Using probabilistic and decision-theoretic methods in treatment and prognosis modeling

Causal probabilistic networks, also called Bayesian networks, allow both qualitative knowledge about the structure of a problem and quantitative knowledge, derived from case databases, expert opinion and literature to be exploited in the construction of decision support systems for diagnosis, treatment and prognosis. This mixing of qualitative and quantitative knowledge will be illustrated, using the selection of antibiotics for a subset of patients with severe infections. The subset consists of patients where bacteria or fungi have been found in the blood. A simple pathophysiological model of infection is used to calculate a prognosis, dependent on the choice of antibiotics. A decision-theoretic approach is used to balance the therapeutic benefit of antibiotic treatment against the cost of antibiotics in the form of direct monetary cost, side effects and ecological cost. A retrospective trial on patients with bacteria or fungi in the blood stemming from the urinary tract indicates that with this approach, it may be possible to suggest balanced choices of antibiotics that not only achieve greater therapeutic benefit, but also reduce the cost of therapy.     

Hydroxymethylglutaryl-CoA reductase inhibitors (statins) for the treatment of sepsis in adults – A systematic review and meta-analysis

Objectives

The pleiotropic effect of hydroxymethylglutaryl-CoA reductase inhibitors (statins) might have a beneficial effect in sepsis through several mechanisms. The aim was to assess the efficacy and safety of statins, compared with placebo, for the treatment of sepsis in adults.

Effect of hyperthermia and thermochemotherapy on primary and metastatic tumour cells of AKR lymphoma

The cure of metastatic disease constitutes a serious problem. Recent findings showed cell membrane differences between slightly and highly metastasizing tumour cells, suggesting that since this cell organelle determines the metastatic phenotype, it might serve as a target for future drugs programmed against advanced cancer. The cell membrane has also been shown to be involved in the evolution of drug resistance which often accompanies tumour progression. In the present study, the effect of hyperthermia--an antitumoral treatment modality partly exerting its effect on the cell membrane--on primary and metastatic AKR lymphoma cells was compared. The effect of hyperthermia in conjunction with adriamycin (ADR) on the two cell types was also tested. Hyperthermic treatment, alone and in combination with ADR, was more effective in reducing the tumorigenicity of cells derived from metastatic tumours than of the primary tumour cells. Fluorescent microscopy and cytofluorometry showed that the increased effect of ADR by hyperthermia was due to an increased drug uptake at the supranormal temperature.     

Mandated managed care for Medicaid recipients

The need to control governmental health expenditures has led to experiments with mandated managed care for Medicaid recipients. Loss of freedom to choose care providers was considered a worthy sacrifice. The authors examine the historical and legislative background, including research and demonstration projects. Although they view some form of rationing as inevitable, they argue that Medicaid recipients should not be singled out to bear the main part of the burden.     

Infective endocarditis in diabetic and non-diabetic patients

We compared clinical, microbiological, and prognostic characteristics of infective endocarditis in patients with and without diabetes mellitus. In 1987--1996, 213 patients with definite or possible infective endocarditis were included, of which 39 (18%) had diabetes mellitus. Diabetic patients were older than non-diabetic (median age of 71 vs 65 y, respectively; p =0.04), had more aortic valve and less mitral valve involvement (71% vs 27%, and 21% vs 62%; p = 0.004). There was no significant difference in the frequency of Staphylococcus aureus involvement between the 2 groups (21% in diabetic vs 20% in non-diabetic group; p = ns). On multivariate analysis diabetes mellitus was not found to be an independent factor for mortality. Unlike other infections diabetes mellitus does not significantly affect clinical and microbiological features, and outcome of infective endocarditis.