Chemical variability of Copaifera reticulata Ducke oleoresin

The copaiba tree (Copaifera spp.) produces an oleoresin which is highly valued due to its medicinal properties. The chemical composition of C. reticulata oleoresin was characterized, and its variability related to seasonal variation (dry and rainy seasons), to successive extractions, and to several factors associated with tree morphometry, disease, and surrounding vegetation structure was investigated. Oleoresin was collected from 24 C. reticulata individuals between October 2006 and March 2008. For seven individuals, oleoresin was extracted for a second time between three and nine months after the first extraction. For each tree, several morphometric variables, viz., the presence of termites, vines, and holes as well as the soil type and surrounding vegetation structure, were recorded. The chemical composition and concentration of the main volatile compounds were identified by GC/MS. Almost 100% of the constituents were sesquiterpenes, the three main ones being β-caryophyllene, trans-α-bergamotene, and β-bisabolene. A classification analysis separated the C. reticulata individuals in two main groups and further divided one of the main groups in two subgroups, which were defined by different concentrations of the three main compounds. The results showed high intra-population variability in the composition and concentration of sesquiterpenes, this being comparable to the interspecific variability. It was not possible to determine a clear influence of environmental, morphometrical, and structural factors on the oleoresin composition, although some compounds varied according to the soil type, the volume of oleoresin extracted, and the crown surface.

[Budget impact analysis of the first-line treatment of relapsing remitting multiple sclerosis in Spain]

AIM

To assess the budget impact of the treatment for relapsing remitting multiple sclerosis (RRMS), interferons, and glatiramer acetate, from the National Health System perspective in Spain.

PATIENTS AND METHODS

A budget impact model was designed to compare the cost of RRMS treatment in different settings, using a five year time-horizon, considering different percentages of administration of each medication. A reference setting o base case using all the available first line treatments (interferons and glatiramer acetate) was compared with five alternatives scenarios excluding each one of these treatments. The cost analysis (euros, year 2010) includes direct medical resources (drugs, administration, visits, disease management, diagnostic tests). Unitary cost data was obtained from the health costs database e-Salud and drugs catalogue.

RESULTS

Considering a cohort of 22 255 patients with RRMS, the mean global budget impact per year would be 260 775 470 euros in the base case. The setting that excluded glatiramer acetate increases the budget impact in a 3.23% (372 euros per patient per year). Pharmacological costs were the key drivers of total cost (90%).

CONCLUSION

The use of glatiramer acetate in the first-line-treatment of RRMS patients is a cost-saving strategy, which may decrease the budget impact from the National Health System perspective in Spain.

Systematic review of the use of fibrin sealant in abdominal-wall repair surgery

PURPOSE

Our objective was to analyze the advantages and inconveniences associated with the use of fibrin sealant compared with mechanical means for mesh fixation following abdominal-wall surgery.

METHODS

Literature search was conducted in MedLine, EMBASE, and Cochrane Library Plus databases. Articles were randomized clinical trials, nonrandomized comparative studies, and case series containing at least ten patients.

RESULTS

The fibrin sealant was shown to be biocompatible with the surrounding tissue. In patients treated with fibrin sealant, lower prevalence of acute and chronic postoperative pain was observed, and less hemorrhagic complications occurred. There are no data on the influence of fibrin sealant on seroma decrease. Efficiency in experimental models was similar to that observed for mechanical methods of fixation. Also, adhesions with fibrin sealant were less than that for mechanical methods.

CONCLUSIONS

Compared with mechanical methods, fibrin sealant is an efficacious alternative for mesh fixation postsurgery of the abdominal wall.

Global spending on orphan drugs in France, Germany, the UK, Italy and Spain during 2007

BACKGROUND

Orphan drugs are indicated for the treatment of rare diseases which, in the EU, are defined as those with a prevalence of <5 per 10000 inhabitants. Characteristically, these diseases negatively affect health-related quality of life and may be life threatening. The EU has passed legislation to encourage pharmaceutical companies to invest in research programmes into rare diseases, with the aim of developing new, safe and effective orphan drugs.

OBJECTIVES

To describe the status of orphan drugs in five countries in the EU (France, Germany, the UK, Italy and Spain), estimate the mean annual cost per patient and indication of these orphan drugs, and determine the associated cost of these drugs in comparison with overall spending on drugs in each country (year 2007 values).

METHODS

The analysis was limited solely to costs of orphan drugs with sales data available for 2007. The mean annual cost per patient was estimated using recommended regimens for maintenance dose and duration from the summary of product characteristics. Likewise, the ratio between annual costs per patient for treatment of each disease and its prevalence was calculated. Sales data were available for at least one of the countries studied for 38 of the 44 orphan drugs authorized by the European Medicines Agency. Only 21 products had data available for all five countries studied.

RESULTS

Germany was the country with access to the largest number of orphan drugs (36), followed by the UK (34), Spain (28), France (27) and Italy (25). The mean annual cost per patient and indication of the 38 orphan drugs on the market ranged widely from €331 to €337,501. It appears that orphan drugs indicated to treat diseases with a prevalence of <2 per 10000 inhabitants have higher annual per-patient costs than those indicated to treat diseases with a higher prevalence. The percentage of total drug spending accounted for by orphan drugs in 2007 was 1.7% in France, 2.1% in Germany, 1.0% in the UK, 1.5% in Italy and 2.0% in Spain, with an average overall percentage of 1.7% for these five countries.

CONCLUSIONS

In 2007, spending on orphan drugs in five European countries was acceptable in terms of the percentage of these countries' overall drug expenditure. Mean annual costs per patient of orphan drugs varied widely, with costs being related to the prevalence of the disease for which the product is indicated.

Suboxone (buprenorphine/naloxone) as an agonist opioid treatment in Spain: a budgetary impact analysis

OBJECTIVE

To evaluate the economic impact of buprenorphine/naloxone (B/N) as an agonist opioid treatment for opiate dependence.

METHODS

A budgetary impact analysis model was designed to calculate the annual costs (drugs and associated costs) to the Spanish National Healthcare System of methadone versus B/N. Data for the model were obtained from official databases and expert panel opinion.

RESULTS

It was estimated that 86,017 patients would be in an agonist opioid treatment program each of the 3 years of the study. No increase in the number of patients is expected with the introduction of B/N combination. The budgetary impact (drugs and associated costs) for agonist opiate treatment in the first year of the study would be 89.53 million EUR. In the first year of B/N use, the budgetary impact would rise by 4.39 million EUR (4.6% of the total impact), with an incremental cost of 0.79 million EUR (0.9% of the total impact). The budgetary increase would be 0.6% (0.48 million EUR increase) and 0.6% (0.49 million EUR increase) in the second and third years of use, respectively. The mean cost per patient in the first year with and without B/N would be EUR 1,050 and 1,041, respectively. The most influential variables in the sensitivity analysis were logistics and production costs of methadone and the percentage use of B/N.

CONCLUSION

With an additional cost of only EUR 9 per patient, B/N is an efficient addition to the therapeutic arsenal in the drug treatment of opiate dependence, particularly when considering clinical aspects of novel pharmacotherapy.

Modeling the cost-effectiveness of different oral antiviral therapies in patients with chronic hepatitis B

BACKGROUND/AIMS

Chronic hepatitis B (CHB) is a common disease associated with high morbidity, mortality and impact on healthcare costs. Several oral antiviral therapies can lead to complete virologic response, which is associated with prevention of disease progression. The aim of this study was to estimate the cost-effectiveness of the oral antiviral treatments lamivudine, adefovir, telbivudine, entecavir and tenofovir, in patients with CHB.

METHODS

A Markov model was used to project the lifetime complications and costs in cohorts of both HBeAg-positive and HBeAg-negative CHB patients treated with one of the above drugs or no treatment. Rescue therapy with two different combination therapies (adefovir plus lamivudine or tenofovir plus entecavir) with their corresponding costs and efficacy rates was also considered. The probabilities of disease progression were based on serum HBV DNA levels. Disease and complication costs were assessed using the perspective of the Spanish National Health System.

RESULTS

The highest rate of virologic response was obtained with tenofovir, and this translated to its higher life years saved (LYS) and quality adjusted life years (QALY) compared with the rest of the alternatives in HBeAg-positive and HBeAg-negative patients. Tenofovir is associated with lower costs and higher efficacy over entecavir, telbivudine and adefovir in HBeAg-positive patients, and telbivudine and entecavir in HBeAg-negative patients. The incremental cost-effectiveness ratios with respect to the rest of the alternatives are below the common reference efficiency threshold of 30,000 euro per LYS/QALY.

CONCLUSION

In chronic HBV infected patients, tenofovir is a cost-effective or even cost-saving strategy compared with other available treatment options for CHB.

[Budget impact of a set-dose combination of efavirenz-emtricitabine-tenofovir in the treatment of patients infected with HIV-1]

OBJECTIVE

Estimate the budgetary impact of using a set-dose combination of efavirenz-emtricitabine-tenofovir for the Spanish health care system's treatment of patients infected with HIV-1, while evaluating repercussions for each autonomous community in 2008.

METHODS

We developed a budgetary impact model with pharmacological costs for the different currently available treatment options, based on GeSida's recommended guidelines for treating HIV-positive patients. The model defines five possible scenarios in which various possibilities for substituting different drug cocktails with the efavirenz-emtricitabine-enofovir combination are contemplated.

RESULTS

The investment per patient on a national level amounts to euro7,989 in the base scenario (without considering the availability of the efavirenz-emtricitabine-tenofovir combination) and to euro7,997, euro8,424, euro7,830, euro8,375 and euro8,527 for scenario 1 (substitution of recommended drugs with efavirenz, emtricitabine and tenofovir or efavirenz, lamivudine and tenofovir); scenario 2 (substitution of recommended drugs with efavirenz); scenario 3 (substitution of recommended drugs with tenofovir); scenario 4 (substitution of recommended drugs with tenoforvir or zidovudine) and scenario 5 (total substitution), respectively. Compared with the base scenario this means increments of 0.11 %, 5.45 %, -1.99 %, 4.83 % and 6.73 % for scenarios 1, 2, 3, 4 and 5.

CONCLUSION

Use of a set combination of efavirenz, emtricitabine and tenofovir to treat adult patients with the HIV-1 virus would lead to slight surpluses or even budgetary savings by decreasing the number of daily doses, which could increase patients' quality of life and help them stay on the treatment properly.

Coordination features of a hybrid scorpionate/phosphane ligand exemplified with Iridium

Although the pentacoordinated complex [Ir{(allyl)B(CH(2)PPh(2))(pz)(2)}(cod)] (1; pz=pyrazolyl, cod=1,5-cyclooctadiene), isolated from the reaction of [{Ir(mu-Cl)(cod)}(2)] with [Li(tmen)][B(allyl)(CH(2)PPh(2))- (pz)(2)] (tmen=N,N,N',N'-tetramethylethane-1,2-diamine), shows behavior similar to that of the related hydridotris(pyrazolyl)borate complex, the carbonyl derivatives behave in a quite different way. On carbonylation of 1, the metal--metal-bonded complex [(Ir{(allyl)B(CH(2)PPh(2))(pz)(2)}CO)(2)(mu-CO)] (2) that results has a single ketonic carbonyl bridge. This bridging carbonyl is labile such that upon treatment of 2 with PMe(3) the pentacoordinated Ir(I) complex [Ir(CO){(pz)B(eta(2)-CH(2)CH=CH(2))(CH(2)PPh(2))(pz)}(PMe(3))] (3) was isolated. Complex 3 shows a unique fac coordination of the hybrid ligand with the allyl group eta(2)-bonded to the metal in the equatorial plane of a distorted trigonal bipyramid with one pyrazolate group remaining uncoordinated. This unusual feature can be rationalized on the basis of the electron-rich nature of the metal center. The related complex [Ir(CO){(pz)B(eta(2)-CH(2)CH=CH(2))(CH(2)PPh(2))(pz)}(PPh(3))] (4) was found to exist in solution as a temperature-dependent equilibrium between the cis-pentacoordinated and trans square planar isomers with respect to the phosphorus donor atoms. Protonation of 3 with different acids is selective at the iridium center and gives the cationic hydrides [Ir{(allyl)B(CH(2)PPh(2))(pz)(2)}(CO)H(PMe(3))]X (X=BF(4) (5), MeCO(2) (6), and Cl (7)). Complex 7 further reacts with HCl to generate the unexpected product [Ir(CO)Cl{(Hpz)B(CH(2)PPh(2))(pz)CH(2)CH(Me)}(PMe(3))]Cl (9; Hpz=protonated pyrazolyl group) formed by the insertion of the hydride into the Ir-(eta(2)-allyl) bond. In contrast, protonation of complex 4 with HCl stops at the hydrido complex [Ir{(allyl)B(CH(2)PPh(2))(pz)(2)}(CO)H(PPh(3))]Cl (8). X-ray diffraction studies carried out on complexes 2, 3, and 9 show the versatility of the hybrid scorpionate ligand in its coordination.

Resource use in patients with Crohn's disease treated with infliximab

AIM

To estimate the impact of infliximab (IFX) on hospital resources for patients with Crohn's disease.

METHODS

Resource use data for at least 1 year before (B-IFX) and after (A-IFX) infliximab administration were retrospectively collected for all patients treated with IFX at the Hospital Cabueñes (Spain). Direct costs calculated were: hospital-stays, surgeries, out-patient visits, diagnostic and laboratory tests, pharmacological treatments, and day-care hospitalization for IFX administration.

RESULTS

Patients (n = 34; mean age at treatment: 43.6 years) with 9.8 and 4.3 years (B-IFX and A-IFX, respectively) had their costs estimated. Partial or complete response was achieved in 82% of patients. Total annual B-IFX costs per patient were Euro 4,464, of which 62.4% was for hospitalization, 3.1% for surgery, 8.7% for consultation visits, 16.2% for diagnostic and laboratory tests, and 9.6% for other treatments. Total annual A-IFX costs per patient were Euro 10,594; of which 6.4% was for hospitalization, 0.8% for surgery, 4.2% for consultation visits, 7.6% for diagnostic and laboratory tests, 5.5% for other treatments, and 75.5% for IFX and its administration. The primary cost item was hospitalization (Euro 2,783) during the B-IFX period as opposed to IFX itself (Euro 7,996) during the subsequent A-IFX period.

CONCLUSIONS

In routine practice, IFX appears to be an effective treatment by reducing hospital-stays, but increases overall budgetary cost for patients with Crohn's disease.

Evaluating the cost of sustained virologic response in naïve chronic hepatitis C patients treated à la carte

BACKGROUND

There is a tendency to individualize treatment in chronic hepatitis C patients depending on viral load and rapid clearance of HCV-RNA.

AIM

To evaluate the cost (euro, 2006) per sustained virologic response in naïve patients with therapy à la carte compared with standard combination therapy.

METHODS

A decision analysis model was used to compare standard therapy with peginterferon alpha and ribavirin for 24 weeks for genotype (G) 2/3, and 48 weeks for G1 and therapy à la carte with the same drugs but different durations: G1 high viral load for 48 weeks, G1 low viral load with rapid virologic response for 24 weeks, and without rapid virologic response for 48 weeks, and G2/3 with rapid virologic response for 12 weeks, and without rapid virologic response for 24 weeks.

RESULTS

Sustained virologic response was similar in both strategies. The cost per successfully treated patient for standard therapy is 17,812 euros and for therapy à la carte 12,313 euros. Assuming that 13,309 patients with standard therapy and 14,450 patients with therapy à la carte achieve sustained virologic response, therapy à la carte has an overall cost-saving of 59.13 million euros.

CONCLUSION

Therapy à la carte is a cost-saving strategy for chronic hepatitis C infection compared to standard therapy, with lower investment requirement per patient to achieve sustained virologic response.

Costs and quality of life of multiple sclerosis in Spain

This cost-of-illness analysis is based on information from 1.848 patients in Spain and is part of a Europe-wide study on the costs of multiple sclerosis. The objective was to analyze the costs and quality of life (QOL) related to the level of disease severity and progression. Patients were identified by the Asociación Española de Esclerosis Múltiple (AEDEM) and participated in the survey by answering a mail questionnaire (response rate 31.8%). In addition to details on the disease (type of disease, relapses, level of functional disability), the questionnaire asked for information on all resource consumption, medical, non-medical, work absence and informal care, as well as utility (QOL). The mean age of the cohort was 45 years, and only 5.5% of patients were 65 years of age or more. Approximately 36% of patients had mild disease (Expanded Disability Status Scale [EDSS] score of 0-3), 44.8% had moderate disease (EDSS score of 4-6.5) and 17.7% had severe disease (EDSS score > or =7). The mean EDSS score in the sample was 4.5 (median 5.0), with a utility of 0.554. Costs and utility are highly correlated with disease severity. Workforce participation decreases from around 70% in early disease to less than 5% in the very late stages. Hospitalization is very infrequent in early disease, representing less than euro 1.300 per patient per year for patients at EDSS scores <6, but increases steeply for patients at scores > or =7. Ambulatory care increases fivefold between early and late disease, while investments and services increase from basically no cost to just over euro 6.000 at EDSS scores > or =7. Productivity losses increase more than eightfold, and informal care increases from euro 593 at EDSS scores of 0-1 to nearly euro 34.228 at scores of 8-9. Hence, total mean costs per patient are driven by the distribution of the severity levels in the sample, increasing from euro 10.425 at EDSS scores of 0-1 to euro 45.264 at a score of 7, and euro 65.693 at scores of 8-9. The same is true for utility, which decreases from 0.865 to 0.084 as patients progress from the mildest to the most severe disability levels. However, the utility loss compared to the age- and gender-matched general population is high at all levels of the disease ( approximately 0.25 in patients below 30 years of age with an EDSS score of 2-3, and approximately 0.4 in patients over 60 years of age and a score of > or =6), leading to an estimated annual loss of 0.276 quality-adjusted life-year per patient. Relapses for patients with an EDSS score below 5 are associated with a cost of approximately euro 2.750 and a utility loss of 0.1 during the quarter in which they occur.

Effects of elevation, slope position and livestock exclusion on microfungi isolated from soils of Mediterranean grasslands

The fungal communities of grassland soils in Spain from four sites at different elevations were studied. Each site contained grazed and fenced ungrazed plots. These plots were situated in two slope positions (upper and lower zones). The ungrazed plots, fenced off 6 y before the sampling, were part of a study of global change that simulates conditions of rural abandonment, which is widespread in Iberian countries, since Spain joined the European Union. We analyzed the structure of the soil fungi communities and its relationship with herbaceous vegetation. The distribution of 207 taxa of fungi revealed that the elevation was the main factor of fungal variability; the effect of grazing and slope position were associated with less variability. Although a halt in grazing resulted in the accumulation of standing plants and plant litter in these ecosystems, it had relatively little effect on soil microfungi and appeared to be related mainly to growing conditions affected by that accumulation.

Cost-effectiveness analysis of lamivudine and adefovir dipivoxil in the treatment of patients with HBeAg-negative chronic hepatitis B

AIM

To estimate the cost-effectiveness over a 4-year duration of lamivudine and adefovir dipivoxil for patients with hepatitis B 'e' antigen-negative chronic hepatitis B.

METHODS

A decision analysis model has been used to perform a cost-effectiveness analysis of lamivudine and adefovir dipivoxil from the perspective of the Spanish Public Health System. Data were obtained from clinical trials.

RESULTS

For the base-case, the total estimated cost per patient treated with lamivudine or adefovir dipivoxil for 4 years was 11,457 and 21,939 respectively. Virological response at year 4 for the lamivudine arm was 40.4% and 78.0% for the adefovir dipivoxil arm. The average cost-effectiveness ratio (cost per responding patient at year 4) was 28,375 for the lamivudine arm and 28,132 for the adefovir dipivoxil arm. The incremental cost-effectiveness ratio of adefovir dipivoxil vs. lamivudine (cost per additional responding patient with adefovir dipivoxil) was 27,872, demonstrating that this cost was slightly lower than the average cost-effectiveness ratios of adefovir dipivoxil or lamivudine. The sensitivity analysis demonstrated that the factors that most influence the cost-effectiveness were the response to adefovir dipivoxil and lamivudine at year 4.

CONCLUSION

Long-term treatment with adefovir dipivoxil is a cost-effective strategy in patients with chronic hepatitis B 'e' antigen-negative hepatitis.

Tris(pyrazolyl)borate carbosilane dendrimers and metallodendrimers

A modified tris(pyrazolylborate) ligand has been prepared in two steps. First, reaction of triisopropylborate with allylmagnesium bromide and further treatment with benzoyl chloride gave CH(2) = CHCH(2)B(O(i)Pr), which was then reacted with potassium pyrazolate and pyrazole to give the compound K[CH(2) = CHCH(2)Bpz(3)]. The new allyl-containing scorpionate anion of acts as a bi- or tri-dentate ligand, as shown by the mononuclear complexes [CH(2) = CHCH(2)Bpz(3)M(LL)] (M = Rh, LL = nbd, ; LL = tfb, ; LL = (CO)(PPh(3)), ; M = Ir, LL = cod, ), obtained from reactions of the chlorido-bridged dinuclear complexes [{M(mu-Cl)(LL)}(2)] with 2. Furthermore, the borate represents a key material to achieve the attachment of tris(pyrazolyl)borate groups to the peripheries of carbosilane dendrimers. Thus, the platinum-catalyzed hydrosilylation reactions of compound with the dendritic cores Si[(CH(2))(3)SiMe(2)H](4) (G(0)-(SiH)(4)), (G(1)-(SiH)(8)), and (G(2)-(SiH)(16)) gave the corresponding borate-containing dendrimers Si[(CH(2))(3)SiMe(2)(CH(2))(3)B(O(i)Pr)(2)](4) (G(0)-B(4)), Si[(CH(2))(3)SiMe{(CH(2))(3)SiMe(2)(CH(2))(3)B(O(i)Pr)(2)}(2)](4) (G(1)-B(8)), and Si[(CH(2))(3)SiMe{(CH(2))(3)SiMe[(CH(2))(3)SiMe(2)(CH(2))(3)B(O(i)Pr)(2)](2)}(2)](4) (G(2)-B(16)) selectively in the anti-Markovnikov direction. Further reactions of G(0)-B(4), G(1)-B(8) and G(2)-B(16) with potassium pyrazolate and pyrazole rendered the corresponding polyanionic dendrimers K(4)[Si{(CH(2))(3)SiMe(2)(CH(2))(3)Bpz(3)}(4)] (G(0)-(Bpz(3))(4)), G(1)-(Bpz(3))(8), and G(2)-(Bpz(3))(16), respectively, which contain 4, 8, and 16 tris(pyrazolyl)borate groups symmetrically located around the dendritic peripheries. These unusual polyanionic dendrimers are excellent scaffolds to support metal centres, as shown by the reactions of G(0)-(Bpz(3))(4), G(1)-(Bpz(3))(8), and G(2)-(Bpz(3))(16) with [{Rh(mu-Cl)(nbd)}(2)] to give the neutral rhodadendrimers [Si{(CH(2))(3)SiMe(2)(CH(2))(3)Bpz(3)Rh(nbd)}(4)] G(0)-(Bpz(3)Rh)(4), G(1)-(Bpz(3)Rh)(8) and G(2)-(Bpz(3)Rh)(16) as stable solids in excellent yields. Following this protocol, mixed rhodium/iridium metallodendrimers can be prepared.

Lipase Active-Site-Directed Anchoring of Organometallics: Metallopincer/Protein Hybrids

The work described herein presents a strategy for the regioselective introduction of organometallic complexes into the active site of the lipase cutinase. Nitrophenol phosphonate esters, well known for their lipase inhibitory activity, are used as anchor functionalities and were found to be ideal tools to develop a single-site-directed immobilization method. A small series of phosphonate esters, covalently attached to ECE "pincer"-type d8-metal complexes through a propyl tether (ECE=[C6H3(CH2E)(2)-2,6]-; E=NR2 or SR), were designed and synthesized. Cutinase was treated with these organometallic phosphonate esters and the new metal-complex/protein hybrids were identified as containing exactly one organometallic unit per protein. The organometallic proteins were purified by membrane dialysis and analyzed by ESI-mass spectrometry. The major advantages of this strategy are: 1) one transition metal can be introduced regioselectively and, hence, the metal environment can potentially be fine-tuned; 2) purification procedures are facile due to the use of pre-synthesized metal complexes; and, most importantly, 3) the covalent attachment of robust organometallic pincer complexes to an enzyme is achieved, which will prevent metal leaching from these hybrids. The approach presented herein can be regarded as a tool in the development of regio- and enantioselective catalyst as well as analytical probes for studying enzyme properties (e.g., structure) and, hence, is a "proof-of-principle design" study in enzyme chemistry.