David Knight

Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction

BACKGROUNDnPatients with acute myocardial infarction who were treated with accelerated tissue plasminogen activator (t-PA) (given over a period of 1 1/2 hours rather than the conventional 3 hours, and with two thirds of the dose given in the first 30 minutes) had a 30-day mortality that was 15 percent lower than that of patients treated with streptokinase in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) study. This was equivalent to an absolute decrease of 1 percent in 30-day mortality. We sought to assess whether the use of t-PA, as compared with streptokinase, is cost effective.nnnMETHODSnOur primary, or base-case, analysis of cost effectiveness used data from the GUSTO study and life expectancy projected on the basis of the records of survivors of myocardial infarction in the Duke Cardiovascular Disease Database. In the primary analysis, we assumed that there were no additional treatment costs due to the use of t-PA after the first year and that the comparative survival benefit of t-PA was still evident one year after enrollment.nnnRESULTSnOne year after enrollment, patients who received t-PA had both higher costs (

Bigram Frequency, Number of Syllables and Morphemes and Their Effects on Lexical Decision and Word Naming

2,845) and a higher survival rate (an increase of 1.1 percent, or 11 per 1000 patients treated) than streptokinase-treated patients. On the basis of the projected life expectancy of each treatment group, the incremental cost-effectiveness ratio--with both future costs and benefits discounted at 5 percent per year--was

Use of Resources, Quality of Life, and Clinical Outcomes in Patients With and Without New Q Waves After Thrombolytic Therapy for Acute Myocardial Infarction (from the GUSTO-I Trial)

32,678 per year of life saved. The use of t-PA was least cost effective in younger patients and most cost effective in older patients. At all ages, the use of t-PA in patients with anterior infarctions yielded more favorable cost-effectiveness values. In our secondary analyses, the cost-effectiveness values were most sensitive to a lowering of the projected long-term survival benefits of t-PA and to moderate or greater increases in the projected medical costs for patients in the t-PA group after the first year. In contrast, our results were not sensitive to even very unfavorable assumptions about the additional costs associated with the higher rate of disabling stroke that was noted in patients treated with t-PA in the GUSTO study.nnnCONCLUSIONSnThe cost effectiveness of treatment with accelerated t-PA rather than streptokinase compares favorably with that of other therapies whose added medical benefit for dollars spent is judged by society to be worthwhile.

Agriculture and chemistry in Britain around 1800

There has been an increasing volume of evidence supporting the role of the syllable in word processing tasks. Recently it has also been shown that orthographic redundancy, related to the pattern of bigram frequencies, could not explain the syllable number effect on lexical decision times. This was demonstrated on a large sample of words taken from the British Lexicon Project. In this study we extend this research by examining both lexical decision and word naming times taken from the English Lexicon Project . There was a syllable number effect for both tasks in the expected direction, and this effect was independent of the presence of a bigram trough. The research also examined the role of other bigram related variables and the number of morphemes on lexical decision and word naming times. The number of morphemes had a significant effect on both word processing tasks, with words with more morphemes producing faster reaction times and also fewer errors. This pattern was reversed for nonword lexical decision times. The results are discussed in the light of recent developments in models of reading.

Lexical decision and the number of morphemes and affixes.

Previous reports indicate that patients who do not develop Q waves after thrombolytic therapy are a different population with a better long-term survival than those who do develop Q waves. However, the use of resources, quality of life, and health status of this population have not been fully evaluated. Using data from the Economics and Quality of Life subset of the Global Utilization of Streptokinase and tPA for Occluded Arteries study, we examined 30-day and 1-year mortality, use of resources, and quality-of-life measures among 1,830 of 3,000 patients with acute myocardial infarction and ST-segment elevation treated with thrombolytic therapy. At hospital discharge, 555 patients (30.2%) had not developed Q waves. These patients had lower mortality than patients with Q waves at 30 days (1.6% vs 4.5%, p <0.01) and at 1 year (4.7% vs 6.8%, p <0.04). Recurrent chest pain and dyspnea were similar at 30 days and 1 year. Patients without Q waves had significantly more angiography and trends toward higher readmission, revascularization, and use of calcium antagonists at 30 days. Angiography, revascularization, readmission, and quality of life were equivalent from 30 days to 1 year, with no sign of late instability. Logistic regression analysis showed an association between in-hospital revascularization and better survival and quality of life at 1 year. Conversely, there was no association between in-hospital use of calcium antagonists and outcome to explain the lower mortality in non-Q-wave patients. The absence of Q waves after thrombolytic therapy is a marker of success, implying better prognosis and equivalent quality of life, use of resources, and health status than for patients with Q-wave acute myocardial infarction and no sign of long-term unstable clinical course.

Altering attentional control settings causes persistent biases of visual attention

Summary This paper is concerned with the application of science to a practical activity. The story begins in the late eighteenth century, a period of agricultural innovation, with various authors urging that definite chemical knowledge should replace rule of thumb in the application of fertilisers. In the work of Archibald Cochrane, ninth Earl of Dundonald, we find this exhortation beginning to give way to descriptions of actual chemical experiments, and interpretations of equilibria in the soil. But it is only with Davys Agricultural chemistry of 1813 that we get clear descriptions of soil analyses that could be undertaken by a farmer, accompanied with a certain amount of biochemical information on the growth of plants. Davys recommendations were essentially conservative; he provided support for the best practices already being recommended by innovators. His book is interesting too, for the light it casts upon his more theoretical writings.

Light social drinkers are more distracted by irrelevant information from an induced attentional bias than heavy social drinkers.

There has been a considerable amount of research looking at the effects of both syllable number and syllable frequency on lexical decision and word naming times. Recently, there has also been an increased interest in morphological variables, but there have been no large scale studies that have examined the role of the number of morphemes in lexical decision for nonwords. This is partly because of the difficulty of identifying morphemes in nonwords. We present a program that identifies the presence of affixes and, therefore, can be used to count the number of morpheme-like elements in a nonword. We then used the program to measure the importance of affixes/morphemes in predicting lexical decision in nonwords. The results suggested that morphemes have an important role in lexical decision for both words and nonwords.

Prognostic value of predischarge electrocardiographic measurement of infarct size after thrombolysis: Insights from GUSTO I Economics and Quality of Life substudy

Attentional control settings have an important role in guiding visual behaviour. Previous work within cognitive psychology has found that the deployment of general attentional control settings can be modulated by training. However, research has not yet established whether long-term modifications of one particular type of attentional control setting can be induced. To address this, we investigated persistent alterations to feature search mode, also known as an attentional bias, towards an arbitrary stimulus in healthy participants. Subjects were biased towards the colour green by an information sheet. Attentional bias was assessed using a change detection task. After an interval of either 1 or 2 weeks, participants were then retested on the same change detection task, tested on a different change detection task where colour was irrelevant, or were biased towards an alternative colour. One experiment included trials in which the distractor stimuli (but never the target stimuli) were green. The key finding was that green stimuli in the second task attracted attention, despite this impairing task performance. Furthermore, inducing a second attentional bias did not override the initial bias toward green objects. The attentional bias also persisted for at least two weeks. It is argued that this persistent attentional bias is mediated by a chronic change to participants’ attentional control settings, which is aided by long-term representations involving contextual cueing. We speculate that similar changes to attentional control settings and continuous cueing may relate to attentional biases observed in psychopathologies. Targeting these biases may be a productive approach to treatment.

Religion and the ‘new philosophy’

It is well established that alcoholics and heavy social drinkers show a bias of attention towards alcohol-related items. Previous research suggests that there is a shared foundation of attentional bias, which is linked to attentional control settings. Specifically, attentional bias relates to a persistent selection of a Feature Search Mode which prioritises attentional bias-related information for selection and processing. However, no research has yet examined the effect of pre-existing biases on the development of an additional attentional bias. This paper seeks to discover how pre-existing biases affect the formation of a new, additional attentional bias. Twenty-five heavy and 25 light social drinkers, with and without a pre-existing bias to alcohol-related items, respectively, had an attentional bias towards the colour green induced via an information sheet. They then completed a series of one-shot change detection tasks. In the critical task, green items were present but task-irrelevant. Irrelevant green items caused significantly more interference for light than heavy social drinkers. This somewhat counter intuitive result is likely due to heavy drinkers having more experience in exerting cognitive control over attentional biases, something not previously observed in investigations of the effects of holding an attentional bias. Our findings demonstrate for the first time that an established attentional bias significantly modulates future behaviour.