A novel neurotropic microsporidium from the swamp guppy Micropoecilia picta from Grenada, West Indies.

A novel microsporidium was observed in wild swamp guppies Micropoecilia picta from Levera Pond within Levera National Park Grenada, West Indies. Initial observations indicated similarity with Pseudoloma neurophilia, an important pathogen in zebrafish Danio rerio. P. neurophilia exhibit broad host specifity, including members of the family Poecillidae, and both parasites infect the central nervous system. However, spore morphology and molecular phylogeny based on rDNA showed that the swamp guppy microsporidium (SGM) is distinct from P. neurophilia and related microsporidia (Microsporidium cerebralis and M. luceopercae). Spores of the SGM were smaller than others in the clade (3.6 µm long). Differences were also noted in histology; the SGM formed large aggregates of spores within neural tissues along with a high incidence of numerous smaller aggregates and single spores within the surface tissue along the ventricular spaces that extended submeninx, whereas P. neurophilia and M. cerebralis infect deep into the neuropile and cause associated lesions. Analysis of small subunit ribosomal DNA sequences showed that the SGM was <93% similar to these related microsporidia. Nevertheless, one of 2 commonly used PCR tests for P. neurophilia cross reacted with tissues infected with SGM. These data suggest that there could be other related microsporidia capable of infecting zebrafish and other laboratory fishes that are not being detected by these highly specific assays. Consequently, exclusive use of these PCR tests may not accurately diagnose other related microsporidia infecting animals in laboratory and ornamental fish facilities.

Physician deaths from COVID-19 have been lower than expected.

BACKGROUND: More than 100 US physicians have died from COVID-19. I considered the number of US physician deaths in comparison to the expected COVID death rate in the general population. AIMS: To estimate the whether US physicians are at increased risk of death from COVID-19 due to occupational exposures. METHODS: COVID-related physician deaths were identified through searches using Medscape In Memoriam, and multiple internet searches using Google and Facebook. An obituary or death notice was obtained in all but one case. Death rates among physicians were compared to the expected rate based on COVID deaths in the US population. RESULTS: Up to 7 October 2020, there were 108 deaths among US physicians. Physicians make up about 0.33% of the US population. By 1 October 2020, there were 210 000 COVID deaths in the US population with 693 expected physician deaths. Observed deaths were 16% of expected. Seventy-five per cent of the deaths occurred among physicians older than age 60 and about half appeared to be among those retired from clinical practice. CONCLUSIONS: Observed physician deaths were significantly below expected based on deaths the general population. Prudent use of personal protective equipment may explain the lower-than-expected death rates.

Importation of macrocyclic lactone resistant cyathostomins on a US thoroughbred farm.

Anthelmintic resistance in equine cyathostomins is both widespread and highly prevalent in the benzimidazole and tetrahydropyrimidine classes; however, reports of resistance to macrocyclic lactone (ML) drugs are sparse and sporadic. This study reports a case of clear ML resistance in a group of Thoroughbred yearlings imported from Ireland to the US in 2019. Fecal egg count reduction (FECR) following ivermectin administered in February 2020 demonstrated 100% reduction in the US bred yearlings, but 93.5%, 70.5%, and 74.5% reduction in three groups of the imported yearlings. The two former groups were then retreated with ivermectin, yielding FECRs of 33.8% and 23.5%, respectively. Horses from these two groups were then assigned randomly to two possible treatments; moxidectin or a triple combination of moxidectin, oxibendazole, and pyrantel pamoate. The groups treated with moxidectin had FECRs of 90.2%, 57.3%, and 50.0%, while the triple combination had a 100% FECR in all treated groups. Subsequently, the efficacy of ivermectin was reassessed in June 2020 yielding FECRs of 99.8%, 87.7%, and 62.0% in the three imported groups. The FECRs of the US bred yearlings all remained in the 99-100% range. This is the first study to clearly demonstrate ML resistance in cyathostomins and to confirm the suspicion through reassessment. These data demonstrate that ML-resistant cyathostomins were imported from Ireland and serve to illustrate that the global movement of horses has the potential to quickly spread ML-resistant parasite isolates around the world. The equine industry is strongly encouraged to routinely monitor anthelmintic efficacy, so occurrence of ML resistant cyathostomins can be detected and appropriate interventions implemented as early as possible.

Herbal dewormer fails to control gastrointestinal nematodes in goats.

Gastrointestinal nematode (GIN) parasitism is the most important disease of small ruminants. Control is usually based on the use of chemical anthelmintics (dewormers); but these are prohibited from use in organic livestock, and the effectiveness of chemical anthelmintics in conventional operations is limited by high levels of anthelmintic resistance. Consequently, herbal dewormers are increasing in popularity as an alternative to chemical dewormers for GIN control. However, the effectiveness of herbal dewormers remains unproven. The objective of this study was to examine the effectiveness of a commercially available herbal dewormer to control GIN in goats. Lactating (n=16) and young (n=8) dairy goats grazed poor quality mixed grass pastures between March and July 2006 at the Heifer International Ranch in Perryville, AR. Goats were supplemented with grass hay and concentrate. Goats were untreated or administered herbal dewormer (n=12/treatment) according to manufacturer recommendations. FAMACHA scores (1=red or healthy; 5=severely anemic) were determined and fecal samples collected for fecal egg count (FEC) determination every 14 days between Days 0 (day of first herbal treatment) and 112. FAMACHA scores in the herbal treated group were greater than in the untreated control group (P<0.005), indicating a higher level of anemia. FEC were greater for herbal treated goats on Pasture A compared with B by Day 42, but similar among groups thereafter. FEC (P<0.03) and FAMACHA scores (P<0.001) were greater in lactating than in non-lactating goats. Herbal dewormer treatment yielded no measurable health benefits indicating that the herbal dewormer failed to control GIN in these goats.

The role of polymorphisms at beta tubulin isotype 1 codons 167 and 200 in benzimidazole resistance in cyathostomins.

Cyathostomins are recognised as the primary parasitic pathogens of horses. Despite the use of benzimidazole (BZ) anthelmintics in horses for more than 40 years and widespread drug resistance in the field, the mechanisms of resistance to this drug class in cyathostomins are not fully understood. The results presented here constitute a detailed comparison of beta tubulin gene mutations and mRNA transcript levels in populations of BZ-susceptible (BZ-S) and -resistant (BZ-R) cyathostomins. Full-length cDNA sequences were generated from individual parasites of four (n=24) and two (n=19) cyathostomin species for isotypes 1 and 2, respectively. Levels of intra- and inter-specific nucleotide sequence variation were comparable with previous findings and single amino acid substitutions were observed at several locations. On comparison of BZ-S and BZ-R parasites, differences were consistently observed at only two sites, codons 167 and 200 of the beta tubulin isotype 1 gene. Four populations of parasites were genotyped at these two loci by pyrosequencing; one that was fenbendazole (FBZ)-sensitive (FBZ-rS), two that were FBZ-resistant (FBZ-R1 and -R2) and one that was oxibendazole-resistant (OBZ-R), as previously assessed by faecal egg count reduction tests. This analysis revealed statistically significant differences between FBZ-rS and FBZ-R populations at both loci and this was highly significant for codon 167. For the OBZ-R population, the only significant difference compared with the FBZ-rS population was observed at codon 200. These observations suggest that mutations at codons 167 and 200 are important in BZ resistance and raise the possibility that selection at different loci may occur in FBZ- and OBZ-resistant parasites. Multiple parasites (n=158) were genotyped for both codons 167 and 200, the majority of which showed homozygous 'resistant' mutations at one locus only and none showed homozygous 'resistant' genotypes at both loci. No significant differences in mRNA levels of beta tubulin isotypes 1 and 2 were observed between the FBZ-rS and FBZ-R1 populations.

Evaluation of the validity of the Quality of Well-being Scale in Trinidad and Tobago.

Both developing countries in the Caribbean and developed countries face resource allocation challenges. However, cost-effectiveness analysis instruments that may assist in allocation of resources have not been tested in Caribbean countries. Trinidad and Tobago is an advantageous location to test an instrument for potential use in the Caribbean. It has a single payer healthcare system and a literate population. Due to historical and current migration from other Caribbean countries, the population might be a fair representation of English-speaking Caribbean nations. We tested the validity of the Quality of Well-being Scale (QWB) on a sample of the non-institutionalized general population in Trinidad. The survey included reports of chronic conditions and items from the Trinidad and Tobago National Health Interview Survey. Data were analyzed using a multivariable regression model. One adult from each of 235 households consented to the interview. The results are consistent with results obtained in the United States of America. Being older female, more chronic conditions and more symptoms/problems were significantly associated with lower mean QWB scores. These results suggest that the QWB with US-derived weights show evidence of validity in Trinidad and Tobago. Thus, health decision makers can use the QWB to compare the effects of different health conditions and health interventions. In addition, investigators can make cross-cultural comparisons of QWB scores for diseases or health conditions.

Equine parasite control and the role of national legislation - A multinational questionnaire survey.

Experts recommend a change in the control of equine parasites across the world in order to adopt a surveillance-based approach utilizing parasite faecal egg counts (FEC). Several European countries have implemented prescription-only restrictions of anthelmintic usage by law, which is in stark contrast to US, where all anthelmintic products continue to be available over the counter. This study aimed to describe and compare equine parasite control strategies employed in Germany, Austria, the Netherlands, US, and Denmark. An invitation to participate in an online questionnaire survey was published on a large equine news website in each of the participating countries. The main focus of the study was on usage of FEC and anthelmintic treatment intensity in three different equine age groups; foals, 1-3 year-olds and >3 years old. A total of 3092 respondents participated in the study. Danish respondents used significantly more faecal analyses in their parasite control strategies than participants from the other four countries (p < 0.0001). Similarly, Danish participants administered significantly fewer anthelmintic treatments per horse per year (p < 0.0001) independent of the age of the horse, and had been using a selective treatment strategy for a significantly longer time period than their counterparts in other countries (p < 0.0001). Only minor differences were found between respondents from the other four countries. This is remarkable as both Austria and Germany have had prescription-only restrictions for 3-4 decades. Yet, their parasite control strategies were more similar to those employed by American respondents. The Netherlands had only recently introduced prescription-only restrictions by the time this survey was conducted which can explain why Dutch respondents were also similar to their American counterparts. Taken together, this study illustrates substantially different worm control strategies practiced in Denmark, and this difference cannot be explained by legislation alone.

A novel approach for combining the use of in vitro and in vivo data to measure and detect emerging moxidectin resistance in gastrointestinal nematodes of goats.

Ivermectin and moxidectin are closely related avermectin/milbemycin anthelmintics and available data suggest that side resistance occurs with these two drugs. However, moxidectin remains effective against many species of ivermectin-resistant worms due to its higher potency. The larval development assay (LDA) is routinely used to diagnose ivermectin resistance in Haemonchus contortus but laboratory diagnosis of moxidectin resistance is hampered by the lack of any validated in vitro tests. The objective of this study was to measure the relative susceptibility/resistance of H. contortus to moxidectin on goat farms in Georgia, and to validate the DrenchRite LDA for detecting resistance to moxidectin. Fecal egg count reduction tests (FECRT) were performed at five different moxidectin dose levels and DrenchRite LDAs were performed in duplicate on nine meat goat farms in Georgia, USA. To improve our ability to make inferences on the relative levels of resistance between farms, FECRT data were first analysed using a linear mixed model, and then Tukey's sequential trend test was used to evaluate the trend in response across dose levels. LDA data were analysed using log-dose logit-response and probit models. Using these statistical results, we were able to rank the nine farms from the least to the most resistant, and to develop a set of criteria for interpreting DrenchRite LDA results so that this assay can be used to diagnose both clinically apparent moxidectin resistance, as well as sub-clinical emerging resistance. These results suggest that our novel approach for examining these types of data provides a method for obtaining an increased amount of information, thus permitting a more sensitive detection of resistance. Based on results of the LDA, moxidectin-resistant farms had resistance ratios, compared with an ivermectin-sensitive farm, ranging from 32 to 128, and had resistance ratios of 6-24 compared with an ivermectin-resistant/moxidectin naive farm. Moxidectin resistance was diagnosed both in Haemonchus and Trichostrongylus on almost half of the farms tested, despite this drug only being used on these farms for 2-3 years.

Accuracy of the FAMACHA system for on-farm use by sheep and goat producers in the southeastern United States.

FAMACHA is a practical on-farm system designed to provide small ruminant producers a tool for improving their management of Haemonchus contortus infections. Although this system has become very popular and widely accepted by small ruminant producers in many regions of the southern United States, there is very limited data reported on the effectiveness of the FAMACHA system when performed by farmers. The objective of this study was to evaluate the accuracy of the FAMACHA system for on-farm use by small ruminant producers during the summer season. Small ruminant producers from Georgia, Louisiana, Florida, and Puerto Rico were trained to use the FAMACHA system by veterinarians and scientists experienced with this method. FAMACHA scores were assigned at least every 2 weeks by producers to weaned and mature sheep (n=552) and goats (n=676) of various breeds and ages between April and September 2004. At intervals that varied among farms from 2 to 8 weeks, researchers determined body condition scores (BCS; 1=thin and 5=fat) and collected blood and feces from a group of animals selected randomly to determine packed cell volume (PCV) and fecal egg counts (FEC). Two separate anemia thresholds were evaluated; these were defined by either FAMACHA score (>or=3 versus >or=4) or PCV (or=3 were considered anemic and PCV cutoff was or=3 were considered anemic and PCV cutoff was

Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment.

Reports on long-term complications resulting from treatment for localized prostate cancer are very inconsistent. In order to estimate the risks of long-term erectile dysfunction, urine symptoms and bowel symptoms following prostatectomy (RP), external conventional or conformal beam radiation (ERT or CRT) and brachytherapy (BRT), 98 papers from the PubMed and Cochrane Clinical Trial databases were selected, reviewed and critically evaluated. The majority of papers were institution-based retrospective and prospective follow-up studies; only two of these studies measured the risk of developing more than one treatment complication. Due to differences in study designs and populations, it is difficult to directly compare studies and not meaningful to calculate summary estimates. In addition to focusing on randomized clinical trials and well-designed population based studies, future research should adopt standardized methodologies and should measure the risk of developing more than one treatment complication.

Targeted selective treatment for worm management--how do we sell rational programs to farmers?

Seriously escalating global anthelmintic resistance in gastrointestinal nematodes of small ruminants has spawned a variety of alternatives to anthelmintics for worm management, based on the need for sustainable Integrated Parasite Management (sIPM). Pivotal to the sIPM approach is the concept of refugia, the proportion of a given parasite population that escapes exposure to control measures. By balancing drug applications with the maintenance of refugia, the accumulation of anthelmintic resistance alleles in worm populations can be considerably delayed, while still providing good levels of control. The over-dispersed nature of parasitic infections provides an opportunity to achieve this balance, by targeting treatments to the members of a flock or herd that are least tolerant to nematode infection. However, implementation of this strategy has only recently become feasible, with the development of the FAMACHA((c)) system for clinical evaluation of anaemia due to haemonchosis. Subsequently, the use of milk yields has proven an effective indicator in dairy goats infected predominantly with nematodes other than Haemonchus contortus. In addition, short-term weight changes and perhaps also body condition scoring may provide indices of parasitism, permitting the rapid identification of animals likely to benefit from treatment. However, sIPM and refugia-based approaches are more complex than whole-flock treatments in conventional programs, and adoption by farmers is most likely where the theoretical basis is understood. As close communication with informed advisors is generally limited, there is a danger that sIPM will remain a theoretical concept without alternative modes of communication. The development of computer-based decision support programs, which use epidemiological, seasonal and clinical information to provide recommendations for specific situations, should be accorded high priority in the future development of worm management systems.

Sericea lespedeza hay as a natural deworming agent against gastrointestinal nematode infection in goats.

Infection with gastrointestinal nematodes (GIN), particularly Haemonchus contortus, is the biggest constraint to profitable goat production in the United States (US). Due to widespread prevalence of anthelmintic resistance in goat GIN, alternative, non-chemical control methodologies are needed to increase profitability of small ruminant industries. A study was designed to test the efficacy of a high condensed tannin (CT) legume, sericea lespedeza [SL, Lespedeza cuneata (Dum.-Cours. G. Don)] against GIN of goats fed in confinement. The goats were given a trickle infection of 500 H. contortus larvae/animal three times per week during the trial to simulate natural infection. Twenty Boer bucks (6-8 months old) were fed bermudagrass [BG, Cynodon dactylon (L.) Pers.] hay plus concentrate for 5 weeks in confinement and then 10 animals were switched to SL hay for an additional 7 weeks. Throughout the trial, feces and blood were collected weekly from individual animals to determine fecal egg count (FEC) and blood packed cell volume (PCV). Fecal cultures were made weekly from pooled samples to determine treatment effects on GIN larval development. All goats were slaughtered at the end of the trial, with adult worms in the abomasum and small intestine of each goat recovered, counted, and identified to species. Feeding SL hay to goats significantly (P<0.01) reduced FEC and increased PCV compared with BG hay. In addition, a lower percentage of ova in feces from SL-fed goats developed into infective (L3) larvae. There was a direct effect of SL hay on adult worms, with significantly (P<0.01) lower numbers of both abomasal (H. contortus, Teladorsagia circumcincta) and small intestinal (Trichostrongylus colubriformis) nematodes compared with goats fed BG hay. Feeding SL hay to goats is an effective means of controlling parasitic nematodes and may be a potential supplement/replacement for chemical anthelmintics.

Effect of moxidectin selection on the genetic variation within Cylicocyclus nassatus based on amplified fragment length polymorphism (AFLP).

Cyathostomins are among the most important intestinal nematodes of horses, yet, the literature on the molecular genetics of these worms is scarce. In this study, the technique of amplified fragment length polymorphism (AFLP) was applied to study the genetic diversity as well as to determine the effect of moxidectin selection on the population genetic diversity for Cylicocyclus nassatus, one of the most common cyathostomin species. Genomic DNAs from 30 individual male worms were used from each of two populations: an avermectin-milbemycin (AM)-naive population (Population-S) and a population derived from Population-S following 21 treatments with moxidectin (Population-Mox). Three selective primer pairs were used for each worm, yielding a total of 229 AFLP markers. Calculation of average pair wise Jaccard indices revealed a high degree of genetic variation within both populations using all three primer combinations. In addition, selection by moxidectin during a 3-year period caused a significant decrease in the level of genetic diversity as evidenced by analysis of AFLP markers for two primer combinations but not for the third. A dendrogram of relationships among individuals based on AFLP markers did not show a clear classification of individuals in separate groups. It was concluded that a high degree of genetic intrapopulation variation exists in C. nassatus and that moxidectin selection has a significant effect on the genetic composition of C. nassatus.

Isolation and characterisation of a beta tubulin isotype 2 gene from two species of cyathostomin.

This study describes the isolation and characterisation of beta tubulin isotype 2 cDNA sequences from two common species of cyathostomin, Cylicocyclus nassatus and Cyathostomum catinatum. The full-length cDNAs for these species were 1709 and 1753 bp in length, respectively, including 1350 bp of sequence inferred to encode 450 amino acids of peptide sequence. They had greatest identity with previously characterised isotype 2 sequences from Trichostrongylus colubriformis, Cooperia oncophora and Haemonchus contortus (96% for C. nassatus and 95% for C. catinatum), and grouped together with these sequences in phylogenetic analysis. Both cyathostomin beta tubulin isotype 2 sequences contained the isotype-specific carboxyl terminal region described previously in other nematode species. Alignment with beta tubulin isotype 1 proteins from other trichostrongyloids, indicated 95 and 94% identity for the isotype 2 sequences of C. nassatus and C. catinatum, respectively. This comparison revealed 14 isotype-specific amino acid substitutions. Also, 2605 bp of beta tubulin isotype 2 genomic DNA sequence were isolated from C. nassatus. Comparison with the previously published isotype 1 gene of C. nassatus indicated differences in genomic organisation between the two isotypes. Reverse transcriptase (RT)-polymerase chain reaction analysis revealed constitutive temporal expression of beta tubulin isotype 1, whilst isotype 2 appeared to be developmentally expressed, with transcripts detected only in RNA derived from adult parasites.

Relationship of advance directives to physician-patient communication.

BACKGROUND: Although advance medical directives, such as living wills and durable powers of attorney for health care, are by themselves imperfect instruments for expressing patients' treatment preferences, a possible benefit of these documents is that they will enhance patient-physician communication, especially when end-of-life treatment decisions have to be made. METHOD: Structured interviews were completed for 115 seriously ill cancer patients and 22 of their physicians. The questions dealt with various aspects of advance directives, including communications between the two parties regarding general and specific treatment wishes. Responses were compared in 37 physician-patient pairs for patients who had executed advance directives and in 31 physician-patient pairs for patients who had not executed advance directives. RESULTS: Physicians were frequently unaware of their patients' advance directives. Although patients with advance directives were marginally more likely than patients without advance directives to report discussions about end-of-life treatment decisions, only 34 (30%) out of the total of 115 patients claimed that they had any discussion of treatment decisions with their physicians. Such discussions tended to be about general life attitudes and feelings rather than specific treatments, such as use of artificial nutrition or ventilation. CONCLUSION: Despite public enthusiasm for the use of advance directives and great efforts to promote them, we found little evidence that these documents are associated with enhanced communication between patients and physicians about end-of-life treatment decisions.

Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness.

OBJECTIVE: To determine whether brief general instructions in a typical proxy-instruction advance directive (California Durable Power of Attorney for Health Care [DPAHC]) provide interpretable information about patient requests to limit life-saving treatments, and to determine whether patient treatment preferences are stable over time. DESIGN: Prospective structured interviews. SETTING: University of California, San Diego Medical Center and Veterans Affairs Medical Center, La Jolla. PATIENTS: One hundred four patients (from a randomly chosen sample of 185) with a 5-year life expectancy of no better than 50% as judged by their physicians. MAIN OUTCOME MEASURES: Patients completed the California DPAHC, a proxy-instruction advance directive, at entry and at 1 year. The patients also completed a questionnaire at entry, after 6 months, and after 1 year, indicating their preferences on a five-point Likert-format comparative rating scale for cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, and hospitalization for pneumonia. RESULTS: Sixty-eight percent of the subjects executed the DPAHC. Most patients wished treatments to be limited or withheld under certain conditions of reduced quality of life. Although general instructions noted on the DPAHC and preferences regarding specific procedures were stable over the course of a year, the advance directive's general instructions were often inconsistent with, and poor predictors of, specific procedure preferences. CONCLUSIONS: The brief general instruction component of the California DPAHC is not helpful in communicating patient wishes regarding specific life-saving procedures.

Evaluating the costs and benefits of outpatient diabetes education and nutrition counseling.

The Board of Directors of the American Diabetes Association (ADA) recently endorsed a resolution recommending third-party payment for outpatient education and nutritional counseling. One of the major rationales for the statement was that education and nutritional counseling will lead to reductions in health care costs. This article critically reviews the 13 studies cited in support of the ADA Policy Statement. Among these studies, only 2 compared a treated group with a control group. Both of the studies with control groups failed to randomly assign patients to treatment condition. Only 4 of the studies showed an accounting of program costs. Upon close inspection, it appears that some of the programs actually increased, rather than decreased, health care expenditures. Attrition from programs was reported in only a minority of cases, and was large when reported. The effect of the programs upon diabetes control was inconsistent across studies. It is suggested that the rationale for education and nutritional services be based on improved health status. In addition, the execution of a systematic experimental study to evaluate these services is urged.

Social learning intervention to promote metabolic control in type I diabetes mellitus: pilot experiment results.

Patients with type I, or insulin-dependent, diabetes mellitus (IDDM) must comply with a complex behavioral regimen to control their diabetes. Compliance is often poor in teenage patients who are adversely influenced by peers. During a diabetes summer school, we randomly assigned 21 IDDM patients to one of two groups. One group participated in daily social-learning exercises designed to improve social skills and the ability to resist peer influence. The second group spent an equal amount of time learning medical facts about diabetes care. Four months after the intervention, hemoglobin A1 was significantly lower in the social skills intervention group. A variety of variables were significantly correlated with good metabolic control. These included self-reported compliance with a diabetes regimen and attitudes toward self-care. Unexpectedly, variables correlated with poor diabetes control included social problem-solving ability and satisfaction with social support.

Prospective evaluation of HDL cholesterol changes after diet and physical conditioning programs for patients with type II diabetes mellitus.

High-density lipoprotein (HDL) cholesterol is known to be low in patients with diabetes mellitus. Low HDL levels are correlated with premature cardiovascular mortality in several major epidemiologic studies and many investigators believe increases in HDL cholesterol may reduce the risk of coronary heart disease. We evaluated dietary and exercise interventions in relation to HDL cholesterol in patients with type II diabetes mellitus. Sixty-five volunteers were randomly assigned to one of four experimental conditions: diet, exercise, diet plus exercise, or education control. Three months after entering the program, those exposed to the dietary intervention had significant increases in HDL cholesterol. HDL increases for the other two treatment groups did not differ significantly from the education control.

Quality of life assessment for cost/utility studies in cancer.

The goals of cancer treatment and cancer prevention are to extend life expectancy and to improve quality of life in the years prior to death. Typically, outcomes of cancer treatment are evaluated in terms of survival time. Although quality of life is often measured, interpretation of these outcomes in relation to mortality is difficult. Survival analysis places each individual into one of two categories: alive or dead. Among those alive, all individuals are considered equivalent. Thus, a patient confined to bed with severe symptoms is scored the same as someone who is active and asymptomatic. A General Health Policy Model is proposed as a solution to this problem. The model adjusts life expectancy for diminished quality of life, which is measured using a standardized instrument known as the Quality of Well-being (QWB) scale. The model expresses the effect of treatment in a unit known as a Well-Year or Quality Adjusted Life Year (QALY). These units integrate side-effects and benefits of treatment by combining into a single number, mortality, morbidity, and duration of each health state. Similar methods, such as the Q-TWiST, have been proposed for use in cancer clinical trials. However, the Q-TWiST is a subset of the more general model and carries limitations for cross-disease comparisons. We conclude that general health outcome models can be of considerable value for analysing the costs, risks and benefits of cancer therapies.