CONTEXT: A high homocysteine level has been identified as an independent modifiable risk factor for coronary heart disease (CHD) events and death. Since January 1998, the US Food and Drug Administration has required that all enriched grain products contain 140 microg of folic acid per 100 g, a level considered to decrease homocysteine levels. OBJECTIVES: To examine the potential effect of grain fortification with folic acid on CHD events and to estimate the cost-effectiveness of additional vitamin supplementation (folic acid and cyanocobalamin) for CHD prevention. DESIGN AND SETTING: Cost-effectiveness analysis using the Coronary Heart Disease Policy Model, a validated, state-transition model of CHD events in adults aged 35 through 84 years. Data from the third National Health and Nutrition Examination Survey (NHANES III) were used to estimate age- and sex-specific differences in homocysteine levels. INTERVENTION: Hypothetical comparison between a diet that includes enriched grain products projected to increase folic acid intake by 100 microg/d with the same diet without folic acid fortification; and a comparison between vitamin therapy that consists of 1 mg of folic acid and 0.5 mg of cyanocobalamin and the diet that includes grains fortified with folic acid. MAIN OUTCOME MEASURES: Incidence of myocardial infarction and death from CHD, quality-adjusted life-years (QALYs) saved, and medical costs. RESULTS: Grain fortification with folic acid was predicted to decrease CHD events by 8% in women and 13% in men, with comparable reductions in CHD mortality. The model projected that, compared with grain fortification alone, treating all patients with known CHD with folic acid and cyanocobalamin over a 10-year period would result in 310 000 fewer deaths and lower costs. Over the same 10-year period, providing vitamin supplementation in addition to grain fortification to all men aged 45 years or older without known CHD was projected to save more than 300 000 QALYs, to save more than US $2 billion, and to be the preferred strategy. For women without CHD, the preferred vitamin supplementation strategy would be to treat all women older than 55 years, a strategy projected to save more than 140 000 QALYs over 10 years. CONCLUSIONS: Folic acid and cyanocobalamin supplementation may be cost-effective among many population subgroups and could have a major epidemiologic benefit for primary and secondary prevention of CHD if ongoing clinical trials confirm that homocysteine-lowering therapy decreases CHD event rates.

Adult↗

PubMedDate not supplied

Predictors of functioning of patients with chronic obstructive pulmonary disease.

OBJECTIVE: To determine the extent to which mood, symptoms, lung function, and social support of patients with chronic obstructive pulmonary disease (COPD) predicted their level of functioning over a 30-month period. DESIGN: Prospective, longitudinal. SETTING: The homes of patients living in or adjacent to metropolitan Toronto. SUBJECTS: Seventy-one patients (48 men and 23 women) with COPD who had a forced expiratory volume in 1 second less than 50% of predicted (FEV1 < 50%) and who spoke English. They ranged in age from 43 to 81 years (mean 66.37 years). OUTCOME MEASURES: The patients' level of functioning at the final data collection visit, 30 months after the initial measure. INSTRUMENTS: At both data collection visits patients completed measures of mood (negative mood scales of the Profile of Mood States), symptoms (Bronchitis-Emphysema Symptom Checklist), social support (Personal Resource Questionnaire), and functioning (Sickness Impact Profile). RESULTS: Data were analyzed by use of multiple regression analysis. From measures taken at the initial visit (T1), the best predictors of patients' functioning at 30 months (T2) were their functioning at T1, symptoms, FEV1, and age. Together these accounted for 70% of the variance in the final functioning scores, with initial functioning scores accounting for 51% of the variance. The most prevalent symptoms were dyspnea and fatigue, and both were highly correlated with functioning scores 30 months later. CONCLUSIONS: In this study, symptoms, FEV1, and age are predictive of functioning in patients with COPD over a 30-month time frame. However, only 50% of the 143 patients recruited into the study completed it. Therefore caution needs to be exercised when the results are applied to other patients with COPD.

Activities of Daily Living↗

PubMedDate not supplied

Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome.

A decision analytic study was conducted using computer simulation to project the outcomes in a simulated cohort of patients whose treatment for back surgery had failed. The objective of this study was to estimate the direct cost of intrathecal morphine therapy (IMT) delivered via an implantable pump relative to alternative therapy (medical management) over a 60-month course of treatment. IMT administered by way of an implantable pump can provide effective pain relief for selected patients whose less invasive treatment modalities have failed. Previous research suggested that a pump implant is less costly than alternative methods providing comparable analgesia for treatment exceeding 12 to 18 months. However, those analyses did not include the cost of complications or pump replacement. Scenarios representing the course of IMT, devised by a panel of experts, were represented as treatment pathways in a Monte Carlo simulation. Adverse event rates were drawn from published data supplemented by expert judgment. Direct costs were based on a health insurer paid claims perspective (direct costs) discounted at a 5% annual rate. The cost-effectiveness of IMT was calculated based on a report of 65% to 81% "good to excellent" pain relief relative to alternative (medical) management. With both adverse event probabilities and costs set at most likely (base case) values, the expected total cost of IMT over 60 months was $82,893 (an average of $1382 per month). In a sensitivity analysis, the best case (low adverse event rate, low cost) estimate was $53,468 ($891/mo), whereas the worst case (high adverse event rate, high cost) estimate was $125,102 ($2085/mo). Cost-effectiveness estimates ranged from $7212 (best case) to $12,276 (worst case) per year of pain relief. Results from a computer simulation designed to collect the costs not included in previous empiric research indicate that IMT appears to be cost-effective when compared with alternative (medical) management for selected patients when the duration of therapy exceeds 12 to 22 months.

Back↗

PubMedDate not supplied

Hospital procedure volume and teaching status do not influence treatment and outcome measures of rectal cancer surgery in a large general population.

A clear benefit of increased hospital procedure volume or teaching hospital status on outcomes of rectal cancer surgery has yet to be shown. Few have examined treatment differences that may lead to varying outcomes. This study assessed the impact of hospital procedure volume and teaching status on both treatment and outcome measures of rectal cancer surgery in a large general population. Data were obtained for 1072 incident cases of rectal adenocarcinoma diagnosed in 1990 from Ontario, Canada, and treated with a major resection. Hospitals were classified by teaching status and procedure volume. Pathology reports were examined for 418 procedures. Abdominoperineal resections accounted for 31.0% of all procedures. There were no clinically significant differences in treatment measures, operative mortality, and long-term survival among the hospital groups according to both univariate and multivariate analyses. In conclusion, the absence of a hospital volume or teaching status effect on treatment and outcome measures suggests that for rectal cancer surgery in Ontario, centralization of procedures into high-volume or teaching centers is unlikely to improve surgical quality.

Adenocarcinoma↗

PubMedDate not supplied

Magnetic resonance imaging findings and correlations in spasmodic dysphonia patients.

A sample of 19 spasmodic dysphonia (SD) patients was selected from a larger population of such patients to undergo magnetic resonance imaging (MRI), auditory brain stem response (ABR) testing, speech analysis, and extensive physical examination. Six patients had abnormal spin-echo MRI findings, ranging from infarcts within the basal ganglia to demyelinating lesions within the supralateral angles of the lateral ventricles. A weakly positive correlation was noted between the abnormal MRI findings and an abnormal ABR. The lack of a significant correlation between the MRI findings and other predictors of brain stem and midbrain disease, and the current spatial resolution limitations of MRI, suggest that we are visualizing the associated lesions rather than the actual foci of SD. The range of MRI findings is consistent with the concept that SD is a voice disorder in a heterogeneous patient population.

Adult↗

PubMedDate not supplied

Renal and electrolyte effects of total parenteral nutrition.

Effects of short-term (4-14 days) total parenteral nutrition on renal handling of water and electrolytes were studied retrospectively in 24 patients and prospectively in eight patients. There was 33% incidence of hyponatremia and significant reductions in serum creatinine (from 1.03 +/- 0.06 to 0.88 +/- 0.06 mg/dl, p less than 0.001), phosphorus (from 3.2 +/- 0.14 to 2.5 +/- 0.17 mg/dl, p less than 0.005) and uric acid (from 6.09 +/- 0.38 to 3.66 +/- 0.24 mg/dl, p less than 0.001) were observed. Hypouricemia correlated with increased fractional excretion of urate (r = 0.81, p less than 0.05). Hypophosphatemia was associated with increased tubular reabsorption of phosphate. Clearance studies in eight patients showed high urine flow rate (1.7 +/- 0.2 ml/min), osmolar clearance (3.2 +/- 0.7 ml/min), urinary nonelectrolyte, nonurea solute excretion (0.23 +/- 0.14 mmol/min), and negative free water clearance (TcH2O = 1.5 +/- 0.6 ml/min). These data suggest presence of compartmental shifts, expanded extracellular fluid volume, and possible direct effects on renal tubular transport functions during total parenteral nutrition.

Aged↗