Sexual dysfunction after simultaneous pancreas-kidney transplantation.

Simultaneous pancreas-kidney transplantation (SPK) is the treatment of choice for patients with type 1 diabetes mellitus and end-stage renal disease (ESRD) because it improves survival, is cost-effective, and can mitigate secondary complications of diabetes. Patient-reported outcomes such as quality of life (QoL) have recently received increased attention among transplant recipients. However, the impact of erectile dysfunction on patient QoL has not been investigated in this high-risk group with a history of diabetes and uremia. We applied the International Index of Erectile Function (IIEF) to describe the prevalence and severity of self-reported changes in erectile function after transplantation, comparing the quality of well-being (QWB) index of subgroups of 101 consecutive male SPK recipients with varying degrees of erectile function. Only 21% of patients did not suffer from erectile dysfunction; 18% were classified as mild erectile dysfunction, 31% as mild to moderate, 21% as moderate, and 9% as severe according to the IIEF scores. Forty-one percent of patients reported subjective overall improvement in erectile dysfunction compared with their pretransplant status; 7% considered their sexual function to be worse than before, and 51% did not note any change. The QWB index was highest among the group of patients without erectile dysfunction, decreasing gradually but significantly with increasing severity. A direct impact of erectile dysfunction on QoL, as well as a confounding effect of underlying vascular comorbidities, could explain this finding.

Approaches to the denominator in practice-based epidemiology: a critical overview.

OBJECTIVES: An accurate knowledge of the population at risk is a fundamental requirement for determining rates and making comparisons in epidemiological research. The major obstacle of studying the epidemiology of sentinel practice networks is the determination of population at risk, in this case, the reference population of medical practices. This article is intended to give a brief overview of major denominator approaches used in practice based epidemiology today, to discuss their underlying assumptions, their strengths and limitations. DESIGN: The literature used in this paper was searched from Medline databases of 1970-1997 using the logical expression "denominator and practice". More literature was identified from the references cited in those articles and from research reports that were available to the authors. MAIN RESULTS: There are various approaches to the denominator at different levels of complexity, which were presented akin to the well known "iceberg phenomenon": with only a small portion of the iceberg visible above the surface, inference as to the size of the invisible part may still be made under certain assumptions. Crude numbers of cases may still reflect trends in the true epidemiology of disease and may be useful for time-series analyses. Differences in the number of network participants over time and across region may be controlled for by using the number of sentinel practices as a denominator. The number of consultations is a first step towards a population-based denominator, reflecting characteristics of both patients and the network. The yearly or quarterly contact group is a true person-based denominator, yet disregarding the population not consulting. The population in practices' catchment areas can be either determined from patient lists or estimated using mathematical models. The ideal denominator is the total population in a geographically defined area, though this information can be directly related to medical practices only in very few countries. CONCLUSIONS: Although a person, or ideally a population-based denominator is desirable, even "lower-level" denominators may be suitable for certain research topics. In countries without patient registration, the estimation of incidences and prevalences has many methodological uncertainties that limit the use of sentinel practice systems. Assuming representativeness, valid analytical or time-series studies, however, can still be carried out even if there is very little information on the population at risk covered by particular medical practices.

Socioeconomic evaluation of rheumatoid arthritis and osteoarthritis: a literature review.

Limited resources and the need to improve the cost-effectiveness of medical procedures underlie the increasing importance of socioeconomic evaluations of health care. A search of MEDLINE was conducted to identify publications on the socioeconomic aspects of the two most important joint diseases: rheumatoid arthritis (RA) and osteoarthritis (OA). Analysis of the retrieved publications focused on three areas: (1) description of the socioeconomic effects of these diseases; (2) methodological approaches of the economic analyses; and (3) discussion from the perspective of patients, clinicians, or public health policy-makers. Of 52 publications dealing with cost data for RA and OA, 44 presented original and recently collected and developed data. Twenty-six were classified as cost analyses, three as cost-benefit analyses, and 11 as cost-effectiveness analyses (four did not fit into any of these classifications). Eight established methodological criteria were used to test for "full economic evaluation"; none of the reviewed studies fulfilled all eight, and only one study fulfilled seven. The gap between the importance of the socioeconomic effects of RA and OA and the research conducted in this field is considerable. A quality standard could be developed to serve as a guideline for further research.

Heart disease mortality and economic changes; including unemployment; in Western Germany 1951-1989.

Research over the last two decades has indicated that changes in cardiovascular disease mortality rates have been influenced by those in national economic indicators as well as by measures of consumption of tobacco, animal fats and alcohol. These findings predominantly involved the United States, United Kingdom and Scandinavian countries. The economic indicators included real per capita income and social welfare expenditures (beneficial relationships to mortality rates), and unemployment rates and business failure rates (detrimental relationships to mortality). James Henry's formulations have emphasized that many different illnesses respond to emotional stresses in different psychophysiological patterns depending on the specific constellations of emotions aroused. On the assumption that the impact of national economic changes on cardiovascular mortality reflects emotional stresses, losses, frustrations and deprivations, similar tests were undertaken using Western German heart disease mortality rate data over 1951-1989. Time-series regression analysis showed that, holding constant the effects of tobacco, animal fats and alcohol, increased income and social welfare expenditures are related to heart disease mortality rate declines, whereas increased unemployment and business failure rates are related to heart disease mortality rate increases over more than a decade.

The proximal-distal continuum of multiple health outcome measures: the case of cataract surgery.

This paper presents the concept of a proximal-distal continuum in health outcome measures. It indicates how this continuum can be used in the selection of outcome measures in health technology evaluation studies. Finally, it demonstrates several ways in which the placement of a specific health outcome measure in the proximal-distal continuum determines the overall statistical model of treatment and nontreatment variables. We identify five principles that relate to the above issues. The first three principles state that a larger effect of treatment on health outcomes will be seen when the following occur: 1) more proximal (e.g., signs and symptoms, disease-specific outcomes) measures are examined, 2) the initial illness is more severe; and 3) pretreatment distal (e.g., role functioning, life satisfaction) outcome measures show relatively high impairment. Principle four indicates that distal outcomes are influenced more heavily by external (i.e., nontreatment) factors. Principle five states that a causal chain links each outcome measure in the continuum to the next more distal outcome measure. This last principle enables the determination of indirect relationships between treatment and outcomes. These principles are illustrated with data from a study on the effects of cataract surgery with intraocular lens implantation on patient outcome variables across the proximal-distal continuum.

A stopping rule for standard chemotherapy for metastatic breast cancer: lessons from a survey of Maryland medical oncologists.

The sequential administration of standard chemotherapy regimens to treat metastatic breast cancer may keep patients and oncologists from considering other important, but more psychologically difficult, issues such as the patient's declining health or approaching death. This practice also utilizes health care resources for ever-decreasing individual patient benefit. If generally agreed-upon rules or guidelines were developed about stopping standard chemotherapy after a limited number of regimens, oncologists could recommend treatment discontinuation with greater confidence. Also, resources could be redirected. To inform the development of guidelines on when to stop chemotherapy for metastatic breast cancer, we surveyed fully trained Maryland medical oncologists about their knowledge and beliefs about chemotherapy for metastatic breast cancer. The survey instrument included open-ended questions and clinical vignettes. There was consensus about the value of first-line chemotherapy. Even though oncologists employed second-line chemotherapy, they were unenthusiastic about it. The frequent utilization of second-line regimens probably reflects an effort to offer marginal regimens to patients who want them. Based on these data, it is suggested that standard chemotherapy be stopped after breast cancer fails to stabilize or respond on a standard regimen. Patients who wish further treatment could be referred for investigational therapy if it is available and if they are eligible.

The influence of patient-related variables in the timing of cataract extraction.

Data from a prospective study of quality of life after cataract extraction with intraocular lens implantation were used to examine associations between patient factors and the timing of cataract extraction. The 495 patients were drawn from 76 ophthalmologists' offices in three cities. Patients were categorized as waiting three months or less or four months or more to schedule their operations after their physicians' recommendations. Patients who delayed scheduling their operations were more likely to be younger, have higher incomes, be working full-time, have higher life satisfaction, have lower levels of depression and higher levels of vigor, have had a less than perfect previous operation, have lower scores for mid-range vision and higher scores for cataract symptoms, be fearful of nighttime driving, and be heavy drinkers. Conversely, patients who delayed their operations were less likely to be covered by Medicare and to expect excellent postoperative vision and a short recovery time. A discriminant analysis correctly classified 68.9% of the patients according to timing group.

Vision change and quality of life in the elderly. Response to cataract surgery and treatment of other chronic ocular conditions.

OBJECTIVE: Evaluation of health care in older populations has increasingly focused on quality of life as a critical outcome of treatment. Vision is assumed to be central to functioning. Data suggest that aging, in itself, is associated with a decline in visual functioning, which, in turn, is related to a decline in physical and mental functioning. Other studies indicate that cataract surgery is followed by significant improvement in vision and visual function. Our objective was to test these assumptions. DESIGN: Prospective study of 1021 patients, consecutively drawn from 76 randomly selected ophthalmologists' offices in three cities. Structured interviews were completed at baseline, 2 months, and 1 year after entry. PATIENTS: Six hundred thirteen patients with cataracts and 408 other ophthalmic patients drawn from the same offices but treated for other chronic ocular disorders. All received refractive services as needed. SETTING: Patients from three cities (Baltimore, Md, St Louis, Mo, and San Diego, Calif) were interviewed once in their homes and twice by telephone. INTERVENTIONS: The study involved the measurement of the effects of usual treatment for cataracts and other degenerative eye diseases. MAJOR OUTCOME MEASURES: Visual, social, and psychological functioning. RESULTS: Within 1 year of treatment, change in visual function was accompanied by significant changes, in the same direction, in quality of life functions: night-time driving, daytime driving, community activities, home activities, mental health, and life satisfaction. In addition, the patients with cataracts showed significantly greater improvement in measures of vision than did the noncataract group. CONCLUSIONS: Regardless of treatment, improvement across quality of life functions occurred when visual function improved. Thus, many types of functional degeneration observed in older populations, attributed to a decline in vision, can be slowed, or even reversed, when visual function is improved. Cataract surgery was effective in improving vision and quality of life functions.

Outcomes of cataract surgery. Improvement in visual acuity and subjective visual function after surgery in the first, second, and both eyes.

OBJECTIVE: No previous study documents improvement in visual acuity and subjective visual function associated with cataract surgery in the first eye, second eye, and both eyes. Measurement of subjective aspects of visual function and quality of life provides information that cannot be obtained with simple measurement of Snellen visual acuity. METHODS: From 76 ophthalmology practices in three cities, patients undergoing cataract extraction with intraocular lens implantation (n = 613) and comparison patients (n = 408) were enrolled in a prospective study. Questionnaires elicited visual function information before and after surgery, and visual acuity was obtained from the ophthalmologic record. RESULTS: Among patients with cataract and no other eye disease, baseline subjective visual function before surgery in the second eye was better than that before surgery in the first eye. Improvement in subjective visual function was approximately equal postoperatively in first and second eyes. Improvement in subjective function in both eyes postoperatively was significantly greater than that after surgery in the first eye or second eye alone. No statistically significant difference across surgical groups in the proportion of patients demonstrating improvement in visual acuity was observed. CONCLUSION: Patients who underwent surgery in both eyes reported greater improvement in subjective visual function than did those who underwent surgery in one eye. Thus, there seems to be a benefit associated with restoring binocular vision in this population. These findings support the policy recommendation that cataract surgery in both eyes remains the appropriate treatment for patients with bilateral, cataract-induced visual impairment.

Economic instability, unemployment rates, behavioral risks, and mortality rates in Scotland, 1952-1983.

Short-term relations (under five years) between national unemployment and cause-specific mortality rates have been found in several industrialized countries in Europe and North America including the United States and, separately, Scotland and England/Wales. Long-term cumulative relations (at least a decade) have been found between national unemployment and age-adjusted mortality rates for eight countries including England/Wales. In this article it is demonstrated that, controlling for the significant effects of per capita cigarette, spirits, and fat consumption, and cold winter temperatures, there is in Scotland a significant long-term relation (at least a decade) between cumulative change in unemployment rates and mortality rates-for all causes, for total heart disease, and in particular for ischemic heart disease. Also, the exponential trend in real per capita income is related to mortality declines. Other writers have encountered difficulty in measuring this long-term relation between unemployment and cause-specific mortality in Scotland in the absence of controls for at least alcohol and tobacco consumption per capita.

Economic change, alcohol consumption and heart disease mortality in nine industrialized countries.

This paper examines the question of whether economic changes--including economic growth, unemployment and business failures--and alcohol consumption by beverage type are independently related to heart disease mortality. Controls for cigarette and animal fat consumption are also employed in a multivariate time series analysis. Data for nine countries in the post World War II era are investigated: Australia, Canada, England and Wales, Denmark, Federal Republic of Germany, Finland, France, Sweden and the United States. In all nine countries unemployment and business failures are positively related to heart disease mortality, and in eight countries the trend of economic growth shows an inverse relationship. The relation of alcohol consumption to heart disease mortality depends on beverage type. When spirits or wine consumption shows a significant relation, occasionally requiring controls for other beverages, it is positive. On the other hand, beer consumption shows an inverse relation to heart disease mortality in all countries. The statistical significance of that relationship also occasionally must be based on controls for other beverages.

Relation of economic change to Swedish health and social well-being, 1950-1980.

To what extent, and through what mechanisms, does the deterioration of economic conditions affect the health of the population at the national level? In this paper, the author presents the results of a study of Swedish data, analyzing the post-World War II changes in mortality rates in relation to deleterious economic changes, especially unemployment, business failure rates, and declines in real per capita income. The analysis uses a version of the 'Economic Change Model of Pathology' which includes the influence of health risks related to patterns of consumption and production. It is found that economic growth plays a principal role in reducing mortality at nearly all ages, and specifically mortality due to total cardiovascular disease, cerebrovascular disease, total heart disease, ischemic heart disease, total malignancies, disorders of infancy, and motor vehicle accidents. Economic recession, by contrast, is related to increases in total mortality for virtually all age groups, in both sexes, for major causes of death and causes due to psychopathological conditions. Per capita alcohol consumption, by specific beverage, is an important risk to mortality rates in cerebrovascular disease, malignancies, cirrhosis, motor vehicle accidents, suicide, homicide, and infant diseases. Cigarette consumption rates are positively related to mortality due to cardiovascular, malignant, and infant diseases; fat consumption rates are positively related to cardiovascular and cancer mortality.

Unemployment and health in the context of economic change.

Evidence relating unemployment to health is found at every level of social science analysis from national population rates to individual psychophysiological stress response. At the population level of analysis, increase in the unemployment rate indicates recession and/or structural economic decline. At the individual level, unemployment is interpreted as a stressful life event. In both cases, inverse associations are found between measures of unemployment and indicators of health. We identify social science literatures associating health indicators with each of the following: economic growth, socioeconomic status, sociocultural change, economic instability, the status of being unemployed, social stress and work stress. Outstanding research issues include the requirements to identify and measure the effects of conditional factors and control variables in multivariate analysis and to examine a broader range of both severity of unemployment and severity of health outcomes. A research agenda proposes studies at the macro, meso and micro levels of analysis. We urge such research for its potential contribution both to analytic social science and to economic and social policy.

Mortality and economic instability: detailed analyses for Britain and comparative analyses for selected industrialized countries.

This paper discusses a first-stage analysis of the link of unemployment rates, as well as other economic, social and environmental health risk factors, to mortality rates in postwar Britain. The results presented represent part of an international study of the impact of economic change on mortality patterns in industrialized countries. The mortality patterns examined include total and infant mortality and (by cause) cardiovascular (total), cerebrovascular and heart disease, cirrhosis of the liver, and suicide, homicide and motor vehicle accidents. Among the most prominent factors that beneficially influence postwar mortality patterns in England/Wales and Scotland are economic growth and stability and health service availability. A principal detrimental factor to health is a high rate of unemployment. Additional factors that have an adverse influence on mortality rates are cigarette consumption and heavy alcohol use and unusually cold winter temperatures (especially in Scotland). The model of mortality that includes both economic changes and behavioral and environmental risk factors was successfully applied to infant mortality rates in the interwar period. In addition, the "simple" economic change model of mortality (using only economic indicators) was applied to other industrialized countries. In Canada, the United States, the United Kingdom, and Sweden, the simple version of the economic change model could be successfully applied only if the analysis was begun before World War II; for analysis beginning in the postwar era, the more sophisticated economic change model, including behavioral and environmental risk factors, was required. In France, West Germany, Italy, and Spain, by contrast, some success was achieved using the simple economic change model.

Economic change and sex-specific cardiovascular mortality in Britain 1955-1976.

Analyses directed toward recent declines in cardiovascular disease mortality rates have typically focused on alterations in important physiological and behavioral risk factors resulting from lifestyle changes and medical advances. In this study, a multivariate model of the impact of more fundamental changes in the socioeconomic and bio-physical environments has been developed and applied to cardiovascular disease mortality rates, by sex, in England and Wales and Scotland during 1955-1976. The predictive model includes factors associated with (1) long-term growth in the economy, (2) deleterious behavioral risk factors loosely associated with economic growth--especially cigarette consumption per capita, (3) economic instability--especially recession as indicated by factors related to unemployment, income loss, and recessional declines in average weekly hours worked in manufacturing industries, (4) health care, and (5) physical environmental disturbances--especially very cold temperatures. This model proves to be an excellent instrument for the statistical explanation of trends and fluctuations in CVD mortality rates for both sexes and both regions in Britain in the post-War period. In general, the overall exponential rate of economic growth is found to be the most powerful factor in the long-term decline in CVD mortality rates. Similarly, disturbances to the national and regional economic situations--especially recessions--have regularly been associated with elevated death rates for all populations observed. Cigarette and unusually high spirits consumption, as well as particularly cold winter temperatures, have also had important deleterious effects on CVD mortality. The proportion of government expenditures devoted to health care is associated with a reduction in CVD mortality in England and Wales.