDs/1000 population/day in 1995. Amoxycillin, although declining in use, remained the most dispensed antibiotic. Compared with the other countries surveyed, Australia had the highest percentage use of tetracyclines, such as doxycycline, and the lowest percentage use of fluoroquinolones. Use of trimethoprim-sulfamethoxazole and flucloxacillin declined in Australia. In new cases of upper respiratory tract infection or pharyngitis, an antibiotic prescription was recorded for 57% of urban patient encounters and 73% of rural patient encounters.

CONCLUSIONS

Antibiotic use in Australia is high, as in many other developed countries, but did not increase between 1990 and 1995. The overall profile of antibiotic use in Australia by drug class was similar to that in the United Kingdom. Antibiotics were still commonly prescribed for upper respiratory tract infection (which is usually viral), more commonly by rural than by urban general practitioners.

Neuropsychological function in adults after high dose fractionated radiation therapy of skull base tumors

PURPOSE

To evaluate the long term effects of high dose fractionated radiation therapy on brain functioning prospectively in adults without primary brain tumors.

METHODS AND MATERIALS

Seventeen patients with histologically confirmed chordomas and low grade chondrosarcomas of the skull base were evaluated with neuropsychological measures of intelligence, language, memory, attention, motor function and mood following surgical resection/biopsy of the tumor prior to irradiation, and then at about 6 months, 2 years and 4 years following completion of treatment. None received chemotherapy.

RESULTS

In the patients without tumor recurrence or radiation necrosis, there were no indications of adverse effects on cognitive functioning in the post-acute through the late stages after brain irradiation. Even in patients who received doses of radiation up to 66 Cobalt Gy equivalent through nondiseased (temporal lobe) brain tissue, memory and cognitive functioning remained stable for up to 5 years after treatment. A mild decline in psychomotor speed was seen in more than half of the patients, and motor slowing was related to higher radiation doses in midline and temporal lobe brain structures.

CONCLUSION

Results suggest that in adults, tolerance for focused radiation is relatively high in cortical brain structures.

Pattern of non-steroidal anti-inflammatory drug use in Australia 1990-1994. A report from the Drug Utilization Sub-Committee of the Pharmaceutical Benefits Advisory Committee

OBJECTIVE

To determine the pattern of use of non-steroidal anti-inflammatory drugs (NSAIDs) in the Australian community, 1990-1994.

DESIGN

Data from the national drug utilisation database were expressed in defined daily doses per 1000 population per day (DDDs/1000 population per day). Temporal trends were assessed and comparisons were made with NSAID use in other countries. Epidemiological data were used to estimate the likely impact of changing NSAID use on peptic ulcer hospitalisation rates.

SETTING

Australian community (excluding hospitals).

MAIN OUTCOME MEASURES

Estimated consumption of prescription NSAIDs, expressed in DDDs/1000 population per day.

RESULTS

NSAID use in the Australian community fell from 50.1 DDDs/1000 population per day in 1990 to 34.6 DDDs/1000 population per day in 1994 (down 31%). From this reduced exposure we estimated that the number of admissions for NSAID-related upper gastrointestinal complications will have fallen by about 400 per year. Market research data for this period show a lower percentage use of NSAIDs for osteoarthritis and a decrease in the proportion of use in age groups over 50 years.

CONCLUSIONS

The level of use of non-steroidal anti-inflammatory drugs in Australia has been high in comparison with other countries, but in recent years has fallen markedly. This fall occurred in conjunction with regulatory interventions, educational campaigns and increased concern in the medical and lay press regarding the risks associated with the use of NSAIDs.

A collaborative community approach to homeless care

Homelessness is a social, economic, and public health problem of increasing magnitude in the United States. The past methods and approaches to delivering health care to those without homes have been inadequate because of the many complex problems faced by homeless persons today. To facilitate a discussion of a collaborative community approach to homeless care, it is helpful to include a definition of homelessness, describe the homeless population and the health status of homeless individuals, and explain what is meant by health care for the homeless.

Modelling the market uptake of new drugs following listing for subsidy in Australia. A report from the Drug Utilisation Subcommittee of the Australian Pharmaceutical Benefits Advisory Committee

The market uptake of five drugs following subsidy listing in Australia during the period 1990 to 1992 has been modelled using the sigmoid Emax model for drug-receptor binding. Utilisation trends for simvastatin, omeprazole, budesonide, fluoxetine and moclobemide in defined daily dose (DDD) per 1000 population per day were smoothed by expressing as rolling annual averages. The results indicate good fits of the model to the data except for omeprazole, with good estimates of uptake rate and eventual maximum utilisation. Substantial differences between the drugs occurred in uptake rate which may be related to public education campaigns on asthma and coronary heart disease occurring during the release period. The very slow uptake of omeprazole relative to other drugs is likely to be due to restrictions on subsidised use. Modelling the market uptake rate and eventual utilisation of new drugs is useful as an aid to regulatory, quality use of medicines and financial decisions and allows comparisons between drugs to investigate factors important in market uptake.

Base of skull and cervical spine chordomas in children treated by high-dose irradiation

PURPOSE

To evaluate the outcome of children with base of skull or cervical spine chordomas treated by high dose irradiation.

METHODS AND MATERIALS

Eighteen children, 4 to 18 years of age, with base of skull or cervical spine chordomas, received fractionated high-dose postoperative radiation using mixed photon and 160 MeV proton beams. The median tumor dose was 69 Cobalt Gray-equivalent (CGE) with a 1.8 CGE daily fraction.

RESULTS

The median follow-up was 72 months. The 5-year actuarial survival was 68% and the 5-year disease-free survival (DFS) was 63%. The only significant prognostic factor was the location: patients with cervical spine chordomas had a worse survival than those with base of skull lesions (p = 0.008). The incidence of treatment-related morbidity was acceptable: two patients developed a growth hormone deficit corrected by hormone replacement, one temporal lobe necrosis, and one fibrosis of the temporalis muscle, improved by surgery.

CONCLUSION

Chordomas in children behave similarly to those in adults: children can receive the same high-dose irradiation as adults with acceptable morbidity.

RFLP characterization of the upstream regulatory region of the HLA-DQA1 gene

We have performed population and family studies of the distribution of DNA restriction length polymorphisms (RFLPs) in the 5' region of the HLA-DQA1 gene using a probe which corresponds to a sequence of the 5' flanking region of HLA-DQA1. Southern analysis detected four polymorphic fragments (X1, X2, X3 and X4) with XbaI and three fragments (E1, E2 and E3) with EcoRI. Family segregation studies showed that these RFLPs segregated in cis with the parental HLA haplotypes. Analysis of haplotypic associations of the X and E polymorphisms with each other and with HLA-DQA1 alleles demonstrates that DQA1 alleles can be further subtyped according to the particular XE combination which they carry. Hence, definition of these alleles provides new markers for HLA haplotyping and allows further splitting of otherwise identical DQA1 alleles. This information may be helpful for studies of association of disease susceptibility and autoimmunity with HLA haplotypes.

Benzodiazepine utilisation in Australia: report from a new pharmacoepidemiological database

This study surveys the total community prescription use of benzodiazepine agents in Australia for the years 1990 and 1991. Also included is information on the utilisation of these agents on the Pharmaceutical Benefits and Repatriation Pharmaceutical Benefits Schemes (PBS/RPBS) over the period 1987 to 1991. The Australian data are from the Drug Utilization Subcommittee (DUSC) database, which is derived from two sources: the PBS/RPBS (subsidized prescriptions), and a national sample of Pharmacy Guild of Australia pharmacies (private and under-copayment general prescriptions). The data are converted to defined daily doses per 1000 inhabitants per day (DDD/1000/day) in accordance with the unit of measurement for drug utilisation studies approved by the World Health Organization. Benzodiazepine utilisation was 33.96 DDD/1000/day for 1990 and 29.31 DDD/1000/day for 1991. The four drugs listed on the Pharmaceutical Benefits Scheme, namely diazepam, oxazepam, nitrazepam and temazepam, constituted 82 per cent of the Australian market. The availability of government subsidy appears to influence benzodiazepine- prescribing behaviour. Benzodiazepine utilisation has been falling in recent years. The fall may be related to the impact of new guidelines and community awareness campaigns. There are major differences in the composition of the market between Australia and the Nordic countries.

Population and family studies of HLA-DR4 by use of oligonucleotide typing

Using PCR and DR4 group-specific primers and SSO's we have examined DRB1*04 nucleotide polymorphisms in a population of 123 DR4-positive individuals (86 NAC, 27 Hispanics and 10 African Americans) from New York carrying a total of 134 DR4 haplotypes. We found that the distribution of DRB1*04 alleles on DR4 haplotypes differs in these three ethnic groups. In this relatively small population, certain alleles such as DRB1*0406 and 0411 were encountered only in Hispanics, while others such as DRB1*0403, 0408 and 0409 were found only in NAC (North American Caucasians). Such differences may be important in studies of HLA-DR4 and disease associations. Evidence from MLC and PLT studies of an HLA-B/DR crossover family, which was informative for the segregation of HLA-DRB1*0406 and DRB1*0407, supports the concept that subtypes of HLA-DR4 and/or associated HLA-DP alleles elicit T-cell alloreactivity, and may thus play a role in transplantation.