The use and cost of HIV service provision in England in 1996. National Prospective Monitoring System (NPMS) Steering Group and NPMS Working Party on Costs.

OBJECTIVE: The aim of the study was to measure the use and estimate the cost of HIV service provision in England. DESIGN AND SETTING: Standardised activity and case-severity data were collected prospectively in 10 English HIV clinics (5 London and 5 non-London sites) for the periods 1 January 1996 to 30 June 1996 and 1 July 1996 to 31 December 1996 and linked to unit cost data. In total, 5440 patients with HIV infection attended during the first 6 months and 5708 during the second 6 months in 1996. MAIN OUTCOME MEASURES AND RESULTS: The mean number of inpatient days per patient-year for patients with AIDS was 19.7 [95% confidence interval (CI): 13.7 to 25.7] for January to June and 20.8 (95% CI: 15.3 to 26.4) for July to December 1996. The mean number of outpatient visits for asymptomatic patients with HIV infection was 14.8 (95% CI: 11.9 to 17.6) and 13.3 (95% CI: 10.8 to 15.7) for the respective periods and 16.1 (95% CI: 13.21 to 18.97) and 15.7 (95% CI: 11.2 to 20.2), respectively, for patients with symptomatic non-AIDS (i.e. symptomatic patients with HIV infection but without AIDS-defining conditions). Substantial centre-to-centre variation was observed, suggesting that many clinics can continue the shift from an inpatient- to an outpatient-based service. Cost estimates per patient-year for HIV service provision for 1996 varied from 4695 Pounds (95% CI: 3769 Pounds to 5648 Pounds) for asymptomatic patients, to 7605 Pounds (95% CI: 6273 Pounds to 8909 Pounds) for symptomatic non-AIDS patients to 20,358 Pounds (95% CI: 17,681 Pounds to 23,206 Pounds) for patients with AIDS. CONCLUSIONS: Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatient-related activity through the increased use of combination antiretroviral therapy will further shift service provision from an inpatient- to outpatient-based service and reduce costs per patient-year. The extent and duration of such effects are currently unknown. The long term effects of combination treatment on the morbidity and mortality patterns of individuals infected with HIV are also currently unknown, as are their implications on the use and cost of HIV service provision. Multicentre databases like the National Prospective Monitoring System (NPMS) will provide healthcare professionals with information to improve existing services and anticipate the impact of new developments.     

Enzyme immunoassay for Q fever: comparison with complement fixation and immunofluorescence tests and dot immunoblotting.

Enzyme-linked immunosorbent assays (ELISA) for the detection of specific immunoglobulin G (IgG) and IgM antibodies were developed by using purified Coxiella burnetii cells. Variables, including type of microtiter plate, blocking agent, incubation conditions, antigen stability, and substrate type, were examined to achieve optimal ELISA performance. The reliabilities of the assay systems were compared with those of complement fixation (CF) and enhanced immunofluorescence (EIF) tests with 600 human serum samples from defined clinical cases of Q fever, routine samples, and serum specimens from farmers. ELISA and EIF test results agreed in all cases. Dot immunoblotting was also used to test some of these sera and gave a rapid, qualitative result, which agreed with ELISA and EIF test results in all cases. No instances were found in which both ELISA and EIF test results were negative and the CF test results was positive. However approximately 5% of the sera were positive by ELISA and the EIF test while the CF test result was either negative or unreadable because of serum anticomplementary activity. We conclude that dot immunoblotting is a useful screening test, whereas ELISA and the EIF test are both rapid and sensitive tests when used for the serodiagnosis of Q fever and should be considered to be replacements for the CF test.     

Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial

BACKGROUND: A randomized trial of a primary care-based intervention to prevent depression relapse resulted in improved adherence to long-term antidepressant medication and depression outcomes. We evaluated the effects of this intervention on behavioural processes and identified process predictors of improved depressive symptoms. METHOD: Patients at high risk for depression recurrence or relapse following successful acute phase treatment (N=386) were randomly assigned to receive a low intensity 12-month intervention or continued usual care. The intervention combined education about depression, shared decision-making regarding use of maintenance pharmacotherapy and cognitive-behavioural strategies to promote self-management. Baseline, 3, 6, 9 and 12-month interviews assessed patients' self-care practices, self-efficacy for managing depression and depressive symptoms. RESULTS: Intervention patients had significantly greater self-efficacy for managing depression (P<0.01) and were more likely to keep track of depressive symptoms (P<0.0001), monitor early warning signs (P<0.0001), and plan for coping with high risk situations (P<0.0001) at all time points compared to usual care control patients. Self-efficacy for managing depression (P<0.0001), keeping track of depressive symptoms (P=0.05), monitoring for early warning signs (P=0.01), engaging in pleasant activities (P<0.0001) and engaging in social activities (P<0.0001) positively predicted improvements in depression symptom scores. CONCLUSIONS: A brief intervention designed to target cognitive-behavioural factors and promote adherence to pharmacotherapy in order to prevent depression relapse was highly successful in changing several behaviours related to controlling depression. Improvements in self-efficacy and several self-management behaviours that were targets of the intervention were significantly related to improvements in depression outcome.     

The outcome of childhood conduct disorder: implications for defining adult personality disorder and conduct disorder.

The effect of conduct disorder on adult social functioning in the areas of work, sexual/love relationships, social relationships and criminality was studied in a sample of young adults who spent much of their childhoods in group-cottage children's homes and an inner-city comparison group. Most subjects with conduct disorder had pervasive (but not necessarily severe) social difficulties compared to peers without conduct disorder. Less than half of this group met DSM-III adult criteria for antisocial personality disorder and just over half were given a diagnosis of personality disorder on interviewer clinical ratings. A latent class model that used both the retrospective and contemporaneous indicators of conduct disorder confirmed the very high continuity with adult social difficulties. Current diagnoses did not adequately describe this group and conduct disorder appeared to be an almost necessary condition for multiple social disability in adults in these samples.     

Lymphocytic choriomeningitis virus

Lymphocytic choriomeningitis (LCM) virus-specific complement-fixing (CF) antigen (ECFA) has been solubilized, concentrated, and partially purified. When inoculated together with Freund's adjuvant, ECFA induced CF antibody but not neutralizing antibody or protective immunity. By itself it boosted pre-existing CF antibody but not neutralizing antibody. In double diffusion tests one line developed between ECFA and its antiserum, and a corresponding line became visible when ECFA interacted with an antiserum directed against all LCM virus-specific antigens. Absorption of either serum with ECFA abolished all ECFA-precipitating qualities. Ouchterlony tests also revealed that ECFA prepared from cells and tissues of various species is immunologically identical. By a variety of procedures ECFA was not found to be represented on the surface of either the virion or the infected cell. When purified infectious LCM virus was disrupted, a CF antigen corresponding immunologically to ECFA was set free. In double diffusion tests this antigen gave a line of identity with ECFA. Thus, ECFA appears to be an internal component of the infectious LCM virus.Part of the work reported here has been published in preliminary communications [8, 10, 24, 25].     

Which boys respond to stimulant medication? A controlled trial of methylphenidate in boys with disruptive behaviour

Thirty-eight boys, referred for psychiatric treatment because of serious problems of behaviour, underwent a double-blind, placebo-controlled, crossover trial of methylphenidate and placebo. Methylphenidate was an effective treatment over a 3-week period. A good response to methylphenidate was predicted by higher levels of inattentive and restless behaviour, impaired performance on tests of attention, clumsiness, younger age and by the absence of symptoms of overt emotional disorder. DSM-III and ICD-9 diagnoses of 'hyperactivity' were not good predictors. The results support the validity of a construct of hyperactivity in describing childhood psychopathology, but emphasize the need for a refinement of diagnostic criteria.     

Adult outcomes of childhood and adolescent depression. I. Psychiatric status

The present study was based on the clinical data summaries ("item sheets") of children who attended the Maudsley Hospital, London, England, during the late 1960s and early 1970s. These summaries were used to identify a group of 80 child and adolescent psychiatric patients with an operationally defined depressive syndrome. The depressed children were individually matched with 80 nondepressed psychiatric controls on demographic variables and nondepressive childhood symptoms by a computer algorithm. At follow-up, on average 18 years after the initial contact, information was obtained on the adult psychiatric status of 82% of the total sample. Adult assessments were made "blind" to case/control status. The depressed group was at an increased risk for affective disorder in adult life and had elevated risks of psychiatric hospitalization and psychiatric treatment. They were no more likely than the control group to have nondepressive adult psychiatric disorders. These findings suggested that there is substantial specificity in the continuity of affective disturbances between childhood and adult life.