Any new technology that promises significant costs as well as potential benefits generates considerable interest. Such innovations bring into bold relief the fundamental problem of achieving maximal medical benefits while efficiently and equitably allocating scarce resources (II). Two tools that decision makers can use to assess the benefits and costs of implementing new technologies are cost- benefit analysis (CBA) and cost-effectiveness analysis (CEA). One technology that seems especially appropriate for the application of CBA and CEA is nuclear magnetic resonance (NMR) imaging.

When a National Health System was established in Cuba and the health services regionalized, three levels of increasing complexity were established for prenatal care. This led to the use throughout the country of a system for the classification of pregnant women according to risk.

The first system used in 1969 was a qualitative system which divided pregnant women into 4 risk groups. This made it possible to establish levels and standards of care, to supervise and control the quality of prenatal care, and to use nurse-midwives for providing prenatal care efficiently. This very expeditious and practical system seemed somewhat inadequate because it gave little attention to biological and social factors, but stressed the complications of pregnancy and concomitant diseases.

Beginning in 1975, another system was used throughout the country to classify pregnant women during prenatal care. In this quantitative risk classification, an arbitrary value was given to each risk factor, and when these values were added up, the final score made it possible to divide pregnant women into 4 risk categories. This new system was also used for the administration of maternal and child health, but its use resulted in too many pregnant women being put into the high-risk category and many protective measures being taken for pregnant women who possibly did not need them. Validation tests such as sensitivity, specificity, and predictive power were used in this system, and it was found that it suffered from problems in discriminating the risk groups.

The need for a system of classifying pregnant women according to risk led to an epidemiological study whose purpose was to give a more appropriate numerical value to each risk factor. It is also emphasized that the objectives of prenatal care include not only the preventive treatment of diseases of women and children, but also the preparation of women for delivery, encouragement of breast feeding, and preparation of couples for assuming their responsibility as parents.

For patients who have had the misfortune to develop terminal renal failure, three basic modes of treatment can be offered. One is renal transplantation, with a graft taken from either a living or a cadaveric donor. When successful, it offers the best quality of life and treatment for patients with end-stage kidney disease. However, the elderly and those with severe cardiovascular or systemic complications are not always suitable candidates for renal transplantation (1).

Although a relative latecomer in the industrialization process, Japan has managed to catch up with the more advanced nations and become a major competitor in the international marketplace for goods and services. As a result of their excellent economic performance and rapid technological development, the Japanese people enjoy a level of general well-being that is among the highest in the world. This is especially true with respect to health status. In terms of most commonly accepted indicators, Japan compares quite favorably with other industrial nations. Indeed, the life expectancy for males of 74.20 years and that for females of 79.78 years in 1984 were the highest in the world.

The field of perinatal medicine has been experiencing dramatic changes recently, mostly due to technological breakthroughs in antepartum and intrapartum care. Concomitantly, a substantial decline in perinatal morbidity and mortality has been observed. Whether these two phenomena are causally related has yet to be demonstrated. In fact, a recent report has suggested that this may not be the case (18).

That new health technologies often diffuse into the health care systems of developed countries without adequate evaluation has long been a cause of concern (I). In addition, where clinical or economic assessments have been carried out, they often contain methodological weaknesses which reduce their usefulness to health policy makers or clinical practitioners (5,6).

The kidneys are the body's main organs of excretion. They are, however, subject to serious, progressive, and irreversible deterioration, and as a result, to a decreased ability to extract poisonous wastes and excess fluids from the blood. Almost invariably, this condition proceeds to the point where it is termed end-stage renal failure (ESRF). As the name suggests, ESRF is fatal.

Economic appraisals of health care come in various forms and tackle different questions. A treatment is worth providing, in economic terms, if the benefits it produces outweigh the costs of provision. New treatments and methods of delivery should be substituted for old ones if they allow more patients to be treated for the same cost, or the same patients at less cost. These are the basic issues which cost benefit and cost-effectiveness analyses address.

Tom Halper is not the only American who has been looking at the rationing of renal replacement therapy in the United Kingdom. All are appalled at the denial of effective lifesaving therapy to elderly and high-risk patients, such as diabetics, with end stage renal failure (1). Some realize that the rationing practiced in the United Kingdom today may have to be applied in other countries tomorrow (2). Medical resources are not unlimited (3).

The purpose of this paper is to outline some of the key methodologic issues in designing clinical trials to assess the cost-effectiveness of clinical magnetic resonance imaging (MRI). Because the possible objectives of such trials are so diverse, and the appropriate methodologies correspondingly numerous, no attempt is made to identify a single objective or methodology as appropriate. Rather, this paper should be read as an “options paper,” in which alternative formulations of objectives, outcome measures, study design, and protocol instrumentation are reviewed, with critical discussion of their theoretical strengths and weaknesses, as well as their practical implementability.

This essay traces the evolution in France of a clinical research program to perfect an artifical parenteral nutrition device which would be well tolerated by the patient, an ambulatory system which could eventually be used at home. It began in 1970, when we were struck by the number of patients being treated in hospitals for denutrition and the length of time required to reestablish nutritional equilibrium. Moreover, the denutrition of these patients retarded their oncological therapy. Our main goal was home nutrition. Adequate nutrition should be viewed as an adjunct therapy and since people generally eat at home, why not artifical nutrition at home?

As critics such as Thomas McKeown (12) have pointed out, Western medicine is concerned firstly with the promotion of medical care and only secondarily with the promotion of health care. Medical care and health care are not necessarily the same thing. There are ways of caring for people's health which do not involve medical examinations, procedures, and drugs—they involve such activities as health education, preventive health care, self-help, and community support. However, since these alternative routes to health mostly lie outside the theory and practice of professional medical care provision, their impact on health and illness is largely unexamined.

That the United Kingdom has comparatively low figures for acceptance of patients over the age of 55 for renal replacement therapy is remarkable, because, on a comparative basis, the United Kingdom is not a poor country and many U.K. nephrologists were pioneers in the technical and medical development of he-modialysis. While most nephrologists in the United Kingdom agree that age per se is not a valid criterion to be used for excluding patients, the “hard” use of age as a rigid line demarcating those to be treated from those to be denied treatment predominates. Professor Halper has made a very thorough analysis of which factors at the macroallocative as well as the microallocative level are responsible for this. It would have been of interest to know how the health system in the United Kingdom deals with other categories of elderly, severely ill patients (e.g., patients with malignant diseases), for whom immediate surgery may be life-saving, but the long-term prognosis is questionable. Are such patients also denied treatment in the United Kingdom because of age?

As in all European countries, Germany's public health service expenditures have climbed significantly over the last few years, outstripping increases in GNP and cost of living increases. A detailed analysis of this development shows hospitals to be the sector where costs are escalating the most rapidly.

Pregnancy care is undergoing an evolution. The trend toward professional control and technological intervention begun decades ago is under challenge by some women's groups and health professionals, who seek to make the pregnant woman herself the locus of control. In the same period, a developing literature concerning the relation of health to psychological and social factors has demonstrated their importance (3) and raised the issue of the place of social support and social action in health care (24).

Magnetic resonance (MR) undoubtedly constitutes a major technological advance, but as yet we do not know whether this invention also represents a breakthrough from the clinician's point of view.

Guyatt and Drummond suggest that the clinical value of MR is tested by means of a randomized clinical trial (RCT) in a well-defined and limited clinical area, and I fully agree with the authors that the use of such trials should not be confined to the testing of new treatments. In this particular field, however, I miss a discussion of alternative options. With few exceptions, new drugs can only be tested satisfactorily by means of an RCT, but the superiority of one imaging technique over another can sometimes be proved in other ways. Imagine, for instance, that the CT-scan is normal but that MR reveals a space-occupying lesion, the presence of which is confirmed by surgical operation or an autopsy. In that case the diagnostic superiority of MR has been proved in that particular patient. If such cases are seen frequently, and if it is known from controlled therapeutic trials that they are susceptible to treatment, then the value of MR has been proved without doing an RCT.

In the last decade, the incidence of mortality caused by malignant disease has risen. Cancer related deaths are more frequent than those caused by infections or accidents, exceeded only by heart and vascular diseases. In most cases, it is not the primary tumor that kills patients, but its metastatic spread: metastases have a fatal outcome more than 90% of cases (1). By the time metastases have occurred, cure is rarely obtained through surgical procedures. Local radiotherapy to distant metastases is also rarely successful in the treatment of disseminated malignancies. Most patients with metastatic disease need a palliative systemic treatment, which means cytotoxic cancer chemotherapy. Its objective is to destroy cancer cells. Systemic chemotherapy has become standard in the last decades for most disseminated malignancies (1).

Ceará occupies an area of 146,817 km2 in northeastern Brazil, where the climate is tropical and there are only two seasons, rainy and dry. Frequent droughts have serious consequences for subsistence farming, resulting in precarious living conditions for the rural inhabitants. In the absence of any industry to provide employment for labor, low incomes prevail, with 90% of the population receiving incomes below the minimum wage for farm workers (9).

The term orthopedics was introduced in 1741 by Nicolas André in Paris for “the Art of Prevention and Correction of Deformities in Children” and for 200 years orthopedic institutions were mainly concerned with locomotor problems in children and young adults. After World War II, however, the majority of orthopedic patients were not children. Devas (6) has coined the expression “geriatric orthopedics”, a semantic contradiction which highlights that we now face an increasing volume of elderly patients in whom the locomotor system causes severe problems. For example, in my own institution an orthopedic wing built in 1928 contained 135 beds, the majority of which were occupied by children. Today 10 beds suffice for our orthopedic children. Half of all orthopedic beds in Sweden are used for hip surgery in the very old.

The first successful demonstration of the phenomenon of nuclear magnetic resonance (NMR), or nuclear induction in solids and liquids, was published almost simultaneously in 1946 by Bloch, Hansen, and Packard (7) working at Stanford University and Purcell, Torrey, and Pound (75) working at Harvard University. The immediate impact of their work was in physics and chemistry, but the applications have steadily widened and recently the application of NMR in medicine has become very exciting.