Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists.

OBJECTIVE: To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis. METHODS: In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists. RESULTS: Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK. CONCLUSIONS: Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

The Value of Preventative Dental Care: A Discrete-Choice Experiment.

Scale and polish (SP) and oral hygiene advice (OHA) are commonly provided in primary care dental practice to help prevent periodontal disease. These services are widely consumed by service users, incurring substantial cost, without any clear evidence of clinical benefit. This article aims to elicit general population preferences and willingness to pay (WTP) for preventative dental care services and outcomes. An online discrete-choice experiment (DCE) was completed by a nationally representative sample of the UK general population. Respondents each answered 10 choice tasks that varied in terms of service attributes (SP, OHA, and provider of care), outcomes (bleeding gums and aesthetics), and cost. Choice tasks were selected using a pivoted segmented experimental design to improve task realism. An error components panel logit model was used to analyze the data. Marginal WTP (mWTP) for each attribute and level was calculated. In total, 667 respondents completed the DCE. Respondents valued more frequent SP, care provided by a dentist, and personalized OHA. Respondents were willing to pay for dental packages that generated less frequent ("never" or "hardly ever") bleeding on brushing and teeth that look and feel at least "moderately clean." Respondents were willing to pay more (+£145/y) for improvements in an aesthetic outcome from "very unclean" (-£85/y) to "very clean" (+£60/y) than they were for reduced bleeding frequency (+£100/y) from "very often" (-£54/y) to "never" (+£36/y). The general population value routinely provided SP, even in the absence of reductions in bleeding on brushing. Dental care service providers must consider service user preferences, including preferences for both health and nonhealth outcomes, as a key factor in any service redesign. Furthermore, the results provide mWTP estimates that can be used in cost-benefit analysis of these dental care services.

Models of intrapartum care and women's trade-offs in remote and rural Scotland: a mixed-methods study.

OBJECTIVE: To explore women's preferences for, and trade-offs between, key attributes of intrapartum care models. DESIGN: Mixed-methods study using discrete choice experiments (DCEs) and focus groups. SETTING: The North of Scotland. POPULATION: Women from the catchment areas of eight rural maternity units in the North of Scotland. METHODS: Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery. MAIN OUTCOME MEASURES: Preferences for attributes of intrapartum care. RESULTS: Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances. CONCLUSIONS: In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.

Examining the association between surface bioburden and frequently touched sites in intensive care.

BACKGROUND: Critical care patients are at increased risk of infection. Near-patient surfaces act as reservoirs of microbial soil, which may contain pathogens. AIM: To correlate soil levels with hand-touch frequency of near-patient sites in an intensive care unit (ICU). METHODS: Five sites around each bed in a 10-bed ICU were screened for total microbial soil (cfu/cm2) and Staphylococcus aureus every month for 10 months. Selected sites were infusion pump and cardiac monitor, left and right bedrails, and bed table. Ten 1 h covert audits of hand-touch frequency of these sites were performed in order to provide an average hand-touch count, which was modelled against soil levels obtained from microbiological screening. FINDINGS: Seven of 10 staphylococci were found in conjunction with gross contamination of a specific site (P=0.005) and the same proportion from three most frequently touched sites (bedrails and bed table). There was a linear association between four sites demonstrating gross microbial contamination (>12 cfu/cm2) and mean number of hand-touch counts (P=0.08). The bed table was handled most but was not the most contaminated site. We suspected that customary placement of alcohol gel containers on bed tables may have reduced microbiological yield. Removing the gel container from one table confirmed its inhibitory effect on microbial contamination after rescreening (19% vs 50% >12 cfu/cm2: P=0.007). CONCLUSION: Surface bioburden at near-patient sites in ICU is associated with hand-contact frequencies by staff and visitors. This supports the need for targeted hygienic cleaning in a high-risk healthcare environment.

"Doctor my eyes": A natural experiment on the demand for eye care services.

Preventive health care is promoted by many organisations from the World Health Organisation (WHO) to regional and national governments. The degree of cost-sharing between individuals and the health care service affects preventive service use. For instance, out-of-pocket fees that are paid by individuals for curative services reduce preventive care demand. We examine the impact of subsidised preventive care on demand. We motivate our analysis with a theoretical model of inter-temporal substitution in which individuals decide whether to have a health examination in period one and consequently whether to be treated if required in period two. We derive four testable hypotheses. We test these using the subsidised eye care policy introduced in Scotland in 2006. This provides a natural experiment that allows us to identify the effect of the policy on the demand for eye examinations. We also explore socio-economic differences in the response to the policy. The analysis is based on a sample from the British Household Panel Survey of 52,613 observations of people, aged between 16 and 59 years, living in England and Scotland for the period 2001-2008. Using the difference-in-difference methodology, we find that on average the policy did not affect demand for eye examinations. We find that demand for eye examinations only increased among high income households, and consequently, inequalities in eye-care services demand have widened in Scotland since the introduction of the policy.

Cytokine mRNA expression and serum cortisol evaluation during murine lung inflammation induced by Mycobacterium tuberculosis.

A model system was characterized for investigating the potential role of cortisol in MTB induced immunopathology. Serum cortisol levels were evaluated in two mouse strains; C57BL/6 mice develop lung granulomas following acute Mycobacterium tuberculosis infection while A/J mice are deficient in this process. Serum cortisol levels were examined post infection, as well as immunoregulatory mRNA expression in the lung, measured using bioluminescent RT-PCR techniques. Prior to infection, the A/J mice constitutively maintain nearly 75&percent; higher serum cortisol than C57BL/6 mice. Both A/J and C57BL/6 mice exhibited approximately 30&percent; reduction in relative serum cortisol following infection. At no time did serum cortisol levels in the A/J fall below constitutive levels in the non-infected C57BL/6. The overall elevated cortisol in the A/J may affect pulmonary immunoresponsiveness; A/J mice exhibited earlier induction of IL-10 and TNF-alpha than C57BL/6 mice, with a relative lack of IL-2 during late infection. Conversely, the C57BL/6 mice demonstrated higher IL-12(p40) and IL-2 messages at the latter stages of disease than the A/J mice. Both mice demonstrated high IFN-&gama; mRNA. The high constitutive serum cortisol in the A/J mice may therefore contribute to establishment of an environment counter-productive to initiation of protective Th1 cell and granulomatous responses.

Hepatitis B vaccines: assessment of the seroprotective efficacy of two recombinant DNA vaccines.

BACKGROUND: In universal vaccination programs, when there is no postvaccination sero-1 logic assessment of response, there must be confidence that the vaccines used provide a high degree of seroprotection. OBJECTIVE: This parallel analysis of 2 recombinant hepatitis B vaccines (Engerix B and Recombivax/HB-Vax II) was conducted to review the seroprotective efficacy of each vaccine in defined populations. METHODS: Clinical studies of the 2 vaccines published as manuscripts or conference abstracts in the public domain between January 1986 and April 1999 were identified retrospectively by unrestricted screening of journals through BIOSIS, MEDLINE, and EMBASE and the Internet. Unpublished or internal company data were excluded to maintain impartiality. The studies were reviewed and analyzed. The studies were not assessed for quality other than a judgment of their eligibility for inclusion in the analysis. The primary outcome measure was the proportion of subjects in defined populations who showed an early seroprotective response to currently licensed vaccination schedules. Summary statistical analyses of seroprotective response rates and 95% CIs were calculated for each vaccine for each population. Seroprotective response was defined by an anti-hepatitis B surface antigen titer > or =10 IU/L measured between 1 and 3 months after the final vaccination. Because the study was designed specifically to review published immunogenicity data, safety data were not assessed. The study was not designed to demonstrate superiority of one vaccine over the other. RESULTS: A total of 181 clinical studies representing 32,904 vaccinated subjects were reviewed and analyzed, of whom 24,277 had been vaccinated with Engerix B and 8627 vaccinated with Recombivax/ HB-Vax II. Seroprotection was achieved in 20,060 subjects (95.8%) with Engerix B and in 7774 subjects (94.3%) with Recombivax/HB-Vax II in the normal population vaccinated according to currently licensed 3-dose schedules. In a subgroup analysis, response rates in health care workers were 6492 subjects (94.5%) for Engerix B and 3245 subjects (92.2%) for Recombivax/HB-Vax II. Children and adolescents (1-19 years) showed the highest response rates to vaccination (4612 [98.6%], Engerix B; 2292 [98.9%], Recombivax/HB-Vax II). A total of 2875 infants (<1 year) (95.8%) achieved seroprotection with Engerix B; 701 (88.5%) achieved seroprotection with Recombivax/ HB-Vax II. CONCLUSIONS: Hepatitis B vaccination programs using either Engerix B or Recombivax/HB-Vax II can achieve high seroprotective response rates, particularly in childhood and adolescence. Ideally, younger populations should be a primary target in current universal vaccination programs.

Pain in participants of adult day care centers: assessment by different raters.

The aim of this study is to compare the assessment of pain in 200 elderly persons participating in five senior day care programs, as rated by family caregivers, day care staff members, and the participants themselves. Staff members and participants provided information in a face-to-face interview. Family members provided information about the participants and their demographic characteristics via a mailed questionnaire. Agreement rates among informants ranged between 63% and 69%, showing moderate agreement rates. Health status (as reflected in number of medications taken and the presence of a diagnosis of musculoskeletal disease) and depression were associated with ratings of pain by all the informants. The assessment of pain in the elderly population is very difficult and there is a need for reliable and valid pain assessments to be used by different raters. The relationship between pain, depression and other variables should be further explored.

Saphenous vein interposition graft for recurrent carotid stenosis after prior endarterectomy and stent placement. Case report.

Although the use of carotid artery stents is increasing, the management of recurrent stenosis after their placement is undefined. The authors report on a patient who underwent two left carotid endarterectomies followed by left carotid angioplasty and stent placement for recurrent stenosis. A third symptomatic recurrence was subsequently managed by placement of a saphenous vein interposition graft from the common carotid artery to the distal cervical internal carotid artery. The patient remained without hemispheric or retinal ischemia at his 5-month follow-up visit. Interposition grafting should be considered as a treatment option for carotid restenosis after initial endarterectomy and stent placement.

In vivo cytokine production and resistance to infection after acute exposure to 3,4-dichloropropionaniline.

3,4-Dichloropropionaniline (propanil) is an extensively used postemergent herbicide that has been shown to produce toxic and immunotoxic effects. The present report examined if acute exposure to propanil altered in vitro or in vivo cytokine production in response to antigenic stimulation. Studies to determine resistance to infection by the intracellular bacterium Listeria monocytogenes after exposure to propanil were also conducted. Our experiments demonstrate that in vivo exposure to propanil during bacterial infection reduced the subsequent in vitro production of interferon-gamma (IFN-gamma) by splenocytes and liver nonparenchymal cells in response to antigenic and mitogenic stimulation. Additional experiments examined the production of cytokines in vivo after propanil exposure alone or combined propanil exposure and L. monocytogenes infection. It was found that the endogenous levels of cytokines in the liver, spleen, and blood were similar in control and propanil-treated mice. The levels of cytokines were also similar in control and exposed mice that were infected with L. monocytogenes. Initial resistance to the infection was not affected by exposure to propanil. These results demonstrate that in vivo exposure to propanil during a bacterial infection suppresses the subsequent in vitro production of cytokines but that the endogenous levels are not affected during the initial stages of infection.

New neurointerventional therapies for stroke patients.

New neurointerventional procedures affect patient outcomes following stroke. Intraarterial thrombolysis, cerebral angioplasty, coils placed inside aneurysms, and vessel occlusion with embolic agents serve as options for stroke patients with conditions not as amenable to traditional surgical or medical management. By understanding these new neurointerventional therapies, critical care nurses can utilize a focused neurological assessment to intervene and maintain perfusion to the brain following the procedures.

Focal intestinal lipogranulomatous lymphangitis in 6 dogs (2008-2011).

BACKGROUND: Lipogranulomatous lymphangitis is inflammation of the intestinal lymphatic vessels and surrounding tissues caused by chronic leakage of lipid-laden chyle. Grossly, lipogranulomas are typically disseminated small masses on the serosa and surrounding lymphatic vessels and consist of epithelioid macrophages, multinucleated giant cells, and cholesterol. Lipogranulomatous lymphangitis is occasionally seen in patients with lymphangiectasia and protein-losing enteropathy (PLE). OBJECTIVES: To characterize the historical features, clinical signs, treatment, histopathology, and outcome of dogs with focal lipogranulomatous lymphangitis. ANIMALS: Six dogs with ultrasonographic evidence of focal, regional small intestinal masses, often with involvement of the adjacent mesentery, and a diagnosis of focal lipogranulomatous lymphangitis based on histopathology of biopsied masses. RESULTS: The median age of dogs was 6.9 years (range 3-10 years). All dogs had total protein, globulin, and albumin concentrations within the reference range at initial presentation and had intestinal masses identified on abdominal ultrasound examination. Histopathologic evaluation of lesions identified severe mural and mesenteric lipogranulomatous lymphangitis. Lymphangiectasia was noted in 5 cases and only in sections within the mass-like lesion; tissue without lipogranulomas had minimal lymphangiectasia, suggesting a localized phenomenon. Postoperative outcomes ranged from remission of clinical signs with no subsequent treatment for 10-12 months in 2 dogs, postoperative management with medical and nutritional management in 3 dogs, and no outcome for 1 case. CONCLUSIONS AND CLINICAL IMPORTANCE: This case series describes a unique mass-like manifestation of intestinal lipogranulomatous lymphangitis and should be considered as a possible differential diagnosis in dogs with an intestinal mass.

"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland.

OBJECTIVE: To explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available. SETTING AND METHODS: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. RESULTS: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice." CONCLUSIONS: Provision of different models of maternity services may not be sufficient to convince women they have "choice." The paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Precision placement of instruments for minimally invasive procedures using a "needle driver" robot.

Medical practice continues to move toward less invasive procedures. Many of these procedures require the precision placement of a needle in the anatomy. Over the past several years, our research team has been investigating the use of a robotic needle driver to assist the physician in this task. This paper summarizes our work in this area. The robotic system is briefly described, followed by a description of a clinical trial in spinal nerve blockade. The robot was used under joystick control to place a 22 gauge needle in the spines of 10 patients using fluoroscopic imaging. The results were equivalent to the current manual procedure. We next describe our follow-up clinical application in lung biopsy for lung cancer screening under CT fluoroscopy. The system concept is discussed and the results of a phantom study are presented. A start-up company named ImageGuide has recently been formed to commercialize the robot. Their revised robot design is presented, along with plans to install a ceiling-mounted version of the robot in the CT fluoroscopy suite at Georgetown University.

The duration of the second stage of labour.

Fetal outcomes following extended second-stage labour include respiratory acidosis, lower umbilical vein and artery pH, lactacidaemia and early neonatal seizures. Maternal outcomes following extended second-stage labour include postpartum haemorrhage, puerperal fever, backache, musculoskeletal problems, stress incontinence and denervation of the pelvic floor. It is suggested that intervention should be based on the use of judgement and skill rather than strict adherence to timetables.