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Biomedical subjects

Peter Singer

Publications and source records attributed to Peter Singer.

At least 19 recordsLinked to original sources
PubMed2006

Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting?

OBJECTIVE: Limited resources mean that decision-makers must set priorities among competing opportunities. Programme budgeting and marginal analysis (PBMA) is an economic approach that focuses on optimizing benefits with available resources. Accountability for reasonableness (A4R) is an ethics approach that focuses on ensuring fair priority-setting processes. PBMA and A4R have been used separately to provide decision-makers with advice about how to set priorities within limited resources. The goals of this research were to use the A4R framework to evaluate the fairness of using PBMA for priority setting and to assess how A4R might make PBMA fairer. METHODS: Qualitative case studies to describe priority setting using PBMA in the Calgary Health Region (Alberta, Canada) evaluated using A4R as a conceptual framework. RESULTS: The use of PBMA for priority setting was fairer than previous priority setting because of its emphasis on explicit rational decision-making. However, there were opportunities to improve the process, particularly by collecting data related to the decision criteria, by developing a communication plan to engage internal and external stakeholders about priority-setting, and by providing a formal mechanism to review priority-setting decisions and resolve disputes. CONCLUSIONS: There is potential for combining A4R and PBMA in a more comprehensive approach to priority setting, which uses a fair priority-setting process to reach decisions aimed at achieving optimal benefits with available resources.

Alberta↗
PubMed2005

Health innovation networks to help developing countries address neglected diseases.

Gross inequities in disease burden between developed and developing countries are now the subject of intense global attention. Public and private donors have marshaled resources and created organizational structures to accelerate the development of new health products and to procure and distribute drugs and vaccines for the poor. Despite these encouraging efforts directed primarily from and funded by industrialized countries, sufficiency and sustainability remain enormous challenges because of the sheer magnitude of the problem. Here we highlight a complementary and increasingly important means to improve health equity: the growing ability of some developing countries to undertake health innovation.

Biomedical Research↗
PubMed2005

Tyrosine hydroxylase Val-81-Met polymorphism associated with early-onset alcoholism.

The present study examined the association of the Tyrosine hydroxylase Val-81-Met polymorphism with alcohol dependence. One hundred and fifty-nine patients in a psychiatric unit with alcohol dependence were genotyped as well as 92 healthy volunteers. The Val allele was more frequent in patients with alcohol dependence (69.5%) than in controls (62.5%). This effect was largely due to the association with early-onset alcoholism (77.8%), whereas no difference was noted between late-onset patients and controls. Our results suggest a role for tyrosine hydroxylase in early-onset alcoholism.

Adult↗
PubMed2004

The TPH intron 7 A218C polymorphism and TCI dimension scores in alcohol-dependent patients: hints to nonspecific psychopathology.

AIMS: A linkage of certain alleles of the tryptophan hydroxylase (TPH) intron 7 A218C polymorphism to suicidality and antisocial behaviour has been described. The aim of our study was to find any association between dimensions of the Temperament and Character Inventory (TCI) indicating impulsivity and the TPH polymorphism alleles in unselected alcohol-dependent patients and age-matched controls. METHODS: We examined 159 alcohol-dependent patients and 161 controls with the TCI and genotyped them for the TPH intron 7 A218C polymorphism alleles. RESULTS: Although homozygous TPH genotypes were found more often in alcohol-dependent patients than in controls, an association between TCI dimensions and TPH alleles was not observed in the complete sample. Alcohol-dependent patients, however, scored significantly higher for harm avoidance (HA) and lower for self-directedness (SD) than controls regardless of TPH genotype. Among controls, for those with the A/A genotype, harm avoidance was as high as in the group of alcohol-dependent patients, persistence (P) in that genotype was significantly lower than for all other genotypes in the patient and control group. CONCLUSION: Even if there is no association between TCI dimensions and TPH genotype in our sample, hints to nonspecific psychopathology in connection with the A/A genotype are found.

Adult↗
PubMed2004

Polymorphisms in the NMDA subunit 2B are not associated with alcohol dependence and alcohol withdrawal-induced seizures and delirium tremens.

OBJECTIVE: Ethanol-inhibited glutamatergic neurotransmission has been shown to mediate pathophysiological mechanisms in the development of alcoholism, including withdrawal symptoms. NMDA-receptor 2B (NR2B) is a subunit that confers a high sensitivity to ethanol-induced inhibition. Previously we had reported a lack of association between the single nucleotide polymorphism (SNP) rs1806201 in the NR2B gene (GRIN2B) and alcoholism. Shortly thereafter, an association between the polymorphism and early-onset alcoholism has been reported. One aim of the present study was to test whether the association between the GRIN2B polymorphism rs1806201 and early-onset alcoholism can be replicated in a larger sample. Moreover, we hypothesized that another genetic variation within GRIN2B (rs1806191) may have an effect in the etiology of alcoholism or withdrawal-related traits. METHODS: We extended our original study sample to a size of 377 patients and 464 healthy volunteers and performed a replication study, including the second GRIN2B SNP. Associations between allele, genotype and haplotype frequencies of the two polymorphisms and alcoholism as well as with patients' phenotypes were investigated. RESULTS: No associations were found between any of the two polymorphisms, tested individually or as haplotypes, and alcoholism, respectively withdrawal-related traits. CONCLUSION: Neither the analyzed SNPs nor any of their haplotypes likely modify susceptibility to alcohol dependence or withdrawal-related phenotypes.

Adult↗
PubMed2004

Combination treatment with nefazodone and cognitive-behavioral therapy for relapse prevention in alcohol-dependent men: a randomized controlled study.

BACKGROUND: This study evaluated the serotonergic antidepressant nefazodone versus placebo and specific cognitive-behavioral therapy (CBT) versus nondirective group counseling (GC) for relapse prevention in alcohol dependence in a large prospective, randomized, and placebo-controlled double-blind study at 3 German university centers. METHOD: 242 male patients fulfilling at least 5 criteria for alcohol dependence according to DSM-IV and ICD-10 were eligible, after detoxification, for one of the following treatment combinations: nefazodone + CBT, nefazodone + GC, placebo + CBT, and placebo + GC. Either nefazodone or placebo was administered throughout the evaluation period of 15 months. Either CBT or GC was applied during the first 12 weeks as group therapy according to operationalized manuals. The main outcome measures (assessed at 3 and 12 months of treatment) were the cumulative number of abstinent days, the amount of ethanol consumed during specified evaluation periods of 3 and 12 months, the number of relapses, and the duration of time until first relapse. RESULTS: After 12 weeks of treatment, no statistically significant differences were observed between the 4 treatment combinations in any outcome measure. After 52 weeks, the only significant difference was observed in the amount of ethanol consumed, with the nefazodone + GC group showing higher alcohol intake than the other 3 groups. CONCLUSIONS: The results from this carefully designed clinical trial suggest that the 4 treatment combinations do not differ substantially in their efficacy for relapse prevention in nondepressed, severely alcohol-dependent patients. Nefazodone might even increase the risk of consuming a larger amount of ethanol per relapse in a subset of patients. CBT as performed in this study was associated with little additional benefit compared with structured GC.

Adult↗
PubMed2003

Priority setting in a hospital drug formulary: a qualitative case study and evaluation.

Dramatically rising costs for new drugs are posing major challenges for hospital budgets. In response to these pressures, hospitals must set priorities for which drugs they will list on their formularies. While there have been studies relevant to decision making in hospitals regarding drugs, none have described how priority setting for drugs in hospitals is done and evaluated it against a framework of how it should be done. In this paper we describe the process of priority setting for new drugs in a hospital formulary and evaluate it using a leading conceptual framework for healthcare priority setting--Daniels and Sabin's 'accountability for reasonableness'. The findings from this study provide an evidence base for developing strategies to improve this hospital's priority setting regarding its drug formulary. The process we utilized here, describing using case study methods and evaluating using 'accountability for reasonableness', is a generalizable process for improving the fairness of priority setting in hospital drug formularies.

Data Collection↗
PubMed2003

A strategy to improve priority setting in health care institutions.

Priority setting (also known as resource allocation or rationing) occurs at every level of every health system and is one of the most significant health care policy questions of the 21st century. Because it is so prevalent and context specific, improving priority setting in a health system entails improving it in the institutions that constitute the system. But, how should this be done? Normative approaches are necessary because they help identify key values that clarify policy choices, but insufficient because different approaches lead to different conclusions and there is no consensus about which ones are correct, and they are too abstract to be directly used in actual decision making. Empirical approaches are necessary because they help to identify what is being done and what can be done, but are insufficient because they cannot identify what should be done. Moreover, to be really helpful, an improvement strategy must utilize rigorous research methods that are able to analyze and capture experience so that past problems are corrected and lessons can be shared with others. Therefore, a constructive, practical and accessible improvement strategy must be research-based and combine both normative and empirical methods. In this paper we propose a research-based improvement strategy that involves combining three linked methods: case study research to describe priority setting; interdisciplinary research to evaluate the description using an ethical framework; and action research to improve priority setting. This describe-evaluate-improve strategy is a generalizable method that can be used in different health care institutions to improve priority setting in that context.

Empirical Research↗
PubMed2003

Voluntary euthanasia: a utilitarian perspective.

Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life--if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.

Belgium↗
PubMed2003

Priority-setting and hospital strategic planning: a qualitative case study.

OBJECTIVES: To describe and evaluate the priority-setting element of a hospital's strategic planning process. METHODS: Qualitative case study and evaluation against the conditions of 'accountability for reasonableness' of a strategic planning process at a large urban university-affiliated hospital. RESULTS: The hospital's strategic planning process met the conditions of 'accountability for reasonableness' in large part. Specifically: the hospital based its decisions on reasons (both information and criteria) that the participants felt were relevant to the hospital; the number and type of participants were very extensive; the process, decisions and reasons were well communicated throughout the organization, using multiple communication vehicles; and the process included an ethical framework linked to an effort to evaluate and improve the process. However, there were opportunities to improve the process, particularly by giving participants more time to absorb the information relevant to priority-setting decisions, more time to take difficult decisions and some means to appeal or revise decisions. CONCLUSION: A case study linked to an evaluation using 'accountability for reasonableness' can serve to improve priority-setting in the context of hospital strategic planning.

Communication↗
PubMed2003

Transsphenoidal microsurgical treatment of Cushing disease: postoperative assessment of surgical efficacy by application of an overnight low-dose dexamethasone suppression test.

OBJECT: Transsphenoidal adenomectomy with resection of a defined pituitary adenoma has been the treatment of choice for CD for the last 30 years. Surgical resection, however, may not always result in long-term remission of CD. This is particularly important in light of the high risk of morbidity and mortality in patients in the unsuccessfully treated cushingoid state. As such, it is interesting to identify prognostic factors that may predict the likelihood of long-term remission. METHODS: The authors review their series of 174 patients who have undergone transsphenoidal procedures for CD over a period of 20 years with minimum follow-up periods of 5 years. Selection of these patients was based on clinical, imaging, and laboratory criteria that included serum cortisol levels, loss of diurnal variation in serum cortisol levels, urinary free cortisol concentration, and results of a dexamethasone suppression test, petrosal sinus sampling, and corticotroph-releasing hormone stimulation tests as indicated. All patients who met the biochemical criteria underwent transsphenoidal microsurgery. The authors found an overall rate of remission of 74% at 5 years postoperatively. Patients in whom morning serum cortisol concentrations were lower than 3 microg/dl (83 nmol/L) on postoperative Day 3, following an overnight dexamethasone suppression test, had a 93% chance of remission at the 5-year follow-up examination. Patients with cortisol concentrations higher than this level uniformly failed to achieve long-term remission. CONCLUSIONS: Transsphenoidal microsurgery is an effective means of control for patients with adrenocorticotrophic hormone-producing microadenomas. Clinical outcome correlated well with the size of the tumor, as measured on preoperative imaging studies, and with postoperative morning cortisol levels following an overnight dexamethasone suppression test. Postoperative cortisol levels can be used as a useful prognostic indicator of the likelihood of future recurrence following transsphenoidal adenomectomy in CD.

Adenoma↗
PubMed2003

A review of olanzapine-associated toxicity and fatality in overdose.

OBJECTIVE: Given the increasing use of atypical antipsychotics in psychiatric populations and the very limited data concerning the safety of such drugs, we examined the available data on olanzapine in untreated overdose situations. METHODS: Available toxicity data concerning olanzapine were obtained from the Offices of the Medical Examiners of Canada, the Canadian Adverse Drug Reaction Monitoring Program and a review of the literature. RESULTS: Despite the complexities and limitations of postmortem data analysis, 29 deaths were identified where an overdose of olanzapine was either the principal cause of toxicity or a significant contributor in combined toxicity. CONCLUSIONS: Olanzapine is associated with toxicity in certain overdose situations, but evidence of any relation is limited and likely influenced by the higher rates of cardiovascular disease and sudden death in subjects with schizophrenia. RECOMMENDATIONS: Similar toxicity data reviews should be conducted for all commonly prescribed psychotropics. Early signal detection and effective notification processes are crucial in the event that serious adverse effects do occur.

Antipsychotic Agents↗