Vascular disease and lipids in diabetes.

Atherosclerosis kills more patients with diabetes than all other causes combined. Aggressive reversal and treatment of dyslipidemias is the only proven prevention for coronary events in the patient with type 2 diabetes. Glycemic control with diet, oral hypoglycemic agents, and insulin, when necessary, is often only partially effective in normalizing lipid values in type 2 diabetes.

Localization of a multiple synostoses-syndrome disease gene to chromosome 17q21-22.

Multiple synostoses syndrome is an autosomal dominant disorder characterized by premature onset of joint fusions, which initially affect the interphalangeal joints, by characteristic facies, and by deafness. We performed linkage analysis on a large Hawaiian family with multiple synostoses syndrome. Because another autosomal dominant disorder, proximal symphalangism, shares some clinical symptoms with multiple synostoses syndrome and has been linked to markers at loci at chromosome 17q21-22, we tested the hypothesis that multiple synostoses syndrome is linked to the same chromosomal region.

Cost effectiveness of coronary heart disease prevention strategies in adults.

Although risk-factor modification has gained wide acceptance as an effective approach to the prevention of coronary heart disease (CHD), health planners, physicians and patients confront considerable uncertainty over the most appropriate and efficient preventive strategies. Some preventive approaches are both inexpensive and effective; others are expensive while their effectiveness is slight or unproven. Effectiveness varies with an individual's age, gender and other risk factors.

The effect of search procedures on utility elicitations.

Objective: Elicited preferences for health states vary among scaling methods, manners of describing health states, and other features of the elicitation process. The authors examined the effects of changing the search procedure for a subject's utility on mean utility values.

Methods: A randomized controlled trial of two search procedures (titration and "ping-pong") using two otherwise identical computer programs that describe health states related to Gaucher's disease, then measuring subjects' preferences.

Efficacy of metformin in type II diabetes: results of a double-blind, placebo-controlled, dose-response trial.

Purpose: To study the efficacy and safety of various dosages of metformin as compared with placebo in patients with type II diabetes mellitus.

Patients And Methods: A 14-week, multicenter, double-blind, dose-response study was conducted. After a 3-week, single-blind, placebo-controlled washout, 451 patients with fasting plasma glucose levels of at least 180 mg/dL were randomized to receive an 11-week course of placebo or metformin given at 500, 1000, 1500, 2000, or 2500 mg daily.

Cognitive manifestations of Huntington disease in relation to genetic structure and clinical onset.

Objective: To examine the cognitive manifestations of Huntington disease (HD) with respect to age, clinical onset, progression, and genetic analyses.

Design: Case series of people with HD or at risk (AR) for HD.

Setting: Movement disorders and medical genetics clinics.

Measurement of the validity of utility elicitations performed by computerized interview.

Objectives: The authors evaluate a measure of the validity of utility elicitations and study the potential effects of invalid elicitations on population utility values.

Methods: The authors used a computerized survey to describe and measure preferences for three common side-effects of anti-psychotic drugs (tardive dyskinesia [TD], akathesia [AKA], pseudo-parkinsonism). The authors compared the validity of elicitations in 41 healthy volunteers to 22 schizophrenic patients.

Dyslipidemia as a risk factor for coronary disease in patients with diabetes.

Objective: To highlight the frequency of lipid abnormalities in patients with diabetes and the need for appropriate treatment strategies for coronary disease.

Methods: The epidemiologic features of coronary artery disease in the diabetic population are reviewed, and the pathogenesis of atherosclerotic disease is discussed. Various risk factors for predicting coronary artery disease and guidelines for therapeutic intervention are presented.

Mortality, hospital admissions, and medical costs of end-stage renal disease in the United States and Manitoba, Canada.

Objectives: National registry data suggest that mortality rates among patients with end-stage renal disease are lower in Canada than in the United States. Casemix and treatment variables, although limited in such instances, do not explain this difference. Using a more complete set of casemix and treatment variables from clinical databases, this study assesses mortality, hospital admission, and the cost of medical care for patients with end-stage renal disease treated in Manitoba, Canada and the United States.

The effect of assessment method and respondent population on utilities elicited for Gaucher disease.

Measured preferences have been reported to vary with the method of elicitation and respondent population surveyed. We elicited utilities for Gaucher disease using a multimedia implementation of the time trade-off, standard gamble, and a conceptually different, largely untested approach, the risk-risk trade-off, from those who are healthy, those with a chronic illness and those with Gaucher disease. The risk-risk trade-off produced significantly lower utilities than the other two preference assessment methods and had the poorest test-retest reliability.

Assessing for sexual abuse.

1. Knowing the sexual abuse history of a patient contributes to a greater understanding of the patient's clinical problems and facilitates appropriate discharge planning. 2.

Cost-effectiveness of screening for carotid stenosis in asymptomatic persons.

Background: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented.

Objective: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention.

Cholesterol screening should be targeted.

For primary prevention of coronary heart disease (CHD), the American College of Physicians (ACP) has recommended that initial cholesterol screening be targeted to people who have other risk factors in addition to elevated cholesterol. This would include those with symptoms of heart disease, asymptomatic men 35-65 years old and women 45-65 years old, or younger people who have > or = 2 risk factors or who might benefit from treatment for high blood cholesterol. After the age of 75, cholesterol is no longer a risk factor, so there is no rationale for testing.

Economic foundations of cost-effectiveness analysis.

To address controversies in the applications of cost-effectiveness analysis, we investigate the principles underlying the technique and discuss the implications for the evaluation of medical interventions. Using a standard von Neumann-Morgenstern utility framework, we show how a cost-effectiveness criterion can be derived to guide resource allocation decisions, and how it varies with age, gender, income level, and risk aversion. Although cost-effectiveness analysis can be a useful and powerful tool for resource allocation decisions, a uniform cost-effectiveness criterion that is applied to a heterogeneous population level is unlikely to yield Pareto-optimal resource allocations.

Willingness-to-pay utility assessment: feasibility of use in normative patient decision support systems.

The authors developed an automated patient interviewing tool to elicit individuals' willingness-to-pay (WTP) utilities under conditions of uncertainty and examined the reliability of this method and its potential usefulness in clinical decision support. We tested this method in 52 healthy volunteers using a computer-based interview that trained subjects in standard gamble (SG) and WTP methods, and elicited preferences for moderate Gaucher disease using WTP and SG. We assessed the validity of the WTP method by calculating the cost-effectiveness threshold implied by subjects' WTP and SG utilities; we also assessed subjects' understanding and comfort with using WTP for decision making by a questionnaire.

Evaluating the federal role in financing health-related research.

This paper considers the appropriate role for government in the support of scientific and technological progress in health care; the information the federal government needs to make well-informed decisions about its role; and the ways that federal policy toward research and development should respond to scientific advances, technology trends, and changes in the political and social environment. The principal justification for government support of research rests upon economic characteristics that lead private markets to provide inappropriate levels of research support or to supply inappropriate quantities of the products that result from research. The federal government has two basic tools for dealing with these problems: direct subsidies for research and strengthened property rights that can increase the revenues that companies receive for the products that result from research.

The cost of VA-sponsored research.

Background: Under pressures to reduce health care costs, clinical income is a shrinking source of support for research. Such pressures also threaten research at the medical centers of the Department of Veterans Affairs (VA). VA research is particularly vulnerable because medical care appropriations constitute a large, though unknown, source of support.

Creatine kinase in trout male germ cells: purification, gene expression, and localization in the testis.

High creatine kinase (CK) activity (16.5 +/- 7.6 IU/mg) is present in trout spermatozoa.

Prevention and treatment of diabetic nephropathy: role of angiotensin-converting enzyme inhibitors.

Objective: To discuss the role of angiotensin-converting enzyme inhibitors in the management of diabetes-related renal disease.

Methods: We review the published data from animal studies and clinical trials and outline the adverse effects that may limit the use of these drugs.

Results: Diabetic nephropathy is the most common cause of end-stage renal disease and dialysis in the United States.