Systematic review of the effectiveness and cost-effectiveness of weight management schemes for the under fives: a short report

OBJECTIVE

To search for, review and synthesise studies of the effectiveness and cost-effectiveness of weight management schemes for the under fives.

DATA SOURCES

MEDLINE [Ovid], MEDLINE In-Process [Ovid], EMBASE [Ovid], CAB [Ovid], Health Management Information Consortium [Ovid], The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, Science Citation Index Expanded [Web of Science], Conference Proceedings Citation Index [The Web of Science], Database of Abstract Reviews [CRD; Centre for Reviews and Dissemination], HTA [CRD], PsycINFO [Ebsco], NHS CRD. These databases were searched from 1990 to February 2009. Supplementary internet searches were additionally conducted.

REVIEW METHODS

Relevant clinical effectiveness studies were identified in two stages. Titles and abstracts returned by the search strategy were examined independently by three researchers and screened for possible inclusion. Disagreements were resolved by discussion. Full texts of the identified studies were obtained. Three researchers examined these independently for inclusion or exclusion, and disagreements were again resolved by discussion.

RESULTS

One of the randomised controlled trials (RCTs) was from the UK. It measured the effects of a physical activity intervention for children in nurseries combined with home-based health education for their parents; this was compared to usual care. The main outcome measure was body mass index (BMI); secondary measures were weight and physical activity. At the 12-month follow-up, no statistically significant differences were found between the groups on any measure. However, a trend, favouring the intervention, was found for BMI and weight. The other two RCTs were from the USA. The larger trial investigated the effects of a combined preschool and home intervention in African American and Latino communities. Nutrition education and physical activity programmes were aimed at under fives in preschool. The home component consisted of related health education and homework for the parents, who received a small financial reward on completion. The 1- and 2-year results for the African American sites showed a significantly slower rate of increase in BMI than for results at baseline, for the intervention group than for the control group. However, in the Latino communities no such differences were found. The second US trial was a much smaller home-based parental education programme in Native American communities in the USA and Canada. The intervention consisted of a parental skills course for parents to improve their children's diet and physical activity. This was compared with a course providing skills to improve child behaviour. Follow-up was at 16 weeks and showed no significant differences between groups in BMI.

CONCLUSIONS

No controlled trials addressing the issue of treating obesity or evidence of cost-effectiveness studies in the under fives' population were found. From the three prevention studies, apart from the larger US trial, the interventions showed no statistically significant differences in BMI and weight between the intervention and control groups (although there was some evidence of positive trends for BMI and weight). It should also be noted that these conclusions are based on only three dissimilar studies, thereby making the drawing of firm conclusions difficult. Research is urgently needed in further well-designed UK-based RCTs of weight management schemes aimed at the prevention of obesity, that combine with cost-effectiveness studies targeted at preschool children with long-term follow-up.

Renal outcomes after liver transplantation in the model for end-stage liver disease era

The proportion of patients undergoing liver transplantation (LT) with renal insufficiency has significantly increased in the Model for End-Stage Liver Disease (MELD) era. This study was designed to determine the incidence and predictors of post-LT chronic renal failure (CRF) and its effect on patient survival in the MELD era. Outcomes of 221 adult LT recipients who had LT between February 2002 and February 2007 were reviewed retrospectively. Patients who were listed as status 1, were granted a MELD exception, or had living-donor, multiorgan LT were excluded. Renal insufficiency at LT was defined as none to mild [estimated glomerular filtration rate (GFR) >or= 60 mL/minute], moderate (30-59 mL/minute), or severe (<30 mL/minute). Post-LT CRF was defined as an estimated GFR < 30 mL/minute persisting for 3 months, initiation of renal replacement therapy, or listing for renal transplantation. The median age was 54 years, 66% were male, 89% were Caucasian, and 43% had hepatitis C. At LT, the median MELD score was 20, and 6.3% were on renal replacement therapy. After a median follow-up of 2.6 years (range, 0.01-5.99), 31 patients developed CRF with a 5-year cumulative incidence of 22%. GFR at LT was the only independent predictor of post-LT CRF (hazard ratio = 1.33, P < 0.001). The overall post-LT patient survival was 74% at 5 years. Patients with MELD >or= 20 at LT had a higher cumulative incidence of post-LT CRF in comparison with patients with MELD < 20 (P = 0.03). A decrease in post-LT GFR over time was the only independent predictor of survival. In conclusion, post-LT CRF is common in the MELD era with a 5-year cumulative incidence of 22%. Low GFR at LT was predictive of post-LT CRF, and a decrease in post-LT GFR over time was associated with decreased post-LT survival. Further studies of modifiable preoperative, perioperative, and postoperative factors influencing renal function are needed to improve outcomes following LT.

Sunitinib and bevacizumab for first-line treatment of metastatic renal cell carcinoma: a systematic review and indirect comparison of clinical effectiveness

Background:

Two new agents have recently been licensed for use in the treatment of metastatic renal cell carcinoma (RCC) in Europe. This paper aims to systematically review the evidence from all available randomised clinical trials of sunitinib and bevacizumab (in combination with interferon-α (IFN-α)) in the treatment of advanced metastatic RCC.

Methods:

Systematic literature searches were performed in six electronic databases. Bibliographies of included studies were searched for further relevant studies. Individual conference proceedings were searched using their online interfaces. Studies were selected according to the predefined criteria. All randomised clinical trials of sunitinib or bevacizumab in combination with IFN for treating advanced metastatic RCC in accordance with the European licensed indication were included. Study selection, data extraction, validation and quality assessment were performed by two reviewers with disagreements being settled by discussion. The effects of sunitinib and bevacizumab (in combination with IFN-α) on progression-free survival were compared indirectly using Bayesian Markov Chain Monte-Carlo (MCMC) sampling in Win BUGS, with IFN as a common comparator.

Results:

Three studies were included. Median progression-free survival was significantly prolonged with both interventions (from approximately 5 months to between 8 and 11 months) compared with IFN. Overall survival was also prolonged, compared with IFN, although the published data are not fully mature. Indirect comparison suggests that sunitinib is superior to bevacizumab plus IFN in terms of progression-free survival (hazard ratios 0.796; 95% CI 0.63–1.0; P=0.0272).

Conclusion:

There is evidence to suggest that treatment with sunitinib and treatment with bevacizumab plus IFN has clinically relevant and statistically significant advantages over treatment with IFN alone in patients with metastatic RCC.

Impact of fatness, insulin, and gynecological age on luteinizing hormone secretory dynamics in adolescent females

OBJECTIVE

To study the link between fatness and gonadotropin secretion. Overweight status is linked to polycystic ovary syndrome (PCOS) in adolescents. We postulated that heavier adolescents without symptoms would secrete LH with: [1] increased pulse frequency (LHPF) and [2] exaggerated integrated concentrations (LHAUC).

DESIGN

Cross-sectional.

SETTING

General clinical research center.

PATIENT(S)

Eighty-seven postmenarcheal cyclic adolescents from lean to overweight recruited during the follicular phase.

INTERVENTION(S)

Luteinizing hormone sampling: [1] every 10 minutes/24 hours; [2] at 20-minute intervals after a GnRH challenge.

MAIN OUTCOME MEASURE(S)

The LHPF and LHAUC (calculated by the CLUSTER algorithm). Hormonal and metabolic covariates included percent body fat (PercentBF), insulin-like growth factor-I (IGF-I), fasting insulin, and the insulin resistance index HOMA-IR. The SAS software was used for analyses.

RESULT(S)

The PercentBF and younger gynecological age predicted faster LHPF. Fatness was negatively linked to LHAUC, which was best predicted by PercentBF and IGF-1 in multivariate modeling (R(2) = 0.25). The PercentBF and insulin predicted a lower 20-minute LH response to GnRH.

CONCLUSION(S)

[1] Higher adiposity and younger gynecological age predict rapid LHPF. [2] The early years after menarche represent a vulnerable window for an exaggerated LHPF with weight gain. [3] In healthy adolescents, higher adiposity is linked to lower LHAUC, thereby preserving pituitary stores.

Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs

OBJECTIVES

To review the evidence on the clinical effects and associated treatment costs of surgical procedures and non-surgical devices for the management of non-apnoeic snoring.

DATA SOURCES

Major electronic databases were searched for relevant studies published between 1980 and 2007. All treatment costs were estimated based on data from NHS reference costs, device manufacturers and clinical opinion.

REVIEW METHODS

Studies were screened, data extracted and quality assessed according to standard methods. Results were broadly grouped according to the intervention and comparator when applicable, and further subgrouped according to the specific intervention type and study design. Results were combined using a narrative synthesis with relevant quantitative results tabulated. Differences between studies assessing the same intervention were explored narratively by examining differences in the intervention, study duration and study quality.

RESULTS

The systematic review included 27 studies (three randomised controlled trials, two controlled clinical trials and 22 pre-post studies) reported in 30 publications assessing uvulopalatopharyngoplasty (UP3) versus laser-assisted uvulopalatoplasty (LAUP), UP3 alone, LAUP alone, palatal stiffening techniques (Pillar implants and injection snoreplasty), radiofrequency ablation (RFA) of the soft palate or tongue base, continuous positive airway pressure (CPAP) devices and mandibular advancement splints (MAS). Studies were generally of a low methodological quality with small sample sizes. A total of 1191 patients was included. Both UP3 and LAUP reduced the number of snores per hour and produced a modest reduction in snoring loudness. UP3 was effective in reducing a number of subjectively reported snoring indices, but results on objective measures were equivocal. Limited evidence indicates that subjectively assessed snoring is improved after LAUP; no objective measures were assessed. RFA was associated with a reduction in partner-assessed snoring intensity, though evidence for an objective reduction in snoring sound levels was mixed. Pillar implants were moderately effective at reducing partner-rated snoring intensity, but had no effect on objective snoring indices. Use of CPAP reduced the number of snores per hour; no subjective measures were evaluated. Use of MAS improved objective snoring outcomes, including the maximal snoring sound volume, the mean snoring sound volume and the percentage of time spent in loud snoring; no subjective measures were evaluated. The cost for UP3 ranges from approximately 1230 pounds to approximately 1550 pounds. For LAUP the cost varies from 790 pounds to 2070 pounds depending on the number of stages of the procedure. The treatment costs associated with the use of Pillar implants range from 1110 pounds to 1160 pounds. The approximate annual treatment costs associated with the use of a CPAP machine and MAS are 220 pounds and 130 pounds respectively.

CONCLUSIONS

This study highlighted the paucity and poor quality of the evidence available on the effects of both surgical procedures and non-surgical devices for the management of primary snoring. Any conclusions to be drawn from the results are therefore somewhat tentative. There was no procedure that was clearly the least-cost option. Further research should focus on standardising methods of measuring outcomes and reporting, undertaking active controlled trials, and investigating the longer-term effects of treatments.

Time to full publication of studies of anti-cancer medicines for breast cancer and the potential for publication bias: a short systematic review

OBJECTIVES

To identify the expected delay between publication of conference abstracts and full publication of results from trials of new anti-cancer agents for breast cancer and to identify whether there are any apparent biases in publication and reporting.

DATA SOURCES

Major electronic databases were searched to identify randomised controlled trials (RCTs) of the selected interventions for the treatment of breast cancer.

REVIEW METHODS

A systematic review was conducted according to standard methods. Data were extracted from the included studies using a predesigned and piloted data extraction template.

RESULTS

Six anti-cancer treatments for breast cancer were included in the review: docetaxel, paclitaxel, trastuzumab, gemcitabine, lapatinib and bevacizumab. The literature searches generated 1556 references, from which 71 publications were retrieved and screened for inclusion. Screening identified 41 publications of 18 RCTs with at least one arm of treatment meeting the inclusion criteria for the review. Of the 18 included RCTs, only four publications (from three RCTs) reported the same outcomes in both an abstract and a full publication. Time between the abstract and full publication was 5 months in two cases, 7 months in one case and 19 months in one case (overall mean delay = 9 months). Eleven trials were identified that have not currently published in a full publication the data presented in an abstract or conference proceeding. The duration between publication of the abstracts and the end of August 2007 varied from 3 months to 38 months (mean delay 16.5 months). The longest delays in publication were for trials investigating gemcitabine (38 months) or bevacizumab (33 months). Observational analysis of the published and unpublished trials did not indicate any particular biases in terms of whether positive results were more likely to be fully published than non-significant ones.

CONCLUSIONS

It was surprising that only three of the 18 relevant RCTs had one or more full papers that reported the same outcome measures (and stage of analysis) as an earlier conference abstract. However, a limitation of this review is the small number of studies included. With a larger sample size than that in the present report, investigation into the effect of publication delay on decision-making might be feasible. Future research should include extension of this work to other anti-cancer drugs and investigation into the reasons for lengthy delays to full publication noted for some trials.

Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta2 agonists for the treatment of chronic asthma in children under the age of 12 years

OBJECTIVES

To assess the clinical and cost-effectiveness of inhaled corticosteroids (ICS) alone and ICS used in combination with a long-acting beta2 agonist (LABA) in the treatment of chronic asthma in children aged under 12 years.

DATA SOURCES

Major electronic bibliographic databases, e.g. MEDLINE and EMBASE, were searched up to February/March 2006 (and updated again in October 2006).

REVIEW METHODS

A systematic review of clinical and cost-effectiveness studies and economic analyses were carried out. A flexible framework was used to allow different types of economic analyses as appropriate, with either a cost comparison or cost-consequence comparison conducted.

RESULTS

Of 5175 records identified through systematic literature searching, 34 records describing 25 studies were included (16 were fully published randomised controlled trials, six were systematic reviews, and three were post-2004 conference abstracts). The most frequently reported relevant outcomes in the 16 RCTs were peak expiratory flow rate (13 trials), FEV1 (13 trials), symptoms (13 trials), adverse events or exacerbations (13 trials), use of rescue medication (12 trials), markers of adrenal function (e.g. blood or urine cortisol concentrations) (13 trials), height and/or growth rate (seven trials) and markers of bone metabolism (two trials). In the trials that compared low-dose ICS versus ICS and high-dose ICS versus ICS, no consistent significant differences or patterns in differential treatment effect among the outcomes were evident. Where differences were statistically significant at high doses, such as for lung function and growth, they favoured formoterol fumarate (FF), but this was generally in studies that did not compare the ICS at the accepted clinically equivalent doses. Differences between the drugs in impact on adrenal suppression were only significant in two studies. At doses of 200, 400 and 800 microg/day, beclometasone dipropionate (BDP) appears to be the current cheapest ICS product both with the inclusion and exclusion of chlorofluorocarbon (CFC)-propelled products. In the trials comparing ICS at a higher dose with ICS and LABA in combination, most outcomes favoured the combined inhaler. Only the combination inhaler, Seretide Evohaler, is slightly cheaper than the weighted mean cost of all types of ICS at increased dose except BDP 400 microg/day (including CFC-propelled products). Both the combination inhalers, Seretide Accuhaler and Symbicort Turbohaler, are more expensive than the weighted mean cost for all types of ICS at a two-fold increased dose. Compared with the lowest cost preparation for each ICS drug, all the combination inhalers are always more expensive than the ICS products at increased dose.

CONCLUSIONS

The limited evidence available indicates that there are no consistent significant differences in effectiveness between the three ICS licensed for use in children at either low or high dose. BDP CFC-propelled products are often the cheapest ICS currently available at both low and high dose, and may remain so even when CFC-propelled products are excluded. Exclusion of CFC-propelled products increases the mean annual cost of all budesonide (BUD) and BDP, while the overall cost differences between the comparators diminish. There is very limited evidence available for the efficacy and safety of ICS and LABAs in children. From this limited evidence, there appear to be no significant clinical differences in effects between the use of a combination inhaler versus the same drugs in separate inhalers. There is a lack of evidence comparing ICS at a higher dose with ICS and LABA in combination and comparing the combination products with each other. In the absence of any evidence concerning the effectiveness of ICS at higher dose with ICS and LABA, a cost-consequence analysis gives mixed results. There are potential cost savings with the use of combination inhalers compared to separate inhalers. At present prices, the BUD/FF combination is more expensive than those containing FP/SAL, but it is not known whether there are clinically significant differences between them. A scoping review is required to assess the requirements for additional primary research on the clinical effectiveness of treatment for asthma in children under 5 years old. Such a review could also usefully include all treatment options, pharmacological and non-pharmacological, for asthma. A direct head-to-head trial that compares the two combination therapies of FP/SAL and BUD/FF is warranted, and it is important to assess whether the addition of a LABA to a lower dose of ICS could potentially be as effective as an increased dose of ICS alone, but also be steroid sparing. There is also a need for the long-term adverse events associated with ICS use to be assessed systematically. Future trials of treatment for chronic asthma in children should aim to standardise further the way in which outcome measures are defined. There should be a greater focus on patient-centred outcomes to provide a more meaningful estimation of the impact of treatment on asthma control. Methods of reporting also require standardisation.

Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta2 agonists for the treatment of chronic asthma in adults and children aged 12 years and over

OBJECTIVES

To assess the clinical and cost-effectiveness of inhaled corticosteroids (ICS) alone and ICS used in combination with a long-acting beta2 agonist (LABA) in the treatment of chronic asthma in adults and children aged over 12 years.

DATA SOURCES

Major electronic bibliographic databases, e.g. MEDLINE and EMBASE, were searched up to February/March 2006 (and updated again in October 2006).

REVIEW METHODS

A systematic review of clinical and cost-effectiveness studies was conducted. Cost comparison and cost-consequence analyses were performed where appropriate.

RESULTS

The assessment of clinical effectiveness was based on the 67 randomised controlled trials selected from the 5175 reports identified through the systematic literature search. The most frequently reported relevant outcomes were lung function, symptoms, use of rescue medication and adverse events. The trials varied considerably. In the trials that compared low-dose ICS versus ICS and high-dose ICS versus ICS, there were few significant differences in clinical effectiveness, although a few of the trials had assessed non-inferiority between the comparators rather than superiority. At doses of 400, 800 and 'high-level' doses of 1500 or 1600 microg/day, beclometasone dipropionate (BDP) appears to be the current cheapest ICS product both with the inclusion and exclusion of chlorofluorocarbon (CFC)-propelled products. A significant treatment benefit for combination ICS/LABA therapy across a range of outcomes compared with ICS alone was identified [when the ICS was double the accepted clinically equivalent dose of the ICS in the combination inhaler, and dry powder inhalers (DPIS) were used to deliver the drugs]. When a formoterol fumarate (FF)/salmeterol (SAL) combination inhaler and a budesonide (BUD)/FF combination inhaler were each compared with their constituent drugs delivered in separate inhalers, there were very few statistically significant differences between the treatments across the various efficacy outcomes and the rate of adverse events. Combination inhalers were more often cheaper than doubling the dose of ICS alone. However, the costs were highly variable and dependent on both the dose required and the preparation used in the trials. The estimated mean annual cost of FP/SAL combination varied from being 94 pounds cheaper to 109 pounds more expensive than the alternative of BUD at a higher dose. The BUD/FF combination varied from being 163 pounds cheaper to 66 pounds more expensive than the higher dose of either BUD or FP. When the combination inhalers were compared to each other, the results were mixed, with the FP/SAL combination significantly superior on some outcomes and the BUD/FF combination superior on others; however, meta-analysis showed that there were no significant differences between the two treatments in the rate of adverse events. Taking an ICS with a LABA as either of the two currently available combination products, FP/SAL and BUD/FF, is usually cheaper than taking the relevant constituent drugs in separate inhalers. At very high doses of BUD (1600 microg/day), however, the BUD/FF combination inhaler can be up to 156 pounds more expensive than having the same drugs in separate inhalers. In terms of the relative costs associated with taking one of the combination inhalers, at low dose (400 microg BUD or 200 microg FP/day) the cheapest combination inhaler is FP/SAL as a pressurised metered dose inhaler (pMDI) (Seretide Evohaler). However, this is only slightly cheaper than using BUD/FF as a DPI (Symbicort Turbohaler). At higher dose levels (800 microg BUD or 500 microg FP/day) FP/SAL as either pMDI aerosol (Seretide Evohaler) or a DPI (Seretide Accuhaler) is the cheapest combination product available, but again only slightly cheaper than the DPI BUD/FF combination (Symbicort Turbohaler). It should be highlighted, however, that the three head-to-head trials that compared the effects of FP/SAL with BUD/FF used the FP/SAL DPI combination inhaler, Seretide Accuhaler.

CONCLUSIONS

The evidence indicates that there are few consistent significant differences in effects between the five ICS licensed for use in adults and adolescents over the age of 12 years, at either low or high dose. On average, BDP products currently tend to be the cheapest ICS available and tend to remain so as the daily ICS dose required increases. There is evidence that the addition of a LABA to an ICS is potentially more clinically effective than doubling the dose of ICS alone, although consistent significant differences between the two treatment strategies are not observed for all outcome measures. The cost differences between combination therapy compared with ICS monotherapy are highly variable and dependent on the dose required and the particular preparations used. For the combination therapies of ICS/LABA there are potential cost savings with the use of combination inhalers compared with separate inhalers, with few differences between the two treatment strategies in terms of effects. The only exception to this cost saving is with BUD/FF at doses higher than 1200 microg/day, where separate inhaler devices can become equivalent to or cheaper than combination inhalers. Neither of the two combination inhalers (FP/SAL or BUD/FF) is consistently superior in terms of treatment effect. A comparison of the costs associated with each combination therapy indicates that at low dose FP/SAL delivered via a pMDI is currently the cheapest combination inhaler but only marginally cheaper than BUD/FF delivered as a DPI. At higher doses, both the FP/SAL combination inhalers (PMDI and DPI) are marginally cheaper than BUD/FF (DPI). Future trials of treatment for chronic asthma should standardise the way in which outcome measures are defined and measured, with a greater focus on patient-centred outcomes. For informing future cost-utility and cost-effectiveness analyses from a UK NHS perspective, there is a need for longitudinal studies that comprehensively track the care pathways followed when people experience asthma exacerbations of different severity. Further research synthesis, quantifying the adverse effects of the different ICS, is required for treatment choices by patients and clinicians to be fully informed.

Chronic sepsis mortality characterized by an individualized inflammatory response

Late mortality in septic patients often exceeds the lethality occurring in acute sepsis, yet the immunoinflammatory alterations preceding chronic sepsis mortality are not well defined. We studied plasma cytokine concentrations preceding late septic deaths (days 6-28) in a murine model of sepsis induced by polymicrobial peritonitis. The late prelethal inflammatory response varied from a virtually nonexistent response in three of 14 to a mixed response in eight of 14 mice to the concurrent presence of nearly all measured cytokines, both proinflammatory and anti-inflammatory in three of 14 mice. In responding mice a consistent prelethal surge of plasma MIP-2 (1.6 vs 0.12 ng/ml in survivors; mean values), MCP-1 (2.0 vs 1.3 ng/ml), soluble TNF receptor type I (2.5 vs 0.66 ng/ml), and the IL-1 receptor antagonist (74.5 vs 3.3 ng/ml) was present, although there were infrequent increases in IL-6 (1.9 vs 0.03 ng/ml) and IL-10 (0.12 vs 0.04 ng/ml). For high mobility group box 1, late mortality was signaled by its decrease in plasma levels (591 vs 864 ng/ml). These results demonstrate that impeding mortality in the chronic phase of sepsis may be accurately predicted by plasma biomarkers, providing a mechanistic basis for individualized therapy. The pattern of late prelethal responses suggest that the systemic inflammatory response syndrome to compensatory anti-inflammatory response syndrome transition paradigm fails to follow a simple linear pattern.

Childhood body mass index and perioperative complications

BACKGROUND

Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children.

METHODS

This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children.

RESULTS

There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children.

DISCUSSION

Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.

The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation

OBJECTIVES

To establish the effectiveness and cost-effectiveness of cinacalcet for the treatment of secondary hyperparathyroidism (SHPT) for people on dialysis due to end-stage renal disease (ESRD).

DATA SOURCES

Electronic databases were searched up to February 2006.

REVIEW METHODS

Included randomised controlled trials (RCTs) on the clinical effectiveness of cinacalcet for SHPT in ESRD were critically appraised, had relevant data extracted and were summarised narratively. A Markov (state transition) model was developed that compared cinacalcet in addition to current standard treatment with phosphate binders and vitamin D to standard treatment alone. A simulated cohort of 1000 people aged 55 with SHPT was modelled until the whole cohort was dead. Incremental costs and quality-adjusted life-years (QALYs) were calculated. Extensive one-way sensitivity analysis was undertaken as well as probabilistic sensitivity analysis.

RESULTS

Seven trials comparing cinacalcet plus standard treatment with placebo plus standard treatment were included in the systematic review. A total of 846 people were randomised to receive cinacalcet. Cinacalcet was more effective at meeting parathyroid hormone (PTH) target levels (40% vs 5% in placebo, p < 0.001). In those patients meeting PTH targets, 90% also experienced a reduction in calcium-phosphate product levels, compared with 1% in placebo. Significantly fewer people treated with cinacalcet were hospitalised for cardiovascular events, although no difference was seen in all-cause hospitalisation or mortality. Significantly fewer fractures and parathyroidectomies were also seen with cinacalcet. Findings on all patient-based clinical outcomes were based on small numbers. The authors' economic model estimated that, compared to standard treatment alone, cinacalcet in addition to standard care costs an additional 21,167 pounds and confers 0.34 QALYs (or 18 quality-adjusted weeks) per person. The incremental cost-effectiveness ratio (ICER) was 61,890 pounds/QALY. In most cases, even extreme adjustments to individual parameters did not result in an ICER below a willingness-to-pay threshold of 30,000 pounds/QALY with probabilistic analysis showing only 0.5% of simulations to be cost-effective at this threshold. Altering the assumptions in the model through using different data sources for the inputs produced a range of ICERs from 39,000 pounds to 92,000 pounds/QALY.

CONCLUSIONS

Cinacalcet in addition to standard care is more effective than placebo plus standard care at reducing PTH levels without compromising calcium levels. However, there is limited information about the impact of this reduction on patient-relevant clinical outcomes. Given the short follow-up in the trials, it is unclear how data should be extrapolated to the long term. Together with the high drug cost, this leads to cinacalcet being unlikely to be considered cost-effective. Recommendations for future research include obtaining accurate estimates of the multivariate relationship between biochemical disruption in SHPT and long-term clinical outcomes.

Circulating cytokine/inhibitor profiles reshape the understanding of the SIRS/CARS continuum in sepsis and predict mortality

Mortality in sepsis remains unacceptably high and attempts to modulate the inflammatory response failed to improve survival. Previous reports postulated that the sepsis-triggered immunological cascade is multimodal: initial systemic inflammatory response syndrome (SIRS; excessive pro-, but no/low anti-inflammatory plasma mediators), intermediate homeostasis with a mixed anti-inflammatory response syndrome (MARS; both pro- and anti-inflammatory mediators) and final compensatory anti-inflammatory response syndrome (CARS; excessive anti-, but no/low proinflammatory mediators). To verify this, we examined the evolution of the inflammatory response during the early phase of murine sepsis by repetitive blood sampling of septic animals. Increased plasma concentrations of proinflammatory (IL-6, TNF, IL-1beta, KC, MIP-2, MCP-1, and eotaxin) and anti-inflammatory (TNF soluble receptors, IL-10, IL-1 receptor antagonist) cytokines were observed in early deaths (days 1-5). These elevations occurred simultaneously for both the pro- and anti-inflammatory mediators. Plasma levels of IL-6 (26 ng/ml), TNF-alpha (12 ng/ml), KC (33 ng/ml), MIP-2 (14 ng/ml), IL-1 receptor antagonist (65 ng/ml), TNF soluble receptor I (3 ng/ml), and TNF soluble receptor II (14 ng/ml) accurately predicted mortality within 24 h. In contrast, these parameters were not elevated in either the late-deaths (day 6-28) or survivors. Surprisingly, either pro- or anti-inflammatory cytokines were also reliable in predicting mortality up to 48 h before outcome. These data demonstrate that the initial inflammatory response directly correlates to early but not late sepsis mortality. This multifaceted response questions the use of a simple proinflammatory cytokine measurement for classifying the inflammatory status during sepsis.

Spatial extent of degraded sediment quality in Puget Sound (Washington State, U.S.A.) based upon measures of the sediment quality triad

A survey was designed and conducted to determine the severity, spatial patterns, and spatial extent of degraded sediment quality in Puget Sound (Washington State, USA). A weight of evidence compiled from results of chemical analyses, toxicity tests, and benthic infaunal analyses was used to classify the quality of sediments. Sediment samples were collected from 300 locations within a 2363 km(2) area extending from the US/Canada border to the inlets of southern Puget Sound and Hood Canal. Degraded conditions, as indicated with a combination of high chemical concentrations, significant toxicity, and adversely altered benthos, occurred in samples that represented about 1% of the total area. These conditions invariably occurred in samples collected within urbanized bays and industrial waterways, especially near the urban centers of Everett, Seattle, Tacoma, and Bremerton. Sediments with high quality (as indicated by no toxicity, no contamination, and the presence of a relatively abundant and diverse infauna) occurred in samples that represented a majority (68%) of the total study area. Sediments in which results of the three kinds of analyses were not in agreement were classified as intermediate in quality and represented about 31% of the total area. Relative to many other estuaries and marine bays of the USA, Puget Sound sediments ranked among those with minimal evidence of toxicant-induced degradation.

Viscoelastic characterization of compacted pharmaceutical excipient materials by analysis of frequency-dependent mechanical relaxation processes

A newly developed method for determining the frequency-dependent complex Young's modulus was employed to analyze the mechanical response of compacted microcrystalline cellulose, sorbitol, ethyl cellulose and starch for frequencies up to 20 kHz. A Debye-like relaxation was observed in all the studied pharmaceutical excipient materials and a comparison with corresponding dielectric spectroscopy data was made. The location in frequency of the relaxation peak was shown to correlate to the measured tensile strength of the tablets, and the relaxation was interpreted as the vibrational response of the interparticle hydrogen and van der Waals bindings in the tablets. Further, the measured relaxation strength, holding information about the energy loss involved in the relaxation processes, showed that the weakest material in terms of tensile strength, starch, is the material among the four tested ones that is able to absorb the most energy within its structure when exposed to external perturbations inducing vibrations in the studied frequency range. The results indicate that mechanical relaxation analysis performed over relatively broad frequency ranges should be useful for predicting material properties of importance for the functionality of a material in applications such as, e.g., drug delivery, drug storage and handling, and also for clarifying the origin of hitherto unexplained molecular processes.

Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria

STUDY OBJECTIVE

We determine whether the use of an emergency medical services (EMS) protocol for selective spine immobilization would result in appropriate immobilization without spinal cord injury associated with nonimmobilization.

METHODS

A 4-year prospective study examined EMS and hospital records for patients after the implementation of an EMS protocol for selective spine immobilization. EMS personnel were trained to perform and document a spine injury assessment for out-of-hospital trauma patients with a mechanism of injury judged sufficient to cause a spine injury. The assessment included these clinical criteria: altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness. The protocol required immobilization for patients with a positive assessment on any of those criteria. Outcome characteristics included the presence or absence of spine injury and spine injury management.

RESULTS

The study collected data on 13,483 patients; 126 of the patients were subsequently excluded from the study because of incomplete data, leaving a study sample of 13,357 patients with complete data. Spine injuries were confirmed in the hospital records for 3% (n=415) of patients, including 50 patients with cord injuries and 128 patients with cervical injuries. Sensitivity of the EMS protocol was 92% (95% confidence interval [CI] 89.4 to 94.6%) resulting in nonimmobilization of 8% of the patients with spine injuries (33 of 415). None of the nonimmobilized patients sustained cord injuries. The specificity was 40% (95% CI 38.9 to 40.5%).

CONCLUSION

The use of our selective immobilization protocol resulted in spine immobilization for most patients with spine injury without causing harm in cases in which spine immobilization was withheld.

Incidence of stillbirth and perinatal mortality and their associated factors among women delivering at Harare Maternity Hospital, Zimbabwe: a cross-sectional retrospective analysis

Background

Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. Infant mortality remains a challenge in the care of pregnant women worldwide, but particularly for developing countries and the need to understand contributory factors is crucial for addressing appropriate perinatal health.

Methods

Using information available in obstetric records for all deliveries (17,072 births) at Harare Maternity Hospital, Zimbabwe, we conducted a cross-sectional retrospective analysis of a one-year data, (1997–1998) to assess demographic and obstetric risk factors for stillbirth and early neonatal death. We estimated risk of stillbirth and early neonatal death for each potential risk factor.

Results

The annual frequency of stillbirth was 56 per 1,000 total births. Women delivering stillbirths and early neonatal deaths were less likely to receive prenatal care (adjusted relative risk [RR] = 2.54; 95% confidence intervals [CI] 2.19–2.94 and RR = 2.52; 95% CI 1.63–3.91), which for combined stillbirths and early neonatal deaths increased with increasing gestational age (Hazard Ratio [HR] = 3.98, HR = 7.49 at 28 and 40 weeks of gestation, respectively). Rural residence was associated with risk of infant dying in utero, (RR = 1.33; 95% CI 1.12–1.59), and the risk of death increased with increasing gestational age (HR = 1.04, HR = 1.69, at 28 and 40 weeks of gestation, respectively). Older maternal age was associated with risk of death (HR = 1.50; 95% CI 1.21–1.84). Stillbirths were less likely to be delivered by Cesarean section (RR = 0.64; 95% CI 0.51–0.79), but more likely to be delivered as breech (RR = 4.65; 95% CI 3.88–5.57, as were early neonatal deaths (RR = 3.38; 95% CI 1.64–6.96).

Conclusion

The frequency of stillbirth, especially macerated, is high, 27 per 1000 total births. Early prenatal care could help reduce perinatal death linking the woman to the health care system, increasing the probability that she would seek timely emergency care that would reduce the likelihood of death of her infant in utero. Improved quality of obstetric care during labor and delivery may help reduce the number of fresh stillbirths and early neonatal deaths.