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Biomedical subjects

B Jönsson

Publications and source records attributed to B Jönsson.

At least 19 recordsLinked to original sources
PubMed1999

Economic consequences of the progression of rheumatoid arthritis in Sweden.

OBJECTIVE: To develop a simulation model for analysis of the cost-effectiveness of treatments that affect the progression of rheumatoid arthritis (RA). METHODS: The Markov model was developed on the basis of a Swedish cohort of 116 patients with early RA who were followed up for 5 years. The majority of patients had American College of Rheumatology (ACR) functional class II disease, and Markov states indicating disease severity were defined based on Health Assessment Questionnaire (HAQ) scores. Costs were calculated from data on resource utilization and patients' work capacity. Utilities (preference weights for health states) were assessed using the EQ-5D (EuroQol) questionnaire. Hypothetical treatment interventions were simulated to illustrate the model. RESULTS: The cohort distribution among the 6 Markov states clearly showed the progression of the disease over 5 years of followup. Costs increased with increasing severity of the Markov states, and total costs over 5 years were higher for patients who were in more severe Markov states at diagnosis. Utilities correlated well with the Markov states, and the EQ-5D was able to discriminate between patients with different HAQ scores within ACR functional class II. CONCLUSION: The Markov model was able to assess disease progression and costs in RA. The model can therefore be a useful tool in calculating the cost-effectiveness of different interventions aimed at changing the progression of the disease.

Arthritis, Rheumatoid↗
PubMed1998

[Vulvar complaints in young girls need instant professional evaluation].

As vulvovaginal disease are nog very common in prepubescent girls, it may seem reasonable to suspect sexual abuse when a small girl presents with complaints in the genital area. However, the very fact that there are visible changes suggests that it is no a case of sexual abuse, the signs of which are usually more subtle. To arrive at a correct diagnosis, and avoid unnecessary, traumatic investigation into the possibility of sexual abuse, it is essential that such patients be examined from the outset by physicians experienced in this field.

Child↗
PubMed1998

Phase coexistence in cholesterol-fatty acid mixtures and the effect of the penetration enhancer Azone.

Small and wide-angle X-ray diffraction was used to study the phase behaviour of cholesterol-fatty acid mixtures in an attempt to understand lipid interaction occurring in the stratum corneum, the outermost layer of skin. The effect of the penetration enhancer Azone was investigated as well. It was found that equimolar mixtures of cholesterol, palmitic acid and oleic acid (with the acids neutralised to 41 mol%) in 25% (wt/wt) water typically showed three phases at room temperature, two crystalline and one gel phase. The crystalline phases consisted mainly of palmitic acid:soap and cholesterol, respectively. The water present was unevenly distributed and was associated with the gel phase. Both cholesterol and palmitic acid seemed to be depleted from their crystalline phases by Azone. The electrostatic effects on titration of fatty acids in lamellar aggregates were calculated in view of the present results, and the effects of phase separation were discussed.

Azepines↗
PubMed1998

Management of nonsteroidal anti-inflammatory drug-associated lesions: a cost-effectiveness perspective.

Results are presented from a cost-effectiveness analysis of the acute healing phases of two new clinical studies. Acute treatment with omeprazole, 20 mg once daily, is compared with misoprostol, 200 microg four times daily, or ranitidine, 150 mg twice daily, in patients with nonsteroidal anti-inflammatory drug (NSAID)-associated gastroduodenal lesions (gastric ulcer, duodenal ulcer, and/or >10 erosions in either the stomach or duodenum). The cost-effectiveness comparisons indicate that omeprazole is cost-effective when compared with ranitidine in the treatment of gastric ulcers, duodenal ulcers, and erosions only, and that omeprazole is cost-effective when compared with misoprostol in the treatment of gastric ulcers and duodenal ulcers. In patients with erosions only, misoprostol is cost-effective when compared with omeprazole. When assessing the uncertainty of these estimates, a definite conclusion can be made in only two comparisons: omeprazole is cost-effective when compared with ranitidine in the treatment of gastric ulcers, and misoprostol is cost-effective when compared with omeprazole in the treatment of erosions only. However, the clinical studies were not powered for assessing the cost-effectiveness of the treatment alternatives, which impedes the uncertainty assessment. The determinants of the cost-effectiveness of prophylactic strategies are also discussed, as well as the need for further studies that include relevant outcome measures and a design that reflects actual clinical practice.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1998

Contained and noncontained lumbar disc herniation in the same patient. Two case reports.

STUDY DESIGN: A case report containing description of symptoms, signs, and selected treatment in two patients with lumbar disc herniation where the type of herniation changed from contained to noncontained in less than 1 year. OBJECTIVES: To demonstrate the difference in clinical appearance related to the type of herniation. SUMMARY OF BACKGROUND DATA: The clinical appearance of lumbar disc herniation regarding onsets of symptoms, severity of pain, and clinical findings are related to the type of herniation, as is the treatment. METHODS: Two cases reports are presented with description of anamneses, clinical findings, neuroradiographic findings, and treatment. RESULTS: Both patients suffered from a transient left-side sciatica due to a contained lumbar disc herniation, improved by physiotherapy. After several months, both patients had an instantaneous increase in contralateral leg pain, and the recurrent, intense pain was caused by a sequestration of the previous contained herniation. The neurologic findings were more severe, and the patients were operated on, with subsequent improvement. CONCLUSIONS: The case reports illustrate the difference in clinical appearance of disc herniation related to the type of herniation, with a more aggressive clinical appearance in conjunction with perforation of the posterior longitudinal ligament with extrusion of disc material.

Adult↗
PubMed1998

The economic impact of diabetes.

In assessing the economic impact of diabetes for a population, several factors should be considered, including the incidence and prevalence of the disease, the level of development of the health care system, and the population's overall level of economic development. Two different approaches have been used to address the economic impact of an increasing incidence of diabetes. The first approach uses disability-adjusted life-years (DALYs) to measure intangible costs associated with diabetes. It combines the number of healthy life-years lost as a result of early mortality with those lost because of disability. The second approach, which has been used more frequently, is the cost-of-illness approach, which includes the concepts of direct, indirect, and intangible costs. A study conducted by the World Bank found that of the 1,362 million DALYs lost to all illnesses in 1990, 7.97 million DALYs were lost because of diabetes. In a 1992 study that assessed the direct costs of treating diabetes in the U.S., the American Diabetes Association used the cost-of-illness approach and found that the estimated total expenditure for 1 year was $45.2 billion. The 1994 epidemiological studies by Zimmet and the World Health Organization include estimates of increased prevalence of diabetes resulting from an increase in population. Estimates of the global cost of diabetes based on these studies reveal that diabetes accounts for 2-3% of the total health care budget in every country; therefore, an increase in diabetes incidence and prevalence translates into a significant economic impact.

Cost of Illness↗
PubMed1998

Diabetes: the cost of illness in Sweden.

OBJECTIVES: To estimate the total cost of diabetes mellitus in Sweden in 1994 and to compare the cost structure with a former Swedish study and with American studies. The study also aims to investigate how the total cost is distributed between control of and complications of the disease. DESIGN: In order to estimate the economic burden of diabetes mellitus in Sweden in 1994, the cost-of-illness method, based on the human capital theory, has been used. Both direct and indirect costs have been estimated using a prevalence approach and a 'top-down' method. RESULTS: The economic burden of diabetes mellitus is estimated at 5746 MSEK (1US$ = 7.50 SEK) in Sweden in 1994. The direct costs are estimated at 2455 MSEK and constitute about 43% of the total cost. The indirect costs (production loss due to morbidity and premature mortality) were the dominant costs and amounted to 3291 MSEK, or 57% of total cost. Comparisons with a previous Swedish study from 1978 show some interesting results. Firstly, the distribution of direct and indirect costs is identical between the two studies. Secondly, the distribution of costs between management/control of the disease and complications was about the same, comparing the situation 16 years apart. Four American studies show a cost structure similar to the cost structure presented in this study. CONCLUSIONS: The overall conclusion must be that very little has changed in the cost structure of diabetes in Sweden between 1978 and 1994.

Absenteeism↗
PubMed1997

A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings.

STUDY DESIGN: A prospective study of consecutive patients undergoing surgery for central lumbar spinal stenosis. OBJECTIVES: To evaluate symptoms and signs in patients undergoing surgery for central spinal stenosis and to correlate the findings to age, preoperative duration of symptoms, and radiographically detected constriction. SUMMARY OF BACKGROUND DATA: The degree of constriction of the spinal canal considered to be symptomatic of lumbar canal stenosis is not clear, nor is the relation between the clinical appearance of the disease and the degree of radiographically verified constriction. MATERIAL AND METHODS: One hundred five consecutive patients scheduled for decompression surgery were included in a prospective study. The day before surgery, all patients were interviewed and examined, using a defined protocol that included data on age, gender, preoperative duration of symptoms, walking ability, and occurrence of pain at rest and at night. Included were data recording straight leg raising test results, reflex disturbance, and extensor hallucis longus muscle weakness. All radiographs were examined by a neuroradiologist. The anteroposterior diameters at each site from L1-L2 to L5-S1 were recorded. For the computer analysis, the site of and width at the narrowest site was registered, as well as the number of sites with an anteroposterior diameter of less than 10 mm. A statistical analysis was performed using chi-square analysis, nonparametric tests, analysis of variance, and logistic regression. RESULTS: Pain at rest and at night was reported by 68 and 60 patients, respectively, and was more common in younger patients (P = 0.065 and 0.015, respectively). A severe reduction of walking ability (< 0.5 km) was reported by 70 patients. The straight leg raising test results were negative in 70 patients, positive > 60 degrees in 16, positive 30-60 degrees in 14, and positive < 30 degrees in 5. Younger patients had a positive straight leg raising result (P = 0.028, analysis of variance) more often. Reflex disturbances correlated to patient age: Older patients had reflex disturbances more often. There was no correlation between preoperative duration and pain or neurologic disturbances: Patients with longer preoperative duration of symptoms did not demonstrate more severe symptoms. There was a total myelographic block of the spinal canal in 13 patients. The mean value of the antero-posterior diameter in the other patients was 6.8 mm (range, 4-11 mm). In patients younger than 70 years L4-L5 was the site for the most pronounced constriction, whereas L3-L4 was the narrowest site in the older patients. Degenerative spondylolisthesis was found in 32 patients, and they had a more pronounced constriction of the spinal canal (5.6 mm compared with 6.7 mm in those without displacement, P = 0.02). There was a (nonsignificant) tendency toward more walking disturbances in patients with a more pronounced constriction of the spine. There was no correlation between reflex disturbances or extensor hallucis longus weakness and radiographically detected constriction. CONCLUSION: Pain was more intense and positive straight leg raising test results were more common in younger patients, whereas reflex disturbances were more common in the elderly. The vertebral site for the lowest anteroposterior value was higher with higher age. Preoperative duration did not affect the severity of symptoms or signs. Patients with more pronounced stenosis tended to have a more severe reduction of walking ability. There was no correlation between symptoms and signs and radiographically detected constriction.

Aged↗
PubMed1997

A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part II: Five-year follow-up by an independent observer.

STUDY DESIGN: A prospective and consecutive study of surgical results obtained during serial follow-up investigations in patients who underwent surgery for central lumbar spinal stenosis. OBJECTIVES: To evaluate the result after surgical decompression for lumbar spinal stenosis, at regular intervals after surgery, and to correlate these results with values for preoperative parameters; special interest was focused on the results in relation to the degree of constriction of the spinal canal. SUMMARY OF BACKGROUND DATA: The outcome after surgery for spinal stenosis is debatable; long-term follow-up investigations have indicated deterioration with passing time. Results of studies in nonsurgical patients have demonstrated that the symptoms do not progress with time. Results of a meta-analysis of the literature on surgical results have demonstrated a wide variation of outcomes. MATERIAL AND METHODS: In a prospective study, 105 consecutive patients who underwent surgical decompression (laminectomy with facet-preserving technique, but no fusion) were evaluated at follow-up examinations 4 months and 1, 2, and 5 years after surgery. At the follow-up examinations, the patient's opinion on the surgical result was registered, using a four-grade scale. The occurrence of pain at rest and at night was registered, as well as the patient's walking ability. Statistical analysis was performed, relating the surgical results to patient age, gender, preoperative duration of symptoms and radiographically observed constriction as described in Part I of this study. The radiologist was blinded to patient outcome. Logistic regression analysis was performed. RESULTS: During the follow-up period, 19 patients underwent reoperation, consisting of fusion to treat lumbar pain (n = 4), repeat decompression because of progressive stenosis (n = 13), and repairs in response to surgical complications (n = 2). Follow-up results: The result, related to the recurrence of leg symptoms, deteriorated with passing time. Excellent results were reported by 63% to 67% at 4-month and 2-year follow-ups compared with 52% at the 5-year follow-up. There was a correlation between the constriction of the spinal canal and the outcome at all intervals. Patients with an anteroposterior diameter of 6 mm or less at the narrowest site had significantly better results. The logistic regression analysis demonstrated a significant correlation between a severe reduction of the anteroposterior diameter and excellent results and a tendency toward better results in patients with a shorter preoperative duration of symptoms. Improvement of walking ability was also associated with a pronounced constriction of the spinal canal. CONCLUSION: The results after surgical decompression in patients with central spinal stenosis deteriorated with time. There was a significant correlation between good result and pronounced constriction of the spinal canal. Patients with a preoperative duration of symptoms of less than 4 years and patients with no preoperative back pain tended to have better surgical outcomes. The reoperation rate was 18% within 5 years. When surgery for spinal stenosis is contemplated, these prognostic factors should be taken into consideration: The "ideal patient" has a pronounced constriction of the spinal canal, insignificant lower back pain, no concomitant disease affecting walking ability, and a symptom duration of less than 4 years.

Adult↗
PubMed1997

Crystal structure of ferrochelatase: the terminal enzyme in heme biosynthesis.

BACKGROUND: The metallation of closed ring tetrapyrroles resulting in the formation of hemes, chlorophylls and vitamin B12 is catalyzed by specific enzymes called chelatases. Ferrochelatase catalyzes the terminal step in heme biosynthesis by inserting ferrous ion into protoporphyrin IX by a mechanism that is poorly understood. Mutations in the human gene for ferrochelatase can result in the disease erythropoietic protoporphyria, and a further understanding of the mechanism of this enzyme is therefore of clinical interest. No three-dimensional structure of a tetrapyrrole metallation enzyme has been available until now. RESULTS: The three-dimensional structure of Bacillus subtilis ferrochelatase has been determined at 1.9 A resolution by the method of multiple isomorphous replacement. The structural model contains 308 of the 310 amino acid residues of the protein and 198 solvent molecules. The polypeptide is folded into two similar domains each with a four-stranded parallel beta sheet flanked by alpha helices. Structural elements from both domains build up a cleft, which contains several amino acid residues that are invariant in ferrochelatases from different organisms. In crystals soaked with gold and cadmium salt solutions, the metal ion was found to be coordinated to the conserved residue His 183, which is located in the cleft. This histidine residue has previously been suggested to be involved in ferrous ion binding. CONCLUSIONS: Ferrochelatase seems to have a structurally conserved core region that is common to the enzyme from bacteria, plants and mammals. We propose that porphyrin binds in the identified cleft; this cleft also includes the metal-binding site of the enzyme. It is likely that the structure of the cleft region will have different conformations upon substrate binding and release.

Amino Acid Sequence↗
PubMed1997

Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group.

BACKGROUND: The Scandinavian Simvastatin Survival Study (4S) showed that lowering cholesterol levels with simvastatin reduces mortality and morbidity in patients with angina pectoris or previous acute myocardial infarction. Before the widespread use of cholesterol-lowering drugs in such patients is recommended, its cost effectiveness should be demonstrated. We estimated the cost effectiveness of simvastatin treatment to lower cholesterol levels in relation to the age, sex, and cholesterol level before treatment of patients with coronary heart disease. METHODS: We estimated the cost per year of life gained with simvastatin therapy. To model the increased life expectancy, hazard functions from 4S were used. The costs studied included those of the intervention and the direct and indirect costs associated with morbidity from coronary causes. We prepared separate estimates for men and women at various ages (from 35 to 70 years) and total cholesterol levels before treatment (213 to 309 mg per deciliter). RESULTS: In the analysis limited to direct costs, the cost of each year of life gained ranged from $3,800 for 70-year-old men with 309 mg of cholesterol per deciliter to $27,400 for 35-year-old women with 213 mg of cholesterol per deciliter. When we included indirect costs, the results ranged from a savings in the youngest patients to a cost of $13,300 per year of life gained in 70-year-old women with 213 mg of cholesterol per deciliter. CONCLUSIONS: In patients with coronary heart disease, simvastatin therapy is cost effective among both men and women at the ages and cholesterol levels studied.

Adult↗
PubMed1997

Experimental human exposure to N,N-dimethylbenzylamine: generation of a controlled atmosphere and biological monitoring.

The aim of the present study was to develop a method for generation of dimethylbenzylamine (DMBA) atmospheres in an exposure chamber and to investigate the possibility of using urinary DMBA metabolites for biological monitoring of exposure to DMBA. A DMBA atmosphere was generated by use of the gas-permeation principle. Six health male volunteers were exposed for 8 h to DMBA at air levels of 20, 45, and 80 microns/m3. Air levels of DMBA were analyzed by gas chromatography (GC). The total urinary amount of DMBA (U-SumDMBA; DMBA and metabolites that can be reduced to DMBA, e.g., DMBAO) was analyzed using GC-mass spectrometry (MS). The exposure chamber maintained very low (0-130 micrograms/m3) and steady concentrations for several weeks. DMBA uptake by inhalation was 76%. The amine was quickly distributed and biotransformed to nearly 100%. DMBA was eliminated in the urine with a half-time of 4.3 h. More than 50% was eliminated within 2 h of exposure. However, at all exposure levels the subjects continued to excrete DMBA the next morning. There was a significant correlation between the exposure to DMBA and the U-SumDMBA. Thus, U-SumDMBA may become an important biomarker for monitoring of industrial exposure to DMBA.

Adult↗
PubMed1997

The role of economic evaluation in the pricing and reimbursement of medicines.

In most countries, governments or health insurers have taken initiatives to influence the price and utilization of medicines. One stated objective of these schemes is to encourage efficiency, or cost-effectiveness. In principle, economic evaluation should to be relevant to decisions about the pricing and reimbursement of health technologies, since it offers a way of estimating the additional value to society of a new intervention (e.g. medicine) relative to current therapy. However, the application of economic evaluation in drug pricing and reimbursement schemes is variable. Therefore, this paper reviews the actual and potential role of economic evaluation in different drug pricing and reimbursement schemes, such as 'free pricing' systems (United Kingdom, United States), two-stage administered systems (France), reference pricing systems (Germany, Netherlands, Sweden) and economic evaluation systems (Australia, Canada). It is concluded that, other than in the case of Australia and Canada, the potential role of economic evaluation could be greatly developed, especially in the case of new medicines, for which there is no close substitute. Comments are also given on the practical problems of using this approach. However, it is noted that economic evaluation alone cannot set a price for a medicine, since a decision has to be made about the proportion of added value going to society and the proportion going to the pharmaceutical company as a reward for innovation.

Australia↗
PubMed1997

Economic evaluation of medical technologies in Sweden.

This paper reviews the use of economic evaluations in the Swedish health care system. The most important actors are defined and examples are given how economic evaluations have played a role in the decision making process. The introduction of extracorporal shock-wave lithotripsy (ESWL) is used as an example on how economic evaluation was used for recommendations to the county councils to adopt this technology. Mammography is used as an example of how the evaluation is used in the political process following an initiative in the parliament. A study of the cost-effectiveness of hypertension treatment illustrates how economic evaluations are included as part of a medical technology assessment by SBU, the Swedish Council on Technology Assessment in Health Care. The role of economic evaluations for drug reimbursement and pricing is also reviewed. The main conclusions are that economic evaluations are one of several factors influencing a decision making process that have a strong strive for consensus. It is thus difficult to make a definitive statement of the contribution of such study to the outcome of the decision making process, and there is no evidence that the evaluation was the decisive factor. However, a number of changes in the way resources are allocated in the Swedish health care system speaks for an increasing role for such studies in the future. The county councils are identified as the main target for economic evaluations, and SBU has a key role in supplying the county councils with high quality assessment of new and old technologies.

Cost-Benefit Analysis↗