Long term health and neurodevelopment in children exposed to antiepileptic drugs before birth

Objective: To investigate the frequency of neonatal and later childhood morbidity in children exposed to antiepileptic drugs in utero.

Design: Retrospective population based study.

Setting: Population of the Grampian region of Scotland.

Participants: Mothers taking antiepileptic drugs in pregnancy between 1976 and 2000 were ascertained from hospital obstetric records and 149 (58% of those eligible) took part. They had 293 children whose health and neurodevelopment were assessed.

Main outcome measures: Frequencies of neonatal withdrawal, congenital malformations, childhood onset medical problems, developmental delay, and behaviour disorders.

Results: Neonatal withdrawal was seen in 20% of those exposed to antiepileptic drugs. Congenital malformations occurred in 14% of exposed pregnancies, compared with 5% of non-exposed sibs, and developmental delay in 24% of exposed children, compared with 11% of non-exposed sibs. After excluding cases with a family history of developmental delay, 19% of exposed children and 3% of non-exposed sibs had developmental delay, 31% of exposed children had either major malformations or developmental delay, 52% of exposed children had facial dysmorphism compared with 25% of those not exposed, 31% of exposed children had childhood medical problems (13% of non-exposed sibs), and 20% had behaviour disorders (5% of non-exposed).

Conclusion: Prenatal antiepileptic drug exposure in the setting of maternal epilepsy is associated with developmental delay and later childhood morbidity in addition to congenital malformation.

     

The influence of technology assessments by advisory bodies on health policy and practice

Assessments of 45 health technologies undertaken by Australian advisory bodies are considered in terms of the effect they have had on health care policy. The conduct and impact of the assessments was influenced by selection of topics, timing, other inputs to policy formulation and changes to policy areas and assessment agencies. Seventeen of 26 detailed assessments appear to have influenced policy, with greatest impact occurring when the technology was being introduced and there was collection of local primary data. Continued requests for the assessment reports suggests a possible longer term educational effect. All nine appraisals of proposals for nationally funded centres were influential, but the influence of guidelines for superspecialty services is less clear. Factors decreasing the influence of assessments included limitations of available policy instruments, lack of consensus between governments and professional groups and pressure of more urgent matters on the policy process.     

The relative effectiveness of three reminder letters. On making and keeping mammogram appointments

One hundred fifty women who had previously had at least one mammogram were sent one of three prompt letters informing them that they were due for screening. The letters were either reassuring, anxiety provoking, or the standard hospital prompt. Based on a review of the literature, we hypothesized that the reassuring letter would be most effective in motivating women to schedule and keep appointments, the anxiety-provoking letter would produce an intermediate level fo compliance, and the standard hospital letter would be least effective. Our hypothesis was partially supported. Overall, 45% of the women in the study scheduled mammogram appointments. This included 54% of those who received the reassuring letter, 42% of those who received the anxiety provoking letter, and 38% of those who received the standard letter. Although the results were in the predicted direction, the results of a chi-square test indicated that differences among groups were not statistically significant. When the dependent measure was number of appointments kept, rather than scheduled, however, significantly more women who received the reassuring letter actually kept their appointments compared with those who received the standard hospital letter. Subsequent analyses suggested that having a family history of breast cancer, receiving a reassuring letter, and being older than 50 years were important factors in scheduling appointments.     

Economic evaluation of the cochlear implant

OBJECTIVE: To examine the economic efficiency of current cochlear implant technology under Australian conditions in profoundly deaf adults, partially deafened adults, and children. METHODS: Cost-utility study, with weights based on judgments from persons experienced with the technology, and cost data from Australian sources. RESULTS: Quality-of-life improvements due to functional consequences of hearing improvement were greater than those due to amelioration of hearing disability. Costs in Australian dollars per QALY (15-year assessment) ranged from $5,070-$11,100 for children, $11,790-$38,150 for profoundly deaf adults, and $14,410-$41,000 for partially deaf adults. CONCLUSIONS: Results suggest cochlear implantation is acceptable value for money when compared with other health programs to which resources are committed in Australia.     

The assessment of diagnostic imaging technologies: a policy perspective

Diagnostic imaging technologies are essential in health care but have high costs and poorly defined benefits. Formulation and implementation of policy on their procurement and use is made difficult by the complexity of the diagnostic process, and the limitations of available data and assessment methodology. Informed policy decisions will need to be based on a synthesis of imperfect data from a variety of perspectives, and supplemented by effective dissemination and feedback of information. A list of attributes for consideration in the policy formulation process is presented.     

Toxicology and carcinogenesis studies of microencapsulated citral in rats and mice.

Citral, a widely used natural ingredient, is added to foods and cosmetics as a flavoring and fragrance agent. Male and female F344/N rats and B6C3F1 mice were exposed to microencapsulated citral in the feed for 14 weeks or two years. All studies included untreated and vehicle control groups. In the 14-week studies, rats and mice were given diets containing 3,900, 7,800, 15,600, or 31,300 ppm citral. In rats, food consumption was reduced in the two highest dose groups. In mice an apparent increase in food consumption was observed, but was due to mice scattering the feed. Body weights of all treated animals were less than controls. All rats and four male mice were killed moribund in the high dose groups. In rats, forestomach and kidney lesions were observed. At the higher doses, lesions observed in the bone marrow, testes, and thymus in rats and in the ovary in mice were considered related to inanition and resultant moribundity. In the two-year studies, rats were exposed to 1,000, 2,000, or 4,000 ppm citral. Body weights were reduced in the 4,000 ppm rats. Mice were exposed to 500, 1,000, or 2,000 ppm citral. Body weights in the 1,000 and 2,000 ppm groups were reduced. No neoplasms were attributed to citral in rats or mice. Malignant lymphoma occurred with a positive trend and was significantly greater than controls in female mice in the 2,000 ppm group. However, the incidences were within the NTP historical control range and could not be clearly related to citral administration.     

Leave the levofloxacin? A case report of levofloxacin-induced psychosis

Fluoroquinolones, including levofloxacin, exhibit desirable antimicrobial characteristics, including broad spectrum of activity and excellent bioavailability. This widely prescribed class of antibiotics has come under scrutiny due to a new black box warning of adverse reactions. Central nervous system effects have been sparsely described in previous literature. We present a case of levofloxacin-induced psychosis in a patient without underlying psychological history.     

Circadian Rhythmicity as a Predictor of Quality of Life in Allogeneic Hematopoietic Cell Transplant Patients

Context

Quality of life (QoL) is increasingly recognized as an important outcome of cancer treatment. Previous studies have examined clinical predictors of QoL, but with the increasing prevalence of wearable sensors that monitor sleep and activity patterns, further investigation into whether these behaviors are predictive of post-treatment QoL is now feasible. Among patients receiving aggressive cancer treatment such as hematopoietic cell transplantation (HCT), analysis of circadian rhythms (24-hour patterns of sleep and activity) via wearable sensors is limited.