Drug policy by popular referendum: This, too, shall pass

In formulating policies for drug offenders, lawmakers must decide concrete questions about such matters as legal jurisdiction, burdens of proof, and reporting of progress information. Although these decisions may seem incidental to treatment and beyond the purview of science, they are based on empirically testable assumptions about the behavior of drug abusers and have a direct bearing on the efficacy of drug treatment interventions. Unfortunately, these assumptions have generally not been subjected to empirical inquiry. As a result, drug policy continues to be crafted by non-scientific advocates and subjected to popular vote by an insufficiently informed public. This article identifies several empirically answerable questions that underlie critical decision points in criminal statutes for drug offenders, reviews the available research evidence relevant to these questions, and encourages drug abuse researchers to conduct studies aimed squarely at informing these policy-relevant decisions.     

Visual cortex maps are optimized for uniform coverage

Cat visual cortex contains a topographic map of visual space, plus superimposed, spatially periodic maps of ocular dominance, spatial frequency and orientation. It is hypothesized that the layout of these maps is determined by two constraints: continuity or smooth mapping of stimulus properties across the cortical surface, and coverage uniformity or uniform representation of combinations of map features over visual space. Here we use a quantitative measure of coverage uniformity (c') to test the hypothesis that cortical maps are optimized for coverage. When we perturbed the spatial relationships between ocular dominance, spatial frequency and orientation maps obtained in single regions of cortex, we found that cortical maps are at a local minimum for c'. This suggests that coverage optimization is an important organizing principle governing cortical map development.     

Optimizing a portfolio of health care programs in the presence of uncertainty and constrained resources

Much research has been devoted to handling uncertainty in cost-effectiveness analysis. The current literature suggests summarizing uncertainty in cost-effectiveness analysis using acceptability curves or net health benefits. These approaches, however, focus only on uncertainty associated with costs and effects of the programs under consideration. In the real world, most decision-makers have to fund a portfolio of health care programs. Therefore, a more comprehensive approach would include in the analysis the uncertainty of costs and effects of all programs supported by the fixed budget. This paper extends the decision rule described by Birch and Gafni (J. Health Econ. 11(3) (1992) 279) within the context of a portfolio of programs when costs and effects are uncertain and resources constrained.     

A primary care cardiovascular risk reduction clinic in Canada was more effective and no more expensive than usual on-demand primary care – a randomised controlled trial

The objective of this randomised controlled trial was to compare the effects and expense of three approaches to care (1) proactive cardiovascular risk reduction (CaRR) clinic; (2) nurse telephone calls; or (3) usual care for people with cardiovascular risk factors in a Primary Care, Health Service Organisation (HSO) in Ontario, Canada. Subjects included consenting patients with an identified cardiovascular disease (CVD) risk factor identified from the HSO computerised patient information system in 2004. Patients were excluded if they were mentally incompetent, <18 years of age, in a nursing home, or not English speaking. Of 1570 eligible subjects, 523 (33.3%) verbally declined, 145 (9.2%) could not be contacted, and 249 (15.9%) were not needed. The final sample size was 653 (41.6%), 634 completed the follow-up (97%). The Cardiovascular Risk Score, Health and Social Service Utilisation, Montgomery-Asberg Depression Rating, Billings and Moos Indices of Coping, Personal Resource and Self-Efficacy Questionnaires were measured at baseline and 1-year follow-up by clinical examination and telephone interview. Cardiovascular risk scores were reduced in all treatment groups after 1 year. The proportions of subjects showing reduction in risk score greater than or equal to 10% was greatest in the CaRR group (69.2%) compared with Nurse Phone intervention (57.8%) and Usual Care (59.0%) ( M - H χ² = 4.33, df = 1, P  = 0.037, CaRR-Usual Care). Self-efficacy scores showed the greatest improvements in the CaRR clinic. This effect was achieved with no significant difference in total person per annum costs for direct and indirect health and social service utilisation between all three groups. A CaRR clinic is more effective in reducing CVD risk after 1 year compared with nurse phone intervention and usual care with no additional expense found.     

The prevalence, correlates, and costs of depression in people living with HIV/AIDS in Ontario: implications for service directions.

As new technologies extend the lives of people living with HIV/AIDS (PHA), the need increases for services that optimize their quality-of-life cost effectively. This study of PHAs (n = 297) in Ontario, Canada, examined the prevalence of depression, and its association with quality-of-life, coping strategies, social support, and use of health and social services. Results showed that depression was widespread (54.2%) and largely unrelated to demographic characteristics, but associated with diminished health status, health-related quality-of-life, and coping strategies. Depressed PHAs used significantly more crisis health care and related services, and community-based HIV/AIDS service organizations (ASOs). Findings suggest quality-of-life of PHAs may be improved by expanding the capacity of ASO workers to recognize and address depression, including helping depressed PHA access appropriate medication and sustain medication regimes.     

Radioimmunoassay of human plasma retinol-binding protein

A radioimmunoassay for human plasma retinol-binding protein (RBP) has been developed utilizing a double antibody precipitation technique. RBP was purified 1500- to 2000-fold by procedures described previously. A specific anti-human RBP antiserum was prepared in rabbits by three once-weekly injections of purified RBP emulsified with Freund's adjuvant. RBP was iodinated with (131)I and the RBP-(131)I was purified by gel filtration on Sephadex G-100 after complex formation with human plasma prealbumin. The RBP-(131)I was completely (> 95%) immunoprecipitable in the presence of an excess of specific antiserum, it was not (< 5%) immunoprecipitable in the absence of specific antiserum, and it could be completely displaced from antibody by excess unlabeled RBP. The standard curve obtained in the immunoassay with normal plasma was identical to that with pure RBP. Duplicate samples differed from their mean by 5 +/-5% (+/-SD). There was a quantitative recovery of pure RBP added in varying amounts to normal plasma. The immunoassay accurately measured RBP in amounts of 10-100 ng per assay tube. There was no significant difference in the immunoreactivity of apo-RBP as compared to holo-RBP. The mean plasma values (+/-SEM) for a group of 76 normal subjects were 47.2 +/-1.6 mug/ml for males and 41.6 +/-1.6 mug/ml for females. Plasma RBP levels were markedly depressed (15 +/-2.3 mug/ml) in 14 patients with acute viral hepatitis. There was a highly significant correlation between the plasma levels of RBP and of vitamin A in both normal subjects and patients with hepatitis. In all subjects plasma RBP was generally saturated with retinol. The data suggest that under normal circumstances RBP circulates almost exclusively as the holoprotein.     

Prediction of resource utilization and case cost for acute nonvariceal upper gastrointestinal hemorrhage at a canadian community hospital

OBJECTIVE: Upper gastrointestinal hemorrhage (UGIH) is common, and thus imposes a substantial burden on health care resources. We describe resource utilization and cost for management of acute nonvariceal UGIH, and studied their variation among population subgroups. METHODS: Resource utilization and direct medical case costs were extracted for consecutive admissions for nonvariceal UGIH at a large community hospital in southern Ontario through chart review and adaptation of an administrative case cost database. Univariate and multiple regression models were then developed to identify independent demographic predictors of case cost and length of stay. RESULTS: Among 116 eligible admissions the average length of stay and case cost were 4.26 days and Can$2690, respectively (Can$1 = US$0.70). Both cost and length of stay demonstrated significant univariate relationships with age, comorbid illness, prior peptic ulcer disease (PUD), and prior UGIH. Age and prior PUD persisted as independent predictors in multiple regression models. An inverse transformation of total case cost allowed these variables to explain 26% of the total variance. CONCLUSIONS: Resource utilization for management of acute nonvariceal UGIH at a Canadian community hospital varies substantially among population subgroups, but correlates independently with age and prior ulcer history. Careful attention must be paid to practice environments and demographic profiles before economic models of strategies to prevent or treat UGIH are applied to specific subpopulations.     

Doing Nothing is No Choice: Lay Constructions of Treatment Decision-making Among Women with Early-stage Breast Cancer

Open-ended personal interviews were conducted with 20 women with early stage breast cancer attending a regional cancer centre in Southwestern Ontario. We explored three related issues: (1) the extent to which these women perceived that they had treatment options; (2) their understanding of treatment benefits and risks; and (3) the role they wanted for themselves and their oncologists in treatment decision-making.
We found, first, that many women who were presented with the choice to undergo some form of adjuvant treatment versus no treatment felt that 'doing nothing was no choice'. Second, when interpreting probabilistic information on treatment benefits and risks, some women retained the idea of probability but thought that they personally would beat the odds. Others transformed the information to make it more personally meaningful, and still others assessed their risk status by comparing themselves with friends or relatives having the same disease. Third, many women preferred some form of shared treatment decision-making process with their oncologists. Women perceived treatment decisions as either 'right' or 'wrong' which raised the issue of blame for a 'bad' decision should the cancer return. Implications of these findings for clinical practice and for models of treatment decision-making are discussed.     

Plasma Interleukin-12 Is Elevated in Patients with Preeclampsia

PROBLEM: Abnormal immune activation has been suggested as a contributor to the development of preeclampsia. We hypothesized that intact interleukin (IL)-12 directly, or through its main mediator, interferon (IFN)-γ, contributes to the altered immune response observed in preeclampsia. METHOD OF STUDY: Plasma samples were collected from 20 patients with preeclampsia and 20 normotensive patients with uncomplicated pregnancies who were matched with the preeclamptic patients by age, gestational age, and parity. Samples were collected before the onset of labor, induction, or medical intervention. The samples were assayed for IL-12 and IFN-γ by specific enzyme-linked immunoassays. RESULTS: IL-12 was detected in 35% of the preeclamptic patients and in 5% of the patients with normal pregnancies (P < 0.01). The detection rate and mean concentration of IFN-γ were comparable in both groups. CONCLUSION: Intact plasma IL-12 is detected more frequently in preeclamptic patients, suggesting the involvement of this cytokine in the enhanced immune response observed in preeclampsia.