A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

OBJECTIVE

To determine the relative cost-effectiveness of three classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the modified TCA lofepramine, as first choice treatments for depression in primary care.

DESIGN

Open, pragmatic, controlled trial with three randomised arms and one preference arm. Patients were followed up for 12 months.

SETTING

UK primary care: 73 practices in urban and rural areas in England.

PARTICIPANTS

Patients with a new episode of depressive illness according to GP diagnosis.

INTERVENTIONS

Patients were randomised to receive a TCA (amitriptyline, dothiepin or imipramine), an SSRI (fluoxetine, sertraline or paroxetine) or lofepramine. Patients or GPs were able to choose an alternative treatment if preferred.

MAIN OUTCOME MEASURES

At baseline the Clinical Interview Schedule, Revised (CIS-R PROQSY computerised version) was administered to establish symptom profiles. Outcome measures over the 12-month follow-up included the Hospital Anxiety and Depression Scale self-rating of depression (HAD-D), CIS-R, EuroQol (EQ-5D) for quality of life, Short Form (SF-36) for generic health status, and patient and practice records of use of health and social services. The primary effectiveness outcome was the number of depression-free weeks (HAD-D less than 8, with interpolation of intervening values) and the primary cost outcome total direct NHS costs. Quality-adjusted life-years (QALYs) were used as the outcome measure in a secondary analysis. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were computed. Estimates were bootstrapped with 5000 replications.

RESULTS

In total, 327 patients were randomised. Follow-up rates were 68% at 3 months and 52% at 1 year. Linear regression analysis revealed no significant differences between groups in number of depression-free weeks when adjusted for baseline HAD-D. A higher proportion of patients randomised to TCAs entered the preference arm than those allocated to the other choices. Switching to another class of antidepressant in the first few weeks of treatment occurred significantly more often in the lofepramine arm and less in the preference arm. There were no significant differences between arms in mean cost per depression-free week. For values placed on an additional QALY of over 5000 pounds, treatment with SSRIs was likely to be the most cost-effective strategy. TCAs were the least likely to be cost-effective as first choice of antidepressant for most values of a depression-free week or QALY respectively, but these differences were relatively modest.

CONCLUSIONS

When comparing the different treatment options, no significant differences were found in outcomes or costs within the sample, but when outcomes and costs were analysed together, the resulting cost-effectiveness acceptability curves suggested that SSRIs were likely to be the most cost-effective option, although the probability of this did not rise above 0.6. Choosing lofepramine is likely to lead to a greater proportion of patients switching treatment in the first few weeks. Further research is still needed on the management of depressive illness in primary care. This should address areas such as the optimum severity threshold at which medication should be used; the feasibility and effectiveness of adopting structured depression management programmes in the UK context; the importance of factors such as physical co-morbidity and recent life events in GPs' prescribing decisions; alternative ways of collecting data; and the factors that give rise to many patients being reluctant to accept medication and discontinue treatment early.

Measurement of partial widths and search for direct CP violation in D0 meson decays to K-K+ and pi-pi+

We present a measurement of relative partial widths and decay rate CP asymmetries in K-K+ and pi(-)pi(+) decays of D0 mesons produced in pp collisions at sqrt[s]=1.96 TeV. We use a sample of 2x10(5) D(*+)-->D0pi(+) (and charge conjugate) decays with the D0 decaying to K-pi(+), K-K+, and pi(-)pi(+), corresponding to 123 pb(-1) of data collected by the Collider Detector at Fermilab II experiment at the Fermilab Tevatron collider. No significant direct CP violation is observed. We measure Gamma(D0-->K-K+)/Gamma(D0-->K-pi(+))=0.0992+/-0.0011+/-0.0012, Gamma(D0-->pi(-)pi(+))/Gamma(D0-->K-pi(+))=0.035 94+/-0.000 54+/-0.000 40, A(CP)(K-K+)=(2.0+/-1.2+/-0.6)%, and A(CP)(pi(-)pi(+))=(1.0+/-1.3+/-0.6)%, where, in all cases, the first uncertainty is statistical and the second is systematic.

Involvement in treatment decisions: what do adults with asthma want and what do they get? Results of a cross sectional survey

BACKGROUND

Current healthcare policy advocates patient participation in treatment decision making. However, in asthma there is little evidence regarding patients' views on such involvement. This study explored the preferred and perceived level of involvement in treatment decisions, rationales for role preference, perceived facilitators of/barriers to involvement, and the interrelationship of role preference and demographic variables in a sample of patients with asthma.

METHODS

A cross sectional survey was performed of 230 adults with clinician diagnosed asthma from 10 primary care sites and one specialist respiratory centre in north-west England. Preferred role in treatment decisions was assessed using the Control Preferences Scale.

RESULTS

Fifty five (23.9%) preferred an active role, 82 (35.7%) a collaborative role, and 93 (40.4%) a passive role; 19 (8.2%) perceived their role as active compared with 45 (19.6%) collaborative and 166 (72.2%) passive. Only 33.5% (n = 77) of respondents attained their most preferred role; 55.2% (n = 127) were less involved than they preferred. Patient related, professional related, and organisational factors, especially quality and duration of consultations, facilitated or hampered involvement. Role preferences were not strongly associated with demographic variables or asthma severity.

CONCLUSIONS

This study in patients with asthma highlights the fact that there is a need for professional and patient education regarding partnership working, skilful communication, and innovative approaches to service delivery.

Measurement of the lifetime difference between Bs mass eigenstates

We present measurements of the lifetimes and polarization amplitudes for B(0)(s)-->J/psiphi and B(0)(d)-->J/psiK(*0) decays. Lifetimes of the heavy and light mass eigenstates in the B(0)(s) system are separately measured for the first time by determining the relative contributions of amplitudes with definite CP as a function of the decay time. Using 203+/-15 B(0)(s) decays we obtain tau(L) = (1.05(+0.16)(-0.13) +/- 0.02) ps and tau(H) = (2.07(+0.58)(-0.46) +/- 0.03) ps. Expressed in terms of the difference DeltaGamma(s) and average Gamma(s), of the decay rates of the two eigenstates, the results are DeltaGamma(s)/Gamma(s) = (65(+25)(-33) +/- 1)% and DeltaGamma(s) = (0.47(+0.19)(-0.24) +/- 0.01) ps(-1).

Search for excited and exotic electrons in the egamma decay channel in pp collisions at sqrt[s] = 1.96 TeV

We present a search for excited and exotic electrons (e(*)) decaying to an electron and a photon, both with high transverse momentum. We use 202 pb(-1) of data collected in pp collisions at sqrt[s] = 1.96 TeV with the Collider Detector at Fermilab II detector. No signal above standard model expectation is seen for associated ee(*) production. We discuss the e(*) sensitivity in the parameter space of the excited electron mass M(e(*)) and the compositeness energy scale Lambda. In the contact interaction model, we exclude 132 GeV/c(2)<M(e(*))<879 GeV/c(2) for Lambda = M(e(*)) at 95% confidence level (C.L.). In the gauge-mediated model, we exclude 126 GeV/c(2) < M(e(*)) < 430 GeV/c(2) at 95% C.L. for the phenomenological coupling f/Lambda approximately 10(-2) GeV-1.

First measurements of inclusive W and Z cross sections from run II of the fermilab tevatron collider

We report the first measurements of inclusive W and Z cross sections times leptonic branching ratios for pp collisions at square root[s]=1.96 TeV, based on their decays to electrons and muons. The data correspond to an integrated luminosity of 72 pb(-1) recorded with the CDF detector at the Fermilab Tevatron. We test e-mu universality in W decays, and we measure the ratio of leptonic W and Z rates from which the leptonic branching fraction B(W-->lnu) can be extracted as well as an indirect value for the total width of the W and the Cabibbo-Kobayashi-Maskawa matrix element, |V(cs)|.

Measurement of Wgamma and Zgamma production in pp collisions at square root s=1.96 TeV

The standard model predictions for Wgamma and Zgamma production are tested using an integrated luminosity of 200 pb(-1) of pp collision data collected at the Collider Detector at Fermilab. The cross sections are measured by selecting leptonic decays of the W and Z bosons, and photons with transverse energy ET>7 GeV that are well separated from leptons. The production cross sections and kinematic distributions for the Wgamma and Zgamma data are compared to SM predictions.

Cost-effectiveness of formoterol and salbutamol as asthma reliever medication in Sweden and in Spain

This study aimed to evaluate the cost-effectiveness of formoterol (Oxis) Turbuhaler 4.5 microg and salbutamol 200 microg as reliever medications in Sweden and Spain. The study used data on effectiveness (exacerbations and symptom-free days) and resource utilisation from an open, 6-month, parallel-group, multicentre randomised trial with 18,124 asthma patients in 24 countries. Country-specific unit costs for Sweden and for Spain were used to transform resource utilisation data into costs. Total healthcare costs were not significantly different between formoterol and salbutamol dry powder inhalers in Sweden, whereas in Spain, the healthcare costs were 20% higher for formoterol vs. salbutamol pressurised metered dose inhalers. Total healthcare costs increased with disease severity, defined according to the Global Initiative for Asthma guidelines. Compared with salbutamol, formoterol produced statistically significant improvements in effectiveness, less reliever and maintenance medication usage, reduced healthcare resource utilisation, with no increase or a limited increase in healthcare cost.

Search for doubly charged Higgs bosons decaying to dileptons in pp collisions at square root of s=1.96 TeV

We present the results of a search for doubly charged Higgs bosons (H+/-+/-) decaying to dileptons (ll(')) using approximately 240 pb(-1) of pp collision data collected by the CDF II experiment at the Fermilab Tevatron. In our search region, given by same-sign ll(') mass m(ll('))>80 GeV/c(2) (100 GeV/c(2) for ee channel), we observe no evidence for H+/-+/- production. We set limits on sigma(pp -->H++H---->l(+)l('+)l(-)l('-)) as a function of the mass of the H+/-+/- and the chirality of its couplings. Assuming exclusive same-sign dilepton decays, we derive lower mass limits on H(+/-+/-)(L) of 133, 136, and 115 GeV/c(2) in the ee, mumu, and emu channels, respectively, and a lower mass limit of 113 GeV/c(2) on H(+/-+/-)(R) in the mumu channel, all at the 95% confidence level.

Continuous ambulatory peritoneal dialysis (CAPD) versus hospital or home haemodialysis for end-stage renal disease in adults

BACKGROUND

Renal replacement therapy (RRT) with dialysis and transplantation is the only means of sustaining life for patients with end-stage renal disease (ESRD). Although transplantation is the treatment of choice, the number of donor kidneys are limited and transplants may fail. Hence many patients require long-term or even life-long dialysis. Continuous ambulatory peritoneal dialysis (CAPD) is an alternative to hospital or home haemodialysis for patients with ESRD.

OBJECTIVES

To assess the benefits and harms of CAPD versus hospital or home haemodialysis for adults with ESRD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), the Cochrane Renal Group's specialised register, MEDLINE (1966 - May 2002), EMBASE (1980 - May 2002), BIOSIS, CINAHL, SIGLE and NRR without language restriction. Reference lists of retrieved articles and conference proceedings were searched and known investigators and biomedical companies were contacted. Date of most recent search January 2004.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing CAPD to hospital or home haemodialysis for adults with ESRD were to be included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assess the methodological quality of studies. Data was abstracted from included studies onto a standard form by one reviewer and checked by another. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

One trial, reported in abstract form only, was located in the most recent search. There was no statistical difference in death or quality adjusted life years score at 2 years between peritoneal dialysis or haemodialysis patients.

REVIEWERS' CONCLUSIONS

There is Insufficient data to allow conclusions to be drawn about the relative effectiveness of CAPD compared with hospital or home haemodialysis for adults with ESRD. Efforts should be made to start and complete adequately powered RCTs, which compare the different dialysis modalities.

Measurement of the tt production cross section in pp collisions at sqrt[s]=1.96 TeV using dilepton events

We report a measurement of the tt production cross section using dilepton events with jets and missing transverse energy in pp collisions at a center-of-mass energy of 1.96 TeV. Using a 197+/-12 pb(-1) data sample recorded by the upgraded Collider Detector at Fermilab, we use two complementary techniques to select candidate events. We compare the number of observed events and selected kinematical distributions with the predictions of the standard model and find good agreement. The combined result of the two techniques yields a tt production cross section of 7.0(+2.4)(-2.1)(stat)+1.6-1.1(syst)+/-0.4(lum) pb.

Inclusive double-pomeron exchange at the fermilab tevatron p p collider

We report results from a study of events with a double-Pomeron exchange topology produced in p p collisions at sqrt[s]=1800 GeV. The events are characterized by a leading antiproton and a large rapidity gap on the outgoing proton side. We find that the differential production cross section agrees in shape with predictions based on Regge theory and factorization, and that the ratio of double-Pomeron exchange to single diffractive production rates is relatively unsuppressed as compared to the O(10) suppression factor previously measured in single diffractive production.

Predominance and genetic diversity of community- and hospital-acquired CTX-M extended-spectrum β-lactamases in York, UK

OBJECTIVES

This study was conducted to detect the presence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae within the faecal flora of both community- and hospital-based patients in York and to characterize the bla(TEM), bla(SHV) and bla(CTX-M) genes present in these isolates.

METHODS

One thousand faeces samples were collected and screened at York Hospital during October-December 2003. Ninety-five non-duplicate Enterobacteriaceae isolates resistant to third-generation cephalosporins were recovered; 22 isolates were selected for further study on the basis of a positive double disc diffusion test for ESBL production. Antibiotic susceptibility testing was performed to a range of antibiotics. The TEM, SHV and CTX-M genes were detected by PCR and the DNA sequenced.

RESULTS

The distribution of ESBL-positive isolates from the hospital and community was 1.4:1. These included nine Escherichia coli, seven Enterobacter cloacae, four Citrobacter freundii and a single isolate each of Klebsiella spp. and Salmonella spp. A total of 17 isolates contained bla(CTX-M) (five bla(CTX-M-15), three bla(CTX-M-14) and nine bla(CTX-M-9)). ISEcp1 was present in isolates expressing CTX-M-14 and -15, but was absent upstream of In60-associated bla(CTX-M-9). E. coli isolates also contained either a bla(TEM-1) or bla(TEM-2), whereas six of the E. cloacae carried bla(SHV-12) and the Klebsiella spp. bla(SHV-36) in addition to bla(CTX-M-9). The single Salmonella spp. carried bla(SHV-12).

CONCLUSIONS

The overall prevalence of ESBL in isolates of Enterobacteriaceae from York was 1.9%. ESBL-producing isolates were found in both the community and hospital, with the CTX-M type most common. This is also the first report of an ESBL-producing Salmonella in the UK.

Observation of the narrow state X(3872)-->J/psipi+pi- in pp collisions at sqaure root of s=1.96 TeV

We report the observation of a narrow state decaying into J/psipi+pi- and produced in 220 pb(-1) of p p-bar collisions at =1.96 Tesqaure root of sV in the CDF II experiment. We observe 730+/-90 decays. The mass is measured to be 3871.3+/-0.7(stat)+/-0.4(syst) MeV/c2, with an observed width consistent with the detector resolution. This is in agreement with the recent observation by the Belle Collaboration of the X(3872) meson.

Inclusive search for anomalous production of high-pT like-sign lepton pairs in pp collisions at square root s = 1.8 TeV

We report on a search for anomalous production of events with at least two charged, isolated, like-sign leptons, each with pT > 11 GeV/c using a 107 pb(-1) sample of 1.8 TeV pp collisions collected by the CDF detector. We define a signal region containing low background from standard model processes. To avoid bias, we fix the final cuts before examining the event yield in the signal region using control regions to test the Monte Carlo predictions. We observe no events in the signal region, consistent with an expectation of 0.63(+0.84)(-0.07) events. We present 95% confidence level limits on new physics processes in both a signature-based context as well as within a representative minimal supergravity (tanbeta = 3) model.

Search for B0s-->micro+micro- and B0d-->micro+micro- decays in pp collisions at square root s = 1.96 TeV

We report on a search for B(0)(s)-->micro(+)micro(-) and B(0)(d)-->micro(+)micro(-) decays in pp collisions at square root of s=1.96 TeV using 171 pb(-1) of data collected by the CDF II experiment at the Fermilab Tevatron Collider. The decay rates of these rare processes are sensitive to contributions from physics beyond the standard model. One event survives all our selection requirements, consistent with the background expectation. We derive branching ratio limits of B(B(0)(s)-->micro(+)micro(-))<5.8x10(-7) and B(B(0)(d)-->micro(+)micro(-))<1.5x10(-7) at 90% confidence level.

Utilization of appetite suppressants in England: a putative indicator of poor prescribing practice

The use of appetite suppressants, a putative inverse marker of prescribing quality, was analysed in the former Northern Regional Health Authority (RHA) and in England using National Health Service prescribing data and sales and patient-linked prescribing data supplied by Intercontinental Medical Statistics (IMS). The number (in thousands) of National Health Service prescriptions for appetite suppressants dispensed fell from 393 in 1991 to 235 in 1994. Per capita prescribing frequency varied threefold between different RHA and between individual Family Health Service Authorities (FHSA) within the former Northern RHA (NRHA). Prescribing frequency was higher in the spring and summer quarters and reduced in the winter quarter. Of 532 general practices in the NRHA, 82 (15%) prescribed no appetite suppressants between April 1993 and March 1994, while 70 (13%) prescribed more than 500 defined daily doses (DDDs) per 1000 patients, accounting for 47% of all prescribing. Only 53% of pharmacy purchases of appetite suppressants were accounted for by NHS prescribing and as little as 21% for phentermine, indicating substantial prescribing outwith the NHS. In 1991, 73,759 DDDs were supplied to pharmacies each day, the majority being diethylpropion (31,226) and phentermine (24,349). The fall in NHS prescribing is welcome as these drugs are of dubious clinical value and may be associated with serious adverse effects. Because of substantial non-NHS prescribing, routinely available prescribing data does not accurately quantify total prescribing of these agents.

Endotoxin has an indirect vasodilatory effect on isolated human skeletal muscle arterioles

BACKGROUND

Septic shock and its effects are a major cause of mortality in the intensive care environment. The exact effect and mechanism of endotoxin has yet to be fully described. With a better understanding of this process, better clinical tools could be developed to treat these patients.

HYPOTHESIS

Endotoxin has no direct effect on human skeletal muscle microvasculature and requires the release of an endothelial-derived factor to produce the vasodilation seen in gram-negative sepsis.

DESIGN

Benchtop research using an isolated arteriole model with controlled exposure to endotoxin.

SETTING

University medical center.

METHODS

First-order arterioles (approximately 150- micro m diameter) were isolated from human cremasteric muscles and pressurized to physiologic levels before exposure to an endotoxin-rich effluent with and without an upstream conduit vessel (superficial epigastric vein). The vasodilatory effect was measured with videomicroscopy and compared with control samples.

MAIN OUTCOME MEASURES

Mean vessel diameter and percentage of loss in tone.

RESULTS

When compared with controls, the isolated arteriole had no significant response when exposed to endotoxin alone (3.5% change in basal tone). When the endotoxin was allowed to pass over an upstream conduit vessel, the arteriole showed marked dilation (14.2% loss of basal tone).

CONCLUSIONS

This study demonstrates that endotoxin has no direct vasodilatory effect on human skeletal muscle arterioles, but it is the release of an endothelial factor from the upstream conduit vessels that produces the loss of tone in the microvasculature. Further research is ongoing to characterize the factors involved (nuclear factor-kappaB, tumor necrosis factor alpha, and interleuklin 6) for possible clinical intervention (antioxidants, cyclosporine, and nitric oxdide synthase inhibitors).

Search for Kaluza-Klein graviton emission in pp collisions at square root[s] = 1.8 TeV using the missing energy signature

We report on a search for direct Kaluza-Klein graviton production in a data sample of 84 pb(-1) of ppmacr; collisions at sqrt[s]=1.8 TeV, recorded by the Collider Detector at Fermilab. We investigate the final state of large missing transverse energy and one or two high energy jets. We compare the data with the predictions from a (3+1+n)-dimensional Kaluza-Klein scenario in which gravity becomes strong at the TeV scale. At 95% confidence level (C.L.) for n=2, 4, and 6 we exclude an effective Planck scale below 1.0, 0.77, and 0.71 TeV, respectively.

Search for pair production of scalar top quarks in R-parity violating decay modes in pp collisions at square root of s=1.8 TeV

We present the results of a search for pair production of scalar top quarks (t(1)) in an R-parity violating supersymmetry scenario in 106 pb(-1) of pp collisions at square root of s=1.8 TeV collected by the Collider Detector at Fermilab. In this mode each t(1) decays into a tau lepton and a b quark. We search for events with two tau's, one decaying leptonically (e or mu) and one decaying hadronically, and two jets. No candidate events pass our final selection criteria. We set a 95% confidence level lower limit on the t(1) mass at 122 GeV/c(2) for Br(t(1)-->tau b)=1.