Quantitative and qualitative assessment of a coding system for reporting CT colonography.

AIM: To validate a coding system implemented to summarise computed tomography colonography (CTC) findings for the detection of suspected colorectal cancer (CRC) by assessing interobserver variability and also to evaluate any weaknesses through qualitative analysis. MATERIALS AND METHODS: All CTC investigations over a 6-month period (01/07/2016 to 31/12/2016) were analysed retrospectively. Each study was read initially by an advanced practitioner radiographer with a final report issued by a consultant gastrointestinal radiologist. Rates of interobserver agreement, using the kappa statistic, provided a quantitative assessment of levels of agreement. Areas of poor interobserver agreement were identified for further qualitative assessment. RESULTS: The present study included 1,321 CTC procedures and the mean age of patients was 68.4 years (range 28-96 years). Percentage agreement for colonic coding was 90% and for extra-colonic coding 47%. This corresponds to kappa scores of 0.69 (substantial agreement) and 0.22 (fair agreement), respectively. Reasons and examples of disagreement in the colonic coding are highlighted. CONCLUSIONS: High interobserver agreement was observed for C coding, suggesting it is a reproducible method of classifying intra-colonic CTC findings. Some of the difference in classifying extra-colonic findings is the perceived importance of incidental findings between readers, as well as differences in skill set; however, some themes recurred in areas of disagreement and recommendations for refining and improving the coding system are provided.

Neighbourhood influence on the fourth dose of diphtheria-tetanus-pertussis vaccination.

OBJECTIVES: Using 542,159 vaccination records from children born between April 1, 2007, and March 31, 2012, in the Michigan Care Improvement Registry and data from the American Community Survey, we determine if neighbourhood-level characteristics at the Census tract level and block level are associated with low uptake of the fourth dose of diphtheria-tetanus-acellular pertussis vaccine (DTaP4). STUDY DESIGN: This study was a cross-sectional study. METHODS: We used exploratory factor analysis to determine important socio-economic factors at the Census block level and tract level. We then used generalised estimating equations to test the relationship between block- and tract-level socio-economic factors and DTaP4 uptake. RESULTS: DTaP4 coverage was 88.6% (95% confidence interval [CI]: 88.4%-88.7%) in Michigan. At the Census tract level, two factors surfaced as important for DTaP4 vaccination: 'affluence' (Cronbach's alpha = 0.88) and 'socio-economic disadvantage' (Cronbach's alpha = 0.89). At the Census block level, one factor was important: 'affluence' (Cronbach's alpha = 0.90). Affluence may relate to knowledge about medical exemptions and antivaccination sentiment, while socio-economic disadvantage may indicate limited access to healthcare resources. Children in high-affluence tracts had 1.08% lower vaccination coverage (95% CI: -1.62% to -0.55%) than children in low affluence tracts. Children in low socio-economic disadvantage tracts had 2.92% higher coverage than children in high socio-economic disadvantage tracts (95% CI: 2.58%-3.26%). CONCLUSIONS: This study articulates the need to further understand the contribution of neighbourhood-level characteristics, from both affluent and socioeconomically disadvantaged areas to low vaccination rates. Developing a better understanding of these social environmental factors will help determine useful community-level interventions to improve vaccination rates and reduce disease burden.

Refractory depression: mechanisms and evaluation of radically open dialectical behaviour therapy (RO-DBT) [REFRAMED]: protocol for randomised trial.

INTRODUCTION: Only 30-40% of depressed patients treated with medication achieve full remission. Studies that change medication or augment it by psychotherapy achieve only limited benefits, in part because current treatments are not designed for chronic and complex patients. Previous trials have excluded high-risk patients and those with comorbid personality disorder. Radically Open Dialectical Behaviour Therapy (RO-DBT) is a novel, transdiagnostic treatment for disorders of emotional over-control. The REFRAMED trial aims to evaluate the effectiveness and cost-effectiveness of RO-DBT for patients with treatment-resistant depression. METHODS AND ANALYSIS: REFRAMED is a multicentre randomised controlled trial, comparing 7 months of individual and group RO-DBT treatment with treatment as usual (TAU). Our primary outcome measure is depressive symptoms 12 months after randomisation. We shall estimate the cost-effectiveness of RO-DBT by cost per quality-adjusted life year. Causal analyses will explore the mechanisms by which RO-DBT is effective. ETHICS AND DISSEMINATION: The National Research Ethics Service (NRES) Committee South Central - Southampton A first granted ethical approval on 20 June 2011, reference number 11/SC/0146. TRIAL REGISTRATION NUMBER: ISRCTN85784627.

Characterizing the burden of invasive Pseudomonas infection on neonatal units in the UK between 2005 and 2011.

Concern about Pseudomonas infection in neonatal units has focused on outbreaks. This study analysed cases of invasive Pseudomonas infection in 18 UK neonatal units participating in the NeonIN Neonatal Infection Surveillance Network from January 2005 to December 2011. Forty-two cases were reported. The majority (35/42, 93%) of cases were late-onset (median 14 days, range 2-262 days), the highest incidence was seen in extremely-low-birthweight infants and all cases were sporadic. One-third of cases were known to be colonized prior to invasive disease. Attributable mortality was 18%. Opportunities for preventing invasive disease due to this important pathogen should be prioritized.

Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to improve surgical outcomes.

BACKGROUND: Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. STUDY DESIGN: All NSQIP data from the 10-hospital collaborative for the time periods January to December 2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categories of postoperative complications and 30-day mortality were compared between periods. Complication comparisons and hospital costs associated with complications were calculated per 10,000 procedures. Statistical analysis was performed by Z-test. RESULTS: There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Between periods (per 10,000 cases) there were significant improvements in superficial surgical site infections (-19%, p = 0.0005), on ventilator longer than 48 hours (-15%, p = 0.012), graft/prosthesis/flap failure (-60%, p < 0.0001), acute renal failure (-25%, p = 0.023), and wound disruption (-34%, p = 0.011). Although mortality (per 10,000) was higher in period 2 (237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periods were calculated as $2,197,543 per 10,000 general and vascular surgery cases. CONCLUSIONS: Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.

General surgery at rural Tennessee hospitals: a survey of rural Tennessee hospital administrators.

Rural communities face an impending surgical workforce crisis. The purpose of this study is to describe perceptions of rural Tennessee hospital administrators regarding the importance of surgical services to their hospitals. In collaboration with the Tennessee Hospital Association, we developed and administered a 13-item survey based on a recently published national survey to 80 rural Tennessee hospitals in August 2008. A total of 29 responses were received for an overall 36.3 per cent response rate. Over 44 per cent of rural surgeons were older than 50 years of age, and 27.6 per cent of hospitals reported they would lose at least one surgeon in the next 2 years. The responding hospitals reported losing 10.4 per cent of their surgical workforce in the preceding 2 years. Over 53 per cent were actively recruiting a general surgeon with an average time to recruit a surgeon of 11.8 months. Ninety-seven per cent stated that having a surgical program was very important to their financial viability with the mean and median reported revenue generated by a single general surgeon being $1.8 million and $1.4 million, respectively. Almost 11 per cent of the hospitals stated they would have to close if they lost surgical services. Although rural Tennessee hospitals face similar difficulties to national rural hospitals with regard to retaining and hiring surgeons, slightly more Tennessee hospitals (54 vs 36%) were actively attempting to recruit a general surgeon. The shortage of general surgeons is a threat to the accessibility of comprehensive hospital-based care for rural Tennesseans.

Quality of life outcome measures following partial glossectomy: assessment using the UW-QOL scale.

BACKGROUND: The consequences of a diagnosis of head and neck cancer and the impact of treatment have a clear and direct influence on well-being and associated quality of life (QOL) in these patients. AIMS: To determine the QOL in head and neck cancer patients following a partial glossectomy operation. DESIGN AND SETTING: Cross-sectional cohort study; Head and Neck Oncology Unit, tertiary referral center. MATERIALS AND METHODS: 38 patients with partial glossectomy were assessed with the University of Washington head and neck quality of life (UW-QOL) scale, version 4. STATISTICAL ANALYSIS: Statistical analysis was performed using the Statistical Package for Social Sciences 10.0 (SPSS Inc, Chicago version III). Information from the scale was correlated using the Mann Whitney test. A P value less than/equal to 0.05 was considered as significant. RESULTS: The mean (sd) composite score of the QOL in our series was 73.6 (16.1). The majority (71.8%) quoted their QOL as good or very good. Swallowing (n = 16, 47.1%), speech (n = 15, 44.1%) and saliva (n = 15, 44.1%) were most commonly cited issues over the last 7 days. On the other hand, the groups with reconstruction, neck dissection, complications and radiotherapy demonstrated a significant reduction of quality of life scores (Mann Whitney test, P < 0.005). CONCLUSION: The composite score and overall QOL as assessed using the UW-QOL scale (version 4) were modestly high in our series of partial glossectomy patients. Swallowing, speech, and saliva are regarded as the most important issues. Stage of the disease, neck dissection, reconstruction, complications, radiotherapy and time since operation were seen to significantly affect domain scores.

The economic analyses of the UK prospective diabetes study.

An economic analysis was not initially included in the study design of the UK Prospective Diabetes Study (UKPDS). However, data were collected throughout the study on hospital drugs and medications used and these were supplemented near the end of the study by cross-sectional surveys of non-inpatient healthcare use and quality of life. Evaluations of tight vs. less tight blood pressure control, intensive vs. less conventional blood glucose control and metformin showed that each was highly cost-effective and that all could be provided at modest total cost. Further analyses showed that amputations and stroke had particularly severe consequences for quality of life, and that amputations and non-fatal MI had high cost consequences. Finally, patient-level data were used to construct a diabetes outcomes model, which estimates the probability of longer-term complications from patient-specific risk factors and can be used in populations at different stages of diabetes progression. The economic analyses arising from the UKPDS have provided new evidence to clinicians, policymakers and researchers on the consequences of diabetes and the cost-effectiveness of interventions, thereby assisting the development of treatment guidelines and improved standards of care. The analyses also illustrated a number of methodological innovations. Finally, the UKPDS Outcomes Model is gaining widespread acceptance as a validated tool for long-term economic and clinical prediction in diabetes.

When can group level clustering be ignored? Multilevel models versus single-level models with sparse data.

OBJECTIVE: The use of multilevel modelling with data from population-based surveys is often limited by the small number of cases per level-2 unit, prompting many researchers to use single-level techniques such as ordinary least squares regression. DESIGN: Monte Carlo simulations are used to investigate the effects of data sparseness on the validity of parameter estimates in two-level versus single-level models. SETTING: Both linear and non-linear hierarchical models are simulated in order to examine potential differences in the effects of small group size across continuous and discrete outcomes. Results are then compared with those obtained using disaggregated techniques (ordinary least squares and logistic regression). MAIN RESULTS: At the extremes of data sparseness (two observations per group), the group level variance components are overestimated in the two-level models. But with an average of only five observations per group, valid and reliable estimates of all parameters can be obtained when using a two-level model with either a continuous or a discrete outcome. In contrast, researchers run the risk of Type I error (standard errors biased downwards) when using single-level models even when there are as few as two observations per group on average. Bias is magnified when modelling discrete outcomes. CONCLUSIONS: Multilevel models can be reliably estimated with an average of only five observations per group. Disaggregated techniques carry an increased risk of Type I error, even in situations where there is only limited clustering in the data.

Does flexible videostroboscopy compare with rigid videostroboscopy in the assessment of the neoglottis? A preliminary report.

OBJECTIVE: To evaluate rigid and flexible stroboscopy of the neoglottis. STUDY DESIGN: Prospective pilot study set at a tertiary level Head & Neck Unit. PARTICIPANTS: Twenty-four patients recruited. All had undergone a total laryngectomy and were voicing using a Blom-singer valve. All had stroboscopic evaluation of their neoglottis using flexible and rigid endoscopes. MAIN OUTCOME MEASURES: A rating form was devised based on six parameters with clear definitions. Secondary measures included ability to tolerate the procedure and completeness of the rating form for each parameter using the two systems. RESULTS: There was good reliability between individual raters for the assessment of each system based on Spearman Rho correlation. Importantly, two-thirds of the patients were unable to tolerate the rigid videostroboscopy managed flexible videostroboscopy. Correlation between rigid and flexible videostroboscopy was poor for both raters. Flexible systems picked up more mucosal waves and allowed further analysis of the mucosal wave pattern. CONCLUSIONS: To our knowledge, this is the first study to demonstrate that fibreoptic videstroboscopy is as good as rigid videostroboscopy in the assessment of the neoglottis. In fact, flexible videostroboscopy should be routinely used, as it is better tolerated and allows a more detailed analysis of the neoglottis.

Multidimensional assessment of voice after vertical partial laryngectomy: a comparison with normal and total laryngectomy voice.

The aim of this cross-sectional cohort study was to analyze the acoustic, stroboscopic, and perceptual parameters in patients who had undergone vertical partial laryngectomy (VPL) and to compare them with normal subjects (N) and total laryngectomy (TL) patients. This study was carried out in a tertiary referral Cancer Services Centre. We analyzed data from a total of 51 individuals; six VPL patients, 27 TL patients, and 18 N subjects. Acoustic analysis and videostroboscopy were performed using a computerized speech studio. Perceptual analysis was carried out using the GRBAS scoring system. The mean ages in the three groups were 40.9+/-13.5 (N), 54.3+/-9.5 (VPL), and 63.9+/-10.5 years (TL). Acoustic analysis yielded the following results for N, VPL, and TL, respectively: median fundamental frequency (155.2, 224.9, 106.3 Hz), shimmer (0.6, 1.9, 1.3 dB), and jitter (0.3%, 3.3%, 4.2%). The median maximum phonation time was 21.8 (N), 9.4 (VPL), and 10.3 seconds (TL). The median words per minute (WPM) were 168.5 (N), 126 (VPL), and 127 WPM (TL). Acoustic analysis of VPL voice was significantly different from normal voice (Mann-Whitney, P<0.05) and approximated better to TL parameters. The results of TL and VPL groups show poorer values and larger variability for nearly all the quantitative measures as compared to N subjects. Videostroboscopy demonstrated variable level and amount of closure of the vibrating segment in the reconstructed larynx of the VPL group. VPL GRBAS scores were similar to TL scores with good interrater reliability. The multidimensional assessment of voice in VPL patients is significantly worse than in N subjects and more closely resembles that of patients who have undergone TL with surgical voice restoration.

Postlaryngectomy vocal rehabilitation: assessment using a validated questionnaire in 51 patients.

BACKGROUND: This study aimed to assess valved speech and related issues in total laryngectomy patients with the help of the validated Voice Prosthesis Questionnaire (VPQ). PATIENTS AND METHODS: We identified 61 patients who had undergone a surgical voice restoration with a valve following total laryngectomy and who were sent the VPQ by mail. RESULTS: Fifty-one patients (37 males) completed the questionnaire giving a response rate of 83.6%. Fifty-three percent of the patients (n = 27) were fully aware of the dimensions of their valve including the length and diameter, whilst 25% (n = 13) were aware of only one of the two. There was a strong correlation between the patient's perception of tone and their gender with the tone scores significantly lower in women as compared to men (Mann-Whitney test, p = 0.04). Ten patients (19.6%) had had leakage-related issues during the previous 7 days. CONCLUSIONS: This questionnaire provided a significant amount of valuable data. Based on our experience, we recommend the VPQ for prospective use in the serial monitoring and audit of total laryngectomy patients.

Voice-related Quality of Life in laryngectomees: assessment using the VHI and V-RQOL symptom scales.

The primary purpose of this study was to investigate the effect of the voice impairment across the physical, emotional, and functional domains in patients using valved speech following total laryngectomy with the help of two symptom specific scales. The study design used was a cross-sectional cohort. The setting was the Head and Neck Oncology Unit of a tertiary referral centre. Subjects were 54 patients who had undergone total laryngectomy. Two voice-specific questionnaires, the Voice-Related Quality of Life (V-RQOL-short form) Measure, and the Voice Handicap Index (VHI-long form) were used. The main outcome measure was patient perception of the voice following total laryngectomy in response to specific questions correlated with sociodemographic/treatment factors. Responses were received from 40 males and 14 females (response rate of 85.7%) with a median age of 63.4 years (range: 37-84). The V-RQOL overall analysis showed that 3 patients (5.6%) scored "excellent," 29 patients (53.7%) "fair to good," 14 patients (25.9%) "poor to fair," and 8 patients (14.8%) "poor." Analysis of the VHI revealed that 20 patients (37.0%) had a minimal handicap, 20 patients (37.0%) a moderate handicap, and 14 patients (25.9%) had a serious voice handicap. The individual domain or subscale scores for the VHI revealed a mean (SD) functional score of 15.8 (7.7), a physical score of 13.6 (7.2), and finally an emotional score of 11.6 (8.9). Functional aspects of the voice were significantly affected by age, radiotherapy, and chemotherapy (Spearman rho, P=0.01; Mann-Whitney, P=0.04 and P=0.01). The physical aspects of the voice were significantly affected by age and chemotherapy (Spearman rho, P=0.004; Mann-Whitney, P=0.04). Only age significantly affected the emotional aspects of the voice (Spearman rho, P=0.002). We found a strong correlation (Spearman rho, P<0.001) between the V-RQOL and VHI questionnaires. Our study revealed that the V-RQOL and VHI scores in our series of patients following voice restoration in laryngectomees were consistent with that reported in the literature. Only age, radiation, and chemotherapy were seen to influence the voice handicap scores. In addition, both symptom scales had good correlation between them and either one could be used with reliability in laryngectomees with a few modifications.

Quality of life following total laryngectomy: assessment using the UW-QOL scale.

OBJECTIVES: To determine the quality of life (QOL) in patients using valved speech following total laryngectomy with a validated patient self-report scale. STUDY DESIGN: Cross-sectional cohort study. PATIENTS: 63 patients following total laryngectomy using valved speech. INTERVENTION: University of Washington Quality of Life (UW-QOL) questionnaire. MAIN OUTCOME MEASURES: Patient perception of the QOL over the last 7 days following total laryngectomy in response to specific questions and correlated with sociodemographic and treatment factors. RESULTS: Responses were received from 44 males and 11 females (response rate: 87.3%) with a median age of 66 years (range: 40-84). The mean (SD) composite score of the QOL in our series of patients with total laryngectomy was 81.3 (10.9). As regards the overall QOL, 80% of our patients cited it as very good (45.5%) to good (34.5%). Patients identified speech, appearance, and activity as the most important issues following total laryngectomy. Only age and pharyngo-oesophageal segment closure were significant predictors of QOL scores (Student t test, p < 0.05) and not other demographic and treatment variables. CONCLUSIONS: The composite score and overall QOL were high in our series of total laryngectomy patients and this possibly reflects adequate multidisciplinary management. We strongly urge the use of prospective longitudinal studies that will adequately identify any QOL changes over time. Although the UW-QOL questionnaire is a simple and brief scale, it has limitations that can curtail its effective use in laryngectomy patients and we advise supplementing it with the use of domain-specific questionnaires.

Multidimensional assessment of female tracheoesophageal prosthetic speech.

OBJECTIVE: The objective of this study was to undertake a multidimensional assessment of female tracheoesophageal prosthetic speech. STUDY DESIGN: A cross-sectional cohort study. SETTING: Head and Neck Unit in a tertiary oncology referral centre. PATIENTS: Ten female and 10 male total laryngectomy patients with no signs of recurrence and using voice prosthesis were compared to 10 normal female speakers. INTERVENTION(S): Electroglottographic and acoustic analysis of voice parameters for both sustained vowel /i/ and connected speech, perceptual evaluation using GRBAS (with 2 experienced raters) and questionnaire assessment using the University of Washington Quality of Life and the Voice Handicap Index. Statistical analysis was done using the Statistical Package for Social Sciences, (v. 14, SPSS Inc., Chicago III). RESULTS: Median age of the female larygectomy patients was 65 years (range: 41-81), that of male laryngectomees was 66.5 years (range: 40-79) and that of the normal female subjects was 47.5 years (range: 35-72). All electroglottographic, acoustic parameters and GRBAS ratings of the female laryngectomy patients were significantly worse as compared with the normal female subjects. The median fundamental frequency (111.8 Hz) was comparable to male tracheoesophageal speakers (115.8 Hz). Mean composite University of Washington Quality of Life score and overall Voice Handicap Index score was 79.3(12.5) and 47.5(27.6) for the female laryngectomy patients and for the males was 81.2 (9.6) and 39.4(18.7). CONCLUSIONS: Gender frequency differences as seen in normal subjects are lost following a laryngectomy operation as evidenced by electroglottographic and perceptual data. Although the quality of life scores are comparable to the male tracheoesophageal speakers, they exhibit a greater voice handicap as compared to their male counterparts.

Can objective parameters derived from videofluoroscopic assessment of post-laryngectomy valved speech replace current subjective measures? An e-tool-based analysis.

OBJECTIVES: The primary purpose of this study was to assess the pharyngoesophageal segment in total laryngectomy patients using a videofluoroscopy e-tool. STUDY DESIGN: Cross-sectional study. SETTING: Head and Neck Oncology Unit, Tertiary Referral Centre. PATIENTS: Forty-two patients following total laryngectomy. INTERVENTION: Videofluoroscopy using an e-tool (JRuler). MAIN OUTCOME MEASURES: Subjective and objective videofluoroscopy parameters correlated with the GRBAS scale and treatment variables. RESULTS: Of 32 men and 10 women, mean age 63.5 years (10.8) the majority (64.3%) had a reasonable voice (good = 11 and poor = 4 patients). Comparing subjective and objective parameters, significant correlations were only seen with a smaller minimal neoglottic distance at phonation with no regurgitation of barium at phonation (P = 0.05) and a type 1 shape of neoglottis at phonation (P = 0.02). There were also significant correlations between smaller maximum sub-neoglottic distance at phonation and type 1 shape of neoglottis (P = 0.02), smaller maximum sub-neoglottic distance at rest and absence of stasis of barium at phonation (P = 0.05) and the length of neoglottis at phonation and type 1 shape of neoglottis (P = 0.01). For perceptual evaluation, significant correlation was seen only between G1 voice and a smaller minimal neoglottic distance at phonation (P = 0.03) amongst the subjective and objective parameters. There were no correlations between visual parameters and the clinical parameters. CONCLUSIONS: Our observations suggest that this interesting concept has limitations. While objective and quantifiable data can be obtained using videofluoroscopy in laryngectomees, only a few correlate with each other and with voice quality.

Cost-utility analyses of intensive blood glucose and tight blood pressure control in type 2 diabetes (UKPDS 72).

AIMS/HYPOTHESIS: This study estimated the economic efficiency (1) of intensive blood glucose control and tight blood pressure control in patients with type 2 diabetes who also had hypertension, and (2) of metformin therapy in type 2 diabetic patients who were overweight. METHODS: We conducted cost-utility analysis based on patient-level data from a randomised clinical controlled trial involving 4,209 patients with newly diagnosed type 2 diabetes conducted in 23 hospital-based clinics in England, Scotland and Northern Ireland as part of the UK Prospective Diabetes Study (UKPDS). Three different policies were evaluated: intensive blood glucose control with sulphonylurea/insulin; intensive blood glucose control with metformin for overweight patients; and tight blood pressure control of hypertensive patients. Incremental cost : effectiveness ratios were calculated based on the net cost of healthcare resources associated with these policies and on effectiveness in terms of quality-adjusted life years gained, estimated over a lifetime from within-trial effects using the UKPDS Outcomes Model. RESULTS: The incremental cost per quality-adjusted life years gained (in year 2004 UK prices) for intensive blood glucose control was 6,028 UK pounds, and for blood pressure control was 369 UK pounds. Metformin therapy was cost-saving and increased quality-adjusted life expectancy. CONCLUSIONS/INTERPRETATION: Each of the three policies evaluated has a lower cost per quality-adjusted life year gained than that of many other accepted uses of healthcare resources. The results provide an economic rationale for ensuring that care of patients with type 2 diabetes corresponds at least to the levels of these interventions.

The impact of diabetes-related complications on healthcare costs: results from the United Kingdom Prospective Diabetes Study (UKPDS Study No. 65).

AIMS: To develop a model for estimating the immediate and long-term healthcare costs associated with seven diabetes-related complications in patients with Type 2 diabetes participating in the UK Prospective Diabetes Study (UKPDS). METHODS: The costs associated with some major complications were estimated using data on 5102 UKPDS patients (mean age 52.4 years at diagnosis). In-patient and out-patient costs were estimated using multiple regression analysis based on costs calculated from the length of admission multiplied by the average specialty cost and a survey of 3488 UKPDS patients' healthcare usage conducted in 1996-1997. RESULTS: Using the model, the estimate of the cost of first complications were as follows: amputation pound 8459 (95% confidence interval pound 5295, pound 13 200); non-fatal myocardial infarction pound 4070 ( pound 3580, pound 4722); fatal myocardial infarction pound 1152 ( pound 941, pound 1396); fatal stroke pound 3383 ( pound 1935, pound 5431); non-fatal stroke pound 2367 ( pound 1599, pound 3274); ischaemic heart disease pound 1959 ( pound 1467, pound 2541); heart failure pound 2221 ( pound 1690, pound 2896); cataract extraction pound 1553 ( pound 1320, pound 1855); and blindness in one eye pound 872 ( pound 526, pound 1299). The annual average in-patient cost of events in subsequent years ranged from pound 631 ( pound 403, pound 896) for heart failure to pound 105 ( pound 80, pound 142) for cataract extraction. Non-in-patient costs for macrovascular complications were pound 315 ( pound 247, pound 394) and for microvascular complications were pound 273 ( pound 215, pound 343) in the year of the event. In each subsequent year the costs were, respectively, pound 258 ( pound 228, pound 297) and pound 204 ( pound 181, pound 255). CONCLUSIONS: These results provide estimates of the immediate and long-term healthcare costs associated with seven diabetes-related complications.

Assessment of nicotine dependence symptoms in adolescents: a comparison of five indicators.

OBJECTIVE: To examine the psychometric properties, test-retest reliability, and convergent construct validity of five indicators of nicotine dependence (ND) symptoms in adolescents. DESIGN: Analysis of baseline data from a prospective study on the natural history of ND in 1264 adolescents aged 12-13 years. SETTING: Ten Montreal high schools. SUBJECTS: 233 grade 7 students who had smoked cigarettes one or more times in the three months preceding the baseline data collection. MAIN OUTCOME MEASURES: Five indicators of ND symptoms including two that are multi-dimensional (a proxy measure of ICD-10 criteria for tobacco dependence; the Hooked on Nicotine Checklist (HONC)) and three new indicators of "symptom clusters" that emerged from principal component analysis (ND/cravings, withdrawal symptoms, self medication). RESULTS: All five indicators demonstrated acceptable internal and test-retest reliability. The correlation between the HONC and ND/cravings was 0.910. All other correlations between indicators ranged between 0.716-0.824. There was considerable overlap in the independent correlates identified for each indicator. CONCLUSIONS: All five indicators performed well psychometrically. Until the meaning, relative importance, and usefulness of each scale is clarified in longitudinal work, decisions regarding which scale(s) are most informative will depend more on the content of the scales, the need for a multi- or unidimensional indicator, and whether or not the scale is theory based.