Rapid healing of chronic venous ulcers following ultrasound-guided foam sclerotherapy.

OBJECTIVE: To measure the short term response of venous ulcers in patients treated with ultrasound-guided foam sclerotherapy (UGFS) at a two-week clinic in Honduras. METHODS: Nine females (ages 25-86; mean 48.1 years) with 13 venous ulcers and saphenofemoral junction reflux were treated with UGFS (polidocanol 3% foam; 1-4 injections; 2-11 cc; Mean Volume 5.4 cc). The dimensions of each ulcer and of the great saphenous vein (GSV) were measured before treatment and one week later. RESULTS: At one week follow-up 2 ulcers healed, 2 GSVs closed, and there was significant improvement in ulcer dimensions (p = 0.00) and size of GSV (p = 0.00). CONCLUSIONS: Venous ulcers in patients with serve venous insufficiency responded quickly to UGFS. Long-term follow-up will be important to determine the sustainability of these results.

Rigorous new approach to constructing a gold standard for validating new diagnostic criteria, as exemplified by the eosinophilia-myalgia syndrome.

BACKGROUND: Constructing diagnostic criteria, a common problem in clinical medicine, is particularly difficult for diseases that lack a pathognomonic "gold standard." To develop an improved strategy for constructing such criteria, we used the eosinophilia-myalgia syndrome as an example. The goal, for research classifications, was to construct validated clinically sensible criteria and to develop improved methods that can be used for other disorders. METHODS: Using a "pattern-based" approach with data from several separate sources, a committee of investigators first prepared and informally tested criteria for the diagnosis of eosinophilia-myalgia syndrome. A gold standard challenge set of reports of cases and noncases was independently generated and separately validated by an external panel of clinical experts. The criteria were then tested using the gold standard set, and interobserver variability and diagnostic accuracy were determined. RESULTS: Interobserver variability showed the following mean proportionate agreements: 98.7% for the presence of specific criteria elements, 99% to 100% for diagnosis, and 97% to 98% for diagnostic pattern. kappa Values were correspondingly high. Diagnostic accuracy showed sensitivity at 88%, specificity at 97%, and overall accuracy at 92%. CONCLUSIONS: The proposed criteria are accurate and reproducible, and can be used in future clinical investigations of the eosinophilia-myalgia syndrome. The new strategy and methods developed for this challenge can be valuable for solving analogous problems in constructing criteria for other clinical disorders.

The economic impact of asthma and chronic obstructive pulmonary disease (COPD) in Sweden in 1980 and 1991.

This study was carried out to estimate the direct and indirect costs associated with asthma and chronic obstructive pulmonary disease (COPD) in Sweden in 1980 and 1991, and to identify trends in the use of outpatient care, drugs and inpatient care, and the development of temporary morbidity, permanent disability and mortality for asthma and COPD. Routinely published administrative and population data were used to estimate the costs of asthma and COPD, and these figures were compared to corresponding estimates and trends for all respiratory diseases as well as for all diseases. Asthma and COPD each accounted for about SEK 3 billion, together roughly 2% of the economic cost of all diseases. Although the total costs associated with each disease were similar, the distribution of the different cost components and changes in each component over time differed. During the 1980s, the cost of drugs and out-patient care increased for both diseases. The cost of inpatient care for asthma decreased, whereas that for COPD increased. This study shows that asthma therapy has changed from inpatient to ambulatory care in Sweden, while the treatment of COPD to a higher degree still is based on inpatient care.

Cost-Effectiveness of Budesonide Controlled Ileal Release (CIR) Capsules as Maintenance Therapy versus No Maintenance Therapy for Ileocaecal Crohn's Disease in Sweden.

A decision-analytic model was designed to estimate the associated costs and outcomes of maintenance therapy for Crohn's disease with budesonide controlled ileal release (CIR) capsules (Entocort((R)) capsules, Astra Draco, Lund, Sweden) versus no maintenance therapy. A third-party payer perspective was adopted to compare the direct costs associated with the medication and healthcare resource use for each therapy over a period of 12 four-week cycles. The costs of routine patient care and the consequences of failure, in terms of relapses, acute therapies, hospitalisations and surgery, were included. The outcome was measured as the average number of days in remission per patient per 12-cycle period. Based on the assumptions in the model, the results show that budesonide CIR capsules are associated with a reduction of 16.6 (26%) days in relapse, i.e. a 6% increase in days in remission, over a one-year period compared with no maintenance therapy. Direct healthcare costs are increased by 6% or Swedish kronor (SEK) 1673 ($US1 ~ SEK7.60). Overall, the model shows that there are substantial (non-drug associated) cost offsets from using budesonide CIR capsules as maintenance therapy in Crohn's disease. These cost offsets, in addition to improvements in patients' well-being and quality of life, indicate that maintenance therapy is cost effective compared with no maintenance therapy. The cost per added day in remission is relatively modest (SEK101 ~ $US13). If indirect costs are added to the calculation, it is realistic to argue that a net saving to society would be most likely.

Impact of inhaled corticosteroids on acute asthma hospitalization in Sweden 1978 to 1991.

OBJECTIVES: In clinical studies, it has been found that treating asthmatic patients with inhaled corticosteroids can reduce the need for in-patient care. The purpose of this study was to determine if such a relationship could be observed in available health-care statistics in Sweden and, if such a relationship could be established, what health economic consequences it implied. METHODS: A retrospective study was conducted using regional data on acute hospitalization-ie, number of bed-days in acute somatic in-patient care clinics-and sales of anti-asthmatic drugs from 14 health-care administrative regions, covering 6 million people (71% of the Swedish population) between 1978 and 1991. The data were analyzed in multiple regression analyses where time- and cross-section data were pooled. The variation in bed-days was explained by three variables: (1) the sales of inhaled corticosteroids, (2) the total number of bed-days within acute somatic in-patient care, and (3) the sales of inhaled bronchodilators, which were used as a proxy variable for asthma prevalence. RESULTS: The total number of bed-days due to asthma in the 14 county councils did not show any upward or downward trend between 1978 and 1985. However, after 1985, there was a significant downward trend despite an increase in estimated asthma prevalence. Increased sales of inhaled corticosteroids were significantly correlated (P < 0.01) with a reduction in bed-days due to asthma. The model used indicated that an increase in sales of inhaled corticosteroids by 1 defined daily dose (DDD) per day and 1,000 inhabitants gave, on average over the study period, a reduction of 1.5 bed-days for asthma in acute in-patient care per 1,000 inhabitants. CONCLUSIONS: Clinical trial findings that treating asthmatic patients with inhaled corticosteroids improves asthma control and reduces the need for hospitalization, seem to be realized in clinical practice. The increased costs of inhaled corticosteroids to the health-care system were more than offset by a reduction in the costs for acute somatic hospital care.

Criteria for the definition of the eosinophilia-myalgia syndrome.

The widely disseminated surveillance case definition of the eosinophilia-myalgia syndrome (EMS) recommended by the Centers for Disease Control in 1989 has never been validated by an appropriate challenge and has commonly been used for unintended purposes. To accurately classify patients for clinical and epidemiologic studies and to properly diagnose individual patients, an acceptable set of criteria must be established. In determining which combination of clinical and laboratory manifestations should be properly included in criteria for EMS the following elements should be considered: (1) the presence of a well delineated, documented acute episode with characteristic symptoms, signs, and laboratory abnormalities; (2) the presence of characteristic histopathological abnormalities; (3) the presence of objective evidence for involvement of the most commonly affected major organs: skin, muscle, nerve, and/or lung; and (4) the absence of premorbidities or comorbidities that could explain the components of illness on which the diagnosis is based. A preliminary set of criteria is proposed in this paper. This model requires further scrutiny, revision, and testing.

The eosinophilia-myalgia syndrome: status of 205 patients and results of treatment 2 years after onset.

OBJECTIVE: To describe the course of the eosinophilia-myalgia syndrome during a 2-year period. DESIGN: 15 physicians completed a structured review form to describe symptoms, physical findings, laboratory data, and responses to treatments in 205 patients with the eosinophilia-myalgia syndrome at the onset of illness and after 18 to 24 months of follow-up. SETTING: 15 university and private clinical practice settings. PATIENTS: 205 patients for whom follow-up data were available and who met four criteria at diagnosis: eosinophil count of 1000 cells/mm3 or greater; presence of fasciitis, peripheral neuropathy, polyradiculopathy, interstitial pulmonary disease, pulmonary hypertension, or myocardial involvement; history of L-tryptophan consumption; and absence of other conditions that could account for these findings. INTERVENTION: Empirical interventions by the physicians. MEASUREMENTS: Symptoms, physical findings, laboratory test results, biopsy findings, radiographic reports, therapeutic interventions, and responses to these interventions. RESULTS: After 18 to 24 months, all symptoms except cognitive changes were reported to have improved in most patients. Nearly all physical findings were also reported to have improved or resolved in most patients; only peripheral neuropathy was unchanged. No evidence of ongoing inflammatory disease was reported. Prednisone was reported to be helpful in 79% of patients who received it during the acute phase of the syndrome. No other treatment was reported to be consistently beneficial. CONCLUSIONS: 18 to 24 months after the onset of illness, most symptoms and physical findings in most patients with the eosinophilia-myalgia syndrome resolved or improved. Cognitive changes were reported to be worse in 32% of patients. Prednisone was helpful in the acute phase of illness. No treatment was clearly valuable in management of the later phase of the syndrome.

Repeated coronary artery spasm in a young woman with the eosinophilia-myalgia syndrome.

We report a case of repeated coronary artery spasm with myocardial injury in a 37-year-old woman with the eosinophilia-myalgia syndrome. This patient did not have a medical history of cardiac-related illness or risk factors for coronary artery disease. The presence of eosinophil granule major basic protein in otherwise normal-appearing myocardial tissue, along with normal plasma levels of tryptophan metabolites, suggests that the mechanism of vasospasm in this patient might involve toxic eosinophil proteins or focal myocardial lesions, but not the production of excess tryptophan metabolites.

The eosinophilia-myalgia syndrome: the Los Alamos Conference.

On June 12 and 13, 1990 the Los Alamos National Laboratory in cooperation with the New Mexico Department of Health and Environment, the Centers for Disease Control (CDC), the Food and Drug Administration (FDA), and the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (NIH) hosted a conference on the eosinophilia-myalgia syndrome. Fifty presentations covered a variety of important issues which are summarized herein.

Association of the eosinophilia-myalgia syndrome with the ingestion of tryptophan.

We report on a series of three patients with an unusual syndrome of eosinophilia and myalgia associated with the oral ingestion of tryptophan that was recognized in New Mexico in October 1989. All three patients, who were women 37 to 44 years of age, had severe muscle pain, muscle weakness, mouth ulcers, and striking eosinophilia (more than 8 X 10(9) cells per liter). Other manifestations included fever, abdominal pain, dyspnea, skin rash, and elevated serum concentrations of aminotransferase and aldolase. The women had been taking tryptophan in doses of 1.2 to 2.4 g a day for three weeks to 2 1/2 years. The discontinuation of tryptophan and the initiation of glucocorticoid treatment resulted in improvement, but all three women were still symptomatic three to five months later. Tests for trichinosis and other parasites and for allergic and connective-tissues disorders were negative, and serum immunoglobulin concentrations and erythrocyte sedimentation rates were normal. A muscle biopsy in one patient and biopsies of the vagina, liver, and other abdominal organs in another revealed eosinophilic infiltration, as well as the extracellular deposition of eosinophil-granule major basic protein. All three patients had elevated serum and urinary levels of this protein and eosinophil-derived neurotoxin, indicative of eosinophil degranulation. The syndrome of eosinophilia and myalgia in association with the ingestion of tryptophan that was seen in these three patients is a newly recognized adverse effect of tryptophan ingestion. Our identification of this association in these patients led to the discovery of an epidemic of what is now called the eosinophilia-myalgia syndrome.

Cost-effectiveness analysis of pharmaceuticals: its informational content and an example.

The importance of cost-effectiveness analysis within the health care sector will increase. This is due to changes in the health care sector where there is an emphasis on improving the efficiency. The changes will influence the incentive structure and, subsequently, the demand for reliable managerial information. Cost-effectiveness analysis of pharmaceuticals is a good example of the state-of-the-art of cost-effectiveness applied to health care. A study on the cost-effectiveness of prophylaxis against infection in total joint replacement is presented as an example of an economic evaluation of pharmaceuticals.

Exercise stress testing in blood pressure evaluation.

The purpose of this study was: (1) to confirm exercise stress testing as a standard in the diagnosis of hypertension, (2) to clarify which measurements during exercise testing are most reliable, and (3) to refine the definition of normal blood pressure response during ergometric exercise testing. Blood pressure response during maximal ergometric exercise testing was observed in 183 persons with no history of hypertension, 176 persons with borderline blood pressure readings, and 60 established hypertensives. Men and women had significantly different blood pressure response to exercise (P less than 0.05). Comparison of blood pressures at 100-watts workload, at peak exercise, and 5-minutes postexercise provided significant information for distinguishing between normal, borderline, and established hypertensive persons (P less than 0.025-0.001). Comparing the slopes of pulse rate versus blood pressure linear regression curves was not helpful. Regression equations generated for predicting correct blood pressure classification improved classification accuracy (compared with random classification) by 44.9 percent in men and by 66.8 percent in women. The results showed that ergometric stress testing in blood pressure evaluation is a safe and reliable procedure for aiding in a more accurate diagnosis of hypertension.