Cost-effectiveness of gallbladder histopathology after cholecystectomy for benign disease.

BACKGROUND: The prevalence of incidental gallbladder cancer is low when performing cholecystectomy for benign disease. The performance of routine or selective histological examination of the gallbladder is still a subject for discussion. The aim of this study was to assess the cost-effectiveness of these different approaches. METHODS: Four management strategies were evaluated using decision-analytical modelling: no histology, current selective histology as practised in Sweden, macroscopic selective histology, and routine histology. Healthcare costs and life-years were estimated for a lifetime perspective and combined into incremental cost-effectiveness ratios (ICERs) to assess the additional cost of achieving an additional life-year for each management strategy. RESULTS: In the analysis of the four strategies, current selective histology was ruled out due to a higher ICER compared with macroscopic selective histology, which showed better health outcomes (extended dominance). Comparison of routine histology with macroscopic selective histology resulted in a gain of 12 life-years and an incremental healthcare cost of approximately €1 000 000 in a cohort of 10 000 patients, yielding an estimated ICER of €76 508. When comparing a macroscopic selective strategy with no histological assessment, 50 life-years would be saved and the ICER was estimated to be €20 708 in a cohort of 10 000 patients undergoing cholecystectomy. CONCLUSION: A macroscopic selective strategy appears to be the most cost-effective approach.

Choosing the number of images and image position when analyzing the UNC Passive Aerosol Sampler for occupational exposure assessment.

The University of North Carolina passive aerosol sampler (UNC sampler) could be an alternative when measuring occupational dust exposure, but the time required for microscopic imaging of the sampler needs to be reduced to make it more attractive. The aims of this study were to (1) characterize the effect on precision when reducing imaging, in order to shorten analysis time and (2) assess if the position of the images makes a difference. Eighty-eight samplers were deployed in different locations of an open pit mine. Sixty images were captured for each UNC sampler, covering 51% of its collection surface, using scanning electron microscopy. Bootstrapped samples were generated with different image combinations, to assess the within-sampler coefficient of variation (CVws) for different numbers of images. In addition, the particle concentration relative to the distance from the center of the sampler was studied. Reducing the number of images collected from the UNC sampler led to up to 8.3% CVws for 10 images when calculating respirable fraction. As the overall CV has previously been assessed to 36%, the additional contribution becomes minimal, increasing the overall CV to 37%. The mean concentrations of the images were modestly related to distance from the center of the sampler. The CVws changed from 8.26% to 8.13% for 10 images when applying rules for the image collection based on distance. Thus, the benefit of these rules on the precision is small and the images can therefore be chosen at random. In conclusion, reducing the number of images analyzed from 60 to 10, corresponding to a reduction of the imaged sampling area from 51% to 8.5%, results in a negligible loss in precision for respirable fraction dust measurements in occupational environments.

Trends that have influenced the Swedish radiography profession over the last four decades.

INTRODUCTION: The expansion of the radiography profession in recent decades has widened the scope of radiographic practice. This has raised questions about which trends have had an impact on the profession over the years. The study aim was to explore trends that have influenced the radiography profession over the last four decades. METHODS: A qualitative design was used. Eleven focus group interviews inspired by the Scenario Planning Method were conducted at 11 diagnostic radiology departments in public hospitals in Sweden. The target group consisted of 48 registered radiographers. To analyse the data, qualitative content analysis was used. RESULTS: Thematic data analysis revealed three broad categories; technological development and radiation doses, current status of the radiography profession and specialisation leading to expert knowledge. Each category derived from two or three sub-categories. CONCLUSION: The results demonstrate significant trends of influences on the radiography profession in Sweden over the last four decades. New methods and technology and control of radiation doses have had a favourable effect on the development of the radiography profession. Nevertheless, current status such as shortage of radiographers has had an adverse way. Specialisation leading to expert knowledge has an influence on career advancement and a specialist education regulated by the law, might be a prerequisite for the development of the radiography profession.

A two-year follow-up of work capacity in early rheumatoid arthritis: a study of multidisciplinary team care with emphasis on vocational support.

OBJECTIVE: To explore changes in sick leave patterns and work ability in patients with early rheumatoid arthritis (RA). The patients received active team support focusing on vocational rehabilitation, in addition to treatment with disease-modifying anti-rheumatic drugs (DMARDs). METHODS: This is an observational study of 110 patients with early RA aged 18-60 years and not permanently disabled. All patients were monitored regularly during a 2-year period by a team comprising a nurse, an occupational therapist, a physiotherapist, a rheumatologist, and a social worker. Intervention included work-site visits and rehabilitation meetings with the employer and the official from the local social insurance office in addition to DMARD treatment and different individual treatments, and support from the team members. RESULTS: The number of patients working full-time increased from 65 to 74 (14%), those with full-time work disability decreased from 37 to 13 (65%), and patients working part-time increased from 8 to 23 (65%). This change was already evident during the first year. CONCLUSION: Active vocational support in addition to DMARD treatment may prevent or delay work disability in patients with early RA.

Incidence, management and recurrence rate of acute pancreatitis.

BACKGROUND: Acute pancreatitis is a common condition that is still associated with substantial morbidity and mortality rates. Management, outcome and recurrence rate in acute pancreatitis in a clinical setting using a conservative management approach are described. METHODS: A total of 1376 consecutive cases representing 2211 hospitalizations due to acute pancreatitis treated at the Dept. of Surgery, Lund University Hospital, Lund, were reviewed retrospectively. Management, outcome and recurrence rate were recorded. RESULTS: Incidence, including recurrences, was 300 per million per year; 21% of patients had recurrent (> or =2) attacks. In relapsing disease, two-thirds of patients had the first attack within 3 months. Mortality decreased over the period studied, but overall it was 4.2%; mortality in relapsing attacks was 2.5%, related to multiple organ dysfunction (MODS) in 67% and occurring within the first week in 36%. CONCLUSIONS: Despite a conservative approach in the management of acute pancreatitis, mortality is still substantial, frequently occurs early after admission, is associated with MODS and is also seen in relapsing disease. Early cholecystectomy and bile duct clearance could decrease recurrent attacks of biliary pancreatitis.

[Rethinking social protection in health in Latin America and the Caribbean]. / Repensar la protección social en salud en América Latina y el Caribe.

Despite what is written in the constitutions and other basic document mandates of the countries of the Region, exclusion from social protection in health (SPH) affects an important proportion of the population (at least 20%, which represents, in absolute figures, between 80 and 200 million people). These estimates are obtained through a series of theoretical (social security coverage) and practical indicators that encompass structural indicators (poverty, ethnicity, and geographical barriers) as well as process indicators (non-institutional births, compliance with vaccination schedules, and access to basic sanitation). Exclusion levels in a society are affected by the degree of segmentation of the health system. Traditionally, most countries of the Region have had a public, a social security and a private subsystem in health. Lack of attention to the problem has resulted in the formation of a community-based subsystem. The coexistence of many subsystems, along with poor regulation on the part of health authorities, has resulted in high levels of exclusion and inefficient resource allocation within the sector. The organization of social dialogue processes focusing on SPH within the context of health sector reform initiatives in each country is recommended. The process, which should be participatory, should include a full diagnosis of the situation (how many are excluded, who are they, and why, and what mechanisms are the most appropriate for tackling the issue in each country). It should also provide a political and technical feasibility analysis of the most suitable options for each society, and a determination of whether or not conventional subsystems have exhausted their potential. The process should culminate in a program for implementing the specific proposals made in each society, in an effort to maximize SPH.

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients.

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed to measure upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale. We performed cross-cultural adaptation of the DASH to Swedish, using a process that included double forward and backward translations, expert and lay review, as well as field-testing to achieve linguistic and conceptual equivalence. The Swedish version's reliability and validity were then evaluated in 176 patients with upper-extremity conditions. The patients completed the DASH and SF-12 generic health questionnaire before elective surgery or physical therapy. Internal consistency of the DASH was high (Cronbach alpha 0.96). Test-retest reliability, evaluated in a subgroup of 67 patients who completed the DASH on two occasions, with a median interval of 7 days, was excellent (intraclass correlation coefficient 0.92). Construct validity was shown by a positive correlation of DASH scores with the SF-12 scores (worse upper-extremity disability correlating with worse general health), stronger correlation with the SF-12 physical than with the mental health component, correlation of worse DASH scores with worse self-rated global health, and ability to discriminate among conditions known to differ in severity. The Swedish version of the DASH is a reliable and valid instrument that can provide a standardized measure of patient-centered outcomes in upper-extremity musculoskeletal conditions.

Hormone replacement therapy in postmenopausal women with diabetes mellitus: a risk-benefit assessment.

Hormone replacement therapy (HRT) has been shown to be beneficial in reducing osteoporosis and alleviating climacteric symptoms. HRT has been suggested to reduce the risk for coronary heart disease (CHD), but data are controversial. Unopposed estradiol therapy seems to have a favourable effect on lipid profile and glucose tolerance whereas addition of a progestogen may attenuate these favourable metabolic changes. Data on HRT in women with diabetes mellitus are scarce but of potential interest since these women are often characterised by hyperandrogenicity, insulin resistance and dyslipidaemia and are at a high risk for developing CHD. Present evidence suggests that short term unopposed oral estradiol therapy has a beneficial effect on glucose homeostasis, lipid profile and fibrinolytic activity, which may be compatible with a reduced risk for CHD. Accordingly, it may be hypothesised that HRT in women with diabetes mellitus may be at least as beneficial as in women without diabetes mellitus. However, women with diabetes mellitus are at increased underlying risk for venous thromboembolism and endometrial cancer. Whether HRT further increases this risk is not yet clear, but this possibility must be considered. It is, however, likely that the benefits with HRT in postmenopausal women with diabetes mellitus outweigh the risks, but randomised studies are required before any more definite risk-benefit assessment can be made long term.

Detection and assessment of clusters of disease: an application to nuclear power plant facilities and childhood leukaemia in Sweden.

We review some recent statistical methods for examining geographic patterns of disease incidence for the presence of clusters. General methods search for clusters throughout the study area and then assess the statistical significance of any clusters detected. Focused methods check for elevated incidence rates close to prespecified locations of putative sources of hazard. We apply the methods to leukaemia incidence data for children aged 0-15 years in Sweden (1980-1990), particularly in reference to locations of nuclear power facilities. Unlike some other studies, notably in the United Kingdom, we do not find any significant clusters.

Lateral diffusion of an integral membrane protein: Monte Carlo analysis of the migration of phosphorylated light-harvesting complex II in the thylakoid membrane.

The lateral migration of the integral light-harvesting chlorophyll a/b protein complex of photosystem II, LHCII, has been studied in the undisturbed membranes of thylakoids without artificial probes. LHCII was phosphorylated at 0 degree C. The diffusion of the mobile phospho-LHCII from appressed grana to nonappressed membrane regions was induced by a temperature jump to 20 degrees C and analyzed by a rapid detergent fractionation of the two membrane areas. This long-range diffusion of the integral phospho-LHCII is analyzed by a Monte Carlo calculation which is based on a model of the thylakoid membrane and includes all integral proteins as mobile particles. A comparison of the calculation with the experimental time course indicates a diffusion constant of phospho-LHCII in the range of (2-4) x 10(-12) cm2 s-1. This value is evidence for a severe restriction of protein mobility in the appressed thylakoid membrane. From a statical point of view, the percolation theory predicts that the high protein density in the grana membranes is above the threshold of percolation and the long-range diffusion should be inhibited by finite clusters of lipids. However, the shape of the experimental time course is in favor of a lateral motion also of photosystem II and nonphosphorylated LHCII and not of a rigid lattice of these complexes. Our data and Monte Carlo analysis suggest a dynamic or fluid lattice of the protein complexes with a lifetime of the clusters in the millisecond time range. The consequences of these transient fluctuations on the long-range diffusion of plastoquinone are discussed.

Helicobacter pylori infection: independent risk indicator of gastric adenocarcinoma.

BACKGROUND: Helicobacter pylori has been implicated as a possible etiologic factor in gastric cancer. This case control study was performed to determine the association between H. pylori and gastric cancer, taking into account the possibility of confounding by other background factors. METHODS: Sera were collected from 112 incident case patients with gastric cancer and 103 control patients with nongastroenterological diseases, who were frequency-matched with respect to age and sex. Immunoglobulin G antibodies to H. pylori were identified using the HM-CAP immunoassay (Enteric Products Inc., Wesbury, NY). RESULTS: The prevalence of H. pylori seropositivity was significantly higher (P = 0.002) among case patients than control patients. The odds ratio (OR) was 2.60 (95% confidence interval, 1.35-5.02). The increased OR associated with H. pylori infection was confined to tumors with a noncardia location (OR, 3.06) and men (OR, 4.27). OR increased with decreasing age at cancer diagnosis to reach 9.33 in patients < 60 years of age. Multivariate logistic regression analysis was used as control for potential confounding, but the elevated OR associated with H. pylori infection remained significantly increased. CONCLUSIONS: The results support the hypothesis of H. pylori infection as an independent risk indicator of gastric cancer.

Assessment of digital chest radiography using stimulable phosphor.

In this pilot study, conventional and digital radiography of the chest was compared in 170 patients. Two digitized radiographs, one frequency modified and one simulating the conventional film-screen combination, and the conventional films were reviewed independently by 5 radiologists with different experience. In spite of the smaller size and lower spatial resolution of the digitized compared with the conventional radiograph, only slight differences were revealed in the observation of different pulmonary and mediastinal changes. Digitized radiography is therefore considered suitable for chest examinations.