Impact of health technology assessments. Some experiences of SBU

OBJECTIVE: A recurring question is whether evidence from systematic reviews has any impact on medical practice. We have studied this question in relation to some conclusions in seven reports, where relatively simple means to monitor trends could be used. RESULTS: As recommended, in the report preoperative routines, the number of preoperative examinations diminished at six hospitals, during around 3,000 operations studied, a savings of SEK 130 million. After the report on moderately elevated blood pressure, moderately elevated blood pressure sales of the preferred drugs, diuretics and beta-blockers, stopped falling while calcium blockers and ACE inhibitors stopped rising. As concluded in the report, general prostate cancer screening has not been introduced, but tests as a sign of opportunistic screening have increased. Bone density measurements were not recommended for screening, and sales of equipment have declined after the report. The use of neuroleptics as unspecific calming therapy for old persons was discouraged due to the serious side effects. The frequency of patients given this medication diminished from 34% to 28% at nursing homes after 1 year. For smoking cessation, the use of nicotine substitution medications has increased, which is in line with suggestions presented in the report. For stomach pain proton pump inhibitors given for functional dyspepsia have diminished in a region of the country after special efforts to disseminate the message. CONCLUSIONS: It appears to be possible to monitor changes in practice corresponding to selected conclusions in systematic reviews. After rather extensive disseminating efforts, some results look encouraging.     

Influence of surgery and endotoxin-induced sepsis combined on natural killer cell activity, oxidative burst of granulocytes and antigen presentation capability of monocytes

BACKGROUND: Cell mediated immunity is affected in the course of sepsis and following surgical stress. The natural killer (NK) cells, the granulocytes and the monocytes constitute the immediate unspecific cell mediated immunity. We therefore investigated the effect of surgery- and endotoxin-induced sepsis on NK cells, granulocytes and monocytes in a two-hit model. METHODS: Three groups of 40 mice. Each group was divided into four groups of 10 mice. All the animals were anesthetized and subjected to either: laparotomy; treatment with Escherichia coli endotoxin i.p.; laparotomy followed 20 min later by endotoxin i.p.; or left untreated as a control group. In the first 40 mice the NK cell activity in the spleen and number of NK cells in the liver were measured, in the second the oxidative burst of granulocytes, and in the third the antigen presentation capacity of monocytes. RESULTS: Endotoxin stimulated the NK cell activity and up-regulated the antigen presentation capability on monocytes. In contrast, surgical stress reduced the NK cell activity, the number of NK cells and down-regulated the antigen presentation capability on monocytes. After surgery, followed by administration of endotoxin, the oxidative burst of granulocytes was stimulated while antigen presentation capability on monocytes was down-regulated. Endotoxin prevented or reverted the postoperative suppression of NK cell activity. CONCLUSION: Our two-hit model shows that some cell types of the unspecific immune system exhibit an excessive inflammatory response (NK cells, granulocytes) while specific functions of other cell types (monocytes) are simultaneously diminished. This diversity makes a potential therapeutic immunomodulation very complex as some cell types would need to be down-regulated while others need to be stimulated.     

The effect of adding group-based counselling to individual lifestyle counselling on changes in dietary intake. The Inter99 study – a randomized controlled trial

Background  

Few studies have investigated the specific effect of single intervention components in randomized controlled trials. The purpose was to investigate the effect of adding group-based diet and exercise counselling to individual life-style counselling on long-term changes in dietary habits.     

Magnetic resonance imaging in juvenile Canavan disease

We present a 2-year-old boy and a 6-year-old girl with mild Canavan disease (CD). Aspartoacylase activity in skin fibroblasts was deficient. Magnetic resonance imaging (MRI) of the brain did not show the prominent leucodystrophy previously reported in CD, but there was a hyperintense signal from the lentiform nuclei and the heads of the caudate nuclei on the T2-weighted MR images. This suggests a specific vulnerability of the corpus striatum in these patients. In the older patient, the white matter became affected at the age of 6 years. Proton magnetic resonance spectroscopy (¹H-MRS) of white matter revealed a normal concentration of N-acetyl-l-aspartate (NAA) and a markedly decreased concentration of choline containing compounds (Cho) in the boy but a normal ratio of NAA to Cho in the girl. We conclude that deficient NAA catabolism affects myelin metabolism. This may present as changes in the striatum and/or as a low concentration of Cho before leucodystrophy appears on MRI.