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To assess whether multifocal, high-frequency repetitive transcranial magnetic stimulation (rTMS) of motor and prefrontal cortex benefits motor and mood symptoms in patients with Parkinson disease (PD).Patients with PD and depression were enrolled in this multicenter, double-blind, sham-controlled, parallel-group study of real or realistic (electric) sham rTMS. Patients were randomized to 1 of 4 groups: bilateral M1 ( + sham dorsolateral prefrontal cortex [DLPFC]), DLPFC ( + sham M1), M1 + DLPFC, or double sham. The TMS course consisted of 10 daily sessions of 2,000 stimuli for the left DLPFC and 1,000 stimuli for each M1 (50 × 4-second trains of 40 stimuli at 10 Hz). Patients were evaluated at baseline, at 1 week, and at 1, 3, and 6 months after treatment. Primary endpoints were changes in motor function assessed with the Unified Parkinson's Disease Rating Scale-III and in mood with the Hamilton Depression Rating Scale at 1 month.Of the 160 patients planned for recruitment, 85 were screened, 61 were randomized, and 50 completed all study visits. Real M1 rTMS resulted in greater improvement in motor function than sham at the primary endpoint (p0.05). There was no improvement in mood in the DLPFC group compared to the double-sham group, as well as no benefit to combining M1 and DLPFC stimulation for either motor or mood symptoms.In patients with PD with depression, M1 rTMS is an effective treatment of motor symptoms, while mood benefit after 2 weeks of DLPFC rTMS is not better than sham. Targeting both M1 and DLPFC in each rTMS session showed no evidence of synergistic effects.NCT01080794.This study provides Class I evidence that in patients with PD with depression, M1 rTMS leads to improvement in motor function while DLPFC rTMS does not lead to improvement in depression compared to sham rTMS.

Background— Primary aldosteronism (PA) is a common and underdiagnosed disease with significant morbidity potentially cured by surgery. We aim to assess if the long-term cardiovascular benefits of identifying and treating surgically correctable PA outweigh the upfront increased costs in patients at the time patients are diagnosed with resistant hypertension (RH). Methods and Results— A decision-analytic model compares aggregate costs and systolic blood pressure changes of 6 recommended or implemented diagnostic strategies for PA in a simulated population of at-risk RH patients. We also evaluate a 7th “treat all” strategy wherein all patients with RH are treated with a mineralocorticoid-receptor antagonist without further testing at RH diagnosis. Changes in systolic blood pressure are subsequently converted into gains in quality-adjusted life years (QALYs) by applying National Health and Nutrition Examination Survey data on concomitant risk factors to an existing cardiovascular disease simulation model. QALYs and lifetime costs were then used to calculate incremental cost-effectiveness ratios for the competing strategies. The incremental cost-effectiveness ratio for the strategy of computerized tomography (CT) followed by adrenal venous sampling (AVS) was $82 000/QALY compared with treat all. Incremental cost-effectiveness ratios for CT alone and AVS alone were $200 000/QALY and $492 000/QALY; the other strategies were more costly and less effective. Integrating differential patient-reported health-related quality of life adjustments for patients with PA, and incremental cost-effectiveness ratios for screening patients with CT followed by AVS, CT alone, and AVS alone were $52 000/QALY, $114 000/QALY, and $269 000/QALY gained. Conclusions— CT scanning followed by AVS was a cost-effective strategy to screen for PA among patients with RH.

Background— Early detection and treatment of cardiovascular disease (CVD) risk factors produces significant clinical benefits, but no consensus exists on optimal screening algorithms. This study aimed to evaluate the comparative and cost-effectiveness of staged laboratory-based and non–laboratory-based total CVD risk assessment. Methods and Results— We used receiver operating characteristic curve and cost-effectiveness modeling methods to compare strategies with and without laboratory components and used single-stage and multistage algorithms, including approaches based on Framingham risk scores (laboratory-based assessments for all individuals). Analyses were conducted using data from 5998 adults in the Third National Health and Nutrition Examination Survey without history of CVD using 10-year CVD death as the main outcome. A microsimulation model projected lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios for 60 Framingham-based, non–laboratory-based, and staged screening approaches. Across strategies, the area under the receiver operating characteristic curve was 0.774 to 0.780 in men and 0.812 to 0.834 in women. There were no statistically significant differences in area under the receiver operating characteristic curve between multistage and Framingham-based approaches. In cost-effectiveness analyses, multistage strategies had incremental cost-effectiveness ratios of $52 000/QALY and $83 000/QALY for men and women, respectively. Single-stage/Framingham-based strategies were dominated (higher cost and lower QALYs) or had unattractive incremental cost-effectiveness ratios (>$300 000/QALY) compared with single-stage/non–laboratory-based and multistage approaches. Conclusions— Non–laboratory-based CVD risk assessment can be useful in primary CVD prevention as a substitute for laboratory-based assessments or as the initial component of a multistage approach. Cost-effective multistage screening strategies could avoid 25% to 75% of laboratory testing used in CVD risk screening with predictive power comparable with Framingham risks.

Cost-effectiveness analysis of a randomized plus observational cohort trial.Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH).Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain.Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year.Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088).Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.

India has more than 5.7 million people infected with human immunodeficiency virus (HIV). In 2004, the Indian government began providing antiretroviral therapy (ART), and there are now an estimated 56 500 people receiving ART.To project the life expectancy, cost, and cost-effectiveness associated with different strategies for using ART in India, to inform treatment programs.We utilized an HIV disease simulation model, incorporating data on natural history, treatment efficacy, and costs of care from India. Input parameters for the simulated cohort included mean age 32.6 years and mean CD4 count 318 cells/microl (SD 291 cells/microl). We examined different criteria for starting and stopping ART with a first-line regimen of stavudine/lamivudine/nevirapine, and the impact of a second-line protease-inhibitor-based regimen. Cost-effectiveness in US dollars per year of life saved (US$/YLS) was compared incrementally among alternative starting, sequencing, and stopping criteria.Discounted (undiscounted) mean survival ranged from 34.5 (37.5) months with no ART to 64.7 (73.6) months with one line of therapy initiated at CD4350 cells/microl, to 88.9 (106.5) months with two lines of therapy initiated at CD4350 cells/microl. Lifetime medical costs ranged from US$530 (no ART) to US$5430 (two ART regimens) per person. With one line of therapy, the incremental cost-effectiveness ratios ranged from US$430/YLS to US$550/YLS as the CD4 starting criterion was increased from CD4250 cells/microl to350 cells/microl. Use of two lines of therapy had an incremental cost-effectiveness ratio of US$1880/YLS compared with the use of first-line therapy alone. Results were sensitive to the costs of second-line therapy and criteria for stopping therapy.In India, antiretroviral therapy will lead to major survival benefits and is cost-effective by World Health Organization criteria. The availability of second-line regimens will further increase survival, but their cost-effectiveness depends on their relative cost compared with first-line regimens.

Adherence to antiretroviral medications has been shown to be an important factor in predicting viral suppression and clinical outcomes. The objective of this analysis was to assess the cost-effectiveness of a nursing intervention on antiretroviral adherence using data from a randomized controlled clinical trial as input to a computer-based simulation model of HIV disease. For a cohort of HIV-infected patients similar to those in the clinical trial (mean initial CD4 count of 319 cells/mm 3 ), implementing the nursing intervention in addition to standard care yielded a 63% increase in virologic suppression at 48 weeks. This produced increases in expected survival (from 94.5 to 100.9 quality-adjusted life months) and estimated discounted direct lifetime medical costs ($253,800 to $261,300). The incremental cost-effectiveness ratio for the intervention was $14,100 per quality-adjusted life year gained compared with standard care. Adherence interventions with modest effectiveness are likely to provide long-term survival benefit to patients and to be cost-effective compared with other uses of HIV care funds.

Background— Hypertension is responsible for more deaths worldwide than any other cardiovascular risk factor. Guidelines based on blood pressure level for initiation of treatment of hypertension may be too costly compared with an approach based on absolute cardiovascular disease (CVD) risk, especially in developing countries. Methods and Results— Using a Markov CVD model, we compared 6 strategies for initiation of drug treatment—2 different blood pressure levels (160/95 and 140/90 mm Hg) and 4 different levels of absolute CVD risk over 10 years (40%, 30%, 20%, and 15%)—with one of no treatment. We modeled a hypothetical cohort of all adults without CVD in South Africa, a multiethnic developing country, over 10 years. The incremental cost-effectiveness ratios for treating those with 10-year absolute risk for CVD >40%, 30%, 20%, and 15% were $700, $1600, $4900, and $11 000 per quality-adjusted life-year gained, respectively. Strategies based on a target blood pressure level were both more expensive and less effective than treatment decisions based on the strategy that used absolute CVD risk of >15%. Sensitivity analysis of cost of treatments, prevalence estimates of risk factors, and benefits expected from treatment did not change the ranking of the strategies. Conclusions— In South Africa, current guidelines based on blood pressure levels are both more expensive and less effective than guidelines based on absolute risk of cardiovascular disease. The use of quantitative risk-based guidelines for treatment of hypertension could free up major resources for other pressing needs, especially in developing countries. (Circulation. 2005;112:3569-3576.)

In 2000, WHO/UNAIDS recommended co-trimoxazole prophylaxis for persons at early stages of HIV infection (WHO stageor = 2) in sub-Saharan Africa.To assess the cost-effectiveness of alternative strategies for initiation of co-trimoxazole in Côte d'Ivoire.Cost-effectiveness analysis with an HIV simulation model using clinical and cost data from a randomized trial of co-trimoxazole in HIV-infected adults.The study included HIV-infected patients in Côte d'Ivoire, with median age 33 years. Thirty-four percent were classified as WHO stage 2, 59% as stage 3, and 7% as stage 4. The mean CD4 cell count was 331 x 10(6) cells/l. The interventions were no prophylaxis, clinical criteria-based co-trimoxazole initiation (early: WHO stageor = 2; late: WHO stageor = 3), CD4-based co-trimoxazole initiation (500,200,50 x 10(6) CD4 cells/l). The outcome measures were life expectancy, lifetime costs, and incremental cost-effectiveness.The most effective strategy, initiation of co-trimoxazole prophylaxis at WHO stageor = 2, increased undiscounted life expectancy by 5.2 months, discounted life expectancy by 4.4 months, and lifetime costs by US dollars 60, compared with no prophylaxis. Delaying prophylaxis initiation until WHO stageor = 3 was less costly and less effective. All CD4-based strategies were dominated. The incremental cost-effectiveness of early versus late co-trimoxazole prophylaxis initiation was US dollars 200/year of life gained. Results were stable despite wide variations in plausible assumptions about bacterial resistance and the prophylaxis efficacy on co-trimoxazole-resistant strains.For HIV-infected adults in Côte d'Ivoire, co-trimoxazole prophylaxis is reasonably cost-effective and most effective if initiated when WHO stageor = 2. Early co-trimoxazole prophylaxis will prevent complications prior to antiretroviral therapy initiation and should be considered an essential component of care for early HIV in sub-Saharan Africa.

The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical.The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests.We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs.Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs.Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.

BACKGROUND: Although there are nearly a quarter of a million hospitalizations for traumatic brain injury (TBI) in the United States each year, data on the outcomes and costs of TBI treatment in the acute-care setting are limited. METHODS: Using a large, geographically diverse, multihospital database, we examined inpatient records for persons aged 16 years or older who were hospitalized for TBI between January 1, 1997, and June 30, 1999. Patients were stratified by TBI severity using an adaptation of the Abbreviated Injury Scale for administrative data (ICD/AIS), as follows: 2 = "moderate"; 3 = "serious"; 4 = "severe"; and 5 = "critical." Patient characteristics, patterns of treatment, and outcomes and costs were examined by injury severity and mechanism of injury. RESULTS: Of 8,717 study subjects identified, 12.5% had moderate, 44.8% had serious, 29.6% had severe, and 13.2% had critical TBI. Falls were the most common reported cause of injury (40.8%), followed by motor vehicle crashes (39.3%), blows to the head (11.3%), and gunshot wounds (2.4%). Average length of stay in hospital ranged from 6.7 days for moderate TBI to 17.5 days for critical TBI. The overall rate of death in hospital was relatively low among patients with moderate (1.3%), serious (5.7%), and severe (8.7%) TBIs, but much higher among the most critically injured patients (52.0%). Costs of hospitalization averaged 8,189 dollars for moderate, 14,603 dollars for serious, 16,788 dollars for severe, and 33,537 dollars for critical TBI. Costs also varied by injury type, averaging 20,084 dollars for gunshot wounds, 20,522 dollars for motor vehicle crashes, 15,860 dollars for falls, and 19,949 dollars for blows to the head. CONCLUSION: The economic burden of TBI in the acute-care setting is substantial; treatment outcomes and costs vary considerably by TBI severity and mechanism of injury.

With limited data available on the optimal treatment of primary HIV infection, disease modeling can be used to project clinical outcomes and inform decision makers. The authors developed a simulation model to evaluate the clinical outcomes and life expectancy projections for three primary HIV infection treatment strategies: 1) continuous antiretroviral therapy (ART) initiated at CD4 count

Objectives To determine the net health consequences, costs, and cost-effectiveness of alternative delivery strategies for HIV-infected pregnant women with detectable HIV RNA in the USA. Design Cost-effectiveness analysis using a probabilistic decision model. Methods The model compared two strategies: elective Cesarean section and vaginal delivery. Data for HIV transmission rate, maternal death rate, health-related quality of life and costs were obtained from the literature, national databases, and a tertiary hospital's cost accounting system. Model outcomes included total lifetime costs, quality-adjusted life expectancy, maternal death rate, HIV transmission rate, and incremental cost-effectiveness ratios. Results Elective Cesarean section resulted in a vertical HIV transmission rate of 34.9 per 1000 births compared with 62.3 per 1000 births for vaginal delivery. Elective Cesarean section was more effective (38.7 quality adjusted life years per mother and child pair) and less costly ($10600 per delivery) than trial of labor (38.2 combined quality adjusted life years at a cost of $14500 per delivery). However, elective Cesarean section increased maternal mortality by 2.4 deaths per 100000 deliveries. The results were consistent over a wide range of the variables, but were sensitive to the risk of HIV transmission with vaginal delivery and the relative risk of HIV transmission with elective Cesarean section. Conclusions In pregnant HIV-infected women with detectable HIV RNA, elective Cesarean section would reduce total costs and increase overall quality-adjusted life expectancy for the mother-child pair, albeit at a slight loss of quality adjusted life expectancy to the mother.

Objectives. Although the broad impacts of Alzheimer's disease (AD) are increasingly recognized, little work has focused on the overall health-related quality of life experienced by Alzheimer's disease patients and their caregivers. The study had two main objectives: (1) to test the feasibility of measuring health utilities in Alzheimer's disease with a generic preference-weighted instrument using proxy respondents and (2) to assess the utility scores of Alzheimer's disease patients (and their caregivers) in different disease stages and care setting. Methods. A cross-sectional study of 679 Alzheimer's disease patient/caregiver pairs was conducted at 13 sites in the United States: four academic medical centers, four managed care plans, two assisted living facilities, and three nursing homes. The Health Utilities Index Mark II (HUI:2) questionnaire was administered to caregivers of patients who responded both as proxies for patients and for themselves. Responses to the questionnaire were converted into a global utility score, between 0 and 1, using the HUI:2 multi-attribute utility function. Results. Global utility scores varied considerably across patients' Alzheimer's disease stage: for the six stages assessed (questionable, mild, moderate, severe, profound, and terminal), mean utility scores were 0.73, 0.69, 0.53, 0.38, 0.27, and 0.14, respectively. In multiple regression analyses, Alzheimer's disease stage was a negative and significant predictor of utility scores for patients; setting did not exert an independent effect. Utility scores for the caregivers were insensitive to patients' Alzheimer's disease stage and setting. Conclusions. Patients' Alzheimer's disease stage had a substantial influence on health utilities, as measured by the HUI:2. More research is needed to assess the validity of using proxy respondents.

for coverage recommendations to the National Health Service 2 ; some observers have inferred that explicit criteria such as £30,000 per QALY may be used to guide these recommendations. 3 The World Health Organization has proposed that developing countries might use a cost-per-QALY threshold of 3 times the per-capita gross domestic product to guide their health care resource allocations. 4 Despite widespread use elsewhere in the world, cost-effectiveness analysis has gained only limited traction in the United States as an explicit guide to clinical practice, insurance coverage, and policy decisions. It seems that Americans do not have the inclination to focus on the fact that even in the wealthiest country in the world, resources are limited, and not all beneficial health services can be provided to everyone who might potentially benefit from them. Rationing among health services occurs largely by default and not by design. In the United States, cost per QALY is sometimes cited as part of the justification for guidelines for clinical practice or preventive services, and a decade ago a panel was convened by the US Public Health Service to provide guidance to practitioners of cost-effectiveness analysis. 5 However, despite the attention given to cost-effectiveness analysis in medical journals, The Centers for Medicare and Medicaid Services have avoided explicit use of cost-effectiveness criteria in coverage decisions, and it is unclear to what degree cost-effectiveness is used to guide coverage decisions in the private sector. 6 Because cost per QALY is not used in any systematic or consistent way in the United States, it should not be surprising that there is no consensus as to the appropriate value of cost per QALY that should guide health care decisions and policies. The number $50,000 per QALY has become a mythical benchmark for cost per QALY in this country, although it is impossible to trace its origins. Some authors of cost-effectiveness studies refer to this number when reporting subgroup analyses or sensitivity analyses 7 ; these kinds of statements should not be interpreted as endorsements of a $50,000 per QALY threshold, but rather as a convenient way of representing the conclusion that the intervention in question is good value for money even under pessimistic assumptions. With that interpretation, the reference to the $50,000 threshold could be interpreted as an implied lower bound on the value of a QALY. Braithwaite et al, in this issue of Medical Care, 8 set out to deduce lower and upper bounds on the value Americans place on quality-adjusted life years by analyzing the implications of aggregate decisions that citizens of this country have made—to pay for the increase in the cost of medical care services since 1950; or have not made—to insure the uninsured. They argue that because the gains in life expectancy since 1950 have been bought at an estimated average cost of $183,000 per year of life expectancy gained, on average Americans must be willing to pay at least that much for a year of life. When optimistic imputations of quality of life gains are also considered, the implied lower bound on the value of a QALY drops to $109,000. The number drops below $100,000 when they

OBJECTIVES For contingent valuation to provide valid values for policy making, it is important that respondents be well informed about the goods they are asked to value. Few studies, however, have tested the impact of providing this information This study assessed the impact of risk information on patients' willingness to pay for autologous blood donation and derived the willingness to pay in a sample of informed patients. METHODS Patients were randomized either to receive information about the risks of complications from allogeneic (volunteer) blood transfusions or to base their willingness to pay responses on their own prior knowledge. Four hundred twelve autologous blood donors were recruited from three study sites. Self-administered questionnaires collected information on willingness to pay, risk perceptions, and socioeconomic information. RESULTS As predicted by our theoretical model, providing risk information reduced the variance in the willingness to pay for autologous blood donation. A tendency for information to reduce the willingness to pay was also found, suggesting that uninformed patients, on average, overestimate the risks of allogeneic blood transfusions. The median willingness to pay in the informed sample was approximately $750 to $1,100, depending on the estimation method, compared with $800 to $1,900 in the uninformed group. Willingness to pay was significantly related to perceived transfusion risk, personal income, and dread of transfusions. CONCLUSIONS Our results are consistent with an economic model where individuals update their prior risk perceptions with new information. The willingness to pay in the informed sample was far higher than the costs of autologous blood donation, suggesting that total benefits outweigh the costs of the procedure.

OBJECTIVES. Evidence in the literature suggests that the overall correlation between descriptive and valuational measures of health are weak to moderate. In this study, the relationship between descriptive health status measures, obtained using the Short-Form 36, and health values, measured with the time tradeoff, was explored. METHODS. Two groups of patients matched for age and gender were interviewed. One group comprised 139 human immunodeficiency virus (HIV)-infected patients; the other group comprised 124 primary care patients. The relationship between the SF-36 and the time tradeoff was estimated, assuming homogeneity across patients, using multiple regression analysis. Subsequently, the relationship was examined assuming heterogeneity across patients and using the expectation maximization algorithm in a maximum likelihood context (latent class analysis). RESULTS. Four classes, representing 47%, 13%, 8%, and 32% of the population, respectively, were found. The overall percentage of variation explained under the assumption of a homogeneous relationship was only 33% as compared with 85% when heterogeneity was accounted for. Only three characteristics (educational level, employment status, and the SF-36 social functioning score) sufficed to generate a nearly perfect classification of the patients. CONCLUSIONS. Heterogeneity across subjects should be taken into account in describing the relationship between health values and health status dimensions. Key words: health status measure; health utility measure; latent class analysis; heterogeneity. (Med Care 1998;36:523-532)

BACKGROUND A broad, scientific consensus supports the role of cholesterol as a risk factor for coronary heart disease and agrees that lowering cholesterol levels will reduce coronary heart disease incidence. Cost-effectiveness analysis is a potentially powerful method for measuring the benefits to be achieved by expenditures of health care dollars. METHODS AND RESULTS The literature related to the effectiveness and cost-effectiveness of cholesterol lowering was reviewed. Application of cost-effectiveness methodology to the question of cholesterol reduction generally supports the use of population-wide educational programs and the aggressive use of cholesterol-lowering therapy for the secondary prevention of subsequent coronary events in persons with preexisting coronary heart disease. For primary prevention, however, therapy with medication has a favorable cost-effectiveness ratio only in identifiable high-risk persons, and the different costs of the various available medications should be taken into account. Therapy with medications, especially for primary prevention, would be more appealing if the price of the available medications were lower. CONCLUSIONS High priority should be given to research that could validate these cost-effectiveness projections as well as to further studies of the elderly and women, in whom direct data on the precise costs, risks, and benefits of interventions to lower cholesterol remain sparse.

We compared the screening accuracy of a short, five-item version of the Mental Health Inventory (MHI-5) with that of the 18-item MHI, the 30-item version of the General Health Questionnaire (GHQ-30), and a 28-item Somatic Symptom Inventory (SSI-28). Subjects were newly enrolled members of a health maintenance organization (HMO), and the criterion diagnoses were those found through use of the Diagnostic Interview Schedule (DIS) in a stratified sample of respondents to an initial, mailed GHQ. To compare questionnaires, we used receiver operating characteristic analysis, comparing areas under curves through the method of Hanley and McNeil. The MHI-5 was as good as the MHI-18 and the GHQ-30, and better than the SSI-28, for detecting most significant DIS disorders, including major depression, affective disorders generally, and anxiety disorders. Areas under curve for the MHI-5 ranged from 0.739 (for anxiety disorders) to 0.892 (for major depression). Single items from the MHI also performed well. In this population, short screening questionnaires, and even single items, may detect the majority of people with DIS disorders while incurring acceptably low false-positive rates. Perhaps such extremely short questionnaires could more commonly reach use in actual practice than the longer versions have so far, permitting earlier assessment and more appropriate treatment of psychiatrically troubled patients in primary care settings.

PURPOSE The purpose of this study was to present a case of optic nerve pit maculopathy and reappraise the previous concepts regarding the pathways of the fluid and the development. METHODS A 24-year-old man had an optic nerve pit maculopathy. The visual acuity was 20/50 in the affected eye. Optical coherence tomography showed a multilayered separation of the neurosensory retina, serous retinal detachment, and the optic nerve pit with no membrane on the optic nerve. After 2 months of observations, surgery was performed. RESULTS Surgery included vitrectomy, the separation of the posterior hyaloid, the internal limiting membrane peeling, and gas tamponade. No laser was performed. The vision improved to 20/20, and optical coherence tomography demonstrated that the inner retinal layer separation was resolved except for the ganglion cell layer connected to the optic nerve pit, and subretinal fluid was increased 1 month after surgery. Eventually, the retinal layer separation and the subretinal fluid were resolved completely. CONCLUSIONS Vitrectomy with internal limiting membrane peeling and gas tamponade without any additional laser photocoagulation seems to be sufficient for the treatment. Our observations suggest that the fluid can move directly from the optic pit into multiple layers, and fluid emanating from the optic nerve pit still extended even after surgery.