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BackgroundKawasaki disease (KD), an acute febrile illness and systemic vasculitis, is the leading cause of acquired heart disease in children in industrialized countries. KD leads to the development of coronary artery aneurysms (CAA) in affected children, which may persist for months and even years after the acute phase of the disease. There is an unmet need to characterize the immune and pathological mechanisms of the long-term complications of KD.MethodsWe examined cardiovascular complications in the Lactobacillus casei cell wall extract (LCWE) mouse model of KD-like vasculitis over 4 months. The long-term immune, pathological, and functional changes occurring in cardiovascular lesions were characterized by histological examination, flow cytometric analysis, immunofluorescent staining of cardiovascular tissues, and transthoracic echocardiogram.ResultsCAA and abdominal aorta dilations were detected up to 16 weeks following LCWE injection and initiation of acute vasculitis. We observed alterations in the composition of circulating immune cell profiles, such as increased monocyte frequencies in the acute phase of the disease and higher counts of neutrophils. We determined a positive correlation between circulating neutrophil and inflammatory monocyte counts and the severity of cardiovascular lesions early after LCWE injection. LCWE-induced KD-like vasculitis was associated with myocarditis and myocardial dysfunction, characterized by diminished ejection fraction and left ventricular remodeling, which worsened over time. We observed extensive fibrosis within the inflamed cardiac tissue early in the disease and myocardial fibrosis in later stages.ConclusionOur findings indicate that increased circulating neutrophil counts in the acute phase are a reliable predictor of cardiovascular inflammation severity in LCWE-injected mice. Furthermore, long-term cardiac complications stemming from inflammatory cell infiltrations in the aortic root and coronary arteries, myocardial dysfunction, and myocardial fibrosis persist over long periods and are still detected up to 16 weeks after LCWE injection.

Few cases of Hypervirulent Klebsiella Pneumonia (HvKP) have been described. Even fewer cases with renal abscess and metastatic pulmonary spread are reported. Typically, prompt introduction of intravenous antibiotics leads to clinical resolution and more invasive measures of source control are rarely required. To date only one other case of disseminated metastatic HvKP requiring nephrectomy for infective source control is described. Here we present a rare case of metastatic HvKP refractory to intravenous antimicrobial therapy in an immunocompromised newly diagnosed diabetic patient. Specifically, we seek to illustrate the rapid effectiveness of surgical intervention following a poor response to initial treatment.

Hvordan Norge håndterer sin militæraktivisme og fredsaktivisme ble aktualisert i kampanjen for et sete i sikkerhetsrådet. Aktivisme forstås her som nasjonens villighet til å ta initiativ på tross av kostnader. I denne replikken svarer vi på Friis sin kommentar som trekker verdien av vårt bidrag i tvil, da han omtaler vår analyse av Norges unnlatelse av å fremme sin militæraktivisme til fordel for «mykere verdier», som «gammelt nytt.» I kampanjen fremmet Norge både militæraktivisme og fredsaktivisme, men i ulikt materiale og forum. Vi hevder dermed at dette som et minimum er gammelt nytt i nye klær. Ved bruk av nasjonsbranding-rammeverket finner vi at Norge ønsket å fremstille seg som en aktør som er villig til å bidra, samtidig med å understreke Norge som en ikke utpreget militæraktør.

Hvordan håndterer Norge sin militæraktivisme og sitt NATO-medlemskap når landet vil presentere seg selv som en fredsnasjon? Problemstillingen ble aktuell i det norske utenriksdepartementets nylige kampanje for å få Norge valgt inn i FNs sikkerhetsråd, hvor ideen om Norge som fredsnasjon stod sentralt. I denne artikkelen bruker vi nasjonsbranding som et analytisk rammeverk for å forstå hvordan Norge bygget opp sin kampanje som fredsnasjon og håndterte det konkurrerende narrativet om sin rolle i krig. Som et sekundærfokus ser vi også på hvordan Norges to konkurrenter, Irland og Canada, fremstilte seg på disse to dimensjonene – som er av særinteresse da Irland ikke er NATO-medlem. For å utforske disse spørsmålene analyserer vi taler og tekster fra det norske diplomatiet og regjeringen vedrørende kampanjen, samt ser på kampanjematerialet til de tre landene. Gitt at de tre landenes profil er påfallende lik, fant vi at alle måtte forsøke å finne en måte å brande seg på som uttrykket ens særtrekk og høynet ens relevans i sammenligning med de to andre landene. I analysen av Norge ser vi at militæraktivisme stadig ble hvisket ut i løpet av den norske kampanjen og at andre tematikker ble brukt i brandingen – som for eksempel likestilling og bidrag til internasjonal utvikling. Dette skulle dermed skulle legitimere ideen om fredsnasjonen Norge, et land som alle andre kan stole på.

In this essay, we examine empirically whether the revised draft of the business and human rights (BHR) treaty is a normative advance on the existing jungle of global instruments. Since the 1970s, almost one hundred global corporate social responsibility (CSR) standards have been adopted, half of them addressing human rights. See Figure 1 from our global CSR database, below. What is novel about the current treaty-drafting process within the UN Human Rights Council (HRC) is that it aims to develop a comprehensive standard that would hold states legally accountable for regulating business. The question is whether this is possible. Drawing on our work on the “commitment curve,” we begin theoretically and point out why one should hold modest expectations about the process and treat strong text with skepticism as much as celebration. Using an empirical methodology, we then compare the HRC's Revised Draft Legally Binding Instrument (Revised Draft LBI) with existing standards, and find that while the draft contains a healthy dose of incremental pragmatism, its significant advances require a degree of circumspection about its strengths and prospects.

Enthusiasm abounds about the potential of artificial intelligence to automate public decision-making. The rise of machine learning and computational text analysis together with the proliferation of digital platforms has raised the prospect of “robo-judging” and “robo-administrators.” From a human rights perspective, the reaction has been mixed, and on balance negative. Optimists herald the possibilities of democratizing legal services and making decision-making more predictable and efficient. Critics warn, however, of the specter of new forms of social control, arbitrariness, and inequality. This essay examines the concerns over the turn to automation from the perspective of two international human rights: the rights to social security and a fair trial. It argues that while the critiques deserve a full hearing, they should be evidence-based, informed by an understanding of “technological systems,” and cognizant of the trade-offs between human and machine failure.

Kawasaki disease (KD) is the leading cause of acquired heart disease among children. Murine and human data suggest that the NLRP3–IL-1β pathway is the main driver of KD pathophysiology. NLRP3 can be activated during defective autophagy/mitophagy. We used the Lactobacillus casei cell wall extract (LCWE) murine model of KD vasculitis to examine the role of autophagy/mitophagy on cardiovascular lesion development. LCWE-injected mice had impaired autophagy/mitophagy and increased levels of ROS in cardiovascular lesions, together with increased systemic 8-OHdG release. Enhanced autophagic flux significantly reduced cardiovascular lesions in LCWE-injected mice, whereas autophagy blockade increased inflammation. Vascular smooth muscle cell–specific deletion of Atg16l1 and global Parkin–/– significantly increased disease formation, supporting the importance of autophagy/mitophagy in this model. Ogg1–/– mice had significantly increased lesions with increased NLRP3 activity, whereas treatment with MitoQ reduced vascular tissue inflammation, ROS production, and systemic 8-OHdG release. Treatment with MN58b or Metformin (increasing AMPK and reducing ROS) resulted in decreased cardiovascular lesions. Our results demonstrate that impaired autophagy/mitophagy and ROS-dependent damage exacerbate the development of murine KD vasculitis. This pathway can be efficiently targeted to reduce disease severity. These findings enhance our understanding of KD pathogenesis and identify potentially novel therapeutic avenues for KD treatment.

The Norwegian constitution is the second oldest living constitution in the world, and the country’s Supreme Court was also the second in the world to judicially review legislation. Yet, Norway’s deep constitutional history has gone often unnoticed in comparative scholarship, while comparative constitutional law within Norway has not attracted significant attention, despite the many constitutional influences from abroad. This article introduces the Norwegian constitution to an international audience and places it within a comparative perspective for a Norwegian readership. After a brief overview of comparative method(s), the remainder of the article focuses on three core areas of constitutional law: system of government, judicial review, and constitutional amendments. Using descriptive statistics, qualitative case studies, and legal and archival sources, the Norwegian experience is situated within a global context.

Kawasaki disease (KD), an acute febrile childhood illness and systemic vasculitis of unknown etiology, is the leading cause of acquired heart disease among children. Experimental data from murine models of KD vasculitis and transcriptomics data generated from whole blood of KD patients indicate the involvement of the NLRP3 inflammasome and interleukin-1 (IL-1) signaling in KD pathogenesis. MicroRNA-223 (miR-223) is a negative regulator of NLRP3 activity and IL-1β production, and its expression has been reported to be upregulated during acute human KD; however, the specific role of miR-223 during KD vasculitis remains unknown. Here, using the Lactobacillus casei cell wall extract (LCWE) murine model of KD vasculitis, we demonstrate increased miR-223 expression in LCWE-induced cardiovascular lesions. Compared with control WT mice, LCWE-injected miR-223-deficient mice (miR223−/y) developed more severe coronary arteritis and aortitis, as well as more pronounced abdominal aorta aneurysms and dilations. The enhanced cardiovascular lesions and KD vasculitis observed in LCWE-injected miR223−/y mice correlated with increased NLRP3 inflammasome activity and elevated IL-1β production, indicating that miR-223 limits cardiovascular lesion development by downmodulating NLRP3 inflammasome activity. Collectively, our data reveal a previously unappreciated role of miR-223 in regulating innate immune responses and in limiting KD vasculitis and its cardiovascular lesions by constraining the NLRP3 inflammasome and the IL-1β pathway. These data also suggest that miR-223 expression may be used as a marker for KD vasculitis pathogenesis and provide a novel therapeutic target.

The integration and normalization of multiple CALL systems with more traditional face-to-face learning, or blended learning, is an emerging trend of research. Evaluators are urged to investigate the processes involved in normalization of language learning tools in the classroom. Grounded in blended learning evaluation, this paper adopts an argument-based approach to interrogate the single claim: blended vocabulary learning systems can be normalized in English as a foreign language (EFL) programs. Using needs analysis, survey data, and document analysis, the authors examine what factors contribute to implementation and normalization of a blended language vocabulary program in a private Japanese university EFL program. Results reveal that transparency, constructive alignment, and coordinator’s and teacher’s knowledge, skills, and attitudes are important factors. Finally, it is argued that the normalization of blended learning programs seems to be predicated upon careful alignment with well-defined learning objectives, and on the availability of transparent analytics from online systems for the learner, teacher, and coordinator to ensure the diffusion of alignment from the meso to the micro level of the program.

Systemic Lupus Erythematosus (SLE) is a chronic inflammatory autoimmune disease in which type I interferons (IFN) play a key role. The IFN response can be triggered when oxidized DNA engages the cytosolic DNA sensing platform cGAS-STING, but the repair mechanisms that modulate this process and govern disease progression are unclear. To gain insight into this biology, we interrogated the role of oxyguanine glycosylase 1 (OGG1), which repairs oxidized guanine 8-Oxo-2′-deoxyguanosine (8-OH-dG), in the pristane-induced mouse model of SLE. Ogg1−/− mice showed increased influx of Ly6Chi monocytes into the peritoneal cavity and enhanced IFN-driven gene expression in response to short-term exposure to pristane. Loss of Ogg1 was associated with increased auto-antibodies (anti-dsDNA and anti-RNP), higher total IgG, and expression of interferon stimulated genes (ISG) to longer exposure to pristane, accompanied by aggravated skin pathology such as hair loss, thicker epidermis, and increased deposition of IgG in skin lesions. Supporting a role for type I IFNs in this model, skin lesions of Ogg1−/− mice had significantly higher expression of type I IFN genes (Isg15, Irf9, and Ifnb). In keeping with loss of Ogg1 resulting in dysregulated IFN responses, enhanced basal and cGAMP-dependent Ifnb expression was observed in BMDMs from Ogg1−/− mice. Use of the STING inhibitor, H151, reduced both basal and cGAMP-driven increases, indicating that OGG1 regulates Ifnb expression through the cGAS-STING pathway. Finally, in support for a role for OGG1 in the pathology of cutaneous disease, reduced OGG1 expression in monocytes associated with skin involvement in SLE patients and the expression of OGG1 was significantly lower in lesional skin compared with non-lesional skin in patients with Discoid Lupus. Taken together, these data support an important role for OGG1 in protecting against IFN production and SLE skin disease.

Background: CrossFit is an increasingly popular, rapidly growing exercise regimen. Few studies have evaluated CrossFit-associated musculoskeletal injuries on a large scale. This study explores such injuries and associated risk factors in detail. Objective: To identify the most common musculoskeletal injuries endured during CrossFit training among athletes at different levels of expertise. Design: Survey-based retrospective cross-sectional study. Setting: Distribution at CrossFit gyms in the United States and internationally. Also published on active online forums. Participants: A total of 885 former and current CrossFit athletes. Methods: Institutional review board-approved 33-question Web-based survey focused on CrossFit injuries and associated risk factors. Survey submissions were accepted for a period of 6 months. Main outcome measurements: Specific injuries with associated workouts, risk factors that affected injury including (1) basic demographics, (2) regional differences in reported injuries, (3) training intensity, and (4) expertise level at time of injury. Results: Of the 885 respondents, 295 (33.3%) were injured. The most common injuries involved the back (95/295, 32.2%) and shoulder (61/295, 20.7%). The most common exercises that caused injury were squats (65/295, 22.0%) and deadlifts (53/295, 18.0%). Advanced-level (64/295, 21.7%) athletes were more significantly injured than beginner-level (40/295, 13.6%) athletes. International participants were 2.2 times more likely than domestic US participants to suffer injury. Individuals with 3+ years of CrossFit experience were 3.3 times more likely to be injured than those with 2 or less years of experience. Participants who trained for 11+ h/week were significantly more likely to be injured than those who trained less than or equal to 10 h/week. Conclusions: As CrossFit becomes more popular, it is important to monitor the safety of its practitioners. Further studies are needed to explore how to lower this injury prevalence of 33.3%. Areas to focus on include factors that have caused the regional (international vs US states) differences, level of expertise/experience differences (advanced level vs intermediate and beginner levels), and stretching routine modifications.

Intrinsic limitations of nanoporous graphene limit its applications in water treatment. Here the authors produce post-treatment-free, low-cost graphene-based membranes from renewable biomass and demonstrate their high water permeance and antifouling properties using real seawater.

Hot flushes are best-known for affecting menopausal women, but men who undergo life-saving castration due to androgen-sensitive prostate cancer also suffer from these vasomotor symptoms. Estrogen deficiency in these patients is a direct consequence of androgen deprivation, because estrogens (notably 17β-estradiol, E2) are produced from testosterone. Although estrogens alleviate hot flushes in these patients, they also cause adverse systemic side effects. Because only estrogens can provide mitigation of hot flushes on the basis of current clinical practices, there is an unmet need for an effective and safe pharmacotherapeutic intervention that would also greatly enhance patient adherence. To this end, we evaluated treatment of orchidectomized (ORDX) rats with 10β, 17β-dihydroxyestra-1,4-dien-3-one (DHED), a brain-selective bioprecursor prodrug of E2. A pilot pharmacokinetic study using oral administration of DHED to these animals revealed the formation of E2 in the brain without the appearance of the hormone in the circulation. Therefore, DHED treatment alleviated androgen deprivation-associated hot flushes without peripheral impact in the ORDX rat model. Concomitantly, we showed that DHED-derived E2 induced progesterone receptor gene expression in the hypothalamus without stimulating galanin expression in the anterior pituitary, further indicating the lack of systemic estrogen exposure upon oral treatment with DHED.

Abstract Despite the flourishing of judicialisation of rights across the world, scepticism is not in short supply. Critiques range from concerns over the democratic legitimacy and institutional competence of courts to the effectiveness of rights protections. This article takes a step back from this debate and asks why should we establish or persist with judicial review. For reasons of theory, methodology, and practice, it argues that closer attention needs to be paid to the motivational and not just mitigatory purposes for judicial review. The article examines a range of epistemological reasons (the comparative advantage of the judiciary in interpretation) and functionalist reasons (the attainment of certain socio-political ends) for judicial review and considers which grounds provide the most convincing claims in theory and practice.

La determinación de propiedades para sustancias se realiza usando ecuaciones o gráficos obtenidos bajo condiciones de equilibrio termodinámico, sin embargo, muy pocos procesos reales ocurren en tales condiciones. En un proceso de expansión fuera del equilibrio, la condensación no comienza cuando se alcanza la saturación, este retraso se conoce como sobresaturación definiéndose en términos de la relación entre la presión parcial instantánea después del inicio teórico de la condensación, a su presión de vapor. Al punto de sobresaturación crítica donde se inicia la condensación fuera de equilibrio (formación de núcleos) se le llama, en términos de propiedades termodinámicas, el punto Wilson. La línea Wilson está definida por una serie de puntos Wilson obtenidos a diferentes condiciones de expansión y representa la desviación con respecto a la condición de equilibrio en el proceso de condensación. Esta línea fue determinada para iso-octano en este trabajo a bajas tasas de expansión, basada en una significativa cantidad de mediciones de presión, temperatura y diámetro de gotas (aerosol) durante procesos de expansión fuera de equilibrio en un recipiente para combustión mayormente bajo condiciones laminares y también turbulentas.

La determinación de propiedades para sustancias se realiza usando ecuaciones o gráficos obtenidos bajo condiciones de equilibrio termodinámico, sin embargo, muy pocos procesos reales ocurren en tales condiciones. En un proceso de expansión fuera del equilibrio, la condensación no comienza cuando se alcanza la saturación, este retraso se conoce como sobresaturación definiéndose en términos de la relación entre la presión parcial instantánea después del inicio teórico de la condensación, a su presión de vapor. Al punto de sobresaturación crítica donde se inicia la condensación fuera de equilibrio (formación de núcleos) se le llama, en términos de propiedades termodinámicas, el punto Wilson. La línea Wilson está definida por una serie de puntos Wilson obtenidos a diferentes condiciones de expansión y representa la desviación con respecto a la condición de equilibrio en el proceso de condensación. Esta línea fue determinada para iso-octano en este trabajo a bajas tasas de expansión, basada en una significativa cantidad de mediciones de presión, temperatura y diámetro de gotas (aerosol) durante procesos de expansión fuera de equilibrio en un recipiente para combustión mayormente bajo condiciones laminares y también turbulentas.

In March, France made a controversial move and became the first country in the world to explicitly ban research on individual judicial behaviour. It is now a criminal offence to ‘evaluate, analyse, compare or predict’ the behaviour of individual judges. The result is a flagrant violation of the freedom of expression, represents an affront to basic values of academic freedom, and disregards basic principles of the rule of law.

New Zealand's recent painful experience of health system reforms has shown that professional incentives are more powerful than market incentives, and that medical leadership, with accountability for both cost and quality, may be the key to success.

The New Zealand health system is undergoing a major paradigm shift. Services and programs have largely replaced hospitals and other institutions as the basic organizational framework, with each service having an epidemiologically defined responsibility for the provision of integrated personal and public health services for the population it serves. Primary health care as the infrastructure service is being implemented in some areas. These changes are being reinforced by the National Government's continuing reform process in which population-based and funded regional health authorities are purchasing all health services--primary, secondary, personal, public, acute and continuing--from a capitated and capped budget based on meeting the health needs of their populations.

The cost-effectiveness of treating mild-to-moderate hypertension (diastolic blood pressures, 90-114 mmHg) was evaluated using the latest available information on both costs and benefits. The net health care costs of lifelong treatment for hypertension, at a 5% discount rate, ranged from 1491 pounds to 2752 pounds in men and from 1568 pounds to 2850 pounds in women in New Zealand in 1988 (1.00 pounds = $NZ 2.81). These figures take into account the savings in health care costs arising from stroke prevention. The net health care benefits, measured in quality-adjusted life years (QALYs) discounted at 5%, ranged from--2 days (a net negative effect of treatment) to 64 days in men and from--18 days to 35 days in women. The cost-effectiveness of antihypertensive therapy discounted at 5% (excluding categories of patients for whom the ratio was undefined due to a net negative effect of treatment on QALYs) ranged from 11,058 pounds to 63,760 pounds per QALY gained in men and from 22,060 pounds to 194,989 pounds per QALY gained in women. Treatment was more cost-effective in men than in women, in older age groups and at higher levels of pretreatment diastolic blood pressure. The cost-effectiveness ratios were highly sensitive to the discount rate used (with the majority of ratios in women being undefined at a 10% discount rate) and the costs of the regimen used (diuretic monotherapy being the most cost-effective, followed by beta-blockers, then angiotensin-converting enzyme inhibitors), as well as to the assumptions made about the impact of medication side effects on patient quality of life. These results call for a re-examination of resource allocation to antihypertensive treatment and point to the need to make assessments of the cost-effectiveness of alternative, non-pharmacological approaches to stroke prevention.

Nine hundred and sixty-two postneonatal deaths for 1981-83 were matched to their birth registration forms. Deaths were divided into three categories, sudden infant death syndrome (SIDS) 65.4%, other preventable, 12.8%, and nonpreventable causes, 21.8%, to determine the rates of death as related to known and available risk factors. The risk factor profile for other preventable causes and SIDS was similar, the only exceptions being that other preventable causes showed no north-south gradient and had a higher incidence in the neonatal period (31.2% v 4.7% for SIDS). The most important risk factors for other preventable causes were found to be the mother being Maori (RR 4.35, CI 3.12-6.06), having a low birth weight infant (RR 3.56, CI 2.07-6.13) and being unmarried (RR 3.45, CI 2.47-4.82). These risk factors point to the possibility of selectively targeting of interventions both prenatally as well as postnatally for those who are at high risk.

Results from major clinical trials reported during the 1980s have led to renewed debate about the costs and benefits of treating mild to moderate hypertension. There is general agreement that existing cost-effectiveness analyses of antihypertensive therapy are outdated, and in need of reappraisal. Based on the pooled results of clinical trials, the benefits of treating mild to moderate hypertension [diastolic blood pressure (DBP) of 90-114 mm Hg] were re-examined. Using actuarial methods and estimates of health state utilities, the benefits of treatment were expressed in "quality-adjusted life years" (QALYs). After lifelong treatment for hypertension, the gain in QALYs ranged from 1.8 to 11.5 months in men and from 2.5 to 11.3 months in women. The cost-effectiveness ratios ranged from $30,200 per QALY gained (for 50-year-old men with DBP of 110 mm Hg) to $547,700 per QALY gained (for 30-year-old women with DBP of 110 mm Hg), in 1988 New Zealand dollars, discounted at 5%. In several categories of patients, the analysis suggested a net negative impact on QALYs, i.e., the adverse effects of drug treatment outweighed the benefits. These results have policy implications for both resource allocation and clinical practice.

A quantitative assessment of the benefits of pharmacological treatment of mild to moderate hypertension (diastolic blood pressure 90-114 mmHg) in patients aged 30-60 years was performed, based on the pooled results of nine major clinical trials. The benefits were expressed as added "quality-adjusted life-years" (QALYs), using life-table methods and utility valuations of health states. The expected gains in QALYs were found to be quite small, ranging from 2.3-11.4 months in males, and 1.4-7.6 months in females. Previous attempts to estimate the nature and magnitude of the benefits of antihypertensive therapy have all been based on extrapolations from epidemiological data, instead of on the actual achieved reductions in mortality and morbidity demonstrated in clinical trials. The former method considerably overestimates the potential direct benefits from drug treatment of mild to moderate hypertension.

In this exploratory study information gathered from 520 patients of eight doctors in a city group practice was analysed to identify the collective and separate contributions of selected patient and doctor factors to script cost variations. Results suggested that variance in cost and item numbers was directly related to diagnosis. A principal diagnosis of hypertension or diabetes/endocrine/hormonal problems, or a multiple of diagnoses was associated most with high cost scripts. Other patient conditions, such as gravity of illness, accounted for a much smaller but still significant variance. Although there were only minor differences between males and females, the older age groups in both sexes were over-represented in the higher item and cost categories. Which doctor the patient saw accounted only for approximately half a percent of the total variance, and this was non-significant. The results indicated that doctor prescribing behaviour was related rationally to patient diagnosis, and suggested that peer review, as practised by these doctors, was operating to reduce both variance between doctor factors and prescribing costs.

The Christchurch Health Planning and Research Unit was established in April 1975 to develop an approach to regional health services planning based upon researched community need, making the best use of available resources and involving agencies, health professionals and the community. This paper reports on the background to its establishment, the development of a planning strategy and progress and problems to date, especially in the fields of geriatrics, mental health and primary care.

A random national survey of 50 general practitioners was undertaken to ascertain current trends in the pharmacological management of hypertension. Forty general practitioners entered the study, and scripts written by them over a two month period in 1988 were collected and recorded by the pharmaceutical pricing offices of the health department. The general practitioners provided details on whether the script had been written for hypertension, as well as the age and sex of the patients. Information from 37 general practitioners was available for study, involving 2675 scripts written for hypertension for 1858 patients. Sixty point two percent of the treated hypertensives were female, and 58.9% were aged over 60 years. The most commonly prescribed antihypertensives were the diuretics (47.1% of patients) and beta blockers (47.9%). They were followed by angiotensin converting enzyme inhibitors (18.2%) and calcium antagonists (9.7%). There was substantial variability in the prescription of antihypertensives with respect to the age and sex of the patients treated; the mean costs and duration of supply of different generic drug types; and the prescribing habits of general practitioners. By generic type, the mean monthly costs of therapy ranged from $3.77 (diuretics) to $48.19 (calcium antagonists). The age and sex adjusted geometric mean script costs ranged from $17.78 to $49.11 per month (median: $29.30). It seems unlikely that the observed degree of variability is explained by differences in the severity of hypertension between general practice populations.

A service-based analysis of public sector health expenditure in North Canterbury is presented. The results indicate that the largest share of the $61 million spent by the North Canterbury Hospital Board and the Christchurch District Health Office in 1975-76 was devoted to primary health care, followed by mental health, surgery and medicine. The implications of this approach for the planning and development of health services are discussed and it is suggested that this provides a framework for setting priorities both within and between services.

Pharmaceutical benefit expenditure has grown rapidly and disproportionately in recent years to nearly 15% of Vote Health. Annual average increases in prescribed drugs of 3.1% by volume and of 6.9% in real prices have occurred since 1981. For the 1986/87 year volume and real price increases were 5.7% and 11.5% respectively, possibly due to the lifting of the price freeze and the effect of extending prescribing to three months from February 1985. Factors explaining these trends include the growth in numbers of general practitioners and the availability of new and more expensive drugs supported by promotional activities of pharmaceutical companies. There are almost no effective managerial, professional or educational strategies on the part of government to counter these influences. Pharmaceutical benefit expenditure and its growth is almost totally unmanaged and uncontrolled. With severe limits on government expenditure this growth could threaten other areas of health expenditure. Major changes are required in its management including a substantial part charge to the user, decentralisation to area health boards of primary health care services and funding, and professional mechanisms for better prescribing, supported by national policies for a comprehensive, computerised pharmaceutical and primary health care information system.

This paper reports on a study of the patients and the services provided by the Nurse Maude District Nursing Association in Christchurch. The 1149 recipients were predominantly elderly, 80.8% being over 65, 68.8% female and long term patients with musculoskeletal disorders comprising more than one-third of the principal diagnoses. Services were provided to 26 per 1000 of the elderly population, which is close to suggested guidelines. This rate increased markedly with age. Ten percent of patients utilised 40% of the nursing time. They may be considered as borderline cases for whom community care with community support services was an acceptable and efficient alternative to long term hospital care.

New Zealand is in the process of implementing major changes in the organisation and funding of its health services. Central to these changes is a largely elected area health board responsible for the funding and coordination of all services for a defined population, both public as well as non-government. Four different models of decentralisation, deconcentration (administrative), devolution (political), corporatisation (functional) and privatisation (non-government), have been used to describe and analyse these changes. There is expected to be a major devolution of powers to area health boards from central government, reversing the centralising tendencies which have occurred over the past century. Within boards a pluralistic system of service management, incorporating the above models of decentralisation, is being implemented to replace the present system of institutional administration and to give greater decision-making responsibility to health professionals, non-government agencies and community groups. These initiatives are associated with population-based funding of hospital boards complemented by service planning guidelines. Of particular importance has been the recent government decision to place the funding and management of primary health care under area health boards. However, there are serious concerns as to whether such radical changes, which could put New Zealand ahead of the rest of the world in achieving an integrated health system, can be implemented given the management expertise needed.

The development of a wider range of service alternatives for the care of the intellectually handicapped (IH) has led to the establishment of multiple agencies in the field of service provision. A multi-agency, multi-disciplinary working party has undertaken a survey of all IH persons in the area, including an assessment of problems in service provision. There were a total of 2330 IH persons in the area. The prevalence rate for North Canterbury is 3.94 per 1000 which is substantially higher than the New Zealand figure of 3.29 of a previous survey. The working party has sponsored communication and mutual understanding and support through workshops, the formation of a parents committee and an information exchange system.

The rising cost of treating hypertension has become an issue of concern in several countries, including the United States, parts of Europe, and more recently, New Zealand. In New Zealand between 1981 and 1987, the total inflation-adjusted expenditure on antihypertensive drugs increased by 61.7%, from $21.4 million to $34.6 million in constant 1981 dollars. The major part (56.3%) of this increase in overall expenditure was explained by the rise in real cost of drug treatment, while the number of patients on drug therapy remained virtually static over the same period. The average cost of a prescription for hypertension was estimated to have risen by 46.1% between 1981 and 1987, i.e. from $7.30 to $10.66 in constant 1981 dollars. Pardoxically the mean inflation-adjusted price of antihypertensive drugs fell by 10.8% over the same period. Changing patterns of prescription and the entry of new drugs into the market accounted for most of the rise in average cost per prescription over the study period. Unless the rising expenditure can be justified by demonstrable improvements in treatment outcome, continuation of these trends will have profound effects on the cost-effectiveness of antihypertensive therapy.