3D mapping of somatotopic reorganization with small animal functional MRI

There are few in vivo noninvasive methods to study neuroplasticity in animal brains. Functional MRI (fMRI) has been developed for animal brain mapping, but few fMRI studies have analyzed functional alteration due to plasticity in animal models. One major limitation is that fMRI maps are characterized by statistical parametric mapping making the apparent boundary dependent on the statistical threshold used. Here, we developed a method to characterize the location of center-of-mass in fMRI maps that is shown not to be sensitive to statistical threshold. Utilizing centers-of-mass as anchor points to fit the spatial distribution of the BOLD response enabled quantitative group analysis of altered boundaries of functional somatosensory maps. This approach was used to study cortical reorganization in the rat primary somatosensory cortex (S1) after sensory deprivation to the barrel cortex by follicle ablation (F.A.). FMRI demonstrated an enlarged nose S1 representation in the 3D somatotopic functional maps. This result clearly demonstrates that fMRI enables the spatial mapping of functional changes that can characterize multiple regions of S1 cortex and still be sensitive to changes due to plasticity.

Hsp70 prevents disuse muscle atrophy in senescent rats

This study determined the effects of heat shock protein 70 (Hsp70) overexpression on disuse muscle atrophy in senescent rats. Solei of young and senescent rats were co-injected with Hsp70 plus a nuclear factor kappa B (NF-kappaBeta) reporter plasmid. After 4 days, the hind limbs of half the young and senescent rats were immobilized for 6 days with the remainder serving as weight bearing controls. Hsp70 protein levels and cross-sectional area decreased in both groups (~20%) after immobilization. Atrophy was prevented in those fibers overexpressing Hsp70. NF-kappaBeta activity increased in the soleus of both young (three-fold) and senescent (five-fold) animals after immobilization and was prevented by Hsp70 overexpression. Inhibitor of kappaBeta decreased in young (~30%) and senescent (~10%) animals with immobilization and returned to normal with Hsp70. Heat shock protein 70 overexpression prevents disuse atrophy in senescent rats, possibly through suppression of the NF-kappaB pathway.

Preoperative resolution of jaundice following biliary stenting predicts more favourable early survival in resected pancreatic ductal adenocarcinoma

INTRODUCTION

Despite the widespread use of endoscopic biliary stenting in patients presenting with potentially resectable pancreatic cancer, there is no general consensus regarding whether this represents a superior management approach over expeditious surgical intervention. The objective of this study was to investigate the influence of preoperative biliary stenting and resolution of jaundice on subsequent postoperative survival following resection for pancreatic cancer.

METHODS

155 patients undergoing partial pancreatoduodenectomy for pancreatic ductal adenocarcinoma between January 1997 and August 2007 were identified from a prospectively maintained database.

RESULTS

There was no survival difference when comparing patients undergoing preoperative biliary drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When analysing individual prognostic factors as continuous variables in univariate Cox analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels (P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer overall survival. Multivariable Cox regression demonstrated that both albumin (P = 0.008) and CRP (P = 0.038) remained significant independent predictors of overall survival alongside lymph node ratio (P = 0.018). Although preoperative bilirubin levels were not associated with overall survival when analysed as a continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin >35 micromol/l) at the time of surgery was a significant adverse predictor of early survival in patients undergoing preoperative biliary drainage (Breslow-Gehan-Wilcoxon, P = 0.013) and remained a significant predictor of early survival when included in a further Cox analysis with censoring of cases who survived beyond 6 months (Cox, P = 0.017).

CONCLUSION

These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.

The in vivo rat muscle force model is a reliable and clinically relevant test of consistency among botulinum toxin preparations

To ensure safety and predictable clinical efficacy, the biological activity of type A botulinum toxin (BoNT-A) preparations must remain consistent. Several methods have been employed to assess consistency but lack clinical applicability and/or are associated with animal welfare concerns. Here, we describe a novel in vivo rat muscle force model for evaluating the biological activity of formulated BoNT-A product (Dysport) prepared from bulk toxin batches manufactured at different facilities. Toxin activity was assessed by measuring muscle force generation over time in the triceps surae muscles in the rat hind leg. Animals received 0.1 ml gelatine phosphate buffer (negative vehicle control) or 0.1 or 1.0 LD50 units of BoNT-A in phosphate buffer. Batch equivalence and consistency were confirmed by the lack of significant differences in muscle force generation and duration of effect between each test batch and the reference preparation tested in the same series of experiments. The reduction in muscle force generation was dose-related and reproducible for all active treatment groups. At appropriate dose levels, the rat muscle force model is a reliable tool for measuring biological activity in bulk toxin batches used to formulate clinical product and demonstrates the consistency of batches manufactured over many years.

Micro-engineered local field control for high-sensitivity multispectral MRI

In recent years, biotechnology and biomedical research have benefited from the introduction of a variety of specialized nanoparticles whose well-defined, optically distinguishable signatures enable simultaneous tracking of numerous biological indicators. Unfortunately, equivalent multiplexing capabilities are largely absent in the field of magnetic resonance imaging (MRI). Comparable magnetic-resonance labels have generally been limited to relatively simple chemically synthesized superparamagnetic microparticles that are, to a large extent, indistinguishable from one another. Here we show how it is instead possible to use a top-down microfabrication approach to effectively encode distinguishable spectral signatures into the geometry of magnetic microstructures. Although based on different physical principles from those of optically probed nanoparticles, these geometrically defined magnetic microstructures permit a multiplexing functionality in the magnetic resonance radio-frequency spectrum that is in many ways analogous to that permitted by quantum dots in the optical spectrum. Additionally, in situ modification of particle geometries may facilitate radio-frequency probing of various local physiological variables.

Dopamine dysregulation syndrome: implications for a dopamine hypothesis of bipolar disorder

OBJECTIVE

Rational therapeutic development in bipolar is hampered by a lack of pathophysiological model. However, there is a wealth of converging data on the role of dopamine in bipolar disorder. This paper therefore examines the possibility of a dopamine hypothesis for bipolar disorder.

METHOD

A literature search was conducted using standard search engines Embase, PyschLIT, PubMed and MEDLINE. In addition, papers and book chapters known to the authors were retrieved and examined for further relevant articles.

RESULTS

Collectively, in excess of 100 articles were reviewed from which approximately 75% were relevant to the focus of this paper.

CONCLUSION

Pharmacological models suggest a role of increased dopaminergic drive in mania and the converse in depression. In Parkinson's disease, administration of high-dose dopamine precursors can produce a 'maniform' picture, which switches into a depressive analogue on withdrawal. It is possible that in bipolar disorder there is a cyclical process, where increased dopaminergic transmission in mania leads to a secondary down regulation of dopaminergic receptor sensitivity over time. This may lead to a period of decreased dopaminergic transmission, corresponding with the depressive phase, and the repetition of the cycle. This model, if verified, may have implications for rational drug development.

History of illness prior to a diagnosis of bipolar disorder or schizoaffective disorder

BACKGROUND

There are obstacles to early identification of bipolar disorder. Identifying and treating illness early in its time course may be associated with a better prognosis.

METHODS

A questionnaire was administered at interview, when the participant was euthymic, to participants (n=240) enrolled in the Bipolar Comprehensive Outcomes Study (BCOS). Information was collected about the sequential timeline of specific symptoms of mental illness up to when they first received a diagnosis of Bipolar Disorder or Schizoaffective Disorder.

RESULTS

Any symptoms of mental illness were first experienced at 17.5 years (median; Inter Quartile Range (IQR) 13.8-24.3; n=216) and mood swings at 18.0 years (IQR 14-25; n=197). Symptoms of depression were experienced at 18.0 years (IQR 14-25; n=197), a full episode of depression at 21.2 years (IQR 17-28.5; n=200), symptoms of mania at 21.0 years (IQR 16.8-29.5; n=212) and a full episode of mania at 24.1 years (IQR 19-30.5; n=205). Medical treatment was sought at 24.0 years (IQR 19-31.5; n=217). Participants received a diagnosis of Bipolar Disorder or Schizoaffective Disorder at 30.0 years (IQR 23-37.3; n=215). Having had a previous diagnosis other than Bipolar Disorder or Schizoaffective Disorder was reported by 120 of 216 participants who answered this question, most commonly unipolar depression (26.6%). Diagnostic delay was greater in individuals with early onset disorder.

CONCLUSIONS

Participants typically experience a long sequential course of symptoms, episodes, treatments and diagnosis. The polarity of onset is most commonly depressive, and subthreshold symptoms tend to precede threshold symptoms of both polarities.

LIMITATIONS

Data were collected retrospectively.

Dopamine dysregulation syndrome: implications for a dopamine hypothesis of bipolar disorder

OBJECTIVE

Rational therapeutic development in bipolar is hampered by a lack of pathophysiological model. However, there is a wealth of converging data on the role of dopamine in bipolar disorder. This paper therefore examines the possibility of a dopamine hypothesis for bipolar disorder.

METHOD

A literature search was conducted using standard search engines Embase, PyschLIT, PubMed and MEDLINE. In addition, papers and book chapters known to the authors were retrieved and examined for further relevant articles.

RESULTS

Collectively, in excess of 100 articles were reviewed from which approximately 75% were relevant to the focus of this paper.

CONCLUSION

Pharmacological models suggest a role of increased dopaminergic drive in mania and the converse in depression. In Parkinson's disease, administration of high-dose dopamine precursors can produce a 'maniform' picture, which switches into a depressive analogue on withdrawal. It is possible that in bipolar disorder there is a cyclical process, where increased dopaminergic transmission in mania leads to a secondary down regulation of dopaminergic receptor sensitivity over time. This may lead to a period of decreased dopaminergic transmission, corresponding with the depressive phase, and the repetition of the cycle. This model, if verified, may have implications for rational drug development.

Low-dose aspirin for in vitro fertilisation

BACKGROUND

Low-dose aspirin is sometimes used to improve the outcome in women undergoing in vitro fertilisation, despite inconsistent evidence of efficacy and the potential risk of significant side affects. The most appropriate time to commence aspirin therapy and length of treatment required is also still to be determined.

OBJECTIVES

To determine the effectiveness of low-dose aspirin for improving the outcome of in vitro fertilisation and intracytoplasmic sperm injection treatment cycles.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (April 2007), MEDLINE (1966 to March 2007) and EMBASE (1980 to March 2007) databases using the following research terms: "(aspirin OR acetylsalicylic acid) AND (in-vitro fertilisation OR intracytoplasmic sperm injection)" combined with the Cochrane Menstrual Disorders and Subfertility Group's search strategy for identifying randomised controlled trials for reports which appeared to describe randomised controlled trials of low-dose aspirin for women undergoing in vitro fertilisation.

SELECTION CRITERIA

Prospective randomised controlled trials, published or unpublished, which addressed the objectives of the review. Quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies to include in the review, extracted data and assessed trial quality.

MAIN RESULTS

The searches identified nine trials which were eligible for inclusion in the review, including a total of 1449 participants. No significant differences were found between the treatment and control groups for any of the outcomes assessed. Only two studies (involving 401 participants) investigated the effect of low-dose aspirin on live birth rate, and no significant difference was found between the treatment and control groups (RR 0.94, 95% CI 0.63 to 1.39). No significant difference was found in clinical pregnancy rate between treatment and control groups, based on results from 1240 participants in seven studies (RR 1.09, 95% CI 0.83 to 1.43). No data were reported on adverse events related to aspirin treatment in any of the included studies.

AUTHORS' CONCLUSIONS

Use of low-dose aspirin for women undergoing in vitro fertilisation cannot currently be recommended due to lack of adequate trial data. There is a need for randomised controlled trials investigating the use of low-dose aspirin for different patient groups undergoing in vitro fertilisation. We used control group data from the largest trial included in this review to determine that a sample size of 350 women in each group would be required in order to demonstrate a 10% improvement from the use of aspirin with 80% power at the 5% significance level. Until evidence from appropriately powered trials is available, this treatment can not be recommended.

An in vitro biomechanical study comparing the spiral linking technique against the pulvertaft weave for tendon repair

A new spiral linking technique for tendon repair in which one end of the tendon is spiralled around the other end has been developed. Using pig trotter extensor tendons, the Pulvertaft weave technique was compared with this new technique. Twenty-five repairs using each technique were tested by tensile loading with an Instron testing machine. The spiral linking technique matched the strength of Pulvertaft method: the mean peak loads were 102 and 105 N, respectively. The Pulvertaft weave was stiffer than the spiral linking technique: mean stiffness of 11.1 and 6.7 N/mm, respectively. The spiral linking technique also absorbed considerably more energy: energy absorbed prior to failure to 90% of peak load, 1.75 and 1.13 kN mm, respectively. In conclusion, the spiral linking technique appears as strong as the Pulvertaft weave and we believe it is easier to perform.

Pemetrexed disodium for the treatment of malignant pleural mesothelioma: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of pemetrexed disodium in combination with cisplatin for the treatment of unresectable pleural mesothelioma in chemotherapy-naive patients.

DATA SOURCES

Electronic databases were searched up to May 2005.

REVIEW METHODS

The systematic review was conducted following accepted guidelines. An assessment of the economic submission received from the manufacturer of pemetrexed was also carried out. This comprised two sections, each employing an economic model. One of these models was then reformulated in order to carry out a separate exploration of economic performance.

RESULTS

One randomised controlled trial comparing pemetrexed and cisplatin with cisplatin alone, and involving a total study population of 448 patients, met the inclusion criteria. Pemetrexed in combination with cisplatin in this trial showed a 2.8-month gain in median survival compared with cisplatin alone in an intention-to-treat (ITT) population (12.1 and 9.3 months, respectively, p = 0.020, hazard ratio of 0.77). During the trial, increased reporting of severe toxicity in the pemetrexed arm led to a change in the protocol to add folic acid and vitamin B12 supplementation to therapy. For fully supplemented patients (n = 331) the hazard ratio for median survival in favour of pemetrexed plus cisplatin was also comparable (0.75), but of borderline significance between treatment arms (p = 0.051). The trial inclusion criteria restricted recruitment to those with a Karnofsky performance status of 70 or greater (equivalent to ECOG/WHO 0 or 1 scales more widely used in the UK). Quality of life scores using the Lung Cancer Symptom Scale demonstrated significantly greater improvement for pain and dyspnoea for patients in the combination group compared with those in the cisplatin group. In the ITT population, the incidence of serious toxicities with pemetrexed plus cisplatin was higher compared with cisplatin alone. However, the grade 3/4 toxicities of the combination arm, particularly leucopenia, neutropenia and diarrhoea, were found to be greatly improved by the addition of vitamin B12 and folic acid. The existing published economic literature was very limited. The economic evaluation conducted by the study (and that submitted by the manufacturer) suggested that pemetrexed is unlikely to be considered cost-effective at conventionally accepted thresholds in the UK for all patients, mainly because of the high cost of pemetrexed itself compared with cisplatin. These findings were better for some patient subgroups, e.g. especially for fully supplemented (FS) patients with good performance status (0/1) and advanced disease (AD). These findings seem robust. The estimated cost-effectiveness results were for the FS population, incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained = pound59,600; for the FS with AD population, ICER per QALY = pound47,600; for the FS with performance status 0/1 population, ICER per QALY = pound49,800; and for the FS with performance status 0/1 and AD population, ICER per QALY = pound36,700.

CONCLUSIONS

The new therapy examined in this document demonstrates an extension of life expectancy and palliation, as measured by time to progression of disease and other end-points. However, the absolute benefit obtained is small, and it needs to be weighed against the benefits of effective palliative care services. The limited benefit was also at the expense of considerable toxicity to patients. The economic evaluation conducted in this study and that of the manufacturers suggest that pemetrexed is not cost-effective at conventional thresholds for all patients. Cost-effectiveness seems better for some patient subgroups, e.g. especially for patients with good performance status and with advanced diseases, where it is estimated the ICER per QALY would be pound36,700. Given the relatively small number of patients with mesothelioma, albeit increasing, the overall budget impact of pemetrexed would be unlikely to be more than pound5 million per year at present costs. Much more research is needed into the optimum chemotherapy for patients with mesothelioma and a clear definition of what constitutes best supportive care.

Pemetrexed disodium in combination with cisplatin versus other cytotoxic agents or supportive care for the treatment of malignant pleural mesothelioma

BACKGROUND

Malignant pleural mesothelioma (MPM) is a highly aggressive malignancy whose incidence is expected to increase in the United Kingdom, Western Europe, and Australia over the next 20 years as a result of occupational exposure to asbestos fibres. Surgery is feasible in only a small proportion of cases, and radiotherapy and cytotoxic chemotherapy are used in palliation. Pemetrexed is the first and only chemotherapy agent that has been granted a marketing approval for use in combination with cisplatin for the treatment of chemo-naïve patients with unresectable MPM.

OBJECTIVES

To examine evidence on the clinical effectiveness of pemetrexed disodium used in combination with cisplatin for the treatment of unresectable malignant pleural mesothelioma in chemotherapy naïve patients compared with other cytotoxic agents used alone or in combination, or supportive care.

SEARCH STRATEGY

CENTRAL (Issue 2, 2005), EMBASE (1980-2005), MEDLINE (1980-2005), HTA database (1990-2005), Web of Knowledge (1990-2005) and handsearching (including reference lists of retrieved articles and the pharmaceutical company submission to to NICE), up to October 2005.

SELECTION CRITERIA

Randomised Controlled Trials (RCTs) where the use of pemetrexed disodium in combination with cisplatin is compared with other cytotoxic agents, or supportive care for the treatment of malignant pleural mesothelioma (or non-RCTs, in the absence of RCT data ).

DATA COLLECTION AND ANALYSIS

Outcomes included overall survival, tumour response, progression-free survival, toxicity and quality of life. Data extraction and quality assessment of included trials was completed independently. Trial data and quality assessment were tabulated and presented narratively.

MAIN RESULTS

One RCT involving 448 patients and comparing pemetrexed plus cisplatin versus cisplatin alone for the treatment of unresectable malignant mesothelioma was included in the review. In the intention-to-treat study population, the median survival was statistically significantly longer in the combination arm of pemetrexed plus cisplatin when compared with the cisplatin alone arm. (12.1 and 9.3 months, respectively, p=0.002). The incidence of grade 3/4 toxicities was higher in the combination arm compared with the cisplatin alone arm.

AUTHORS' CONCLUSIONS

Pemetrexed disodium in combination with cisplatin and with folic acid and vitamin B(12 )supplementation may improve survival when used in combination with cisplatin in good performance status patients. Further studies including patients with poor performance status are needed in order to generalise the treatment findings. Further studies are also needed into the optimum chemotherapy, and a clear definition of what constitutes best supportive care.

Comparison of conference abstracts and presentations with full-text articles in the health technology assessments of rapidly evolving technologies

OBJECTIVES

To assess the extent of use of data from conference abstracts and presentations in health technology assessments (HTAs) provided as part of the National Institute for Health and Clinical Excellence (NICE) appraisal process. Also to assess the methodological quality of trials from conference abstracts and presentations, the consistency of reporting major outcomes between these sources and subsequent full-length publications, the effect of inclusion or exclusion of data from these sources on the meta-analysis pooled effect estimates, and the timeliness of availability of data from these sources and full articles in relation to the development of technology assessment reviews (TARs).

DATA SOURCES

A survey of seven TAR groups. An audit of published TARs: included all NICE TARs published between January 2000 and October 2004. Case studies of selected TARs.

REVIEW METHODS

Analyses of the results of the survey and audit were presented as a descriptive summary and in a tabular format. Sensitivity analyses were carried out to compare the effect of inclusion of data from abstracts and presentations on the meta-analysis pooled effect estimates by including data from both abstracts/presentations and full papers, and data from only full publications, included in the original TAR. These analyses were then compared with meta-analysis of data from trials that have subsequently been published in full.

RESULTS

All seven TAR groups completed and returned the survey. Five out of seven groups reported a general policy that included searching for and including studies available as conference abstracts/presentations. Five groups responded that if they included data from these sources they would carry out methodological quality assessment of studies from these sources using the same assessment tools as for full publications, and manage the data from these sources in the same way as fully published reports. All groups reported that if relevant outcome data were reported in both an abstract/presentation and a full publication, they would only consider the data in the full publication. Conversely, if data were only available in conference abstract/presentation, all but two groups reported that they would extract and use the data from the abstract/presentation. In total, 63 HTA reports for NICE were identified. In 20 of 63 TARs (32%) explicit statements were made with regards to inclusion and assessment of data from abstracts/presentations. Thirty-eight (60%) identified at least one randomised controlled trial (RCT) available as a conference abstract or presentation. Of these, 26 (68%) included trials available as abstracts/presentations. About 80% (20/26) of the 26 TARs that included RCTs in abstract/presentation form carried out an assessment of the methodological quality of such trials. In 16 TARs full reports of these trials were used for quality assessment where both abstracts/presentations and subsequent full publications were available. Twenty-three of 63 TARs (37%) carried out a quantitative analysis of results. Of these, ten (43%) included trials that were available as abstracts/presentations in the review; however, only 60% (6/10) of these included data from abstracts/presentations in the data analysis of results. Thirteen TARs evaluated rapidly evolving technologies and only three of these identified and included trial data from conference abstracts/presentations and carried out a quantitative analysis where abstract/presentation data were used. These three TARs were used as case studies. In all three case studies the overall quality of reporting in abstracts/presentations was generally poor. In all case studies abstracts and presentations failed to describe the method of randomisation or allocation concealment. Overall, there was no mention of blinding in 66% (25/38) of the abstracts and in 26% (7/27) of the presentations included in case studies, and one presentation (4%) explicitly stated use of intention-to-treat analysis. Results from one case study demonstrated discrepancies in data made available in abstracts or online conference presentations. Not only were discrepancies evident between these sources, but also comparison of conference abstracts/presentations with subsequently published full-length articles demonstrates data discrepancies in reporting of results. Sensitivity analyses based on one case study indicated a change in significance of effect in two outcome measures when only full papers published to date were included.

CONCLUSIONS

There are variations in policy and practice across TAR groups regarding searching for and inclusion of studies available as conference abstracts/presentations. There is also variation in the level of detail reported in TARs regarding the use of abstracts/presentations. Therefore, TAR teams should be encouraged to state explicitly their search strategies for identifying conference abstracts and presentations, their methods for assessing these for inclusion, and where appropriate how the data were used and their effect on the results. Comprehensive searching for trials available as conference abstracts/presentations is time consuming and may be of questionable value. However, there may be a case for searching for and including abstract/presentation data if, for example, other sources of data are limited. If conference abstracts/presentations are to be included, the TAR teams need to allocate additional time for searching and managing data from these sources. Incomplete reporting in conference abstracts and presentations limits the ability of reviewers to assess confidently the methodological quality of trials. Where conference abstracts and presentations are considered for inclusion in the review, the TAR teams should increase their efforts to obtain further study details by contacting trialists. Where abstract/presentation data are included, reviewers should discuss the effect of including data from these sources. Any data discrepancies identified across sources in TARs should be highlighted and their impact discussed in the review. In addition, there is a need to carry out, for example, a sensitivity analysis with and without abstract/presentation data in the analysis. There is a need for research into the development of search strategies specific to identification of studies available as conference abstracts and presentations in TARs. Such strategies may include guidance with regard to identification of relevant electronic databases and appropriate conference sites relevant to certain clinical areas. As there are limited case studies included in this report, analyses should be repeated as more TARs accrue, or include the work of other international HTA groups.

Expression of survivin, platelet-derived growth factor A (PDGF-A) and PDGF receptor α in primary central nervous system lymphoma

PURPOSE

Primary central nervous system lymphomas (PCNSL) are rare tumours occurring in the brain. Their biology and the factors predicting survival are not well known. This study investigated expression of the antiapoptotic protein survivin and platelet-derived growth factor A (PDGF-A) and receptor (PDGFRalpha) in PCNSL.

EXPERIMENTAL DESIGN

A total of 44 patients with histologically confirmed PCNSL treated between 1992 and 2004 were included in this study, and tumour specimens were investigated immunohistochemically for expression of survivin, PDGF-A and PDGFRalpha. Protein expression and clinical variables were analyzed statistically.

RESULTS

Of the 44 tumours 43(98%) were diffuse large B-cell non-Hodgkin's lymphomas (NHL) and one was a T-cell NHL. Around 37 (84%) of the examined PCNSL specimens showed expression of survivin, 16 (36%) of PDGF-A and 34 (77%) of PDGFRalpha. Tumours expressing surviving co-expressed PDGFRalpha frequently and PDGF-A occasionally. Expression of the above proteins was not predictive for survival in this patient group. Except for age and therapy, no other clinical variables correlated significantly with overall survival.

CONCLUSIONS

PCNSL express survivin and PDGFRalpha in the majority of investigated cases. PDGF-A is expressed less frequently. Immunohistochemical detection of these proteins does not correlate with overall survival and cannot be used as a prognostic factor.

Does repeated electro-ejaculation improve sperm quality in spinal cord injured men?

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To assess the effect of repeated electro-ejaculation on the sperm quality in spinal cord injured men.

SETTING

Regional Spinal Injuries Unit, Southport, UK and Hewitt Center for Reproductive Medicine, Liverpool, UK.

METHOD

Retrospective, observational study of men with spinal cord injuries undergoing repeated electro-ejaculation as a part of fertility treatment.

RESULT

There was no improvement in the volume, sperm concentration, motility or the total motile count in the successive antegrade and retrograde samples following repeated electro-ejaculations.

CONCLUSION

Electro-ejaculation is an invasive procedure and its use should be restricted to obtaining semen sample for carrying out assisted conception procedures only.

A typical mood stabilizers: a "typical role for atypical antipsychotics

OBJECTIVE

To assess the potential role of atypical antipsychotics as mood stabilizers.

METHOD

A MedLine, PsychLIT, PubMed, and EMBASE literature search of papers published up to December 2004 was conducted using the names of atypical antipsychotics and a number of key terms relevant to bipolar disorder. Additional articles were retrieved by scrutinizing the bibliographies of review papers and literature known to the authors. Data pertinent to the objective was reviewed according to the various phases of bipolar disorder.

RESULTS

The data is most substantive for the use of atypical antipsychotics in mania, to the extent that an argument for a class effect of significant efficacy can be made. This does not extend to bipolar depression, however, good data is now emerging for some agents and will need to be considered for each individual agent as it accumulates. As regards mixed states and rapid cycling the evidence is thus far sparse and too few maintenance studies have been conducted to make any firm assertions. However, with respect to long-term therapy the atypical antipsychotics do have clinically significant side-effects of which clinicians need to be aware.

CONCLUSION

Based on the evidence thus far it is perhaps premature to describe the atypical antipsychotics as mood stabilizers. Individual agents may eventually be able to claim this label, however, much further research is needed especially with respect to maintenance and relapse prevention.

Newer hypnotic drugs for the short-term management of insomnia: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical and cost-effectiveness of zaleplon, zolpidem and zopiclone (Z-drugs) compared with benzodiazepines.

DATA SOURCES

Electronic databases, reference lists of retrieved articles and pharmaceutical company submissions.

REVIEW METHODS

Randomised controlled trials (RCTs) that compared either benzodiazepines to the Z-drugs or any two of the non-benzodiazepine drugs in patients with insomnia were included in the review. Data on the following outcome measures were considered: sleep onset latency, total sleep duration, number of awakenings, quality of sleep, adverse effects and rebound insomnia. A search was also undertaken for any study designs that evaluated issues related to adverse events (e.g. dependency and withdrawal symptoms). Full economic evaluations that compared two or more options and considered both costs and consequences including cost-effectiveness, cost-utility analysis or cost-benefit analysis undertaken in the context of high-quality RCTs were considered for inclusion in the review.

RESULTS

Twenty-four studies, involving a total study population of 3909 patients, met the inclusion criteria. These included 17 studies comparing a Z-drug with a benzodiazepine and seven comparing a Z-drug with another Z-drug. The diversity of possible comparisons and the range of outcome measures in the review may be confusing. Outcomes were rarely standardised and, even when reported, differed in interpretation. In addition, variations in assessment and variety in the level of information provided make study comparisons difficult. As a result, meta-analysis has been possible on only a small number of outcomes. However, some broad conclusions might be reached based on the limited data provided. The existing published economic literature in this area is very limited. No relevant economic evaluations were identified for inclusion in the review. The industry submissions did not include detailed evidence of cost-effectiveness. Given the lack of robust clinical evidence, no economic model describing the costs and benefits of the newer hypnotic drugs for insomnia was developed. The systematic review provided in this report suggests that an agnostic approach to cost-effectiveness is required at this stage. In the short-term, no systematic evidence is available concerning significant outcome variations between either the different classes of drugs or between individual drugs within each class. Within this short-term horizon, the one element that does vary significantly is the acquisition cost of the individual drugs.

CONCLUSIONS

The short-acting drugs seem equally effective and safe with minor differences that may lead a prescriber to favour one over another in different patients. There is no evidence that one is more cost-effective than any other. Analysis of the additional costs to the NHS, depending on the rate of change from benzodiazepine prescriptions to Z-drug prescriptions, at current levels of hypnotic prescribing, range from GBP2 million to GBP17 million per year. There are clear research needs in this area; in particular, none of the existing trials adequately compare these medications. It is suggested that further consideration should be given to a formal trial to allow head-to-head comparison of some of the key drugs in a double-blind RCT lasting at least 2 weeks, and of sufficient size to draw reasonable conclusions. We would also recommend that any such trial should include a placebo arm. It should also collect good-quality data around sleep outcomes and in particular quality of life and daytime drowsiness. We do not believe that any formal study of risk of dependency is feasible at present. Finally, the management of long-term insomnia is suggested for further investigation: considering the frequency of this symptom and its recurring course, the short-term trial of medication and lack of long-term follow-up undermine attempts to develop evidence-based guidelines for the use of hypnotics in this condition, or indeed for its whole management.

Cost of illness of inflammatory bowel disease in the UK: a single centre retrospective study

BACKGROUND AND AIMS

The potentially high costs of care associated with inflammatory bowel disease (IBD) are recognised but we have little knowledge of the scale, profile, or determinants of these costs in the UK. This study aimed to describe costs of illness for a group of IBD patients and determine factors associated with increased healthcare costs.

SETTING

A university hospital serving a target population of approximately 330 000.

PATIENTS AND METHODS

A six month cohort of IBD patients receiving any form of secondary care was identified, comprising 307 cases of ulcerative (or indeterminate) colitis and 172 cases of Crohn's disease. Demographic and clinical data were abstracted from clinical records and individual resource use was itemised for all attributable costs (including extraintestinal manifestations). Item costs were derived from national and local sources. Cost data were expressed as mean six month costs per patient (with 95% confidence interval (CI)) obtained using non-parametric bootstrapping. Determinants of cost were analysed using generalised linear regression modelling. A postal survey of patients was undertaken to examine indirect costs, out of pocket expenses, and primary care visits.

RESULTS

Inpatient services (medical and/or surgical) were required by 67 patients (14%) but accounted for 49% of total secondary care costs. Drug costs accounted for less than a quarter of total costs. Individual patient costs ranged from 73 to 33,254 UK pounds per six months. Mean (95% CI) six month costs per patient were 1256 UK pounds ( 988 pounds, 1721 pounds) for colitis and 1652 UK pounds (1221 pounds, 2239 pounds) for Crohn's disease. Hospitalisation, disease severity grade, and disease extent correlated positively with cost of illness but costs were independent of age or sex. Compared with quiescent cases of IBD, disease relapse was associated with a 2-3-fold increase in costs for non-hospitalised cases and a 20-fold increase in costs for hospitalised cases. Survey data suggested average six month costs were < 30 UK pounds per patient for primary care visits (both diseases) and median loss of earnings were 239 UK pounds for colitis and 299 UK pounds for Crohn's disease.

CONCLUSIONS

This study represents the first detailed characterisation of the scale and determinants of costs of illness for IBD in a British hospital. Hospitalisation affected a minority of sufferers but accounted for half of the total direct costs falling on the healthcare system.

Three-pool model of white matter

PURPOSE

To investigate the use of a three-pool relaxation model to measure myelin, myelinated-axon, and mixed water-pool fractions in white matter (WM) during myelination.

MATERIALS AND METHODS

MRI at 1.9 Tesla, and conventional spin-echo imaging were used to acquire T1 and T2 relaxation data in 15 normal children ranging in age from 3 months to 13 years 4 months. Three equations with three unknowns were solved to calculate three water-pool fractions for each child in a frontal association-fiber area and a frontal-parietal projection-fiber area. The temporal trend of the fractions was compared with a theoretical three-pool myelination model.

RESULTS

The myelin level in the projection-fiber area rose earlier than in the association-fiber area following the standard caudal-to-rostral trend. The temporal trend of the three-pool fractions followed that predicted by the theoretical myelination model in both brain areas. The myelinated-axon and mixed pool sizes were significantly different in the two WM areas following early myelination, although their myelin pools were similar. T1 values correlated more highly with the myelinated-axon and mixed pool fractions than with the myelin pool fraction.

CONCLUSION

The three-pool relaxation model provides measurements of water-pool fractions in WM that follow values predicted during myelination.