Analyses of cost effectiveness in the management of essential hypertension: What they can and what they do not teach us

There are approximately 50 million hypertensive individuals in the United States, and their treatment is often life-long. Most are asymptomatic, so the goal of treatment is to prevent complications, which often occur decades after the condition is detected. Although the management of hypertension is potentially very costly, it is now clear that antihyperten-sive therapy can substantially reduce cardiovascular mortality and morbidity. This constellation of an asymptomatic process with a very high prevalence capable of producing severe and potentially costly complications is precisely the circumstance under which cost effectiveness of therapy becomes an important consideration. Several such analyses have been performed, examining the question of which patients should be treated, what procedures should be used in their evaluation, and which therapeutic agents should be used. These studies highlight important issues, but also illustrate the potential pitfalls and fallacies of such analyses, particularly when outcome data are unavailable or inadequate. This article reviews the literature concerning cost-effectiveness analyses in the management of hypertension and discusses the value of this approach.     

Statins augment collateral growth in response to ischemia but they do not promote cancer and atherosclerosis

3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, or statins, are widely prescribed to lower cholesterol. Recent reports suggest that statins may promote angiogenesis in ischemic tissues. It remains to be elucidated whether statins potentially enhance unfavorable angiogenesis associated with tumor and atherosclerosis. Here, we induced hind limb ischemia in wild-type mice by resecting the right femoral artery and subsequently inoculated cancer cells in the same animal. Cerivastatin enhanced blood flow recovery in the ischemic hind limb as determined by laser Doppler imaging, whereas tumor growth was significantly retarded. Cerivastatin did not affect capillary density in tumors. Cerivastatin, pitavastatin, and fluvastatin inhibited atherosclerotic lesion progression in apolipoprotein E-deficient mice, whereas they augmented blood flow recovery and capillary formation in ischemic hind limb. Low-dose statins were more effective than high-dose statins in both augmentation of collateral flow recovery and inhibition of atherosclerosis. These results suggest that statins may not promote the development of cancer and atherosclerosis at the doses that augment collateral flow growth in ischemic tissues.     

Why patients do not attend cardiac rehabilitation: role of intentions and illness beliefs

OBJECTIVE: Many patients fail to attend cardiac rehabilitation. Attempts to identify sociodemographic or clinical predictors of non-attendance have not been very successful; therfore, this study aimed to determine whether the illness beliefs held during hospitalisation by patients who had suffered acute myocardial infarction or who had undergone coronary artery bypass graft surgery could predict cardiac rehabilitation attendance. SUBJECTS AND METHODS: 152 patients were prospectively studied of whom 41% had attended cardiac rehabilitation at six months. RESULTS: In addition to being older, less aware of their cholesterol values, and less likely to be employed, non-attenders were less likely to believe their condition was controllable and that their lifestyle may have contributed to their illness. CONCLUSION: It should now be determined whether interventions aimed at optimising certain perceptions could promote cardiac rehabilitation uptake among those patients who could benefit the most.     

Antipsychotic use in the elderly: What doctors say they do,and what they do

Objective: To review psychiatrists’ attitudes and actual practice on the use of typical and atypical antipsychotics in the elderly. Methods: Audit data were collected from 18‐old‐age psychiatry units across Australia. The attitudes of old age psychiatrists and their perceptions of the efficacy, tolerability and clinical usefulness of antipsychotics were examined. Results: The medications used for 321 patients were audited, and the attitudes of the 57 prescribing doctors were assessed. All available atypicals were prescribed and reported as more efficacious and clinically useful than typicals. Adverse events perceived by doctors as an obstacle to prescribing were more frequent than reported adverse event rates in product information. All diagnostic groups improved. Off‐label use comprised almost 22% in this sample. Conclusions: Adverse events are impediments to prescribing, more so with typical than atypical antipsychotics. All available atypicals were used and appeared effective in this elderly population.     

Thai elderly who do not coreside with their children

In this paper, data from a nationally representative survey of elderly Thais living in private households are analyzed. The analysis focuses on situations of the 756 elderly who do not coreside with an adult child. Only a minority of those elderly who do not coreside with an adult child were childless. The majority have at least one noncoresident child with whom they could potentially live. Daily contact with children for elderly who live alone was not significantly different from that of elderly who live with their children, suggesting that households that are classified as being separate may in fact function as single households or that at least one non-coresident child may live in very close proximity to the elderly person. Differences between urban and rural elderly in terms of type of support received from non-coresident children as well as likelihood of living near a non-coresident child are discussed.     

Forced expiratory manoeuvres in children: do they meet ATS and ERS criteria for spirometry?

The aim of this study was to evaluate the applicability of American Thoracic Society and European Respiratory Society criteria for spirometry in children. Maximal expiratory flow/volume (MEFV) measurements from 446 school-age children, experienced in performing MEFV manoeuvres, were studied and acceptability (start-of-test (backward extrapolated volume as a percentage of forced vital capacity (FVC) ([Vbc%FVC) or as an absolute value (Vbe), end-of-test (forced expiratory time (FET)) and reproducibility criteria (absolute and percentage difference between best and second-best FVC and forced expiratory volume in one second (FEV1) (deltaFVC, deltaFVC %, deltaFEV1 and deltaFEV1 %)) were applied to these manoeuvres. The Vbe%FVC criterion was met by 91.5%, the Vbe <0.15 L criterion by 94.8% and the Vbe <0.10 L by 60.1% of children. Vbe <0.15 L appeared to be a more useful parameter than Vbe%FVC. The FET criterion was met by only 15.3% of children. deltaFVC <0.2 L and deltaFEV1 <0.2 L were met by 97.1% and 98.4%, and deltaFVC <0.1 L and deltaFEV1 <0.1 L by 79.8% and 84.3% of the children, respectively. These criteria appeared to be less useful compared to percentage criteria (deltaFVC % and deltaFEV1 %). Even experienced children did not meet all international criteria for spirometry. However, most of their MEFV curves are useful for interpretation. Based on the performance of these children, a re-evaluation of criteria for maximal expiratory flow/volume measurements in children is proposed.