The population cost-effectiveness of delivering universal and indicated school-based interventions to prevent the onset of major depression among youth in Australia.

AIMS: School-based psychological interventions encompass: universal interventions targeting youth in the general population; and indicated interventions targeting youth with subthreshold depression. This study aimed to: (1) examine the population cost-effectiveness of delivering universal and indicated prevention interventions to youth in the population aged 11-17 years via primary and secondary schools in Australia; and (2) compare the comparative cost-effectiveness of delivering these interventions using face-to-face and internet-based delivery mechanisms. METHODS: We reviewed literature on the prevention of depression to identify all interventions targeting youth that would be suitable for implementation in Australia and had evidence of efficacy to support analysis. From this, we found evidence of effectiveness for the following intervention types: universal prevention involving group-based psychological interventions delivered to all participating school students; and indicated prevention involving group-based psychological interventions delivered to students with subthreshold depression. We constructed a Markov model to assess the cost-effectiveness of delivering universal and indicated interventions in the population relative to a 'no intervention' comparator over a 10-year time horizon. A disease model was used to simulate epidemiological transitions between three health states (i.e., healthy, diseased and dead). Intervention effect sizes were based on meta-analyses of randomised control trial data identified in the aforementioned review; while health benefits were measured as Disability-adjusted Life Years (DALYs) averted attributable to reductions in depression incidence. Net costs of delivering interventions were calculated using relevant Australian data. Uncertainty and sensitivity analyses were conducted to test model assumptions. Incremental cost-effectiveness ratios (ICERs) were measured in 2013 Australian dollars per DALY averted; with costs and benefits discounted at 3%. RESULTS: Universal and indicated psychological interventions delivered through face-to-face modalities had ICERs below a threshold of $50 000 per DALY averted. That is, $7350 per DALY averted (95% uncertainty interval (UI): dominates - 23 070) for universal prevention, and $19 550 per DALY averted (95% UI: 3081-56 713) for indicated prevention. Baseline ICERs were generally robust to changes in model assumptions. We conducted a sensitivity analysis which found that internet-delivered prevention interventions were highly cost-effective when assuming intervention effect sizes of 100 and 50% relative to effect sizes observed for face-to-face delivered interventions. These results should, however, be interpreted with caution due to the paucity of data. CONCLUSIONS: School-based psychological interventions appear to be cost-effective. However, realising efficiency gains in the population is ultimately dependent on ensuring successful system-level implementation.

Medical informatics education: the University of Utah experience.

The University of Utah has been educating health professionals in medical informatics since 1964. Over the 35 years since the program's inception, 272 graduate students have studied in the department. Most students have been male (80 percent) and have come from the United States (75 percent). Students entering the program have had diverse educational backgrounds, most commonly in medicine, engineering, computer science, or biology (59 percent of all informatics students). A total of 209 graduate degrees have been awarded, with an overall graduation rate of 87 percent since the program's start. Alumni are located in the United States (91 percent) and abroad (9 percent); half (51 percent) have remained in Utah. Former students are employed in a wide variety of jobs, primarily concerned with the application of medical informatics in sizable health care delivery organizations. Trends toward increasing managerial responsibility for medical informatics graduates and the emergence of the chief information officer role are noted.

Eosinophilic granuloma in the temporal bone and skull.

Eosinophilic granuloma is a benign lytic lesion of bone, probably arising from an abnormal proliferation of histiocytes. It may occur within the temporal bone and be confused with more common disorders such as aural polyps or chronic suppurative otitis media. If untreated, the disease may destroy the bony labyrinth and spread to the middle and posterior cranial fossas. Temporal bone lesions may represent only one manifestation of a more extensive multifocal disorder (i.e., Hand-Schüller-Christian or Letterer-Siwe disease). From 1967 to 1982, 25 patients with eosinophilic granuloma of the skull were treated in the radiation therapy department of The Methodist Hospital in Houston. Six of these patients had disease involving the temporal bone. After analyzing these cases and reviewing the literature, we conclude that the management of the patient with eosinophilic granuloma in the temporal bone requires a diagnosis based on microscopic examination of the affected tissue, a definition of the extent of disease, therapy consisting of biopsy and low-dosage radiotherapy in the unifocal disease, and careful and continued follow-up.

The two-edged sword: how technology shapes medical practice.

Technology is assuming an increasingly important role in medical practice and health care delivery, fueled by forces such as uncertainty, variability, error, and quality problems. While the benefits of technology are obvious, there are insidious costs that are harder to discern. Technology has a significant, but less appreciated, role in imposing standards and constraints upon medicine. These ancillary effects account for some of the physician reluctance to embrace technological innovations perceived as controlling. This article explores technology's wide-ranging effects in shaping medical care delivery. Technology is not a passive servant of the health care delivery system, but rather acts as a catalyst and shaper of that system. In the process of becoming more technological, medicine has been transformed from a profession with unmatched sovereignty into an industry shaped by technology amidst a context of social and political forces.

Implementation of a blood irradiation program at a community cancer center.

BACKGROUND: Blood component irradiation is an accepted method of preventing transfusion-associated GVHD. Previous publications have largely focused on the technical aspects of the irradiation process itself, but relatively little attention has been paid to the details associated with the implementation of a blood irradiation program at the level of a community cancer center. STUDY DESIGN AND METHODS: An observational study was performed, detailing the specific operational, documentation, and quality assurance measures employed in providing a blood component-irradiation service within the institutional context of a community cancer center. RESULTS: The Montgomery Cancer Center irradiated 589 units of blood components in 1998 and 1999 to provide a local blood bank with an alternative for procurement of irradiated blood components while complying with applicable quality assurance and regulatory requirements. CONCLUSION: Blood component irradiation is within the scope of most well-equipped and adequately staffed community cancer centers. Establishment of a blood component irradiation program requires scrupulous physics and dosimetry support, both to ensure the quality of the irradiated component and to satisfy governmental agency regulatory requirements.

Gastric radiotherapy as treatment of hereditary hemorrhagic telangiectasia.

A patient with hereditary hemorrhagic telangiectasia and von Willebrand's disease is described. He suffered recurrent episodes of gastrointestinal bleeding endoscopically localized to the cardia and body of the stomach. A cobalt 60 source was used to deliver 1600 rad to the patient's stomach. The effect of the radiation was remarkable in that he remained free of bleeding for more than 11 months. Radiotherapy should be considered for control of gastric bleeding in hereditary hemorrhagic telangiectasia.

Further studies on the specific infectious agent isolated in rheumatoid arthritis.

The active agent in crude or extracted materials from patients with acute rheumatoid arthritis (RA), when injected into embryonated eggs, produced an increased percentage of characteristic "crooked toe" defects in the bioassay. Experimental RA chick materials also produced these defects. A protein-free ribonucleic acid extract from RA synovia and joint fluids of patients with acute or subacute classical RA produced the same experimental RA lesions as did the crude materials, but non-RA materials and controls did not. The injected RA material produced the "crooked toe" disease in chicks in direct proportion to the clinically diagnosed severity of the RA in the patient, and inversely with dilution.

A comparison of efficacy of sargramostim (yeast-derived RhuGM-CSF) and filgrastim (bacteria-derived RhuG-CSF) in the therapeutic setting of chemotherapy-induced myelosuppression.

A randomized, double-blind, multicenter study in 181 afebrile cancer patients with ANC levels < 500/microL receiving myelosuppressive chemotherapy was undertaken to compare sargramostim (yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor, RhuGM-CSF) and filgrastim (bacteria-derived recombinant human granulocyte colony-stimulating factor, RhuG-CSF) in the treatment of chemotherapy-induced myelosuppression. Patients received daily subcutaneous (SC) injections of either agent until ANC levels reached at least 1500/microL. There was no statistical difference between treatment groups in the mean number of days to reach an ANC of 500/microL, but the mean number of days to reach ANC levels of 1000/microL and 1500/microL was approximately one day less in patients receiving filgrastim. Fewer patients in the sargramostim arm were hospitalized, and they had a shorter mean length of hospitalization, mean duration of fever, and mean duration of i.v. antibiotic therapy compared with patients who received filgrastim. Both growth factors were well tolerated. No patient was readmitted to the hospital after growth factor was discontinued. Sargramostim and filgrastim have comparable efficacy and tolerability in the treatment of standard-dose chemotherapy-induced myelosuppression in community practice.