Adverse effects and associated costs with second- and third-line therapies for non-small cell lung cancer

e19009

Background: Chemotherapies used in the treatment of non-small cell lung cancer (NSCLC) are associated with a number of adverse effects (AEs), which may increase health care use and costs as patients receive treatment for these AEs.The objectives of this study were to compare occurrence of selected AEs and associated costs among patients receiving docetaxel (D), erlotinib (E), or pemetrexed (P) monotherapy as 2nd- or 3rd-line treatment of NSCLC in a retrospective claims database. Methods: Commercial enrollees with evidence of lung cancer were identified using ICD-9-CM diagnosis codes between 6/2004 and 12/2006. Pharmacy and medical claims were used to identify patients who received D, E, or P monotherapy as 2nd- or 3rd-line treatment. AEs were identified based upon diagnosis, procedure and prescription codes. Costs were compared between cohorts on a per month basis due to variable follow-up time. Results: Of 679 patients receiving 2nd-line treatment, 110 received D, 145 received E, and 116 received P. The most frequent AE was nausea/vomiting (N/V), which occurred in 90% of study subjects. Anemia (64%), neutropenia (35%), dyspnea (34%), and other respiratory AEs (35%) were also common. Compared with D, E was associated with significantly lower rates of neutropenia (3% vs. 46%; p < 0.0001), N/V (60% vs. 100%; p < 0.0001), and dehydration (10% vs. 20%; p = 0.03). P was also associated with higher rates of neutropenia and N/V than E (22% and 97%, respectively; p < 0.0001), as well as having a higher occurrence of anemia (74% vs. 49%; p < 0.0001). Costs to manage these AEs were also lower for E, with total costs related to AEs of $1494 for E, compared with $4386 for D (p = 0.004) and $6317 for P (p < 0.0001). Of 335 patients receiving 3rd-line treatment, 33 received D, 79 received E, and 80 received P. At least one AE was experienced by all patients in the D and P cohorts, while 73 (92%) E patients experienced at least one AE (p = 0.10 vs. D; p = 0.01 vs. P). Costs to manage AEs in the 3rd-line setting were lower for E ($2765) than for P ($4718; p = 0.02), while costs for E and D ($3680) were not significantly different (p = 0.28). Conclusions: Overall, occurrence of AEs commonly associated with 2nd- and 3rd-line agents for NSCLC was less frequent and less costly among E users.

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Haemodynamic effects of intravenously administered prenalterol in patients with severe heart failure

The acute haemodynamic effects of prenalterol 75-225 micrograms/kg i.v. were studied at rest and during exercise in the supine position in 12 patients with chronic congestive heart failure secondary to myocardial infarction (6 pts), chronic valvular disease with valvular replacement (4 pts), ischaemic cardiomyopathy (1 pt) and post myocarditis (1 pt). In 5 of the 6 AMI patients the effect of prenalterol on myocardial oxygen consumption at rest was measured. Pulmonary artery end-diastolic pressure decreased significantly from 17 to 10 mm Hg at rest and from 31 to 21 mm Hg during exercise. Resting heart rate increased from 78 to 90 at rest but was unchanged during exercise. MVO2 in the 5 patients was unchanged or lower in 4 patients and increased in one in whom angina developed after prenalterol. In general, dyspnoea and angina during exercise were less pronounced after prenalterol. The calculated triple product was lower after prenalterol, especially during exercise, indicating lower myocardial oxygen consumption and probably less myocardial ischaemia.

Effects of prenalterol administered orally in patients with congestive heart failure

A single-blind study of prenalterol 20-200 mg daily in a slow-release tablet preparation and a placebo was performed in 15 patients with moderate to severe congestive heart failure (NYHA II-IV) to evaluate the haemodynamic and clinical effects of oral prenalterol. Non-invasive parameters in the measurement of cardiac output, stroke volume, pre-ejection period index (PEPI), PEP/LVET ratio, ejection fraction and mean Vcf were significantly improved, indicating beneficial effects of prenalterol on cardiac contractility. Systolic blood pressure, heart rate and rate-pressure product were slightly increased at rest but were considerably lower during exercise. Arrhythmogenecity was not seen in the patients studied. Subjective improvement was noted in the majority of patients as evidenced by a decreased frequency of dyspnoea, fatigue and angina. Unwanted effects, such as palpitations and transmitted arm pulsations, were transient and disappeared with dose adjustment, while the inotropic effect of the medication was maintained. The clinical response appeared to be sustained for up to 2 weeks of treatment, indicating non-development of tachyphylaxis.

Cost-effectiveness of rituximab plus CVP for first-line treatment of advanced indolent lymphoma

6583

Background: The addition of rituximab (RTX) to CVP (cyclophosphamide, vincristine, prednisone) in the treatment of advanced follicular lymphoma increases median time to progression by 17 months (15 month v 32 months; p < 0.0001) (Marcus et al, Blood 2005). A societal cost-effectiveness analysis was performed to estimate projected lifetime clinical and economic implications of this treatment. Methods: The cost-effectiveness (CE) of RTX + CVP versus CVP was estimated for a 50 yr old patient. Kaplan-Meier estimates of progression-free and overall survival, up to 4 years, were obtained from the M39021 trial. After 4 years, transition rates from initiation of treatment to progression or death were assumed to be the same in both arms. The clinical and economic implications of relapse and its treatment were included in the model. Incremental costs associated with addition of RTX were estimated using Medicare reimbursement rates and published retail price data. Costs included drug and administration costs, adverse events, treatment of relapses, and end-of-life costs. Utility estimates were derived from the literature and a 3% discount rate was employed. Results: Projected mean overall survival is 1.5 yrs longer for patients assigned to RTX+ CVP versus only CVP (13.7 v 12.2 yrs). The addition of RTX to CVP is estimated to cost an additional $26,439 on average, with an expected gain of 0.85 year of quality-adjusted survival. Over a lifetime, the cost per QALY gained is $31,329. Sensitivity analyses revealed that the variables that most influenced cost-effectiveness were the time horizon (range: $18,800- $31,240) and the unit drug cost of RTX (range: $24,000-$38,000). Conclusion: The model estimates a cost-to-QALY gained ratio that is below that of many treatments used for oncology patients. The use of RTX + CVP for first-line treatment of advanced follicular lymphoma is projected to be cost-effective compared to CVP alone under a range of sensitivity analyses.

No significant financial relationships to disclose.

FIGO Save the Mothers Initiative: the Central America and USA collaboration

The American College of Obstetricians and Gynecologists (ACOG) and the Central American Federation of Associations and Societies of Obstetrics and Gynecology (FECASOG), as a part of the FIGO Save the Mothers Initiative, undertook a pilot project to improve provision of basic emergency obstetric care in selected departments in four Central American countries. This article describes the process of the development and implementation of the project. Preliminary results suggest that the capacity to provide this care has been improved by the training of healthcare personnel.

Substance P immunoreactivity in the enteric nervous system in Rett syndrome

Rett syndrome is associated with profound mental retardation and motor disability in girls. It has a characteristic clinical phenotype which includes abnormalities of the autonomic nervous system. Feeding impairment and severe constipation are two symptoms of this autonomic dysfunction. Substance P, an important peptide in the autonomic nervous system, is decreased in the cerebrospinal fluid of Rett syndrome. We have demonstrated that substance P immunoreactivity is significantly decreased in Rett syndrome brain-stem and may be related to the autonomic dysfunction. In this study, we have continued the investigation of substance P in the enteric nervous system. We immunohistochemically examined the normal developing bowel in 22 controls (ages, 14 gestational weeks to 31 years) using formalin fixed tissue, with antibodies to substance P, tyrosine hydroxylase and vasoactive intestinal peptide. We compared the immunoreactivity of normal controls with 14 cases of Rett syndrome (ages, 5-41 years) and observed that the expression of substance P, tyrosine hydroxylase and vasoactive intestinal peptide immunoreactivity in the bowel in Rett syndrome was not significantly different from that of controls. This suggests that the feeding impairment and constipation in Rett syndrome relate to dysfunction of the autonomic nervous system originating outside of the bowel, in the brain-stem, as suggested by our previous study.

A first high-density map of 981 biallelic markers on human chromosome 14

As the largest set of sequence variants, single-nucleotide polymorphisms (SNPs) constitute powerful assets for mapping genes and mutations related to common diseases and for pharmacogenetic studies. A major goal in human genetics is to establish a high-density map of the genome containing several hundred thousand SNPs. Here we assayed 3.7 Mb (154,397 bp in 24 alleles) of chromosome 14 expressed sequence tags (ESTs) and sequence-tagged sites, for sequence variation in DNA samples from 12 African individuals. We identified and mapped 480 biallelic markers (459 SNPs and 21 small insertions and deletions), equally distributed between EST and non-EST classes. Extensive research in public databases also yielded 604 chromosome 14 SNPs (dbSNPs), 520 of which could be mapped and 19 of which are common between CNG (i.e., identified at the Centre National de Génotypage) and dbSNP polymorphisms. We present a dense map of SNP variation of human chromosome 14 based on 981 nonredundant biallelic markers present among 1345 radiation hybrid mapped sequence objects. Next, bioinformatic tools allowed 945 significant sequence alignments to chromosome 14 contigs, giving the precise chromosome sequence position for 70% of the mapped sequences and SNPs. In addition, these tools also permitted the identification and mapping of 273 SNPs in 159 known genes. The availability of this SNP map will permit a wide range of genetic studies on a complete chromosome. The recognition of 45 genes with multiple SNPs, by allowing the construction of haplotypes, should facilitate pharmacogenetic studies in the corresponding regions.

Calculating structures and free energies of complex molecules: combining molecular mechanics and continuum models

A historical perspective on the application of molecular dynamics (MD) to biological macromolecules is presented. Recent developments combining state-of-the-art force fields with continuum solvation calculations have allowed us to reach the fourth era of MD applications in which one can often derive both accurate structure and accurate relative free energies from molecular dynamics trajectories. We illustrate such applications on nucleic acid duplexes, RNA hairpins, protein folding trajectories, and protein-ligand, protein-protein, and protein-nucleic acid interactions.

Does perchlorate in drinking water affect thyroid function in newborns or school-age children?

Perchlorate is known to suppress thyroid function by inhibiting uptake of iodide by the human thyroid at doses of 200 mg/day or greater. A study was conducted to investigate the potential effects of perchlorate in drinking water on thyroid function in newborns and school-age children. A total of 162 school-age children and 9784 newborns were studied in three proximate cities in northern Chile that have different concentrations of perchlorate in drinking water: Taltal (100 to 120 micrograms/L), Chañaral (5 to 7 micrograms/L), and Antofagasta (non-detectable: < 4 micrograms/L). Among schoolchildren, no difference was found in thyroid-stimulating hormone levels or goiter prevalence among lifelong residents of Taltal or Chañaral compared with those of Antofagasta, after adjusting for age, sex, and urinary iodine. No presumptive cases of congenital hypothyroidism were detected in Taltal or Chañaral; seven cases were detected in Antofagasta. Neonatal thyroid-stimulating hormone levels were significantly lower in Taltal compared with Antofagasta; this is opposite to the known pharmacological effect of perchlorate, and the magnitude of difference did not seem to be clinically significant. These findings do not support the hypothesis that perchlorate in drinking water at concentrations as high as 100 to 120 micrograms/L suppresses thyroid function in newborns or school-age children.

Linkage analysis of candidate myelin genes in familial multiple sclerosis

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system. A complex genetic etiology is thought to underlie susceptibility to this disease. The present study was designed to analyze whether differences in genes that encode myelin proteins influence susceptibility to MS. We performed linkage analysis of MS to markers in chromosomal regions that include the genes encoding myelin basic protein (MBP), proteolipid protein (PLP), myelin-associated glycoprotein (MAG), oligodendrocyte myelin glycoprotein (OMGP), and myelin oligodendrocyte glycoprotein (MOG) in a well-characterized population of 65 multiplex MS families consisting of 399 total individuals, 169 affected with MS and 102 affected sibpairs. Physical mapping data permitted placement of MAG and PLP genes on the Genethon genetic map; all other genes were mapped on the Genethon genetic map by linkage analysis. For each gene, at least one marker within the gene and/or two tightly linked flanking markers were analyzed. Marker data analysis employed a combination of genetic trait model-dependent (parametric) and model-independent linkage methods. Results indicate that MAG, MBP, OMGP, and PLP genes do not have a significant genetic effect on susceptibility to MS in this population. As MOG resides within the MHC, a potential role of the MOG gene could not be excluded.

Analysis of an activator:coactivator complex reveals an essential role for secondary structure in transcriptional activation

Ser-133 phosphorylation of CREB within the kinase-inducible domain (KID) promotes target gene activation via complex formation with the KIX domain of the coactivator CBP. Concurrent phosphorylation of CREB at Ser-142 inhibits transcriptional induction via an unknown mechanism. Unstructured in the free state, KID folds into a helical structure upon binding to KIX. Using site-directed mutagenesis based on the NMR structure of the KID:KIX complex, we have examined the mechanisms by which Ser-133 and Ser-142 phosphorylation regulate CREB activity. Our results indicate that phospho-Ser-133 stablizes whereas phospho-Ser-142 disrupts secondary structure-mediated interactions between CREB and CBP. Thus, differential phosphorylation of CREB may form the basis by which upstream signals regulate the specificity of target gene activation.

Delayed repair of congenital diaphragmatic hernia with early high-frequency oscillatory ventilation during preoperative stabilization

PURPOSE

The authors reviewed their experience in the management of CDH after the introduction of early high-frequency oscillatory ventilation (HFOV) during the preoperative stabilization period and delayed CDH repair.

METHODS

This is a retrospective analysis of 24 consecutive infants with CDH treated at University of California, Irvine Medical Center (UCIMC) during a 36-month period from January 1993 to December 1996.

RESULTS

Two patients were excluded from the study: one fetus with a prenatal diagnosis was referred for fetal surgery; one infant received CDH repair at another institution 2 weeks before transfer to UCIMC. Eight (36%) infants were inborn, and nine (41%) had a prenatal diagnosis of CDH. Median gestational age was 40 weeks (range, 29 to 42 weeks). Median birth weight was 3,019 g (range, 1,205 to 4,337 g). The defect was left sided in 18 infants (86%). Twenty-one infants were intubated within 5 hours of life, 15 had an AaDO2 greater than 610, 11 had an oxygenation index greater than 40, and 11 had a pH of less than 7.2. The median ratio of pulmonary artery pressure to systemic blood pressure was 0.93 (range, 0.51 to 1.15) in 12 infants. Eighteen infants were placed on HFOV within a median of 1 hour of life. Nitric oxide was given to six infants and surfactant to eight. Four infants were referred for extracorporeal membrane oxygenation (ECMO). Repair of CDH was performed on infants at a median age of 33.5 hours (range, 5.5 to 322). Six (30%) received a prosthetic patch. Overall 18 of 22 infants survived (81%); three survivors received ECMO. Two infants of the survivor group had congenital heart anomalies: one ventricular septal defect (VSD) and one double-outlet right ventricle with a VSD. Of the four nonsurvivors, one had lethal cardiac anomalies and bilateral CDH, two had severe bilateral pulmonary hypoplasia (one received ECMO), and one infant was a 29-week premature baby who did not qualify for ECMO.

CONCLUSION

We report a survival rate of 81% (18 of 22) with the management of CDH by delayed surgical repair, early postnatal HFOV, and selective referral for ECMO.

Fetal lung maturation. Comparison of biochemical indices in gestational diabetic and nondiabetic pregnancies

OBJECTIVE

To compare the biochemical maturation of the components of the lung profile according to gestational age between reliably dated gestational diabetic and nondiabetic pregnancies.

STUDY DESIGN

Lung maturation was compared in reliably dated pregnancies in 501 gestational diabetic women and 561 nondiabetic women. Lecithin/sphingomyelin ratio (L/S) and phosphatidylglycerol (PG) were evaluated by analysis of variance according to the presence or absence of diabetes and weeks of gestational age. The effect of gestational diabetes on fetal lung maturation was determined by analysis of variance.

RESULTS

The gestational diabetic group had no clinical or statistical differences in L/S ratios as compared to the nondiabetic patients at any gestational age. There were no differences in mean percent PG between the diabetic and nondiabetic groups at any gestational age. By 37 completed weeks, 86% of the L/S ratios and 78% of the PG values were mature in the diabetic group as compared to 80% of the L/S ratios and 78% of the PG values in the control group (P = .33 and .43, respectively).

CONCLUSION

In reliably dated gestational diabetic pregnancies, biochemical maturation of the fetal lung strongly correlates with gestational age and does not appear to be significantly delayed when compared to a nondiabetic control group.

Cytomegalovirus enteritis in a premature infant

BACKGROUND/PURPOSE

Up to 2.5% of newborn infants are cytomegalovirus (CMV) positive at birth. Five percent will be symptomatic at birth, including cytomegalic inclusion disease. Symptoms such as hearing loss and mental retardation will ultimately develop in 15%.

METHODS

The authors describe a case of CMV enteritis in a 2.2-kg newborn that presented as necrotizing enterocolitis (NEC) and subsequently developed a colonic stricture.

RESULTS

There are four reports of neonatal CMV enteritis in the nonEnglish-language literature. Cytomegalovirus enteritis has become prevalent among the immunosuppressed pediatric and adult patient population.

CONCLUSIONS

We propose the addition of CMV to the list of pathogens responsible for NEC. A review of neonatal CMV infection is provided.

A directional clustering technique for random data classification

This paper introduces a new clustering technique for random data classification based on an enhanced version of the Voronoi diagram. This technique is optimized to deal in the best way possible with data distributions which in their spatial representations experience overlap. A mathematical framework is given in view of this enhanced analysis and provides insight to key issues involving (a) the use of a correction process to complement the traditional Voronoi diagram and (b) the introduction of directional vectors in Gaussian and elliptical data distributions for enhanced data clustering. The computational requirements of the proposed approach are provided, and the computer results involving both randomly generated and real-world data prove the soundness of this clustering technique.