Randomized controlled trial of rehabilitation at home after stroke: one-year follow-up of patient outcome, resource use and cost

BACKGROUND AND PURPOSE: This study sought to evaluate early supported discharge and continued rehabilitation at home after stroke, at a minimum of 6 months after the intervention, in terms of patient outcome, resource use and health care cost. METHODS: Eighty-three patients, moderately impaired 5-7 days after acute stroke, were included in a randomized controlled trial, 42 being allocated to the intervention and 41 to routine rehabilitation. One-year follow-up of patient outcome included mortality, motor capacity, dysphasia, activities of daily living, social activities, perceived dysfunction, and self-reported falls. Resource use over 12 months included inpatient hospital care, outpatient health care, use of health-related services, informal care, and cost of health care. RESULTS: On univariate analysis there was no difference in patient outcome. Multivariate regression analysis showed that intervention had a significant effect on independence in activities of daily living. A significant difference in inpatient hospital care, initial and recurrent, was observed, with a mean of 18 (intervention) versus 33 days (control) (p = 0.002). Further significant differences were that the control group registered more outpatient visits to hospital occupational therapists (p = 0.02), private physical therapists (p = 0.03) and day-hospital attendance (p = <0.001), while the intervention group registered more visits to nurses in primary care (p = 0.03) and home rehabilitation (p = <0.001). Other differences in outcomes or resource utilization were nonsignificant. CONCLUSION: In Sweden, early supported discharge with continued rehabilitation at home proved no less beneficial as a rehabilitation service, and provided care and rehabilitation for 5 moderately disabled stroke patients over 12 months after stroke onset for the cost of 4 in routine rehabilitation.     

Remodeling of resistance arteries in renal failure: effect of endothelin receptor blockade

Remodeling of vessels is a known feature of renal failure, but it is unclear whether this represents an appropriate or inappropriate response to the known changes in blood flow, shear stress, and wall tension. To investigate remodeling in response to variations in blood flow, first-order mesenteric arteries were exposed to high- and low-flow conditions via the ligation of second-order branches, according to the technique described by Pourageaud and De Mey. The resulting changes in vessel geometric features, relative proportions of intima and media, submicroscopic structure, and immunostaining for proliferating cell nuclear antigen (PCNA), endothelin-1 (ET-1), and ET(A) receptors were assessed in first-order mesenteric arteries under low-flow and high-flow conditions. Subtotally nephrectomized (SNX) animals were compared with sham-operated rats. Animals either were left untreated or were treated with the ET(A) receptor antagonist (ET-RA) LU-135252, because of suggestions in the literature that ET is involved in vascular remodeling in uremia. A highly significant increase in intimal thickness was noted in low-flow arteries (4.21 +/- 1.39 microm) of SNX animals, compared with normal-flow arteries (2.06 +/- 0.61 microm), but this increase was not observed in sham-operated rats (1.38 +/- 0.77 in low-flow arteries versus 2.40 +/- 0.35 microm in normal-flow arteries). The increase in intimal thickness in low-flow arteries was abrogated by ET-RA. The medial thickness was increased in untreated SNX animals (19.5 +/- 3.61 microm), compared with sham-operated rats, and this increase was also prevented by ET-RA. The medial thickness was not affected by low flow in either sham-operated or SNX animals. In parallel, the number of PCNA-positive intimal cells was higher in low-flow, but not high-flow, arteries of SNX rats, compared with sham-operated rats. No significant change was observed in sham-operated animals. In the media, the number of PCNA-positive cells was higher in untreated SNX animals than in sham-operated rats. The number was even more markedly increased in high-flow, but not low-flow, vessels. This increase was abrogated by ET-RA. It is concluded that, in uremic animals, the response of the intima to low flow and the response of the media to high flow are exaggerated. Both responses are apparently mediated by ET.     

Real-time assessment of intraperitoneal tumor growth in a rat model using CEA immunoscintigraphy

BACKGROUND: In most preclinical models, assessment of intraperitoneal tumor location and size require killing the animal. The dynamics of postoperative intraperitoneal tumor implantation and growth remain unclear. A noninvasive method allowing reliable in vivo, real-time assessment of tumor growth is desirable. METHODS: An intraperitoneal tumor homograft using cultured CC531 colorectal cells was created by laparotomy in 24 Wistar Albino Glaxo rats. Eight additional rats were used as controls. Then, 10 MBq technetium 99m-labeled anticarcinoembryonic antigen (anti-CEA) monoclonal antibodies were administrated intravenously and radioactivity uptake was measured by using extracorporeal gamma counting at various time points. Subsequently, the animals were killed for tumor weighting. In 2 more groups of 8 animals, real-time, repeated measures were performed. RESULTS: Correlation between gamma counting and tumor weight was highly significant (P <.001). The regression equation obtained by using the least squares method was: tumor weight (g) = 2.422 + 0.267 x counts. It was possible to obtain real-time tumor growth curves when repeated measurements of radioactivity were performed. At day 25, the predicted tumor weight was 8.49 +/- 0.76 g, the measured weight was 8.16 +/- 0.99 g. CONCLUSIONS: Immunoscintigraphic measurements with technetium 99m anti-CEA antibodies are highly correlated with tumor weight in this model. As opposed to other tumor graft models based on autopsy findings, real-time monitoring is possible. This will allow dynamic studies of intraperitoneal tumor implantation and growth and will reduce the number of animals used in further studies.     

Comparison of heavy metal concentrations in tissues of red foxes from adjacent urban, suburban, and rural areas

The red fox (Vulpes vulpes) is a representative of the canid family with wide distribution in the Northern Hemisphere and Australia. The increasing utilization of urbanized habitats by red foxes prompted us to test whether this species may be used to monitor the presence of anthropogenic pollutants in cities or suburbs. For that purpose, we compared the concentrations of heavy metals (Cd, Pb, Cu, Zn) in foxes from urban, suburban, and rural areas within the municipality of Zürich (Switzerland). The kidney and liver of suburban and rural foxes contained the highest Cd concentrations, whereas urban foxes contained the highest Pb levels. In the kidney of suburban foxes, Cd concentrations increased from a median value of 0.73 mg/kg in juvenile animals to 1.82 mg/kg in adults. Similarly, the liver of suburban foxes contained increasing Cd levels from a median of 0.21 mg/kg in juvenile animals to 0.94 mg/kg in adults. An age-dependent storage of Cd was also found in foxes from the rural surroundings, but no such accumulation occurred in urban foxes from the city center, where even adult animals contained very low Cd levels. Conversely, foxes from the urban center were characterized by elevated Pb concentrations during the first 2 years of life, but this transient Pb accumulation was absent in suburban or rural animals. The liver of juvenile foxes contained a median Pb concentration of 0.99 mg/kg in the city compared to only 0.47 and 0.37 mg/kg in the suburban and rural area, respectively. Thus, we found that animals from separate environmental compartments contain different patterns of tissue residues, implying that red foxes may serve as a bioindicator species to detect certain toxic hazards in urbanized habitats. Received: 25 July 2000/Accepted: 14 November 2000     

Health technology assessment of three screening methods in Switzerland

OBJECTIVE: To describe the level of health technology assessments for three screening methods in Switzerland. METHODS: Analysis of documents and expert opinions on mammography screening, ultrasound examinations during normal pregnancy, and screening for prostate-specific antigen (PSA) with a focus on services provided, recommendations, formal regulations, national papers, projects, and formal assessments. RESULTS: Preventive services are explicitly recommended by the Swiss federal law on health insurance. Two routine ultrasound examinations during normal pregnancy as well as PSA analysis for men over 40 years of age on medical indication are covered by basic health insurance. Mammography screening every 2 years has been covered since 1997 for women over 50 years. A systematic screening program for mammography exists in the western part of Switzerland, and a nationwide program is planned. However, a national program may not come into being until a quality assurance program for evaluation is established, and a nationwide fee for reimbursement-to include all costs of such a program-is accepted by providers and insurers. CONCLUSION: According to the Swiss health insurance law, the effectiveness of mammography screening and ultrasound examinations during normal pregnancy have to be proven. Systematic evaluation of these screening methods is in preparation. PSA is not part of current evaluation. It can be concluded that health technology assessment in Switzerland is now required by law for several medical services. However, limited financial and personnel resources as well as the lack of disease registers may hamper progress in the near future.     

GIS approaches to the problem of disease clusters: a brief commentary

This commentary considers issues raised in a recent article on GIS-based approaches to modeling disease clusters. 'Modeling exposure opportunities' (Sabel, Gatrell & L?yt?nen et al., 2000. Social Science and Medicine, 50, 1121-37) and the general problem of mapping disease clusters. It notes that the authors' advocate a fundamentally statistical approach, Kerneling estimation, to map the occurrence of a specific illness whose etiology is unknown. Epidemiologists, ironically, have advocated a fundamentally cartographic solution, the cartogram, in addressing the general problem of disease clusters. The advantages and limits of both approaches are reviewed and the potential for their comparison in a single study suggested. Most importantly, perhaps, the commentary seeks to join the epidemiological and medical geographic literatures as they pertain to this analytic problem and medical cartography's potential (GIS-based or traditional) to understand disease etiology.     

Hijacking a chaperone: manipulation of the MHC class II presentation pathway

Novel antigen delivery systems are currently being developed by genetic manipulation of the MHC class II trafficking pathway. Specific targeting of endogenously synthesized antigens to the class II loading compartment can result in massively enhanced presentation of peptide epitopes. This emerging technology holds promise for a variety of clinical applications including vaccine development, cancer therapies and control of autoimmune diseases.