Treatment of multiple sclerosis with interferon beta: an appraisal of cost-effectiveness and quality of life

OBJECTIVE

To evaluate the cost-effectiveness of interferon beta-1b (IFbeta-1b) for relapsing-remitting multiple sclerosis (RRMS).

METHODS

Construction of a cost-effectiveness model using published data on IFbeta-1b effectiveness and the natural history of RRMS, and new data on costs and quality of life (QoL) from a sample of 102 patients with RRMS and resident in northern England.

RESULTS

Poorer QoL was found for patients with multiple sclerosis compared with the general population; those who had had a relapse; those with worse states identified by a clinical measure (expanded disability status scale (EDSS)). Relapses have effects over several months. Health state valuations were higher than in the general population. Costs were higher in relapse than remission and for worse EDSS states. IFbeta-1b costs were larger than cost savings. The best cost-effectiveness estimate was pound28 700 per relapse avoided, which is pound809 900 per QALY gained; or pound328 300 per QALY gained allowing for effects of progression over 5 years. Estimates were robust to changes in assumptions.

CONCLUSIONS

The impact of multiple sclerosis on QoL is substantial. Future trials should base outcomes measurement on QoL and be better linked to natural history and cost data. IFbeta-1b produces important occasional short term QoL gains, but small gains in QALYs overall and large additional costs.

Neural and muscular receptors for motilin in the rabbit colon

Motilin receptors were classically recognized in the gastroduodenal area, where they help to regulate interdigestive motility. More recently, motilin receptors were identified in the colon where their biologic significance remains unclear. We aimed here to characterize the motilin receptors of the rabbit colon. Distal colon and duodenum were obtained from sacrificed rabbits. Tissues homogenized by Polytron were submitted to differential centrifugation to obtain neural synaptosomes or smooth muscle plasma membranes enriched solutions. Motilin binding to these membranes was determined by the displacement of (125)I MOT by the native peptide MOT 1-22, or by peptide analogues MOT 1-12 [CH(2)NH](10-11) or GM-109 and by erythromycin derivative GM-611. Motilin binding capacity was maximum in colon nerves (49.5 +/- 6.5 fmol/mg protein vs. 19.9 +/- 2.5 in colon muscles or 9.4 +/- 2.8 and 6.6 +/- 1.2 in duodenal muscles and antral nerves respectively); all tissues expressed similar affinity for MOT 1-22, and the motilin agonist GM-611 bound equally to neural or muscle tissues from the rabbit colon; the synthetic antagonist MOT 1-12 [CH(2)NH](10-11) showed greater affinity for colon nerves than for colon muscles (plC50: 7.23 +/- 0.07 vs. 6.75 +/- 0.03). Similar results were obtained with the peptide antagonist GM-109; receptor affinity toward MOT 1-12 [CH(2)NH(10-11)] was always five times superior in neural tissues, whether they came from the colon or the antrum, than in muscle tissues, whether they were obtained from colon or from duodenum. Motilin receptors are found in very high concentration in nerves and in muscles from rabbit colon; specific motilin receptor subtypes are identified in nerves (N) and muscles (M) of the rabbit colon; N and M receptor subtypes seem independent of the organ location.

In situ femoral dual-energy X-ray absorptiometry related to ash weight, bone size and density, and its relationship with mechanical failure loads of the proximal femur

The objective of this study was to directly compare in situ femoral dual-energy X-ray absorptiometry (DXA) and in vitro chemical analysis (ash weight and calcium) with mechanical failure loads of the proximal femur, and to determine the influence of bone size (volume) and density on mechanical failure and DXA-derived areal bone mineral density (BMD, in g/cm2). We performed femoral DXA in 52 fixed cadavers (age 82.1 +/- 9.7 years; 30 male, 22 female) with intact skin and soft tissues. The femora were then excised, mechanically loaded to failure in a stance phase configuration, their volume measured with a water displacement method (proximal neck to lesser trochanter), and the ash weight and calcium content of this region determined by chemical analysis. The correlation coefficient between the bone mineral content (measured in situ with DXA) and the ash weight was r = 0.87 (standard error of the estimate = 16%), the ash weight allowing for a better prediction of femoral failure loads (r = 0.78; p < 0.01) than DXA (r = 0.67; p < 0.01). The femoral volume (r = 0.61; p < 0.01), but not the volumetric bone density (r = 0.26), was significantly associated with the failure load. The femoral bone volume had a significant impact (r = 0.35; p < 0.01) on the areal BMD (DXA), and only 63% of the variability of bone volume could be predicted (based on the basis of body height, weight and femoral projectional bone area. The results suggest that accuracy errors of femoral DXA limit the prediction of mechanical failure loads, and that the influence of bone size on areal BMD cannot be fully corrected by accounting for body height, weight and projected femoral area.

Motilin receptors in the human antrum

Motilin is an intestinal peptide that stimulates contraction of gut smooth muscle. The motilin receptor has not been cloned yet, but motilin-receptor agonists appear to be potent prokinetic agents for the treatment of dysmotility disorders. The aim of this study was to determine neural or muscular localization of motilin receptors in human upper gastrointestinal tract and to investigate their pharmacological characteristics. The binding of (125)I-labeled motilin to tissue membranes prepared from human stomach and duodenum was studied; rabbit tissues were used for comparison. Solutions enriched in neural synaptosomes or in smooth muscle plasma membranes were obtained. Various motilin analogs were used to displace the motilin radioligand from the various tissue membranes. The highest concentration of human motilin receptors was found in the antrum, predominantly in the neural preparation. Human motilin receptors were sensitive to the NH(2)-terminal portion of the motilin molecule, but comparison with rabbit showed that both species had specific affinities for various motilin analogs [i.e., Mot-(1-9), Mot-(1-12), Mot-(1-12) (CH(2)NH)(10-11), and erythromycin]. Motilin receptors obtained from synaptosomes or muscular plasma membranes of human antrum expressed different affinity for two motilin-receptor agonists, Mot-(1-12) and Mot-(1-12) (CH(2)NH)(10-11), suggesting that they correspond to specific receptor subtypes. We conclude that human motilin receptors are located predominantly in nerves of the antral wall, are functionally (and probably structurally) different from those found in other species such as the rabbit, and express specific functional (and probably structural) characteristics dependent on their localization on antral nerves or muscles, suggesting the existence of specific receptor subtypes, potentially of significant physiological or pharmacological relevance.

Graphically-enabled integration of bioinformatics tools allowing parallel execution

Rapid analysis of large amounts of genomic data is of great biological as well as medical interest. This type of analysis will greatly benefit from the ability to rapidly assemble a set of related analysis programs and to exploit the power of parallel computing. TurboGenomics, which is a software package currently in its alpha-testing phase, allows integration of heterogeneous software components to be done graphically. In addition, the tool is capable of making the integrated components run in parallel. To demonstrate these abilities, we use the tool to develop a Web-based application that allows integrated access to a set of large-scale sequence data analysis programs used by a transposon-insertion based yeast genome project. We also contrast the differences in building such an application with and without using the TurboGenomics software.

TRIPLES: a database of gene function in Saccharomyces cerevisiae

Using a novel multipurpose mini-transposon, we have generated a collection of defined mutant alleles for the analysis of disruption phenotypes, protein localization, and gene expression in Saccharomyces cerevisiae. To catalog this unique data set, we have developed TRIPLES, a Web-accessible database of TRansposon-Insertion Phenotypes, Localization and Expression in Saccharomyces. Encompassing over 250 000 data points, TRIPLES provides convenient access to information from nearly 7800 transposon-mutagenized yeast strains; within TRIPLES, complete data reports of each strain may be viewed in table format, or if desired, downloaded as tab-delimited text files. Each report contains external links to corresponding entries within the Saccharomyces Genome Database and International Nucleic Acid Sequence Data Library (GenBank). Unlike other yeast databases, TRIPLES also provides on-line order forms linked to each clone report; users may immediately request any desired strain free-of-charge by submitting a completed form. In addition to presenting a wealth of information for over 2300 open reading frames, TRIPLES constitutes an important medium for the distribution of useful reagents throughout the yeast scientific community. Maintained by the Yale Genome Analysis Center, TRIPLES may be accessed at http://ycmi.med.yale.edu/ygac/triples.htm

Dietary exposures to nitrate in the UK

Dietary exposures to nitrate have been estimated for two different groups of UK consumers. The daily dietary exposure of the general population was estimated from the UK 1997 Total Diet study to be 52 mg/day. Vegetables contributed approximately 70% to this total dietary exposure. Dietary exposure estimates for adult consumers of vegetables commonly eaten in the UK were 93 mg/day and 140 mg/day for mean and 97.5th percentile consumers, respectively. Dietary exposures to nitrate of UK consumers are similar to those in other European countries and are less than the Acceptable Daily Intake (ADI) for nitrate set by the European Commission's Scientific Committee for Food.

Large-scale analysis of the yeast genome by transposon tagging and gene disruption

Economical methods by which gene function may be analysed on a genomic scale are relatively scarce. To fill this need, we have developed a transposon-tagging strategy for the genome-wide analysis of disruption phenotypes, gene expression and protein localization, and have applied this method to the large-scale analysis of gene function in the budding yeast Saccharomyces cerevisiae. Here we present the largest collection of defined yeast mutants ever generated within a single genetic background--a collection of over 11,000 strains, each carrying a transposon inserted within a region of the genome expressed during vegetative growth and/or sporulation. These insertions affect nearly 2,000 annotated genes, representing about one-third of the 6,200 predicted genes in the yeast genome. We have used this collection to determine disruption phenotypes for nearly 8,000 strains using 20 different growth conditions; the resulting data sets were clustered to identify groups of functionally related genes. We have also identified over 300 previously non-annotated open reading frames and analysed by indirect immunofluorescence over 1,300 transposon-tagged proteins. In total, our study encompasses over 260,000 data points, constituting the largest functional analysis of the yeast genome ever undertaken.

Truancy and perceived school performance: an alcohol and drug study of UK teenagers

This study is based on a subsample of 15- and 16-year-old school students from the UK, part of the European School Project on Alcohol and Other Drugs (ESPAD). Information was available on truancy rates, perceived school performance, family structure, lifestyle, and usage of alcohol, cigarettes and illicit drugs in 6409 teenagers. Living in a single-parent family, lack of constructive hobbies, presence of psychiatric symptoms, and an aggressive outgoing delinquent lifestyle bore the strongest associations to truancy and to perceived school performance. There were also strong relationships between both these last two variables and use of alcohol, cigarettes, and illicit drugs. However, the effects of alcohol, cigarettes, and illicit drugs were largely accounted for by other variables. Having at least one parent who both supported the respondent and who exercised some control was predictive of better perceived school performance.

Tuberculosis infection and homelessness in Melbourne, Australia, 1995-1996

OBJECTIVE

To describe tuberculosis infection among persons experiencing homelessness in inner Melbourne, Australia.

DESIGN

Homeless people were surveyed during late 1995 and early 1996. In stage one of the study 284 homeless people from crisis and long-term accommodation sites were recruited by means of stratified, systematic, random sampling. In stage two a convenience sample of 100 homeless people from squats and the streets were recruited. Participants completed a questionnaire and Mantoux testing was performed.

RESULTS

A past history of tuberculosis was reported by 3%. Thirty-seven per cent had a Mantoux > or =10 mm; 21% > or =15 mm; and 11% > or =20 mm. A Mantoux > or =15 mm was independently associated with being aged > or =40 years, coming from the accommodated sample, overseas birth, and a past history of tuberculosis. Using logistic regression modelling, a Mantoux > or =15 mm was predicted by being aged > or =40 years, overseas birth, and past history of tuberculosis.

CONCLUSION

Mantoux test results suggest that this group of homeless people had a high prevalence of infection with the tubercle bacillus. Many aspects of the physical and social circumstances of homeless people predispose to reactivation and have the potential to enhance rapid spread should latent infection become active disease.

Dietary exposure estimates of 30 elements from the UK Total Diet Study

Dietary exposures of consumers to 30 elements (aluminium, antimony, arsenic, barium, bismuth, boron, cadmium, calcium, chromium, cobalt, copper, germanium, gold, iridium, iron, lead, lithium, manganese, mercury, molybdenum, nickel, palladium, platinum, rhodium, ruthenium, selenium, strontium, thallium, tin and zinc) estimated from the UK 1994 Total Diet Study are reported, and compared with those from previous UK Total Diet Studies and those from other countries. Dietary exposure estimates were generally low and, where comparisons are possible, similar to those from other countries and below the relevant Provisional Tolerable Weekly Intakes and Provisional Maximum Tolerable Daily Intakes. For most of those elements included in previous UK Total Diet Studies, dietary exposures have declined.

Continued improvement in pressure-flow parameters in men receiving finasteride for 2 years. Finasteride Urodynamics Study Group

OBJECTIVES

To assess the long-term effects of finasteride on pressure-flow parameters in men with urodynamically documented bladder outflow obstruction (BOO).

METHODS

One hundred twenty-one men with benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS) underwent a pressure-flow study (PFS) at 1 of 11 clinical centers. The PFS technique was standardized, and all tracings were read by a single reader unaware of the treatment group. Patients who were obstructed according to a modified Abrams-Griffiths nomogram were randomized to 5 mg finasteride (n = 81) or placebo (n = 40) for 12 months; all patients continuing into an open extension received finasteride during the second 12 months of therapy. Results of the initial 12-month study demonstrated the benefit of finasteride treatment on PFS parameters. To examine the continuing effects over time, an analysis of the data from 54 patients who completed 24 months of treatment with finasteride is provided.

RESULTS

Detrusor pressure at maximum flow (PdetQmax) continued to decrease during the second 12 months of therapy (decreases of 5.3 and 11.7 cm H2O at months 12 and 24, respectively). The percentage of patients obstructed by Abrams-Griffiths classification decreased from 76.2% at baseline to 66.7% at month 12 and 59.6% at month 24. An intention-to-treat analysis yielded similar results.

CONCLUSIONS

Finasteride improves urodynamic measures of obstruction in men with BPE and LUTS, with continued improvement during the second 12 months of therapy.

Measuring progress towards a primary care-led NHS

BACKGROUND

The push towards a 'primary care-led' National Health Service (NHS) has far-reaching implications for the future structure of the NHS. The policy involves both a growing emphasis on the role of primary care practitioners in the commissioning of health services, and a change from hospital to primary and community settings for a range of services and procedures. Although the terminology has changed, this emphasis remains in the recent Scottish Health Service White Paper and its English counterpart.

AIM

To consider three questions in relation to this policy goal. First, does the evidence base support the changes? Secondly, what is the scale of the changes that have occurred? Thirdly, what are the barriers to the development of a primary care-led NHS?

METHOD

Programme budgets were compiled to assess changes over time in the balance of NHS resource allocation with respect to primary and secondary care. Total NHS revenue expenditure for the 15 Scottish health boards was grouped into four blocks or 'programmes': primary care, secondary care, community services, and a residual. The study period was 1991/2 to 1995/6. Expenditure data were supplied by the Scottish Office.

RESULTS

Ambiguity of definitions and the absence of good data cause methodological difficulties in evaluating the scale and the appropriateness of the shift. The data that are available suggest that, at the aggregate level, there have been changes over time in the balance of resource allocation between care settings: relative investment into primary care has increased. It would appear that this investment is relatively small and from growth money rather than a 'shift' from secondary care. In addition, the impact of GP-led commissioning is variable but limited.

CONCLUSION

General practitioners' (GPs') attitudes to the policy suggest that progress towards a primary care-led NHS will continue to be patchy. The limited shift to date, alongside evidence of ambivalent attitudes to the shift on the part of GPs, suggest that this is a policy objective that may not be achieved.

Lamotrigine-induced blepharospasm

Movement disorders such as tremor and ataxia occur commonly during therapy with antiepileptic drugs (AEDs). Dystonias, however, are rare. Blepharospasm, although reported with neuroleptic agents, has never been reported with AEDs. Our patient developed blepharospasm during therapy with lamotrigine.

Gender differences among those exhibiting characteristics of binge eating disorder

One hundred and eighty-seven former residential weight control participants exhibiting binge eating traits were assessed for gender differences regarding demographics, diet, exercise, weight control techniques, behavior modification techniques and binge eating characteristics. Data were gathered using a 68-item paper pencil questionnaire. Results indicate that there were no significant differences between males and females regarding demographic variables, and the number and types of weight control programs tried since leaving the residential program. Significant differences did exist between males and females in the number of times they had started dieting in the past year. No significant differences were observed among males and females regarding severity, binge emotions and compensatory behaviors. Statistically significant differences did exist regarding post-binge emotions. Results from this study suggest that males and females differ in regard to the diet/binge cycle and additionally, males appear to have a different or less emotional response subsequent to a binge.

Models of commissioning health services in the British National Health Service: a literature review

The commissioning of health services is an under-researched area and yet it is critical to the way services meet health needs and to the quality of care. Recent emphasis in the United Kingdom and elsewhere has been on a 'primary care led National Health Service', particularly on locality commissioning through primary care groups. However, there are other models of commissioning using 'programmes of care' (focused on diseases or patient groups rather than geography) which may offer greater benefits. There is little research comparing the benefits and costs of these models, and most are not even clearly enough described to be replicated. There will always be a political dimension to models of commissioning, dependent, for example, on the balance of power in the decision-making process. None the less, a broader knowledge of possible models and a willingness to evaluate rigorously are needed if commissioning of health services is to result in better patient care.

Improvement of pressure flow parameters with finasteride is greater in men with large prostates. Finasteride Urodynamics Study Group

PURPOSE

We assess the effect of finasteride, a 5alpha-reductase inhibitor, on objective voiding parameters in men with lower urinary tract symptoms and benign prostatic enlargement on digital rectal examination (known as clinical benign prostatic enlargement) in a double-blind placebo controlled multicenter study using strict standard pressure flow study techniques.

MATERIALS AND METHODS

A modification of the Abrams-Griffiths nomogram was used by 1 reader to ensure that all patients met objective criteria for bladder outlet obstruction at baseline. After performing a pressure flow study patients with obstruction were randomized 2:1 to receive 5 mg. finasteride (81) or placebo (40) daily. A second pressure flow study was performed at month 12. At baseline and month 12 free urinary flow studies and transrectal ultrasound were performed, and International Prostate Symptom Score questionnaires were completed. Patients were treated between May 1994 and July 1996.

RESULTS

Finasteride caused a significant decrease (-8.1 cm. water) in detrusor pressure at maximum flow (p <0.05 versus placebo p = 0.02), increase (+1.1 ml. per second) in maximum flow rate (p <0.05 versus placebo p = 0.02) and decrease (-22.8%) in prostate volume (p <0.05 versus placebo p <0.001). Men with prostates larger than 40 cc had greater improvement in detrusor pressure at maximum flow (between group difference -14.5 cm. water, 95% confidence interval -26.2 to -2.6, p = 0.02) and maximum flow rate (mean treatment effect +1.6 ml. per second, 95% confidence interval -0.2 to 3.0, p = 0.02) compared to those with prostates 40 cc or less (between group differences not significant).

CONCLUSIONS

Finasteride treatment resulted in improvements in urodynamic parameters, which were greater in men with large prostates.

Preventing injuries in children: cluster randomised controlled trial in primary care

OBJECTIVE

To assess the effectiveness of safety advice at child health surveillance consultations, provision of low cost safety equipment to families receiving means tested state benefits, home safety checks, and first aid training on frequency and severity of unintentional injuries in children at home.

DESIGN

Cluster randomised controlled trial.

SETTING

36 general practices in Nottingham.

SUBJECTS

All children aged 3-12 months registered with participating practices.

INTERVENTIONS

A package of safety advice at child health surveillance consultations at 6-9, 12-15, and 18-24 months; provision of low cost safety equipment to families on means tested state benefits; and home safety checks and first aid training by health visitors.

OUTCOME MEASURES

Primary outcomes measures were frequency and severity of medically attended injuries. Secondary outcome measures were self reported safety practices, possession and use of safety equipment, knowledge and confidence in dealing with first aid, and perceptions of risk of injury and risk of hazards assessed by postal questionnaire at baseline and follow up at 25 months.

RESULTS

At baseline, both groups had similar risk factors for injury, sociodemographic characteristics, safety practices, possession and use of safety equipment, knowledge and confidence in dealing with first aid, and perceptions of risk. No significant difference was found in frequency of at least one medically attended injury (odds ratio 0.97, 95% confidence interval 0.72 to 1.30), at least one attendance at an accident and emergency department for injury (1.02, 0.76 to 1.37), at least one primary care attendance for injury (0.75, 0.48 to 1.17), or at least one hospital admission for injury (0.69, 0.42 to 1.12). No significant difference in the secondary outcome measures was found between the intervention and control groups.

CONCLUSIONS

The intervention package was not effective in reducing the frequency of minor unintentional injuries in children at home, and larger trials are required to assess the effect on more severe injuries.

Organization of heterogeneous scientific data using the EAV/CR representation

Entity-attribute-value (EAV) representation is a means of organizing highly heterogeneous data using a relatively simple physical database schema. EAV representation is widely used in the medical domain, most notably in the storage of data related to clinical patient records. Its potential strengths suggest its use in other biomedical areas, in particular research databases whose schemas are complex as well as constantly changing to reflect evolving knowledge in rapidly advancing scientific domains. When deployed for such purposes, the basic EAV representation needs to be augmented significantly to handle the modeling of complex objects (classes) as well as to manage interobject relationships. The authors refer to their modification of the basic EAV paradigm as EAV/CR (EAV with classes and relationships). They describe EAV/CR representation with examples from two biomedical databases that use it.