[Effects of vertical banded gastroplasty on weight, quality of life and nutrition].

We examined the long term results of vertical banded gastroplasty 3-10 years after operation. They were assessed by weight lost, incidence and severity of untoward effects and improvement in diet and in quality of life in 75 of 122 who had had the operation. Average weight lost was 28.5 +/- 14.9 kg (p < 0.001) in 5 years and 58.6 +/- 30.4% of excess weight, which brought patients to within 32 +/- 25.2% of ideal weight. According to these measures, in 63-76% the operation had been successful in causing weight loss. The 2 criteria for successful weight loss were loss of more than 50% of weight in excess of ideal body weight and residual body weight less than 50% greater than ideal body weight. There was a greater risk of failure in unmarried subjects older than 45 (odds ratio for not losing weight was 6; in those weighing more than 120 kg it was 9). We saw evidence of this mostly 4 years after operation (odds ratio 11). The degree of success in weight loss was correlated with texture of food (softness) preferred and length of operation. Of those interviewed, only 65% were satisfied with their results. The greatest improvement in quality of life measurements was in physical activity, perception of health, and frequency of feeling depressed. Side-effects were vomiting, reflux and fatigue. Only 34.7% were able to digest solid foods, so that subjects are at risk for nutritional deficiencies.

The monetary costs of childhood cancer to the families of patients.

The medical costs of cancer treatment are well described, but there are few reports of expenses incurred by families of children with malignant disease. The objective of this study was to describe the monetary costs borne by families of patients with childhood cancer and to determine whether these costs represent an important component of the burden of illness. Families completed a prospective diary survey about daily expenses incurred during each sample week of therapy. We also undertook a retrospective, cross-sectional questionnaire survey about expenses, incurred during the entire duration of treatment, associated with major or one-time cost items. Seventy families of children treated for high risk acute lymphoblastic leukemia, 19 families of children treated for Wilms' tumor stages 2-5, and 16 families of children treated for neuroblastoma stages 3 and 4 completed diaries or questionnaires detailing the costs resulting from the diseases and their treatment. The mean total expenses (in 1986 Canadian dollars) incurred by families of childhood cancer patients over the entire course of therapy are $26,070 for acute lymphoblastic leukemia? $20,074 for Wilms' tumour, and $10,376 for neuroblastoma. On-going weekly costs rather than major one-time purchases account for the largest share of expenses. Overall, in spite of universal first dollar coverage for medical care in Canada, family-borne costs during the course of these illnesses are at least one-third of the average family's after-tax income.

[Cost of insulin-dependent diabetes vs cost of its prevention].

Accumulating evidence suggests that insulin-dependent diabetes mellitus (IDDM) is an autoimmune disease which can be predicted from immunologic markers. Encouraging results of recent IDDM prevention trials with insulin raises the question of cost benefit of such procedures, in addition to the obvious medical benefit. We estimated the expected cost benefit of national screening and preventive efforts in Israel (population 5 million in 1993). Due to the expense of immunological testing, we considered only relatives of IDDM patients who have a 3-5% risk of developing overt disease. Our screening showed that 225 (3.4%) of 7500 in this group (aged 1-54 years) carried islet autoantibodies, and about 50% progressed to diabetes within 3 years. The cost of testing for serological and metabolic markers was $6000 per subject; an additional $3,000 per subject is estimated to be the cost of preventive treatment. On comparing these numbers to only the minimal, life-long, direct cost of an IDDM patient ($30,000, based on 3 different analyses), we conclude that there is a cost benefit of programs for screening for IDDM and preventive treatment.

A hospice/palliative medicine rotation for fellows training in hematology-oncology.

A clinical hospice/palliative medicine rotation for physicians enrolled in a three-year hematology/oncology fellowship was established in academic year 1993-1994 as a way to accomplish important training goals in pain management and the palliative care of patients with terminal illness. This study was conducted to obtain initial information about its effectiveness. Ten fellows, one at a time, evaluated new hospice/palliative medicine consultations, supervised the care of patients on an inpatient hospice/palliative care unit, and visited patients at home. For the first 13 months, seven fellows were assigned to this rotation for one month each, and three fellows were assigned to spend two separate months each. A self-report evaluation of the experience was administered at the end of each service month. In five of these 13 evaluations, the fellows reported their skills in managing pain and symptoms to be much improved, and in eight they indicated their skills were improved; none stated that there had been no change. Comfort and skill with discussing death, dying, and advanced directives with patients and families were reported by the fellows to be much improved in nine evaluations, improved in three, and unchanged in one. In nine evaluations, the fellows reported their understanding of hospice/palliative care as a program and approach to patient care was much improved; in two, improved; and in two, unchanged. All of the fellows would recommend this rotation to other fellows. A clinical rotation in palliative medicine and hospice care is a useful addition to the curriculum of fellows training in hematology-oncology.

The comprehensive assessment of health status in survivors of childhood cancer: application to high-risk acute lymphoblastic leukaemia.

The health status of 69 survivors of high-risk acute lymphoblastic leukaemia (ALL) is assessed using a multi-attribute classification system. Seven attributes are included: sensation, mobility, emotion, cognition, self-care, pain and fertility. Three to five levels of functioning are defined for each attribute. Comprehensive health states are described as a specific combination of seven attribute levels. The system captures combinations of sequelae. The system provides a compact but comprehensive tool for long term follow up of survivors of childhood cancer. The results underscore the cognitive and emotional burdens of morbidity affecting survivors of high-risk ALL.

Regional differences in appropriateness of cholecystectomy in a prepaid health insurance system.

BACKGROUND: Previous studies have reported variation in the population-based use rate of diagnostic and therapeutic procedures. Cholecystectomy is one of the most common surgical procedures, and we conducted this study to assess whether in Israel the use of this procedure varied by region and whether differences in use can be related to differences in appropriateness of use. In Israel, there is a pre-paid health insurance system and all surgeons are salaried. METHODS: Age-adjusted rates of cholecystectomy in four hospitals, each serving a defined population in Israel, were calculated. Two hundred and sixty-six potential clinical indications for performing cholecystectomy were rated as to their appropriateness by a panel of 9 expert physicians. A trained team abstracted the medical records of all patients who underwent the operation in the four Israeli hospitals in 1986 (n = 702) and recorded the clinical indication for the surgery. RESULTS: The population-based age-adjusted rates of cholecystectomy varied over threefold among the four hospitals. 29% of the cholecystectomies were performed for less than appropriate reasons, and this figure varied by hospital from 36% to 17% (p = 0.002). However, appropriateness did not vary systematically with the population-based use rate. CONCLUSION: Cholecystectomy was performed frequently for inappropriate or equivocal reasons, even in a country in which resources are limited, and physicians are salaried. Efforts to improve surgical decision making should be undertaken.

Legal and policy aspects of home care coverage.

Home health care is a compassionate, cost-effective, and practical alternative for some individuals who require long-term or constant care. However, the coverage of home health care costs is far from comprehensive under the Medicare, Medicaid, and private pay systems. A uniform and comprehensive coverage system is necessary.

AIDS and hospice.

Which AIDS patients should be admitted to hospice programs? Many health care professionals feel that any anti-viral drug or treatment directed against the opportunistic infections characteristic of AIDS to be incompatible with hospice philosophy. Others argue that inclusion of AIDS patients blurs the distinction between hospice and community service programs. We argue that achieving consensus on this issue is best served by focusing on the defining characteristic of hospice programs--the care of the dying. Consensus is not served by dwelling on the specific palliative or supportive measures used to achieve the hospice goal. We suggest a framework by which AIDS patients may be accommodated in existing hospice programs while maintaining hospice program integrity. It is further suggested that these may be used for the consideration of any patient for hospice care.

[Assessment of diabetic autonomic neuropathy by heart rate monitoring].

Assessment of diabetic autonomic neuropathy in a representative sample of 91 noninsulin-dependent diabetics was performed in 3 community clinics. A difference of less than 10 beats/min in heart rate between deep inspiration and deep expiration determined by ECG recording served as the criterion for autonomic neuropathy. By this test, 86% of the patients had diabetic autonomic neuropathy, a slightly higher proportion than that reported by others using similar criteria in more selected populations. The test is very sensitive and can be used for screening.