Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial

BACKGROUND

Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches.

METHODS

We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events.

RESULTS

Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes.

CONCLUSIONS

Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.

Zinc and multivitamin supplementation have contrasting effects on infant iron status: a randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Zinc supplementation adversely affects iron status in animal and adult human studies but few, trials have included young infants.

OBJECTIVE

To determine the effects of zinc and multivitamin supplementation on infant hematologic and iron status.

METHODS

In a double-blind RCT, Tanzanian infants were randomized to daily, oral zinc (Zn), multivitamins (MV), Zn and MV, or placebo treatment arms at age 6 wk. Hemoglobin concentration (Hb) and red blood cell indices were measured at baseline and at 6, 12, and 18 mo of age. Plasma samples from 589 infants were examined for iron deficiency (ID) at 6 mo.

RESULTS

In logistic regression models, Zn treatment was associated with greater odds of ID (OR 1.8 [95% CI 1.0–3.3]), and MV treatment was associated with lower odds (OR 0.49 [95% CI 0.3–0.9]). In Cox models, MV were associated with a 28% reduction in risk of severe anemia (HR=0.72 [95% Cl 0.56–0.94]) and a 26% reduction in risk of severe microcytic anemia (HR=0.74 [0.56–0.96]) through 18 months. No effects of Zn on risk of anemia were seen. Infants treated with MV alone had higher mean Hb (9.9 g/dL [95% CI 9.7–10.1]) than those given placebo (9.6 g/dL [9.4–9.8]) or Zn alone (9.6 g/dL [9.4–9.7]).

CONCLUSIONS

MV treatment improved iron status in infancy, whereas Zn worsened iron status but without an associated increase in risk for anemia. Infants in long-term zinc supplementation programs at risk for ID may benefit from screening and/or the addition of a multivitamin supplement.

Selection of Performance Evaluation Tests for Environmental Research

A battery of Performance Evaluation Tests for Environmental Research (PETER) that is suitable for use in repeated measures experiments is being developed at the Naval Biodynamics Laboratory. This paper describes the sources of tasks which have been considered for inclusion in PETER. It also lists the tests in the source batteries which have or have not yet been considered for inclusion in PETER. The performance content of the tests that have been considered is compared with the content of those that have not. Recommendations are made for selection of additional tests from the source batteries which will not be redundant with tests that already have been considered. This report puts PETER into the context of the tests and test batteries which came before it.

Performance Evaluation Tests for Environmental Research (PETER): Auditory Digit Span Task

Auditory digit span was evaluated as an instrument for repeated measurements experimentation. Twelve subjects were tested for one hour on each of 12 consecutive workdays in a standard environment. Both forward and backward digit span were measured. It was found that forward digit span was suitable for repeated measures after ten days of practice at 30 minutes per day. The criteria for suitability were predictability of the mean scores, constancy of the standard deviations and differential stability of the intertrial correlations. These criteria are sufficient conditions both for repeated measures Analysis of Variance, and for interpretation of experimental effects. Although the backward digit span scores did not meet these criteria, they became more and more correlated with the forward digit span scores as the experiment progressed. This indicates that the mental content of the two tests of memory converged with practice. One implication of this finding is to question the meaningfulness of factor structure after only limited practice. The forward auditory digit span test was recommended for inclusion in a battery of Performance Evaluation Tests for Environmental Research (PETER).

Visual Search and Color Coding

Several experiments were conducted to investigate the effects on search time of display and personnel characteristics. Search time increased by an order of magnitude when the number of display items of the target's color increased from one to the display density. Items not of the target's color affected search time to the extent that their color was similar to that of the target. The similarity of the colors was found to be well represented by a color difference calculation. The distribution on the display of target-colored items also affected search time. Personnel characteristics, including several measures of ability and experience, were unrelated to search speed.

A Catalogue of Performance Evaluation Tests for Environmental Research

Performance Evaluation Tests for Environmental Research (PETER) are under development at the Naval Biodynamics Laboratory and supporting organizations. The tests, or tasks, studied in this program have been largely derived from the literature. Each task was evaluated for suitability for repeated measures experimental designs which are almost universally used in environmental research. Suitability criteria included the “stability” of task means, standard deviations, and between-trial correlations. The magnitude of the “stabilized” between-trial correlations, task definition, was also examined with respect to the administration time. There are 60 active tasks in the present program. All tasks examined to date exhibit stable means and variances after adequate practice but: (a) less than 30% meet minimal stability criteria for intertrial correlations; and (b) substantial practice (typically more than an hour over five days) is required to achieve stability. A tabular catalogue of the research findings and background for 15 tasks is presented and discussed.

Item Recognition as a Performance Evaluation Test for Environmental Research

Item Recognition (Sternberg, 1966) is a task which reflects the operation of human memory. This task was considered as a candidate for use in a battery of Performance Evaluation Tests for Environmental Research (PETER). Environmental research involves comparison of performances in a baseline environment and in a novel environment. It is desirable that scores be stable at different occasions in the baseline environment, so that changes due to the novel environment will be clear if they occur. It was found that item recognition results were similar to those obtained by other investigations, although the traditional item recognition score (slope) was unreliable across repeated measurements. The response time (RT) was stable for each of the four memory set sizes (1, 2, 3 & 4 items), from the standpoint of reliability, after the fourth session.

Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions

BACKGROUND

Semiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA.

PATIENTS AND METHODS

This single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome.

RESULTS

91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01-43.94 95% CI vs 44.00; 32.42-55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison.

CONCLUSION

Semiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.

Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S

INTRODUCTION

Child care facilities influence diet and physical activity, making them ideal obesity prevention settings. The purpose of this study is to quantify the health and economic impacts of a multi-component regulatory obesity policy intervention in licensed U.S. child care facilities.

METHODS

Two-year costs and BMI changes resulting from changes in beverage, physical activity, and screen time regulations affecting a cohort of up to 6.5 million preschool-aged children attending child care facilities were estimated in 2014 using published data. A Markov cohort model simulated the intervention's impact on changes in the U.S. population from 2015 to 2025, including short-term BMI effects and 10-year healthcare expenditures. Future outcomes were discounted at 3% annually. Probabilistic sensitivity analyses simulated 95% uncertainty intervals (UIs) around outcomes.

RESULTS

Regulatory changes would lead children to watch less TV, get more minutes of moderate and vigorous physical activity, and consume fewer sugar-sweetened beverages. Within the 6.5 million eligible population, national implementation could reach 3.69 million children, cost $4.82 million in the first year, and result in 0.0186 fewer BMI units (95% UI=0.00592 kg/m(2), 0.0434 kg/m(2)) per eligible child at a cost of $57.80 per BMI unit avoided. Over 10 years, these effects would result in net healthcare cost savings of $51.6 (95% UI=$14.2, $134) million. The intervention is 94.7% likely to be cost saving by 2025.

CONCLUSIONS

Changing child care regulations could have a small but meaningful impact on short-term BMI at low cost. If effects are maintained for 10 years, obesity-related healthcare cost savings are likely.

The cost-effectiveness of a successful community-based obesity prevention program: the be active eat well program

OBJECTIVE

To examine the cost-effectiveness of Be Active Eat Well (BAEW), a large, multifaceted, community-based capacity-building demonstration program that promoted healthy eating and physical activity for Australian children aged 4-12 years between 2003 and 2006.

DESIGN AND METHODS

A quasi-experimental, longitudinal design was used with anthropometric data collected at baseline (1001 children-intervention; 1183-comparator) and follow-up. A societal perspective was employed, with intervention resource use measured retrospectively based on process evaluation reports, school newsletters, reports, and key stakeholder interviews, and valued in 2006 Australian dollars (AUD). Outcomes were measured as Body Mass Index (BMI) units saved and Disability Adjusted Life Years (DALYs) averted over the predicted cohort lifetime, and reported as incremental cost-effectiveness ratios (with 95% uncertainty intervals).

RESULTS

The intervention cost AUD0.34M ($0.31M; $0.38M) annually, and resulted in savings of 547 (-104; 1209) BMI units and 10.2 (-0.19; 21.6) DALYs. This translated to modest cost offsets of AUD27 311 (-$1803; $58 242) and a net cost per DALY saved of AUD29 798 (dominated; $0.26M).

CONCLUSIONS

BAEW was affordable and cost-effective, and generated substantial spin-offs in terms of activity beyond funding levels. Elements fundamental to its success and any potential cost efficiencies associated with scaling-up now require identification.

Preliminary analysis of the cost-effectiveness of the National Bowel Cancer Screening Program: demonstrating the potential value of comprehensive real world data

BACKGROUND/AIM

The complexity and cost of treating cancer patients is escalating rapidly and increasingly difficult decisions are being made regarding which interventions provide value for money. BioGrid Australia supports collection and analysis of comprehensive treatment and outcome data across multiple sites. Here, we use preliminary data regarding the National Bowel Cancer Screening Program (NBCSP) and stage-specific treatment costs for colorectal cancer (CRC) to demonstrate the potential value of real world data for cost-effectiveness analyses (CEA).

METHODS

Data regarding the impact of NBCSP on stage at diagnosis were combined with stage-specific CRC treatment costs and existing literature. An incremental CEA was undertaken from a government healthcare perspective, comparing NBCSP with no screening. The 2008 invited population (n= 681,915) was modelled in both scenarios. Effectiveness was expressed as CRC-related life years saved (LYS). Costs and benefits were discounted at 3% per annum.

RESULTS

Over the lifetime and relative to no screening, NBCSP was predicted to save 1265 life years, prevent 225 CRC cases and cost an additional $48.3 million, equivalent to a cost-effectiveness ratio of $38,217 per LYS. A scenario analysis assuming full participation improved this to $23,395.

CONCLUSIONS

This preliminary CEA based largely on contemporary real world data suggests population-based faecal occult blood test screening for CRC is attractive. Planned ongoing data collection will enable repeated analyses over time, using the same methodology in the same patient populations, permitting an accurate analysis of the impact of new therapies and changing practice. Similar CEA using real world data related to other disease types and interventions appears desirable.

Cardiopulmonary exercise testing as a predictor of complications in oesophagogastric cancer surgery

Introduction

An anaerobic threshold (AT) of <11ml/min/kg can identify patients at high risk of cardiopulmonary complications after major surgery. The aim of this study was to assess the value of cardiopulmonary exercise testing (CPET) in predicting cardiopulmonary complications in high risk patients undergoing oesophagogastric cancer resection.

Methods

Between March 2008 and October 2010, 108 patients (83 men, 25 women) with a median age of 66 years (range: 38–84 years) underwent CPET before potentially curative resections for oesophagogastric cancers. Measured CPET variables included AT and maximum oxygen uptake at peak exercise (VO₂ peak). Outcome measures were length of high dependency unit stay, length of hospital stay, unplanned intensive care unit (ICU) admission, and postoperative morbidity and mortality.

Results

The mean AT and VO₂ peak were 10.8ml/min/kg (standard deviation [SD]: 2.8ml/min/kg, range: 4.6–19.3ml/min/kg) and 15.2ml/min/kg (SD: 5.3ml/min/kg, range: 5.4–33.3ml/min/kg) respectively; 57 patients (55%) had an AT of <11ml/min/ kg and 26 (12%) had an AT of <9ml/min/kg. Postoperative complications occurred in 57 patients (29 cardiopulmonary [28%] and 28 non-cardiopulmonary [27%]). Four patients (4%) died in hospital and 21 (20%) required an unplanned ICU admission. Cardiopulmonary complications occurred in 42% of patients with an AT of <9ml/min/kg compared with 29% of patients with an AT of ≥9ml/min/kg but <11ml/min/kg and 20% of patients with an AT of ≥11ml/min/kg (p=0.04). There was a trend that those with an AT of <11ml/min/kg and a low VO₂ peak had a higher rate of unplanned ICU admission.

Conclusions

This study has shown a correlation between AT and the development of cardiopulmonary complications although the discriminatory ability was low.

Cardiopulmonary exercise testing as a predictor of complications in oesophagogastric cancer surgery

Introduction

An anaerobic threshold (AT) of <11ml/min/kg can identify patients at high risk of cardiopulmonary complications after major surgery. The aim of this study was to assess the value of cardiopulmonary exercise testing (CPET) in predicting cardiopulmonary complications in high risk patients undergoing oesophagogastric cancer resection.

Methods

Between March 2008 and October 2010, 108 patients (83 men, 25 women) with a median age of 66 years (range: 38–84 years) underwent CPET before potentially curative resections for oesophagogastric cancers. Measured CPET variables included AT and maximum oxygen uptake at peak exercise (VO2 peak). Outcome measures were length of high dependency unit stay, length of hospital stay, unplanned intensive care unit (ICU) admission, and postoperative morbidity and mortality.

Results

The mean AT and VO2 peak were 10.8ml/min/kg (standard deviation [SD]: 2.8ml/min/kg, range: 4.6–19.3ml/min/kg) and 15.2ml/min/kg (SD: 5.3ml/min/kg, range: 5.4–33.3ml/min/kg) respectively; 57 patients (55%) had an AT of <11ml/min/ kg and 26 (12%) had an AT of <9ml/min/kg. Postoperative complications occurred in 57 patients (29 cardiopulmonary [28%] and 28 non-cardiopulmonary [27%]). Four patients (4%) died in hospital and 21 (20%) required an unplanned ICU admission. Cardiopulmonary complications occurred in 42% of patients with an AT of <9ml/min/kg compared with 29% of patients with an AT of ≥9ml/min/kg but <11ml/min/kg and 20% of patients with an AT of ≥11ml/min/kg (p=0.04). There was a trend that those with an AT of <11ml/min/kg and a low VO2 peak had a higher rate of unplanned ICU admission.

Conclusions

This study has shown a correlation between AT and the development of cardiopulmonary complications although the discriminatory ability was low.

Cardiopulmonary exercise testing as a predictor of complications in oesophagogastric cancer surgery

INTRODUCTION

An anaerobic threshold (AT) of <11 ml/min/kg can identify patients at high risk of cardiopulmonary complications after major surgery. The aim of this study was to assess the value of cardiopulmonary exercise testing (CPET) in predicting cardiopulmonary complications in high risk patients undergoing oesophagogastric cancer resection.

METHODS

Between March 2008 and October 2010, 108 patients (83 men, 25 women) with a median age of 66 years (range: 38-84 years) underwent CPET before potentially curative resections for oesophagogastric cancers. Measured CPET variables included AT and maximum oxygen uptake at peak exercise (VO2 peak). Outcome measures were length of high dependency unit stay, length of hospital stay, unplanned intensive care unit (ICU) admission, and postoperative morbidity and mortality.

RESULTS

The mean AT and VO2 peak were 10.8 ml/min/kg (standard deviation [SD]: 2.8 ml/min/kg, range: 4.6-19.3 ml/min/kg) and 15.2 ml/min/kg (SD: 5.3 ml/min/kg, range: 5.4-33.3 ml/min/kg) respectively; 57 patients (55%) had an AT of <11 ml/min/kg and 26 (12%) had an AT of <9 ml/min/kg. Postoperative complications occurred in 57 patients (29 cardiopulmonary [28%] and 28 non-cardiopulmonary [27%]). Four patients (4%) died in hospital and 21 (20%) required an unplanned ICU admission. Cardiopulmonary complications occurred in 42% of patients with an AT of <9 ml/min/kg compared with 29% of patients with an AT of ≥9 ml/min/kg but <11 ml/min/kg and 20% of patients with an AT of ≥11 ml/min/kg (p = 0.04). There was a trend that those with an AT of <11 ml/min/kg and a low VO2 peak had a higher rate of unplanned ICU admission.

CONCLUSIONS

This study has shown a correlation between AT and the development of cardiopulmonary complications although the discriminatory ability was low.

Perceiving color across scale: great and small, discrete and continuous

We generalize, to images with continuously varying colors, our previously published model for comparing color differences of spatially discrete visual fields (icons, symbols) of disparate sizes. Our model is structural, including scattering of light by the intraocular media, followed by sparse retinal cone cell sampling of each physiological color primary. We use our model to show that small subtense of less than half a degree drastically reduces the number of discriminable colors available within a color gamut. The proposed generalization predicts and explains appearance of color fields having a wide range of subtenses (from 1/8 deg to 44 deg in examples given).

Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding

BACKGROUND

Variceal bleeding is an acute medical emergency with high mortality. Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding is more severe and more difficult to control. The optimal therapy for gastric variceal bleeding remains unclear although endoscopic injection of N-Butyl-2-Cyanoacrylate (Histoacryl) glue is often used. However, its long-term efficacy is poorly described. We studied the immediate and long-term effects of Histoacryl glue injection as treatment for bleeding gastric varices in a large UK hospital.

METHOD

Endoscopy records and case notes were used to identify patients receiving Histoacryl injection for gastric variceal bleeding over a 4-year period.

RESULTS

Thirty-one patients received Histoacryl for gastric variceal bleeding. Seventy-four per cent patients had alcohol-related liver disease and 61% of cirrhotics were Childs Pugh grade B or C. Fifty-eight per cent were actively bleeding during the procedure with 100% haemostasis rates achieved. Two patients developed pyrexia within 24 h of injection settling with antibiotics. No other complications were encountered. Mean overall follow-up was 35 months, with mean follow-up of survivors 57 months. Forty-eight per cent patients had endoscopic ultrasound assessment of varices during follow-up with no effect on rebleeding rates. Thirteen per cent required subsequent transjugular intrahepatic portosystemic shunt placement. Gastric variceal rebleeding rate was 10% at 1 year and 16% in total. One- and two-year mortality was 23% and 35%, respectively.

CONCLUSION

Endoscopic injection of Histoacryl glue appears to be a safe and effective treatment for gastric variceal bleeding. Further data are required to compare it with other therapies in this situation.

An assessment of microbiological water quality of six water source categories in north-east Uganda

Target 7C of the Millennium Development Goals is to "halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation". However, the corresponding indicator measures the "proportion of population using an improved drinking water source". This raises the question of whether "safe" and "improved" can be used interchangeably. This paper tests this hypothesis by comparing microbiological water quality in 346 different water sources across the District of Amuria in Uganda to each other and to defined standards, including the WHO drinking water standard of zero TTC per 100 ml, and the Ugandan national standard of 50 TTC per 100 ml. The water sources were grouped into six different categories: boreholes, protected springs, covered hand dug wells, open hand dug wells, open water and roofwater harvesting. The paper concludes that the ranking from the highest to the lowest microbiological quality water was: boreholes, protected springs and roofwater harvesting, open and covered hand dug wells, open water. It also concludes that sanitary surveys cannot be used to predict water quality precisely; however they are an essential component of the monitoring of safe water supplies.

The cost-effectiveness of Australia's Active After-School Communities program

The objective of this study was to assess from a societal perspective the cost-effectiveness of the Active After-school Communities (AASC) program, a key plank of the former Australian Government's obesity prevention program. The intervention was modeled for a 1-year time horizon for Australian primary school children as part of the Assessing Cost-Effectiveness in Obesity (ACE-Obesity) project. Disability-adjusted life year (DALY) benefits (based on calculated effects on BMI post-intervention) and cost-offsets (consequent savings from reductions in obesity-related diseases) were tracked until the cohort reached the age of 100 years or death. The reference year was 2001, and a 3% discount rate was applied. Simulation-modeling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. An assessment of second-stage filter criteria ("equity," "strength of evidence," "acceptability to stakeholders," "feasibility of implementation," "sustainability," and "side-effects") was undertaken by a stakeholder Working Group to incorporate additional factors that impact on resource allocation decisions. The estimated number of children new to physical activity after-school and therefore receiving the intervention benefit was 69,300. For 1 year, the intervention cost is Australian dollars (AUD) 40.3 million (95% uncertainty interval AUD 28.6 million; AUD 56.2 million), and resulted in an incremental saving of 450 (250; 770) DALYs. The resultant cost-offsets were AUD 3.7 million, producing a net cost per DALY saved of AUD 82,000 (95% uncertainty interval AUD 40,000; AUD 165,000). Although the program has intuitive appeal, it was not cost-effective under base-case modeling assumptions. To improve its cost-effectiveness credentials as an obesity prevention measure, a reduction in costs needs to be coupled with increases in the number of participating children and the amount of physical activity undertaken.

The cost of community-managed viral respiratory illnesses in a cohort of healthy preschool-aged children

BACKGROUND

Acute respiratory illnesses (ARIs) during childhood are often caused by respiratory viruses, result in significant morbidity, and have associated costs for families and society. Despite their ubiquity, there is a lack of interdisciplinary epidemiologic and economic research that has collected primary impact data, particularly associated with indirect costs, from families during ARIs in children.

METHODS

We conducted a 12-month cohort study in 234 preschool children with impact diary recording and PCR testing of nose-throat swabs for viruses during an ARI. We used applied values to estimate a virus-specific mean cost of ARIs.

RESULTS

Impact diaries were available for 72% (523/725) of community-managed illnesses between January 2003 and January 2004. The mean cost of ARIs was AU$309 (95% confidence interval $263 to $354). Influenza illnesses had a mean cost of $904, compared with RSV, $304, the next most expensive single-virus illness, although confidence intervals overlapped. Mean carer time away from usual activity per day was two hours for influenza ARIs and between 30 and 45 minutes for all other ARI categories.

CONCLUSION

From a societal perspective, community-managed ARIs are a significant cost burden on families and society. The point estimate of the mean cost of community-managed influenza illnesses in healthy preschool aged children is three times greater than those illnesses caused by RSV and other respiratory viruses. Indirect costs, particularly carer time away from usual activity, are the key cost drivers for ARIs in children. The use of parent-collected specimens may enhance ARI surveillance and reduce any potential Hawthorne effect caused by compliance with study procedures. These findings reinforce the need for further integrated epidemiologic and economic research of ARIs in children to allow for comprehensive cost-effectiveness assessments of preventive and therapeutic options.

Why invest in a national public health program for stroke? An example using Australian data to estimate the potential benefits and cost implications

OBJECTIVES

Stroke is the world's second leading cause of death in people aged over 60 years. Approximately 50,000 strokes occur annually in Australia with numbers predicted to increase by about one third over 10-years. Our objectives were to assess the economic implications of a public health program for stroke by: (1) predicting what potential health-gains and cost-offsets could be achieved; and (2) determining the net level of annual investment that would offer value-for-money.

METHODS

Lifetime costs and outcomes were calculated for additional cases that would benefit if 'current practice' was feasibly improved, estimated for one indicative year using: (i) local epidemiological data, coverage rates and costs; and (ii) pooled effect sizes from systematic reviews.

INTERVENTIONS

blood pressure lowering; warfarin for atrial fibrillation; increased access to stroke units; intravenous thrombolysis and aspirin for ischemic events; and carotid endarterectomy. Value-for-money threshold: AUD$30,000/DALY recovered.

RESULTS

Improved, prevention and management could prevent about 27,000 (38%) strokes in 2015. In present terms (2004), about 85,000 DALYs and AUD$1.06 billion in lifetime cost-offsets could be recovered. The net level of annual warranted investment was AUD$3.63 billion.

CONCLUSIONS

Primary prevention, in particular blood pressure lowering, was most effective. A public health program for stroke is warranted.

Development and application of Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS): an Australian economic model for stroke

OBJECTIVES

To outline the development, structure, data assumptions, and application of an Australian economic model for stroke (Model of Resource Utilization, Costs, and Outcomes for Stroke [MORUCOS]).

METHODS

The model has a linked spreadsheet format with four modules to describe the disease burden and treatment pathways, estimate prevalence-based and incidence-based costs, and derive life expectancy and quality of life consequences. The model uses patient-level, community-based, stroke cohort data and macro-level simulations. An interventions module allows options for change to be consistently evaluated by modifying aspects of the other modules. To date, model validation has included sensitivity testing, face validity, and peer review. Further validation of technical and predictive accuracy is needed. The generic pathway model was assessed by comparison with a stroke subtypes (ischemic, hemorrhagic, or undetermined) approach and used to determine the relative cost-effectiveness of four interventions.

RESULTS

The generic pathway model produced lower costs compared with a subtypes version (total average first-year costs/case AUD$ 15,117 versus AUD$ 17,786, respectively). Optimal evidence-based uptake of anticoagulation therapy for primary and secondary stroke prevention and intravenous thrombolytic therapy within 3 hours of stroke were more cost-effective than current practice (base year, 1997).

CONCLUSIONS

MORUCOS is transparent and flexible in describing Australian stroke care and can effectively be used to systematically evaluate a range of different interventions. Adjusting results to account for stroke subtypes, as they influence cost estimates, could enhance the generic model.

Colorectal cancer screening in Australia: an economic evaluation of a potential biennial screening program using faecal occult blood tests

OBJECTIVE

To evaluate whether the introduction of a national, co-ordinated screening program using the faecal occult blood test represents 'value-for-money' from the perspective of the Australian Government as third-party funder.

METHODS

The annual equivalent costs and consequences of a biennial screening program in 'steady-state' operation were estimated for the Australian population using 1996 as the reference year. Disability-adjusted life years (DALYs) and the years of life lost (YLLs) averted, and the health service costs were modelled, based on the epidemiology and the costs of colorectal cancer in Australia together with the mortality reduction achieved in randomised controlled trials. Uncertainty in the model was examined using Monte Carlo simulation methods.

RESULTS

We estimate a minimum or 'base program' of screening those aged 55 to 69 years could avert 250 deaths per annum (95% uncertainty interval 99-400), at a gross cost of dollarsA55 million (95% UI dollarsA46 million to dollarsA96 million) and a gross incremental cost-effectiveness ratio of dollarsA17,000/DALY (95% UI dollarsA13,000/DALY to dollarsA52,000/DALY). Extending the program to include 70 to 74-year-olds is a more effective option (cheaper and higher health gain) than including the 50 to 54-year-olds.

CONCLUSIONS

The findings of this study support the case for a national program directed at the 55 to 69-year-old age group with extension to 70 to 74-year-olds if there are sufficient resources. The pilot tests recently announced in Australia provide an important opportunity to consider the age range for screening and the sources of uncertainty, identified in the modelled evaluation, to assist decisions on implementing a full national program.

Performance Evaluation Tests for Environmental Research (PETER): evaluation of 114 measures

The goal of the Performance Evaluation Tests for Environmental Research (PETER) Program was to identify a set of measures of human capabilities for use in the study of environmental and other time-course effects. 114 measures studied in the PETER Program were evaluated and categorized into four groups based upon task stability and task definition. The Recommended category contained 30 measures that clearly obtained total stabilization and had an acceptable level of reliability efficiency. The Acceptable-But-Redundant category contained 15 measures. The 37 measures in the Marginal category, which included an inordinate number of slope and other derived measures, usually had desirable features which were outweighed by faults. The 32 measures in the Unacceptable category had either differential instability or weak reliability efficiency. It is our opinion that the 30 measures in the Recommended category should be given first consideration for environmental research applications. Further, it is recommended that information pertaining to preexperimental practice requirements and stabilized reliabilities should be utilized in repeated-measures environmental studies.

Ex vivo delineation of placental angioarchitecture with the microbubble contrast agent Levovist

OBJECTIVE

The aim of this study was to delineate placental vasculature with the microbubble contrast agent Levovist (99.9% galactose and 0.1% palmitic acid; Schering AG, Berlin, Germany), with the ultimate goal of delineating placental vascular anatomy in utero.

STUDY DESIGN

A placental lobule from each of 11 term human placentas was perfused on the fetal side of the circulation under physiologic conditions. Randomly assigned dose-concentration combinations of Levovist were administered through a chorionic artery into the corresponding placental lobule, and the resultant echoenhancement with power Doppler imaging was recorded for digital analysis. Interplacental variability was corrected for by averaging the results of three injections at each dose-concentration combination.

RESULTS

Echoenhancement was seen at all dose-concentration combinations in the injected lobule but not in adjacent control lobules. The three dose-concentration combinations that achieved optimal maximal integrated intensity and duration of action for both chorionic vessel and villus enhancement were 100 microL/kg of 400-mg/mL Levovist, 200 microL/kg of 400-mg/mL Levovist, and 400 microL/kg of 200-mg/mL Levovist.

CONCLUSION

Microbubble contrast injection into the fetal vasculature enabled power Doppler imaging echoenhancement both in chorionic vessels and within the villus tree. We speculate that fetal injection of contrast agent may be applied to the delineation of placental lesions or areas of interfetal transfusion, although its applicability will be hindered by the need for fetal blood sampling.

Is phase-specific, community-oriented treatment of early psychosis an economically viable method of improving outcome?

OBJECTIVE

The Early Psychosis Prevention and Intervention Centre (EPPIC) provides a comprehensive 'real-world' model of early intervention to young people experiencing an emerging psychotic disorder. A prospective study has already provided evidence of improved clinical outcome at 12 months after entry. The present study examined whether the service was also cost-effective.

METHOD

A cost-effectiveness analysis compared EPPIC with its immediate precursor service, from the perspective of the government funding agency. Only direct costs were included.

RESULTS

EPPIC proved to be more cost-effective. The weighted average cost per patient for the first 12 months was cheaper (by $AUD 7110 per patient), while treatment outcomes were superior. The savings were due to the marked reduction in in-patient costs outweighing substantial increases in the costs of community care.

CONCLUSION

These results, while encouraging in terms of the further development of integrated, phase-specific intervention programmes for early psychosis, are not conclusive, and further research is required.

Risk factors for seizure-related motor vehicle crashes in patients with epilepsy

OBJECTIVE

We identified clinical risk factors for seizure-related motor vehicle crashes in patients with epilepsy.

BACKGROUND

Current US laws permit epilepsy patients with controlled seizures to drive. These laws attempt to balance the important economic and social value of driving with the risk to public safety from seizure-related crashes. Various clinical factors are considered in these laws, particularly the seizure-free interval. Driving restrictions range from 3 to 18 months, however, and studies have not established how these various seizure-free intervals and other clinical factors influence the risk for seizure-related motor vehicle crashes.

METHODS

We performed a retrospective case-control study to determine the influence of clinical risk factors associated with seizure-related motor vehicle crashes. Both "case" and "control" patients had epilepsy, drove, and were from the same clinic, but the cases differed in having had seizure-related crashes.

RESULTS

Fifty patients with epilepsy who crashed during seizures and 50 matched control patients were compared. Factors that significantly decreased the odds of patients with epilepsy having motor vehicle crashes due to seizures were: long seizure-free intervals, reliable auras, few prior nonseizure-related accidents, and having had their antiepileptic drugs (AEDs) reduced or switched. For example, patients who had seizure-free intervals > or = 12 months had a 93% reduced odds for crashing compared to patients with shorter intervals. Other findings were: 25% of patients had more than one seizure-related crash and 20% had missed an AED dose just prior to their crash. The majority (54%) of patients who crashed were driving illegally, with seizure-free intervals shorter than legally permitted.

CONCLUSION

Seizure-free intervals, the presence of reliable auras, AED therapy modifications, and a history of nonseizure-induced crashes should be considered when counseling patients with epilepsy on driving and when formulating driving regulatory policy. Case control studies of crashes due to seizures can help in assessing and monitoring such risks.

Evaluation of a series of N-alkyl benzomorphans in cell lines expressing transfected delta- and mu-opioid receptors

Transfection of individual opioid receptors in Chinese hamster ovary (CHO) cells provides a pure, homogeneous population of receptors for screening drug candidates, and an alternative to the use of selective ligands. To evaluate the potential of this system, we chose a series of (-)-5,9 alpha-dimethyl-2-hydroxy-N-substituted-6,7-benzomorphans, for which the receptor selectivity and in vivo activity had been characterized recently, and tested them in CHO cells stably transfected with either the rat delta-opioid receptor or the mouse mu-opioid receptor. [3H]Diprenorphine was used to measure opioid receptors in P2 membrane preparations. A Bmax of 7.58 +/- 0.8 pmol/mg protein and a Kd of 0.42 +/- 0.04 nM was obtained in the mu-opioid receptor expressing cell line used in these studies. In addition, [3H]naltrindole was used to confirm the delta-specificity of the cloned receptor. Both compounds gave a Bmax of 1.2 pmol/mg in the CHO cells expressing the rat delta-opioid receptor. Displacement assays were performed with eleven (-)-N-alkyl-benzomorphans in the absence and presence of 150 mM NaCl, as well as known delta- and mu-selective agonists. Sodium reduced agonist affinity in the transfected cell lines. The benzomorphan compounds displayed a range of affinities in the mu- and delta-opioid receptor expressing cell lines. Good correlations were found between their affinities at the cloned mu- and delta-opioid receptors and those in rat brain and monkey cortex (r2 from 0.73 to 0.89, P < 0.001). Comparative analysis of Ki values with in vivo potency in the mouse tail flick test indicated a high degree of correlation between antinociception and affinity in the mu-opioid receptor cell line (r2 = 0.83, p < 0.0001). Lesser correlations were found between antinociception in the mouse and affinity at the rat mu-opioid receptor (r2 = 0.6610) and at the monkey mu-opioid receptor (r2 = 0.695). In sum, these studies indicate that the cell lines expressing the cloned mu- and delta-opioid receptors are appropriate models for determining the binding affinities of this class of opioid compounds. The diminishing correlations found between species when comparing in vitro and in vivo activity suggest that caution should be taken when extrapolating binding data to pharmacological activity among species.

Performance Evaluation Tests for Environmental Research (PETER): Moran and computer batteries

This investigation was directed at evaluating nine cognitive ability tasks for repeated measures applications and inclusion in the Performance Evaluation Tests for Environmental Research (PETER) battery. In the first study, five tasks from the Moran Battery, which were adapted from the French kit of factor-referenced tests, were administered to 18 subjects daily for 13 workdays. In the second study, four tasks from the Carter and Sbisa Computer Generated Battery were administered daily to 17 subjects (12 in common with first study) for 15 workdays. Examination of the means, variances, and interday reliabilities, together with factor analysis of the cross-task correlations, led to the recommendation of four tasks. Tasks recommended for repeated measures applications were Vertical Addition, Perceptual Speed, Grammatical Reasoning, and Flexibility of Closure.

High-contrast sets of colors

A method is presented for choosing high-contrast sets of colors for additive color mixers (e.g., CRT). The method is based on data about target-location performance of human observers and adapts the color sets to the gamut of the color processor in use. The method produces any specified number of colors spread as far from each other as possible in color space to maximize contrast. Applications of high-contrast sets of colors are indicated, illustrative results are presented and discussed, and variations of the method are suggested.

Visual search with color

Three experiments were conducted to discover how rapidly people can find a particular target when they know the color of the target. The subjects searched for specific-colored three-digit numbers among other three-digit numbers on a circular display screen. Three factors had profound effects on search speed. Search time increased dramatically (and approximately linearly) as the number of display items of the target's color increased from one to all of the items on the display. Search time also increased with the number of items not of the target's color (background items), if the color of those background items was sufficiently similar to that of the target. If the color of those background items was dissimilar to that of the target, then the background items had no effect. An effect of patterned versus random placement of target-colored items was also demonstrated.

Search time with a color display: analysis of distribution functions

Color displays were used for a search task. The task involved locating a particular three-digit number in a background of other numbers, given the first two digits of the target and its color. The display variables were the number of display items of the same color as the target (TCS); the number of background items not of the target's color (NOB); and the color difference between the target and background items (ΔE). Search times obtained with each of 17 combinations of these conditions were discussed in terms of their cumulative distribution functions (CDFs). The observed CDFs were compared with some theoretical CDFs: normal, linear, and exponential. Search times were normally distributed when targets were immediately obvious to searchers (TCS and NOB small,ΔE large). The exponential CDF was best when the target was less conspicuous (TCS and NOB large, ΔE small) so that searchers had to scan the display to locate the target. The exponential model was improved by addition of a parameter to represent human response time. Furthermore, the parameters of the exponential model were shown to respond in a consistent and theoretically meaningful manner to changes of the display variables.

Visual search with color

Three experiments were conducted to discover how rapidly people can find a particular target when they know the color of the target. The subjects searched for specific-colored three-digit numbers among other three-digit numbers on a circular display screen. Three factors had profound effects on search speed. Search time increased dramatically (and approximately linearly) as the number of display items of the target's color increased from one to all of the items on the display. Search time also increased with the number of items not of the target's color (background items), if the color of those background items was sufficiently similar to that of the target. If the color of those background items was dissimilar to that of the target, then the background items had no effect. An effect of patterned versus random placement of target-colored items was also demonstrated.

Color and conspicuousness

The principle that things are easier to find if they contrast with their environment is expressed quantitatively. Two indices of conspicuousness, relative fixation rate and search time, are shown to be related to the color difference between the target and background objects. The color difference equations used are CIELAB, CIELUV, and the Judd modification of the index of fading. None of the equations is superior to the others. Furthermore, neither Judd's modification nor Semmelroth's adjustment accounts for effects of surround lightness. It is suggested that color difference be used as a tool for design and evaluation of visual displays, for construction of color codes to optimize search time, and as a generalization of chromatic contrast in psychophysical research.

Gap junctions in thyroid epithelium of the rat

Gap junctions were observed on the lateral plasma membrane of the typical thyroid epithelial cell in freeze-fracture preparations of rat thyroid gland. The gap junctions were 0.1 to 0.4 mum in diameter and were composed of closely packed, approximately 80 nm particles. They were located from 1 to 6 mum from the apical surface of the cell.

Changes in tight junctions of thyroid epithelium with changes in thyroid activity

The morphology of the tight junction of rat thyroid epithelium was examined in freeze-fractured material fixed in glutaraldehyde and briefly glycerinated. In normal thyroids the overall appearance of this junctional specialization resembled that of other cell types in many respects. Short-term changes in thyroid activity and hypophysectomy for 3 wk did not obviously affect the appearance of tight junctions. Feeding of the goitrogen, thiouracil, which stimulates secretion of thyroid-stimulating hormone, resulted in the appearance of some very narrow and some very wide, tight junctions or sometimes junctions with both wide and narrow regions within the same cell.

Evaluation of methods for reestablishment of L-cell suspension cultures directly from liquid nitrogen stored stocks

Methods were developed and evaluated for the preservation of tissue cells grown in suspension culture and the reestablishment of suspension cultures directly from inoculum stored at -175 C. The factors investigated were processing pH, temperature of processing, freezing medium, and method of inoculation of the starter suspension cultures from the frozen stock (-175 C). Three parameters, cell viability, cell size, and growth potential in suspension culture after freezing, were used to evaluate the various factors. The results indicate that cells processed at 4 C, frozen at 1 C per min to -50 C in a medium containing 5% dimethyl sulfoxide plus 10% bovine serum at concentrations of 2 x 10(7) to 4 x 10(7) cells/ml, and stored at -175 C will reestablish suspension cultures directly from frozen seed. A 1-ml amount of frozen stock inoculated into 99 ml of medium routinely produced 2 x 10(6) to 3 x 10(6) viable cells/ml (2 x 10(8) to 3 x 10(8) total cells) in suspension culture in 4 to 5 days. Inoculum preserved by this procedure grew equally well in either serum-free or serum-containing growth medium.