An economic analysis of immediate delivery and expectant monitoring in women with hypertensive disorders of pregnancy, between 34 and 37 weeks of gestation (HYPITAT-II).

OBJECTIVE: To assess the economic consequences of immediate delivery compared with expectant monitoring in women with preterm non-severe hypertensive disorders of pregnancy. DESIGN: A cost-effectiveness analysis alongside a randomised controlled trial (HYPITAT-II). SETTING: Obstetric departments of seven academic hospitals and 44 non-academic hospitals in the Netherlands. POPULATION: Women diagnosed with non-severe hypertensive disorders of pregnancy between 340/7 and 370/7  weeks of gestation, randomly allocated to either immediate delivery or expectant monitoring. METHODS: A trial-based cost-effectiveness analysis was performed from a healthcare perspective until final maternal and neonatal discharge. MAIN OUTCOME MEASURES: Health outcomes were expressed as the prevalence of respiratory distress syndrome, defined as the need for supplemental oxygen for >24 hours combined with radiographic findings typical for respiratory distress syndrome. Costs were estimated from a healthcare perspective until maternal and neonatal discharge. RESULTS: The average costs of immediate delivery (n = 352) were €10 245 versus €9563 for expectant monitoring (n = 351), with an average difference of €682 (95% confidence interval, 95% CI -€618 to €2126). This 7% difference predominantly originated from the neonatal admissions, which were €5672 in the immediate delivery arm and €3929 in the expectant monitoring arm. CONCLUSION: In women with mild hypertensive disorders between 340/7 and 370/7  weeks of gestation, immediate delivery is more costly than expectant monitoring as a result of differences in neonatal admissions. These findings support expectant monitoring, as the clinical outcomes of the trial demonstrated that expectant monitoring reduced respiratory distress syndrome for a slightly increased risk of maternal complications. TWEETABLE ABSTRACT: Expectant management in preterm hypertensive disorders is less costly compared with immediate delivery.

[Memorandum 'Development of health services research in Bavaria from the perspective of the Bavarian State Working Group 'Health Services Research (LAGeV)': status quo - potential - strategies']. / Memorandum "Weiterentwicklung der Gesundheitsversorgungsforschung in Bayern aus Sicht der Landesarbeitsgemeinschaft Gesundheitsversorgungsforschung: Status quo - Entwicklungspotenziale - Strategien".

The aim of the memorandum on the development of health services research (HSR) in Bavaria is to operationalise the global objectives of the State Working Group "Health Services Research" (LAGeV) and to collectively define future topics, specific implementation steps, methods as well as ways of working for the future course of the LAGeV. The LAGeV is an expert committee that integrates and links the competencies of different actors from science, politics and health care regarding HSR and facilitates their cooperation. The memorandum is based on an explorative survey among the LAGeV members, which identified the status quo of health services research in Bavaria, potential for development, important constraints, promoting factors, specific recommendations as well as future topics for the further development of HSR in Bavaria. From the perspective of the LAGeV members, the 12 most important future topics are: 1) Interface and networking research, 2) Innovative health care concepts, 3) Health care for multimorbid patients, 4)Health care for chronically ill patients, 5) Evaluation of innovations, processes and technologies, 6) Patient orientation and user focus, 7) Social and regional inequalities in health care, 8) Health care for mentally ill patients, 9) Indicators of health care quality, 10) Regional needs planning, 11) Practical effectiveness of HSR and 12) Scientific use of routine data. Potential for development of HSR in Bavaria lies a) in the promotion of networking and sustainable structures, b) the establishment of an HSR information platform that bundles information and results in regard to current topics and aims to facilitate cooperation as well as c) in the initiation of measures and projects. The latter ought to pinpoint health care challenges and make recommendations regarding the improvement of health care and its quality. The cooperation and networking structures that were established with the LAGeV should be continuously expanded and be used to work on priority topics in order to achieve the global objectives of the LAGeV.

Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System.

OBJECTIVES: Although there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays in the complex relationship between economic conditions and suicide. The aims were to compare the postmortem alcohol intoxication rates among male and female suicide decedents before (2005-2007), during (2008-2009) and after (2010-2011) the economic contraction in the USA. METHODS: Data from the restricted National Violent Death Reporting System (2005-2011) for male and female suicide decedents aged 20 years and older were analysed by Poisson regression analysis to test whether there was significant change in the fractions of suicide decedents who were acutely intoxicated at the time of death (defined as blood alcohol content ≥0.08 g/dL) prior, during and after the downturn. RESULTS: The fraction of all suicide decedents with alcohol intoxication increased by 7% after the onset of the recession from 22.2% in 2005-2007 to 23.9% in 2008-2011. Compared with the years prior to the recession, male suicide decedents showed a 1.09-fold increased risk of alcohol intoxication within the first 2 years of the recession. Surprisingly, there was evidence of a lag effect among female suicide decedents, who had a 1.14-fold (95% CI 1.02 to 1.27) increased risk of intoxication in 2010-2011 compared with 2005-2007. CONCLUSIONS: These findings suggest that acute alcohol intoxication in suicide interacts with economic conditions, becoming more prevalent during contractions.

The access rate to diagnosis and treatment modalities in breast cancer patients in Turkey; multicenter observational study.

PURPOSE: To determine the time elapsed between the first notification of the disease and the access to the diagnosis and treatment modalities and the associated factors in female patients with breast cancer in Turkey. METHODS: Data was acquired from a questionnaire involving 535 patients who applied to 14 various oncology clinics in Turkey between 1st and 28th of February 2010. Analyses were performed by the participating clinics and were divided into 3 groups: centers located in metropolitan areas formed group 1 (n=161), those located in Marmara and central Anatolia region formed group 2 (n=189), and centers located in Karadeniz and East-Southeast Anatolia region formed group 3 (n=185). The groups of these centers were formed according to the socioeconomic development of the provinces. RESULTS: The median patient age was 48 years, 56.1% of patients were less than 50 years of age. Eighty-five percent of the patients detected a mass in their breast by self examination and 27% of the patients older than 50 years never had breast imaging until the definite diagnosis was established. The median time elapsed between disease noticed by the patient and application to a health care center was 10 days, between application and biopsy 19 days, between biopsy and surgery 10 days, and between surgery and systemic therapy 31 days. The median time elapsed between patients applying for surgery in groups 1 and 2 centers was 11 and 21 days, respectively (p=0.01). The median time elapsed between biopsy and surgery in groups 1,2 and 3 centers was 14,1.5, and 12 days, respectively (p<0.05). CONCLUSION: A high level of awareness regarding breast cancer in our country is related with the time that is defined as 10 days between disease recognition and medical application. The time elapsed between the application and biopsy, surgery and systemic therapy was longer compared with the corresponding figures in developed countries.

An assessment of cinacalcet HCl effects on bone histology in dialysis patients with secondary hyperparathyroidism.

AIMS: Cinacalcet lowers plasma parathyroid hormone (PTH) levels in patients with secondary hyperparathyroidism (sHPT), but the bone histologic response has not been described. This prospective, double-blind, placebo-controlled trial assessed the effects of cinacalcet on bone histology and serum markers of bone metabolism in dialysis patients with sHPT. METHODS: Patients with intact PTH (iPTH) > or = 300 pg/ml were randomly assigned 2:1 to receive cinacalcet or placebo with concurrent vitamin D and/or phosphate binder therapy. Cinacalcet (30 - 180 mg/day) was used to achieve iPTH levels < or = 200 pg/ml. Bone biopsies were performed before and after one year of treatment. RESULTS: Baseline and end-of-study data were available from 32 patients (19 cinacalcet, 13 placebo). Baseline bone turnover was elevated in 27, reduced in 3 and normal in 2 patients. Serum bone-specific alkaline phosphatase (BSAP) and N-telopeptide (NTx) were elevated. Cinacalcet treatment decreased PTH and diminished activation frequency, bone formation rate/bone surface, and fibrosis surface/bone surface. Adynamic bone was observed in three patients receiving cinacalcet; in two of these, PTH levels were persistently low (< 100 pg/ml). The histomorphometric parameter changes in bone corresponded to PTH, BSAP and NTx reductions. Bone mineralization parameters remained normal. CONCLUSIONS: Treatment with cinacalcet lowered PTH and reduced bone turnover and tissue fibrosis among most dialysis patients with biochemical evidence of sHPT.

Living-donor versus cadaveric liver transplantation for non-resectable small hepatocellular carcinoma and compensated cirrhosis: a decision analysis.

BACKGROUND: Cadaveric liver transplantation is effective for nonresectable early hepatocellular carcinoma. However, the scarcity of cadaveric organs has prompted some centers to use living donors, which guarantees transplantation, but entails a risk to the donor. In the absence of controlled trials, decision analysis can be used to help explicate the tradeoffs involved when considering living donor versus cadaveric liver transplantation for nonresectable early hepatocellular carcinoma. METHODS: Using a Markov model, a hypothetical cohort of patients with Child's A cirrhosis and a single 3.5-cm tumor received one of three strategies: 1) no transplant; 2) intent to perform cadaveric liver transplantation; or 3) living donor liver transplantation. Data were obtained from natural history and retrospective studies. All probabilities in the model were varied simultaneously using a Monte Carlo simulation. RESULTS: Living-donor liver transplantation was the best strategy, improving life expectancy by 4.5 years compared with cadaveric liver transplantation. This strategy remained dominant even when varying severity of cirrhosis, age, tumor doubling time, tumor growth pattern, blood type, regional transplant volume, initial tumor size, and rate of progression of cirrhosis. CONCLUSIONS: Living-donor liver transplantation should confer a substantial survival advantage for patients with compensated cirrhosis and non-resectable early stage hepatocellular carcinoma.

Assessment of Host-Induced Selection on Three Geographic Isolates of Heterodera schachtii Using RAPD and AFLP Markers.

ABSTRACT The hypothesis that host plants exert selection pressure on Heterodera schachtii populations was tested. Host selection of genotypes from three genetically distinct isolates of H. schachtii was assessed using cabbage, sugar beet, oilseed radish (Raphanus sativus), and white mustard (Sinapis alba). The plants represent a range of susceptibility to H. schachtii and included R. sativus and S. alba, because cultivars of those species have been used as trap crops for H. schachtii in Europe. Genotypic differences in amplified fragment length polymorphism (AFLP) and random amplified polymorphic DNA (RAPD) markers were detected among the isolates after they reproduced on the different hosts. The poorest host plant, R. sativus, resulted in the greatest number of changes in both AFLP and RAPD markers. Oilseed radish selected nematode genotypes in less than four nematode generations. The nematode population genotypes detected by RAPD analyses after selection on oilseed radish were observed even after nematode populations were transferred back to the other three hosts. The genetic markers that were detected after selection were influenced by the genotypes of the original nematode isolates. The results indicate the utility of RAPDs and AFLPs for identifying and monitoring intraspecific genetic variability in nematodes and for understanding nematode population responses to host plants. Nematode management practices such as using resistant cultivars may alter gene frequencies, thereby reducing the efficacy of the tactic and exacerbating the nematode's potential to damage subsequent crops.

Prevention of elderly suicide. Physicians' assessment of firearm availability.

INTRODUCTION: Physicians have a unique role to play in the prevention of elder suicide, yet they may not be sufficiently attentive to the prominence of firearms in the rising trend in suicide by elder persons. This study sought to examine the extent to which physicians inquired about firearms with their depressed and suicidal elderly patients and further identified factors associated with physicians' likelihood of asking about firearms. METHODS: A probability sample of 300 primary care physicians in Illinois was drawn from the American Medical Association Physician Masterfile. Physicians were chosen from the specialties most likely to be involved with elderly persons: internal medicine and family practice. A mailed questionnaire yielded a 63% response rate. RESULTS: Although they were treating depressed and suicidal older patients, a sizable proportion of the respondents (42%) reported that they did not ask such patients or their family members whether they had access to a firearm. Several factors distinguished physicians who assessed for firearms from those who did not. The most salient predictors were: continuing medical education training in suicide risk assessment, expertise in geriatric mental health, confidence in diagnosing depression, having a patient mention suicide in the past year, and indicating patient reluctance as a barrier to mental health treatment. DISCUSSION: Physicians working with depressed and suicidal elderly persons need to be informed about the prevalence of elder suicide and about the likelihood of elderly persons using firearms as a method of suicide. Effective suicide prevention will require physician training that directly addresses geriatric mental health and firearm suicide, in particular, at the student, residency, and continuing education levels.

Scatter and attenuation correction for 111In based on energy spectrum fitting.

A combined scatter and attenuation correction that does not require a transmission scan is proposed for 111In imaging. Estimates of the unscattered intensity at both 171 and 245 keV are obtained by fitting the observed energy spectrum at each pixel or region of interest using the measured scatter-free spectrum and a simple model for scatter. The scatter model for the 171 keV peak accounts for scatter contributed by both the 171 and 245 keV emissions. After correcting for scatter, the attenuation is estimated from the observed ratio of photopeak intensities using the known difference in attenuation at the two emission energies and a model based on a point source in water. Accurate scatter correction is a prerequisite for the success of this method because scatter from the higher energy emission will otherwise contaminate the lower photopeak. This differential attenuation method (DAM) of estimating attenuation is demonstrated and calibrated using a series of point source measurements with a wedge-shaped attenuator. The observed absolute and differential attenuation are in good agreement with the narrow-beam linear attenuation coefficients for water. Estimates of precision suggest a depth resolution of 1.0-2.5 cm for realistic count densities over the clinically relevant depth range (0-25 cm). The accuracy of DAM in a more realistic attenuation environment is assessed using a hot sphere inside the anthropomorphic data spectrum torso phantom viewed from several angles (with differing attenuation). Finally, the potential of DAM for SPECT attenuation correction was investigated by computer simulation using the SIMSET Monte Carlo software. Preliminary results based on measured planar data and simulated SPECT data indicate that DAM can improve the quality and quantitative accuracy of 111In images. In one SPECT simulation study, the average error in tumor to soft-tissue ratios was reduced from 32% for uncorrected data to 8% for data corrected with DAM. However, the technique is susceptible to significant noise amplification and can cause substantial streak artifacts in low-count SPECT studies if sufficient smoothing of the depth estimates is not performed.

The Adolescent Sexual Interest Card Sort: test-retest reliability and concurrent validity in relation to phallometric assessment.

Test-retest reliability and concurrent validity studies on the Adolescent Sexual Interest Card Sort (ASIC) were conducted in two samples of 38 juvenile sexual offenders, each. Of the 64 items of the ASIC, 60 were found to be significantly correlated across test administrations. Cronbach's coefficient alpha was employed to determine the internal consistency of ASIC items. Coefficients ranged from .62 to .96 across categories, with an overall alpha of .97. Client ratings of sexual interests via the Card Sort were correlated with phallometric response to similar categories of stimuli. Significant correlations were found for only 4 of the 14 categories examined, suggesting little correspondence between client report of sexual interest on the ASIC and phallometric assessment of the same. Findings are consistent with the adult sex offender literature suggesting that self-report measures are particularly vulnerable to dissimulation and often at variance with more objective measurement. Clinical and research issues pertinent to the measurement of sexual arousal and interest in juvenile sexual offenders are discussed.

Suicide assessment: clinical interview vs. self-report.

This study examined whether patients disclosed the same information about suicidal behaviors on a self-report instrument that they conveyed to a clinician in a face-to-face interview. The results indicated a generally high level of agreement between these two forms of suicide assessment. The one exception was the question that concerns recent suicidal ideation, where patients tended to disclose more on the self-report form.

[A comprehensive radioisotope assessment of the effectiveness of Ferrum Lek in patients with iron-deficiency anemia]. / Kompleksnaia radioizotopnaia otsenka éffektivnosti preparata Ferrum Lek u bol'nykh zhelezodefitsitnoi anemiei.

Before and after treatment iron metabolism was evaluated in 37 iron deficient women given intravenous Ferrum Lek. In addition to standard blood counts and serum iron tests, iron metabolism was investigated with Fe-59 whole body radiometry in a low-background camera. The treatment effect was assessed in 1.3 and 6 months. The red blood cells and iron content in the serum returned to normal values. The effect persisted for 6 months. The initial 3 months iron accumulated in the depot, being further distributed in the blood. Total body iron 6 months after the treatment was at the baseline levels. It is thought adequate to use Ferrum Lek in the management of women with iron deficiency anemia.

Assessment of thyroid function during pregnancy.

Assessment of a woman's thyroid function often is necessary during pregnancy, since either uncorrected hypothyroidism or hyperthyroidism can adversely affect pregnancy outcome. Pregnancy-induced changes in thyroid hormone economy, particularly the major alterations in thyroid hormone binding to serum proteins, change the results of some commonly used thyroid hormone measurements. In vivo isotopic testing, including scintiscanning and thyroid radioiodine uptakes, cannot be used. Because of advances in assay technology, the best strategy for thyroid function assessment is now based on a high sensitivity serum thyroid-stimulating hormone (S-TSH) measurement as the first-line test. When S-TSH levels are high, indicating hypothyroidism, follow-up tests include serum free T4 and, if appropriate, antithyroid antibody measurements. The great majority of cases of hypothyroidism are due to Hashimoto's thyroiditis or prior thyroid ablation for hyperthyroidism or thyroid cancer. When S-TSH levels are low, suggesting hyperthyroidism, confirmatory tests are serum free T4 and free T3 measurements. Graves' disease is by far the most common cause of hyperthyroidism during pregnancy. Other causes, including those mediated by high hCG levels, can be distinguished from Graves' disease by careful clinical evaluation.