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Study Objective: To evaluate costs, clinical consequences, and cost-effectiveness from a German and French health-care system perspective of sequential i.v./po moxifloxacin monotherapy compared to co-amoxiclav with or without clarithromycin (AMC +/- CLA) in patients with community-acquired pneumonia (CAP) who required parenteral treatment.Methods: Costs and consequences over 21 days were evaluated based on clinical cure rates 5 to 7 days after treatment and health resource use reported for the TARGET multinational, prospective, randomized, open-label trial. This trial compared sequential i.v./po monotherapy with moxifloxacin (400 mg qd) to i.v./po co-amoxiclav (1.2 g i.v./625 mg po tid) with or without clarithromycin (500 mg bid) for 7 to 14 days in hospitalized patients with CAP. Since no country-by-treatment interaction was found in spite of some country differences for length of hospital stays, resource data (antimicrobial treatment, hospitalization, and out-of-hospital care) from all centers were pooled and valued using German and French unit prices to estimate CAP-related cost to the German Sickness Funds and French public health-care sector, respectively.Results: Compared to AMC +/- CLA, treatment with moxifloxacin resulted in 5.3% more patients achieving clinical cure 5 to 7 days after therapy (95% confidence interval [CI], 1.2 to 11.8%), increased speed of response (1 day sooner for median time to first return to apyrexia, p = 0.008), and a reduction in hospital stay by 0.81 days (95% CI, - 0.01 to 1.63) within the 21-day time frame. Treatment with moxifloxacin resulted in savings of 266 euro and 381 euro for Germany and France respectively, primarily due to the shorter length of hospital stay. Cost-effectiveness acceptability curves show moxifloxacin has a > or = 95% chance of being cost saving from French and German health-care perspectives, and higher probability of being cost-effective at acceptability thresholds up to 2,000 euro per additional patient cured.Conclusion: i.v./po monotherapy with moxifloxacin shows clinical benefits including increased speed of response and is cost-effective compared to i.v./po AMC +/- CLA in the treatment of CAP. [ABSTRACT FROM AUTHOR]

This descriptive qualitative study of the nurse-client relationship used an interpersonal focus and Leininger's (1985) method of qualitative analysis. The setting was a tertiary care psychiatric hospital in southern Ontario, Canada. Nurses within 10 newly formed dyads participated in interviews. The research questions focused on the nature and progression of the relationship and the identification of helping and hampering influences. Helping influences identified included consistency, pacing, listening, positive initial impressions, and attention to comfort and control Relationships were hampered by inconsistency, unavailability, client factors related to trust, nurses' feelings about the client, confrontation of delusions, and unrealistic expectations. Phases consistent with those described by Peplau (1952, 1991) were identified within dyads that progressed well However, a different set of phases was identified in nontherapeutic relationships. [ABSTRACT FROM AUTHOR]

Three-hundred male alcoholics were selected from consecutive admissions to hospital. They were divided into three diagnostic sub-groups: primary alcoholics; alcoholics with unipolar affective disorder; and alcoholics with bipolar affective disorder. After three follow-up interviews over a 2-year period after hospital discharge, the three sub-groups reported differences in frequency of mood change, amount of treatment received, and hospital attendance, although there were no clear-cut differences in items associated with their alcoholism. There were, however, some indications that bipolar patients functioned at a better level during the follow-up period, particularly those who were older, had a previous history of longer periods of abstinence, and maintained more frequent contact with Alcoholics Anonymous (AA) and their family doctor. [ABSTRACT FROM AUTHOR]

PROBLEM. To identify factors influencing movement of nurse-patient dyads from Peplau's orientation phase to the working phase of the nurse-client relationship in a tertiary care psychiatric setting. METHODS. Ten nurse-client dyads were interviewed after the initial nurse-client assignment until a consensus was reached between client, nurse, and investigator/CNS that the relationship was in the working phase. FINDINGS. Factors causing the relationship to progress, from the clients' perspective, were the perceived attitude of the nurse, the nature of the planned therapeutic sessions, and what happened between therapeutic sessions. Factors hindering the development of the relationship included a nurse's or client's unavailability, a sense of distance/inequity, differences in realities/values, and mutual withdrawal. The relationship was perceived as supportive and 'powerful' when it progressed to the working phase, but as very negative and like 'limbo' if instead it moved to a phase of mutual withdrawal. CONCLUSIONS. Nurses can help clients move from the orientation phase to the working phase by remaining available, consistent, and acting in a way that promotes trust. When the relationship does not progress to the working phase within 6 months, a therapeutic transfer should be considered. [ABSTRACT FROM AUTHOR]

Objectives: Cancer diagnoses at later stages are associated with a decrease in health-related quality of life (HRQOL). Health state utility values (HSUVs) reflect preference-based HRQOL and can vary based on cancer type, stage, treatment, and disease progression. Detecting and treating cancer at earlier stages may lead to improved HRQOL, which is important for value assessments. We describe published HSUVs by cancer type and stage., Methods: A systematic review was conducted using Embase, MEDLINE ® , EconLit, and gray literature to identify studies published from January 1999 to September 2019 that reported HSUVs by cancer type and stage. Disutility values were calculated from differences in reported HSUVs across cancer stages., Results: From 13,872 publications, 27 were eligible for evidence synthesis. The most frequent cancer types were breast (n = 9), lung (n = 5), colorectal (n = 4), and cervical cancer (n = 3). Mean HSUVs decreased with increased cancer stage, with consistently lower values seen in stage IV or later-stage cancer across studies (e.g., - 0.74, - 0.44, and - 0.51 for breast, colorectal, and cervical cancer, respectively). Disutility values were highest between later-stage (metastatic or stage IV) cancers compared to earlier-stage (localized or stage I-III) cancers., Conclusions: This study provides a summary of HSUVs across different cancer types and stages that can inform economic evaluations. Despite the large variation in HSUVs overall, a consistent decline in HSUVs can be seen in the later stages, including stage IV. These findings indicate substantial impairment on individuals' quality of life and suggest value in early detection and intervention., (© 2021. The Author(s).)

Background: Consideration of cost determinants is crucial to inform delivery of public vaccination programs., Objectives: To estimate the average total cost of laboratory-confirmed influenza requiring hospitalization in Canadians prior to, during, and 30 days following discharge. To analyze effects of patient/disease characteristics, treatment, and regional differences in costs., Methods: Study utilized previously recorded clinical characteristics, resource use, and outcomes of laboratory-confirmed influenza patients admitted to hospitals in the Serious Outcomes Surveillance (SOS), Canadian Immunization Research Network (CIRN), from 2010/11 to 2012/13. Unit costs including hospital overheads were linked to inpatient/outpatient resource utilization before and after admissions., Results: Dataset included 2943 adult admissions to 17 SOS Network hospitals and 24 Toronto Invasive Bacterial Disease Network hospitals. Mean age was 69.5 years. Average hospital stay was 10.8 days (95% CI: 10.3, 11.3), general ward stays were 9.4 days (95% CI: 9.0, 9.8), and ICU stays were 9.8 days (95% CI: 8.6, 11.1) for the 14% of patients admitted to the ICU. Average cost per case was $14 612 CAD (95% CI: $13 852, $15 372) including $133 (95% CI: $116, $150) for medical care prior to admission, $14 031 (95% CI: $13 295, $14 768) during initial hospital stay, $447 (95% CI: $271, $624) post-discharge, including readmission within 30 days., Conclusion: The cost of laboratory-confirmed influenza was higher than previous estimates, driven mostly by length of stay and analyzing only laboratory-confirmed influenza cases. The true per-patient cost of influenza-related hospitalization has been underestimated, and prevention programs should be evaluated in this context., (© 2017 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Objective: To evaluate the cost-effectiveness of brentuximab vedotin in patients with R/R sALCL from a UK NHS perspective. Methods: A partitioned survival model used clinical outcomes for brentuximab vedotin from the pivotal phase-2 single-arm trial of brentuximab vedotin in 58 patients with R/R sALCL (SG035-0004; NCT00866047), over a lifetime (30-year) time horizon. Comparison with conventional chemotherapy was based on data from the Canadian British Columbia Cancer Agency registry from 40 patients starting salvage chemotherapy after front-line treatment between 1980 and 2012. Survival was extrapolated using parametric distributions, with brentuximab vedotin risk after the trial period assumed equal to conventional chemotherapy. Other modelling assumptions were based on a systematic literature review and clinical expert opinion. Results: Based on statistical extrapolation, brentuximab vedotin was associated with 3.1 years longer duration in the progression-free survival health state and an overall survival improvement of 5.4 years, prior to discounting. In addition, brentuximab vedotin was associated with 2.5 quality-adjusted life years (QALYs) gained at a total incremental cost of £88 556, resulting in an incremental cost-effectiveness ratio (ICER) of approximately £35 400. Sensitivity analyses of alternative model assumptions provided ICERs ranging from approximately £28 100 to £61 900. Comparing only first-line salvage patients reduced the ICER to £26 800 per QALY gained. Conversely, considering only patients with Eastern Corporative Oncology Group performance status of 0 or 1 increased the ICER to approximately £38 200. At a willingness-to-pay threshold of £50 000, the estimated probability that brentuximab vedotin is cost-effective compared with conventional chemotherapy was 86.5%. Conclusion: Compared to conventional chemotherapy, and considering the full survival period, brentuximab vedotin may provide a valuable treatment choice for patients with R/R sALCL, a population with limited therapeutic options.

Background: Uterine fibroids (UF) represent the most common benign uterine tumor in women of reproductive age. Symptoms including heavy, prolonged menstrual bleeding, pelvic pain/pressure, and/or urinary frequency have a substantial impact on women's quality of life and utility values for UF have not been published., Methods: Health state descriptions associated with UF symptoms and treatment side effects were developed based on patient focus groups; validated using expert clinical input; and pilot tested for understandability. Using a web-based questionnaire, 909 community-dwelling, Canadian women were surveyed to assess their perceived value associated with these states., Results: Utility for uncontrolled bleeding was 0.55 (95% CI: 0.54, 0.57) and the decrement associated with hot flashes was 0.06 (95% CI: -0.07, -0.04). Utility improvement associated with bleeding control was 0.18 (95% CI: 0.17, 0.19) and with smaller fibroid size was 0.03 (95% CI: 0.02, 0.04)., Conclusion: These values illustrate the high utility associated with control of excessive menstrual bleeding.

Objective: To conduct a cost-effectiveness analysis comparing the addition of memantine to standard care (that is, without acetylcholinesterase inhibitors) with standard care alone in moderate-to-severe Alzheimer disease (AD) in Canada., Methods: A 2-year Markov model estimated clinical effects in terms of quality-adjusted life years (QALYs) and time in complete dependence as well as societal costs in four 6-month cycles. Health states were defined by AD severity assessed with the Mini-Mental State Examination (moderate = 10 to 19; severe < 10), by level of dependence in activities of daily living, and by death. Transition probabilities were estimated by combining data of patients with moderate-to-severe AD from all relevant clinical trials. QALYs were estimated from a UK epidemiologic study. The initial distribution and use of medical and support services for each health state was obtained from the Canadian Study on Health and Aging with current estimates of frequency of use and unit prices applied., Results: Compared with standard care, the memantine strategy saved more than 1 month of complete dependence and produced 0.03 additional QALYs, with no additional cost. Probabilistic sensitivity analyses give an 83.3% chance that memantine treatment is cost-neutral, an 89.5% chance of its being cost-effective if the decision maker is willing to pay $20 000 for a QALY, and a 96.2% chance with a willingness to pay $100 000 per QALY. Robustness of results was confirmed through 1-way and scenario-based sensitivity analyses., Conclusions: Our evaluation found that memantine monotherapy produced relevant health benefit, compared with standard care alone, with no additional costs. Results are consistent with other economic evaluations of memantine conducted in Europe and the United States.

Background: A once-daily fixed combination of hydroquinone, tretinoin, and fluocinolone acetonide (Tri-luma) is a newly available treatment for melasma., Objective: To assess cost-effectiveness of triple combination therapy (TCT) applied once daily and hydroquinone alone applied twice daily in the U.S., Argentina, Brazil, Chile, and Colombia from a payer's perspective., Methods: Clinical data and utilization of key health resources (medication only) were assessed within an 8-week clinical trial conducted in Brazil. Total cost per primary success (complete clearing) was used to compare each treatment with not treating and incremental cost effectiveness ratios were used to compare between treatments., Results and Conclusion: TCT had a 30% better rate of complete clearing than hydroquinone with a lower cost in the U.S. and an incremental cost in other countries. In every country, cost per primary success was lower for TCT than for hydroquinone. Results were robust to varying assumptions of success rates and quantity used.

Objective: The Proscar Long-Term Efficacy and Safety Study (PLESS) and the Medical Therapy of Prostatic Symptoms (MTOPS) study provide new evidence regarding the benefits of finasteride in the treatment of benign prostatic hyperplasia (BPH). The objective of this study was to utilize data from the PLESS and MTOPS studies to assess the cost-utility of finasteride and finasteride in combination with doxazosin, compared to doxazosin alone in men with moderate to severe BPH symptoms., Methods: A semi-Markov decision analytic model was constructed to estimate the clinical consequences, costs and cost-utility of doxazosin, finasteride, and combination therapy. Analyses were conducted for a 15-year time frame from the perspective of the Ontario Ministry of Health and Long Term Care (MOHLTC). Results are reported stratified by baseline serum prostate-specific antigen (PSA) level according to all baseline serum PSA levels, patients with baseline serum PSA > 1.3 ng/ml, and patients with baseline serum PSA > 3.2 ng/ml., Results: Compared to doxazosin alone, combination therapy was more expensive but more effective. Cost-utility ratios ranged from 27,823 dollars/QALY for patients with PSA > 3.2 ng/ml to 34,085 dollars/QALY for all patients. Finasteride, although dominated by doxazosin, may be cost-effective compared to watchful waiting in patients who fail doxazosin and do not choose to proceed to surgery. Compared to watchful waiting, cost-utility ratios for finasteride ranged from 35016 dollars/QALY for patients with PSA > 3.2 ng/ml to 44,336 dollars/QALY for all patients. Results were robust across a wide range of sensitivity analyses., Conclusions: Combination therapy is cost-effective compared to doxazosin with cost-utility ratios under 40,000 dollars/QALY across a wide range of scenarios. The cost-effectiveness of combination therapy increases as serum PSA level increases.

Background and Purpose: To compare 3-month stroke outcomes and stroke-related health care resource use between the US and Canada in the Glycine Antagonist in Neuroprotection (GAIN) Americas study. Delivery of medical care for stroke patients, often driven by efforts to curb costs, varies substantially between countries. Data on the potential impact of these variations on clinical outcomes are sparse., Methods: The analysis of health care resource included total length of stay (LOS) in hospital, intensive care unit (ICU), and acute-care ward or rehabilitation unit, or both; number of outpatient rehabilitation sessions and visits to a physician; place of residence after discharge; and employment status. Cox proportional hazards models and logistic regression were used to calculate survival hazards and predictors of favorable functional outcome (Barthel Index of 95 to 100)., Results: One thousand six hundred four patients who were independent before stroke (mean age: 69.9+/-12.7 years, 53% men, 85% ischemic stroke, 69% in the US) were included. Three-month survival and functional outcome did not differ between the US and Canada. Survival rate was 80% in both countries. Favorable functional outcome was achieved in 43% of Canadian and 47% of US patients. Fewer Canadian patients received treatment in ICU (19% versus 63% in the US), and Canadians had longer stays in hospital or rehabilitation facility (median: 33 days versus 16 days in the US)., Conclusions: Despite similar 3-month survival and functional outcome, patterns of health care resource varied substantially between the US and Canada. US patients had more intensive early care; Canadian patients had longer hospitalizations and rehabilitation care. Further research is required to determine the most cost-effective treatment and rehabilitation plan for people who have a stroke.

Foot ulcers secondary to peripheral neuropathy and vascular disease are a commonly occurring complication for people with diabetes. Becaplermin, a genetically-engineered growth factor in a hydrogel vehicle, has been shown to be more effective than vehicle-only control in healing chronic foot ulcers of patients with adequate vasculature receiving best clinical care. To evaluate the cost-effectiveness of adding up to 20 weeks of becaplermin to a regimen of best clinical care, a 1-year decision-analytic model was developed and tested using data from a previously published controlled clinical study involving 251 people with diabetes (124 becaplermin/127 control) and adequate vasculature presenting with an infection-free ulcer that had failed to heal despite appropriate therapy. A 20-week healing rate was estimated based on the clinical trial data assuming becaplermin treatment was terminated at 10 weeks in non-responding ulcers, and follow-up data were extended to 1 year. Resource utilization was estimated by an expert panel using a modified Delphi approach. Using the model, it was found that incorporating becaplermin with best clinical care resulted in 26 fewer ulcer-days per patient per year compared to best clinical care alone with an incremental cost-effectiveness ratio of $6 per ulcer-day averted. Results were sensitive to becaplermin cost, efficacy, and effect on infection and recurrence rates. The clinical benefits of becaplermin deserve further investigation to enhance cost-effectiveness information for informed treatment decisions.

Background and Purpose: Outcome in patients hospitalized for acute stroke varies considerably between populations. Within the framework of the GAIN International trial, a large multicenter trial of a neuroprotective agent (gavestinel, glycine antagonist), stroke outcome in relation to health care resource use has been compared in a large number of countries, allowing for differences in case mix., Methods: This substudy includes 1,422 patients in 19 countries grouped into 10 regions. Data on prognostic variables on admission to hospital, resource use, and outcome were analyzed by regression models., Results: All results were adjusted for differences in prognostic factors on admission (NIH Stroke Scale, age, comorbidity). There were threefold variations in the average number of days in hospital/institutional care (from 20 to 60 days). The proportion of patients who met with professional rehabilitation staff also varied greatly. Three-month case fatality ranged from 11% to 28%, and mean Barthel ADL score at three months varied between 64 and 73. There was no relationship between health care resource use and outcome in terms of survival and ADL function at three months. The proportion of patients living at home at three months did not show any relationship to ADL function across countries., Conclusions: There are wide variations in health care resource use between countries, unexplained by differences in case mix. Across countries, there is no obvious relationship between resource use and clinical outcome after stroke. Differences in health care traditions (treatment pathways) and social context seem to be major determinants of resource use. In making comparisons between countries, great care should be exercised in using outcome variables as indicators of quality of stroke care.

Objective: Our purpose was to determine the extent to which nausea and vomiting of pregnancy affects a woman's quality of life (QOL), ability to function, and health care resource use., Study Design: We conducted an observational, multicenter, prospective cohort study by gathering data on the symptoms, QOL, and health care resource use from women who have nausea and vomiting of pregnancy., Results: All 8 domains of health measured by the Short Form-36 QOL survey were limited by patient symptoms. This limitation manifested itself as patient-time loss from work and other normal activities, unpaid caregiver-time loss from work, and use of health care resources (eg, hospitalization). All types of time loss were correlated to severity of symptoms., Conclusions: Nausea and vomiting of pregnancy can severely reduce a woman's QOL and ability to function. The degree of limitation is associated with the severity of symptoms.

Background: Donepezil is a new drug recently approved in the United States and Canada for the treatment of Alzheimer's disease (AD). We estimated the cost-effectiveness of donepezil 5 mg daily as an adjunct to usual care in the management of persons with mild-to-moderate AD defined as a Mini-Mental Health State Examination (MMSE) score in the range 10 to 26., Methods: Treatment effect data as MMSE change-over-baseline scores were obtained from a 30-week placebo-controlled trial of donepezil. MMSE scores beyond observed trial data were estimated using a Markov model with 10 cycles of 24 weeks based on the placebo MMSE progression observed in the trial. Data from AD subjects in the Canadian Study of Health and Aging were used to estimate costs of nursing home care, community services, medications, and caregiver time as a function of MMSE score. A clinic-based cohort study from Alberta was used to estimate the distribution of AD patients by MMSE score presenting for treatment. The effectiveness measure for the economic model was expected time (over 5 years) spent with nonsevere AD (MMSE > or = 10)., Results: Over 5 years of treatment, donepezil is predicted to reduce health care costs by CA$929 per patient but increase caregiver time costs by CA$48 per patient for an overall cost saving to society of CA$882 per patient. Patients not receiving donepezil are predicted to spend 2.21 years of the 5 years in nonsevere AD compared with 2.41 years for treated patients (a gain of just over 2 months). Sensitivity analysis reveals that cost savings per patient increase if more AD patients are assumed to survive to 5 years; however, if donepezil treatment continues when patients' MMSE score falls below 10, the incremental cost is higher for treatment at CA$1554 per patient., Conclusion: Based on the limited available data, our model predicts that the use of donepezil for mild-to-moderate AD in Canada is associated with lower 5-year costs and less time spent with severe AD when compared with the alternative of usual care with no donepezil therapy. As more reliable long-term data become available, these predictions should be confirmed and/or updated.

Background: Data from the Canadian Study of Health and Aging (CSHA) were used to examine the relation between severity of Alzheimer's disease, as measured by the Mini-Mental State Examination (MMSE), and costs of caring., Methods: The CSHA was a community-based survey of the prevalence of dementia, including subtypes such as Alzheimer's disease, among elderly Canadians. Survey subjects with a diagnosis of possible or probable Alzheimer's disease were grouped into disease severity levels of mild (MMSE score 21-26), mild to moderate (MMSE score 15-20), moderate (MMSE score 10-14) and severe (MMSE score below 10). Components of care available from the CSHA were use of nursing home care, use of medications, use of community support services by caregivers and unpaid caregiver time. Costs were calculated from a societal perspective and are expressed in 1996 Canadian dollars., Results: The annual societal cost of care per patient increased significantly with severity of Alzheimer's disease. The cost per patient was estimated to be $9451 for mild disease, $16,054 for mild to moderate disease, $25,724 for moderate disease and $36,794 for severe disease. Institutionalization was the largest component of cost, accounting for as much as 84% of the cost for people with severe disease. For subjects living in the community, unpaid caregiver time and use of community services were the greatest components of cost and increased with disease severity., Interpretation: The societal cost of care of Alzheimer's disease increases drastically with increasing disease severity. Institutionalization is responsible for the largest cost component.

Objective: To summarize published data to date by Canadian authors and from Canadian sources on risperidone, a novel neuroleptic indicated in the management of schizophrenia and related psychotic disorders. It was introduced in Canada in 1993., Data Sources: A MEDLINE search was performed using "risperidone" as a keyword. Three Canadian journals were also searched manually., Study Selection: Articles published between January 1991 and June 1996 by Canadian authors or involving Canadian patients., Data Extraction: Retrieved articles were categorized according to data on efficacy, safety, resource use/economics and other miscellaneous aspects. Articles were abstracted and summarized. Some non-Canadian sources were used for comparison., Data Synthesis: The initial Canadian multicentre trial found resperidone (6 mg daily) to be superior to haloperidol (20 mg daily) in reducing positive and negative symptoms, with fewer extrapyramidal side effects (EPS). Various case reports have extended both the clinical use and safety profile of risperidone, while neuro-imaging studies have tried to clarify its mechanism of action. Economic studies suggest substantial cost benefits due to prevention of hospitalization as well as improvement in quality of life., Conclusions: Canadian research has contributed considerably to the current knowledge regarding risperidone. Future studies, both controlled and naturalistic, will need to focus on comparisons with the various new compounds now available.

1. Kidney function during long-term lithium treatment was studied in the representative sample of patients with recurrent affective disorders. Creatinine clearance, maximum urinary osmolality and 24-hour urine volume were determined. 2. Patients were divided according to their type of response to long-term lithium treatment, expressed by the effect on the frequency of recurrencies. Various indicators of kidney function were compared in excellent responders and in non-responders. 3. Long-term lithium treatment did not lead to any detectable changes of glomerular filtration in either group. 4. In comparison with responders, non-responders showed a significantly greater increase in 24-hour urine volume and a trend towards a greater reduction of maximum urinary osmolality, and thus a greater impairment of tubular function. 5. The findings stress the need for a careful selection of patients for long-term lithium stabilization.

Assurance of compliance (ingestion of dexamethasone) is crucial for interpreting plasma cortisol results on the DST. In this double-blind study of 13 subjects, methylene blue (MB) 50 mg was combined with dexamethasone 1 mg in single capsules, and the resulting blue-green urinary color after ingestion was found to reliably validate compliance in 100% of patients and controls. The addition of MB did not influence DST results (i.e., plasma cortisol, plasma dexamethasone). Adding MB to dexamethasone as a marker is a reliable and safe means of validating compliance on the DST and is considerably more practical than plasma dexamethasone level determinations.

In a prospective study of 25 patients from the time of hospitalization, seven had recently discontinued psychotropic agents (including antidepressants, neuroleptics, and benzodiazepines). All seven had positive dexamethasone suppression test results after 1 week of hospitalization. This phenomenon did not occur in any of the other subjects who had not discontinued such medications. Some of the subjects with postdexamethasone cortisol increases reported drug discontinuation in the drug histories they gave at admission, but in three, drug screening provided the only evidence of prior drug use. Medication withdrawal may be an underappreciated confounding variable in DST studies.