Issues in the cross-national assessment of health technology.

With the growing international literature in economic evaluation and the rapid spread of new health technologies, there is a need to undertake, or at least interpret, economic evaluations on the international level. However, the ways in which cross-national differences affect the cost-effectiveness of health technologies or their evaluations have never been studied. This paper explores these issues by taking advantage of a unique situation in which the same economic evaluation of a new indication for a health technology was conducted simultaneously in four countries using an identical methodology. The study showed that if prior agreement on methods can be reached and local data applied, economic evaluations can be undertaken in a way that facilitates the extrapolation of results from country to country.     

Distribution and ontogeny of parvalbumin immunoreactivity in the chicken retina.

The distribution of parvalbumin-like immunoreactivity was studied in the embryonic and postnatal chicken retina. In post-hatched chickens, parvalbumin-like immunoreactivity was confined to amacrine cells. Three distinct subpopulations were identifiable based upon soma position and level of dendritic arborization in the inner plexiform layer. The primary dendrites from parvalbumin-immunoreactive amacrine cells descended vertically into the inner plexiform layer and eventually branched to give rise to a laminarly arrayed plexus in sublamina I, sublamina V and, to a lesser extent, at the boundary between sublaminae III and IV. Parvalbumin-like immunoreactive amacrine cells projecting to sublamina I of the inner plexiform layer were consistently monostratified. Some, but not all, contributed thick fibers to sublamina I that could be followed for long distances across the retina and were generally not radially organized. The parvalbumin-like immunoreactive cells that projected to sublamina V gave rise to a primary dendrite from which three to five fibers branched radially. Collateral branches of these same primary dendrites gave rise to the parvalbumin-like immunoreactive plexus at the interface between sublaminae III and IV. In prenatal chickens, parvalbumin-like immunoreactivity was not detected until embryonic day 14. At this time it appeared as a faint band at the inner nuclear layer-inner plexiform layer boundary in the central retina. By embryonic day 18 the intensity of immunoreactivity and the complexity of the arborizations of the parvalbumin-like immunoreactive dendrites approached that seen in the post-hatched chicken. In the chicken retina, parvalbumin-like immunoreactivity was displayed by morphologically distinct subpopulations of amacrine cells suggesting that these amacrine cells may subserve diverse functions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Stereotaxic Interstitial Laser Therapy of Early-Stage Breast Cancer

Abstract: Coagulation leading to fibrosis of mammo-graphically detected breast cancers by interstitial laser therapy was tested as an alternative to surgical removal. Availability of computerized stereotaxic digital imaging allows the precise placement of laser and thermal needles into the target tumor and its controlled ablation by heat. The methodology of interstitial laser therapy (ILT), evolution of the subsequently removed tumors, and their histologic appearance are outlined.
Eight patients with mammographically well-defined tumors were selected. Definitive diagnosis and receptor evaluation were made on core biopsies. Under local anesthesia, stereotaxically guided diode laser energy at 5–10 w was delivered via a 400 xm fiber in a 19-gauge needle placed into the center of the tumor until the peripheral temperature exceeded 60°C. Patients experienced transient pain and pyrexia. Subsequent to ILT, seven invasive carcinomas were excised while one case of multiple papillomas was kept under surveillance. Histologic study revealed central necrosis but some peripheral residual tumor in the first five cases. In the last two, central necrosis surrounded by concentrically arranged, recognizable but severely injured, focally "windswept" and "ghostlike" tumor and granulation tissue were noted. The multiple papillomas showed radiologic shrinkage at 5 months and extensive fibrosis on needle biopsy.
ILT is an attractive new method of treating small, well-defined breast tumors and offers a potentially significant alternative to surgical removal; further exploration is warranted.     

Percutaneous renal surgery and local radiotherapy in the management of renal pelvic transitional cell carcinoma

Six patients with a history of bladder carcinoma and a radiographic filling defect of the pelvicaliceal system have been investigated or treated percutaneously. In two cases of doubtful diagnosis, percutaneous pyeloscopy showed that no pelvicaliceal tumour was present. In four patients with multifocal or recurrent transitional cell carcinoma and difficult clinical problems, intrarenal tumours were cauterised or resected percutaneously. Radioactive iridium wire (192Ir) was inserted into the surgical track to deliver prophylactic irradiation (4500 cGy) to prevent tumour seeding. Follow-up was from 7 to 36 months. One operated patient developed early wide-spread multifocal disease throughout the urothelium, including the operated kidney, and died of uraemia. The other three patients have shown no recurrence in the operated kidney, though two have developed recurrences in the bladder or ureter. There have been no track recurrences.     

Selective aflatoxin B1-induced sister chromatid exchanges and cytotoxicity in differentiating B and T lymphocytes in vivo

The purpose of this study was to assess the genotoxic and cytotoxic effects of the fungal metabolite aflatoxin B1 (AfB1) on the developing immune system of the chick embryo, a model in vivo system. Of particular interest was the assessment of AfB1 -mediated selective toxicity toward developing B lymphocytes as compared to T lymphocytes. In vivo bromodeoxyuridine (BrdU) labelling of DNA was used to detect the induction of sister chromatid exchanges (SCE) in lymphocytes and to assess the progression of these cells through successive cell cycles. Cytotoxicity was also assessed by studying the entrance and maintenance of cells in mitosis (mitotic index). Graded doses of AfB1 (1.09–17.4 μ/g embryo) were applied to chick embryos of 18 days of incubation (Dl). Embryos also received two doses of BrdU at 3 mg/200 μ (3 hr apart) to provide continuous labelling of B and T lymphocyte replicating DNA. B and T lymphocytes were harvested 20 hr post-AfB1/BrdU exposure from the bursa and thymus, respectively, and were processed for cytogenetic analyses. AfB1 induced dose-related increases in SCE in B lymphocytes; this induction was 6- to 8-fold that of controls at the higher doses tested, AfB1 -mediated induction of SCE in T cells was just 2-fold that of controls at the highest dose tested. AfB1 reduced the progression of B cells and to a lesser extent T ceels through successive rounds of replication. Furthermore, AfB1 dramatically reduced the mitotic index of B cells but not of T cells. These data indicate both selective genotoxicity and cytotoxicity of AfB1 toward B cells in the late stage embryo. © 1993 Wiley-Liss, Inc.     

Obstacles to family practitioners' use of screening tests: determinants of practice?

The effect of nine obstacles on family physicians' screening practices is reported. Family physicians, responding to a survey of periodic health screening practices, were asked to check the obstacles that affected their use of the screening tests listed. In the survey, 129 members of the American Academy of Family Physicians and 146 members of the Society of Teachers of Family Medicine responded. The most frequently reported obstacles to screening were cost to the patient, patient refusal, inconvenience to the patient, and lack of facilities or equipment. The tests for which the most obstacles were reported were sigmoidoscopy, tonometry, and mammography. The Society of Teachers of Family Medicine physicians were more likely to list cost, patient reluctance, inconvenience to the patient, "the literature does not recommend to use the test," time to perform the tests, and high rate of false positives and negatives. American Academy of Family physicians were more likely to report two obstacles, lack of facilities or equipment and risk to the patient. An analysis of the relationship between obstacle report and test utilization indicated that for only five of the nine obstacles were physicians who listed the obstacle less likely to use the test than physicians who did not list the obstacle. Obstacles related with decreased test use were those that affected the physician's ability to perform the test or the efficacy of the test itself while "inactive" obstacles were those that more directly affected and emanated from patients.     

Analysis of molecularly cloned DNA reveals minor differences among three virus strains of Aleutian disease of mink parvovirus

Summary Molecular clones representing a 1.55 kbp genomic segment from three strains of Aleutian disease parvovirus (ADV) were studied. All three clones directed synthesis of viral structural antigens. In addition, 19 of 23 restriction sites were shared among viruses.With 3 Figures     

Occurrence, distribution and ontogeny of CGRP immunoreactivity in the rat lower respiratory tract: effect of capsaicin treatment and surgical denervations

The occurrence and distribution of calcitonin gene-related peptide (CGRP) immunoreactivity in the rat respiratory tract were investigated by means of immunocytochemistry and radioimmunoassay using antibodies raised in rabbits to synthetic rat CGRP. Substantial amounts of CGRP immunoreactivity (range 5-37 pmol/g) were detected in all parts of the respiratory tract, the highest being in the stem bronchus. Gel filtration chromatography of extractable CGRP immunoreactivity revealed one single peak, eluting at the position of synthetic rat CGRP. CGRP immunoreactivity was localized both in mucosal endocrine cells and nerve fibres from the larynx down to the peripheral lung. CGRP-immunoreactive endocrine cells were found singly in trachea and stem bronchi and in groups in intrapulmonary airways. They appeared at a late stage of gestation (17 days), reached a maximum number near term and decreased after birth to maintain a population similar to that of the adult animals by postnatal day 21. Similarly, CGRP-immunoreactive nerve fibres were first identified by day 18 of the gestation period and reached the adult distribution by postnatal day 21. CGRP-immunoreactive nerve fibres were localized among smooth muscle, seromucous glands, beneath and within the epithelium of the airways and around blood vessels. CGRP was also found in sensory ganglia and in motor end plates of the larynx musculature. Neonatal pretreatment with capsaicin caused a marked reduction in CGRP immunoreactivity of nerve fibres in the respiratory tracts as well as a less marked decrease in the population of CGRP-containing endocrine cells of the lung. No change was seen in motor end plates immunostaining. Vagal ligation experiments revealed that CGRP-immunoreactive nerve fibres travelling in the vagus originate mainly from neurons located in the jugular ganglion. Infranodosal right vagal ligation induced a marked loss in CGRP-immunoreactive nerves of the trachea, and of the ipsilateral stem bronchus, but no changes were observed in peripheral lung. By contrast infranodosal left side vagal ligation caused a decrease in CGRP-immunoreactive nerves of the ipsilateral lung and bronchus without affecting the peptide content in the trachea. Left vagal ligation also induced a marked increase in both the intensity of staining and number of CGRP-immunoreactive endocrine cells in the lung. We conclude that CGRP immunoreactivity is localized in both nerve fibres and endocrine cells and is associated principally with the afferent (sensory) innervation of the respiratory tract.(ABSTRACT TRUNCATED AT 400 WORDS)     

Calcitonin gene-related peptide in cardiovascular tissues of the rat

The distribution of calcitonin gene-related peptide immunoreactivity in the cardiovascular system of the rat was investigated by radioimmunoassay and immunocytochemistry. The nature of the immunoreactivity was studied by gel permeation and high performance liquid chromatography. Immunocytochemistry demonstrated the existence of calcitonin gene-related peptide-containing nerve fibres throughout the cardiovascular system. These were present in all regions of the heart, particularly in association with the coronary arteries, within the papillary muscles and within the sinoatrial and atrioventricular nodes. Calcitonin gene-related peptide-containing fibres were found mainly in the adventitia of the arteries and veins. Calcitonin gene-related peptide concentrations were high in major arteries and veins but comparatively low in the heart, aortic arch and thoracic aorta. Chromatography showed that approximately 70% of the total immunoreactivity was identical to synthetic calcitonin gene-related peptide. Calcitonin gene-related peptide concentrations in the blood vessels of rats treated neonatally with capsaicin were not found to be significantly different from those in control animals although capsaicin caused significant reductions of calcitonin gene-related peptide levels in certain other tissues. The results of this study suggest that calcitonin gene-related peptide-containing fibres are likely to be of importance in the innervation of vascular tissues and raise the possibility that these fibres are different in character from calcitonin gene-related peptide-containing fibres found in other tissues.