Metabolic effects and cost-effectiveness of aripiprazole versus olanzapine in schizophrenia and bipolar disorder

OBJECTIVE

To assess the cost-effectiveness of aripiprazole versus olanzapine in the treatment of patients with schizophrenia or bipolar disorder in Sweden with focus on the metabolic impact of the treatments.

METHOD

A Markov health-state transition model was developed. The risks of developing metabolic syndrome after one year of treatment with aripiprazole or olanzapine were derived from a pooled analysis of three randomised clinical trials. The subsequent risks of developing diabetes or coronary heart disease were based on previously published risk models. A societal perspective was applied, adopting a lifetime horizon. Univariate and probabilistic sensitivity analyses were conducted.

RESULTS

Treatment with aripiprazole dominates over olanzapine in both schizophrenia and bipolar disorder. In schizophrenia, quality-adjusted life-years (QALYs) gained were 0.08 and cost savings Swedish kronor (SEK) 30,570 (USD 4000); in bipolar disorder, QALYs gained were 0.09 and cost savings SEK 28,450 (USD 3720). In probabilistic sensitivity analyses, aripiprazole resulted in a dominant outcome in 84% of cases in schizophrenia and in 77% of cases in bipolar syndrome.

CONCLUSION

The significantly lower risk of developing metabolic syndrome observed with aripiprazole compared with olanzapine is associated with less risk of diabetes and cardiovascular morbidity and mortality that translates into lower overall treatment cost and improved quality of life over time.

Cardiovascular autonomic dysfunction is associated with central obesity in persons with impaired glucose tolerance

AIMS

The aim of this study was to investigate the prevalence of cardiovascular autonomic neuropathy in persons with previously diagnosed impaired glucose tolerance and to characterize associations between components of metabolic syndrome and cardiovascular autonomic neuropathy in the Finnish Diabetes Prevention Study cohort.

METHODS

Two hundred and sixty-eight individuals with impaired glucose tolerance at baseline in the Finnish Diabetes Prevention Study, but not diagnosed with diabetes during follow-up, were studied for cardiovascular autonomic neuropathy. At the second annual follow-up visit after the end of lifestyle intervention, we performed deep-breathing and active orthostatic tests to detect possible parasympathetic and sympathetic dysfunction. To describe metabolic characteristics, anthropometric measurements, an oral glucose tolerance test and assessments for HbA(1c,) serum lipids and blood pressure were carried out.

RESULTS

Prevalence of parasympathetic dysfunction was 25% and prevalence of sympathetic dysfunction was 6%, with no difference between the former intervention and control group participants or between men and women. Subjects with parasympathetic dysfunction were older, more obese (weight, waist circumference, body mass index) and had higher triglyceride concentration compared with those with normal parasympathetic function (P<0.01 for all). Parasympathetic dysfunction was not significantly associated with other characteristics of metabolic syndrome; for example, high cholesterol, glucose and insulin levels or HbA(1c) . Correlations between the Expiration/Inspiration (E/I) ratio (the longest heart beat duration in expiration divided by the shortest heart beat duration in inspiration) and measures reflecting obesity were statistically significant in the pooled population and in men but not in women.

CONCLUSIONS

Cardiovascular autonomic neuropathy is common in persons with impaired glucose tolerance. Obesity, especially among men, seems to play an important role in the early pathogenesis of cardiovascular autonomic neuropathy.

Functional impairment after treatment with pectoral muscle flaps because of deep sternal wound infection

OBJECTIVE

Pectoral muscle flaps (PMF) are effective in terminating protracted sternal wound infections (SWI) but long-term outcome remains uncertain. Therefore, the aim of this study was to evaluate long-term outcome in patients treated with PMF.

DESIGN

Thirty-four of 263 patients revised because of deep SWI from 1991--2005 were treated with PMF. Of the 21 patients alive, 11 had left-sided, two right-sided and eight bilateral procedures. Sternal debridement without closure of the sternum was done in 17 patients. Nineteen of 21 patients responded to a questionnaire.

RESULTS

At follow-up on average 5.9 years (range 1.9--14.8 years) after surgery 63% (12/19) experienced unstable chest. Two thirds (12/18) reported problems carrying a grocery bag and 37% (7/19) had problems putting on a coat. Reduction of power and mobility was more common in the right arm and shoulder even in patients with left-sided PMF. Thirty-two percent (6/19) would have preferred alternative treatment if possible to avoid sternal instability even if healing had been substantially delayed.

CONCLUSIONS

Surgery with PMF and sternal debridement was associated with long-term disability, which appeared to be significant in one third of the patients. The function of the right arm and shoulder was affected more often despite the majority of procedures being left-sided suggesting that loss of skeletal continuity of the chest wall is more disabling than loss of pectoral muscle function.

Growing up on a farm leads to lifelong protection against allergic rhinitis

BACKGROUND

Various studies have reported a low prevalence of allergic rhinitis in farmers and farmers' children. We sought to investigate whether the protective effect of childhood farm environment is conserved throughout adulthood and how it corresponds to different degrees of urbanization.

METHODS

A questionnaire on respiratory health was mailed in 2008 to 30,000 randomly selected subjects aged 16-75 in West Sweden, 29,218 could be traced and 18,087 (62%) responded. The questionnaire included questions on allergic rhinitis, asthma, respiratory symptoms and possible determinants.

RESULTS

When stratified into age groups of 15 years, subjects that lived on a farm during their first 5 years of life had a lower prevalence of allergic rhinitis in all groups, even among the oldest (61-75 years). The negative correlation between childhood farm living and prevalence of allergic rhinitis was similar in 46-75 years of age (OR 0.82; 95% CI 0.70-0.95) as in 16-45 years of age (OR 0.78; 0.64-0.95). There was a significant trend of increasing prevalence of allergic rhinitis with increasing degree of urbanization independent of the effect of childhood farm living.

CONCLUSIONS

We found a lifelong protective effect of childhood farm living on the prevalence of allergic rhinitis. In addition, we found an increasing prevalence of allergic rhinitis with increasing degree of urbanization both in those raised on a farm and those not, thus emphasizing the influence of both childhood and adult exposure for the development of allergic disease.

Saxagliptin is non-inferior to glipizide in patients with type 2 diabetes mellitus inadequately controlled on metformin alone: a 52-week randomised controlled trial

AIM

To assess the efficacy and safety of saxagliptin vs. glipizide as add-on therapy to metformin in patients with type 2 diabetes mellitus and inadequate glycaemic control on metformin alone.

METHODS AND PATIENTS

A total of 858 patients [age ≥ 18 years; glycated haemoglobin (HbA(1c) ) > 6.5 - 10.0%; on stable metformin doses ≥ 1500 mg/day] were randomised 1 : 1 to saxagliptin 5 mg/day or glipizide up-titrated as needed from 5 to 20 mg/day for 52 weeks. The primary objective was to assess if the change from baseline HbA(1c) achieved with saxagliptin plus metformin was non-inferior to glipizide plus metformin.

RESULTS

The per-protocol analysis demonstrated non-inferiority of saxagliptin vs. glipizide; adjusted mean changes from baseline HbA(1c) were -0.74% vs. -0.80%, respectively; the between-group difference was 0.06% (95% CI, -0.05% to 0.16%). Treatment with saxagliptin vs. glipizide was associated with a significantly smaller proportion of patients with hypoglycaemic events (3.0% vs. 36.3%; p < 0.0001) and a divergent impact on body weight (adjusted mean change from baseline -1.1 kg with saxagliptin vs. 1.1 kg with glipizide; p < 0.0001). There was a significantly smaller rise in HbA(1c) (%/week) from week 24 to 52 with saxagliptin vs. glipizide (0.001% vs. 0.004%; p = 0.04) indicating a sustained glycaemic effect beyond week 24. Excluding hypoglycaemic events, the proportion of patients experiencing adverse events (AEs) was similar (60.0% saxagliptin vs. 56.7% glipizide); treatment-related AEs were less common with saxagliptin vs. glipizide (9.8% vs. 31.2%), attributable to the higher frequency of hypoglycaemia in glipizide patients. Discontinuation rates resulting from AEs were similar (∼4%).

CONCLUSION

Saxagliptin plus metformin was well tolerated, provided a sustained HbA(1c) reduction over 52 weeks, and was non-inferior to glipizide plus metformin, with reduced body weight and a significantly lower risk of hypoglycaemia.

Neutron spectroscopy results of JET high-performance plasmas and extrapolations to DT performance

In a fusion reactor with high energy gain, the fusion power will be mainly thermonuclear (THN). Measurements of the THN neutron rate are a good performance indicator of a fusion plasma, requiring neutron emission spectroscopy (NES) measurements to distinguish thermal and nonthermal contributions. We report here on recent NES results from JET high-performance plasmas with high fractions (about 65%) of THN emission. The analysis is made with a framework for analyzing NES data, taking into account THN reactions and beam-target reactions. The results are used to extrapolate to the equivalent DT rates. Finally, we discuss the applicability of using NES in the deuterium phase of ITER, both for the extrapolations to ITER’s future DT performance as well as for the measurements of confined energetic ions.

Neutron spectroscopy as a fuel ion ratio diagnostic: lessons from JET and prospects for ITER

The determination of the fuel ion ratio n(t)/n(d) in ITER is required at a precision of 20%, time resolution of 100 ms, spatial resolution of a/10, and over a range of 0.01<n(T)/n(D)<10. We use simplified but realistic Monte Carlo models of ITER to assess the possibility to use neutron emission spectroscopy (NES) for such measurements. We show that NES meets the requirements for ion temperatures T(i)>6 keV and for n(T)/n(D)<0.6. A crucial issue is the signal-to-background situation in the measurement of the weak 2.5 MeV emission from DD reactions in the presence of a background of scattered 14 MeV DT neutrons. Important experimental input and corroboration for this assessment are presented from the time-of-flight neutron spectrometer at JET where the presence of a strong component of backscattered neutrons is observed. Neutron emission components on ITER due to beam-thermal and tritium-tritium reactions can further enhance the prospects for NES.

Neutron spectrometry of JET discharges with ICRH-acceleration of helium beam ions

Recent experiments at JET aimed at producing 4He ions in the MeV range through third harmonic ion cyclotron resonance heating (ICRH) acceleration of 4He beams in a 4He dominated plasma. MeV range D was also present through parasitic ICRH absorption on residual D. In this contribution, we analyze TOFOR neutron spectrometer data from these experiments. A consistent description of the data is obtained with d(d,n)3He and 9Be(α,n)12C neutron components calculated using Stix distributions for the fast D and 4He, taking finite Larmor radius effects into account and with a ICRH power partition of P(D)(RF) = 0.01×P(4He)(RF), in agreement with TOMCAT simulations.

The economic consequences of non-adherence to lipid-lowering therapy: results from the Anglo-Scandinavian-Cardiac Outcomes Trial

BACKGROUND

Adherence to lipid-lowering therapy in clinical practice is less than ideal. Analysis of registry data has indicated that this is associated with poor outcomes. The objective of the present analysis was to assess the impact of high adherence to drug (defined as > 80% of days covered), compared with low adherence to drug (< 50% of days covered) in terms of risk of events and long-term economic consequences.

DESIGN

Open-label follow up of a randomised placebo-controlled trial in hypertensive patients.

METHODS

Cox proportional hazards and Poisson regression models were used to assess the hazard ratio of patients with high adherence compared with low adherence while controlling for cardiovascular risk. A Markov model was used to predict the long-term costs and health outcomes associated with poor adherence during the follow-up period.

RESULTS

Both statistical models indicated that high adherence is associated with improved prognosis [Cox model: 0.75; 95% confidence interval (CI): 0.56-0.98, Poisson model hazard ratio: 0.73; 95% CI: 0.58-0.98]. Discounted at 3.5% per year, the Markov model predicts that as a consequence of higher adherence during the follow-up period, costs would be higher (1689 pounds per patient compared with 1323 pounds per patient) because of higher drug costs, but the projected survival and quality-adjusted survival (QALY) would also be longer (10.83 compared with 10.81 life years and 8.13 compared with 8.11 QALYs).

CONCLUSION

Given the higher risk of cardiovascular events associated with low adherence shown here, measures to improve adherence are an important part of the prevention of cardiovascular disease.

Automatic fitting procedures for EPR spectra of disordered systems: matrix diagonalization and perturbation methods applied to fluorocarbon radicals

Two types of automatic fitting procedures for EPR spectra of disordered systems have been developed, one based on matrix diagonalization of a general spin Hamiltonian, the other on 2nd order perturbation theory. The first program is based on a previous Fortran code complemented with a newly written interface in Java to provide user-friendly in and output. The second is intended for the special case of free radicals with several relatively weakly interacting nuclei, in which case the general method becomes slow. A least squares' fitting procedure utilizing analytical or numerical derivatives of the theoretically calculated spectrum with respect to the g- and hyperfine structure (hfs) tensors was used to refine those parameters in both cases. 'Rigid limit' ESR spectra from radicals in organic matrices and in polymers, previously studied experimentally at low temperature, were analyzed by both methods. Fluorocarbon anion radicals could be simulated, quite accurately with the exact method, whereas automatic fitting on, e.g. the c-C(4)F(8)(-) anion radical is only feasible with the 2nd order approximative treatment. Initial values for the (19)F hfs tensors estimated by DFT calculations were quite close to the final. For neutral radicals of the type XCF(2)CF(2)* the refinement of the hfs tensors by the exact method worked better than the approximate. The reasons are discussed. The ability of the fitting procedures to recover the correct magnetic parameters of disordered systems was investigated by fittings to synthetic spectra with known hfs tensors. The exact and the approximate methods are concluded to be complementary, one being general, but limited to relatively small systems, the other being a special treatment, suited for S=1/2 systems with several moderately large hfs.

Inhibition of the cellular uptake of anandamide by genistein and its analogue daidzein in cells with different levels of fatty acid amide hydrolase-driven uptake

BACKGROUND AND PURPOSE

Genistein, a tyrosine kinase inhibitor used to block caveolae dependent endocytosis, reduces the cellular uptake of anandamide in RBL2H3 basophilic leukaemia cells. However, genistein is also a competitive inhibitor of fatty acid amide hydrolase, the enzyme responsible for anandamide hydrolysis. Here we have investigated whether inhibition of fatty acid amide hydrolase rather than inhibition of endocytosis is the primary determinant of genistein actions upon anandamide uptake.

EXPERIMENTAL APPROACH

Cellular uptake of anandamide, labelled in the arachidonoyl part of the molecule was assessed in four different cell lines using a standard method. Fatty acid amide hydrolase activity in homogenates and intact cells was measured using anandamide labelled in the ethanolamine part of the molecule.

KEY RESULTS

The fatty acid amide hydrolase inhibitor URB597 inhibited anandamide uptake into RBL2H3 cells and R3327 AT-1 prostate cancer cells, but not into 3T3-L1 preadipocytes or PC-3 prostate cancer cells. An identical pattern was seen with genistein. The related compound daidzein inhibited anandamide hydrolysis in homogenates and intact cells, and reduced its uptake into RBL2H3 and R3327 AT-1, but not PC-3 cells. Anandamide hydrolysis by cell homogenates was in the order RBL2H3 > R3327 AT-1 > PC-3 approximately 3T3-L1.

CONCLUSIONS AND IMPLICATIONS

The ability of genistein to inhibit anandamide uptake is mimicked by daidzein (which does not affect tyrosine kinase), and is only seen in cells that show sensitivity to URB597. This indicates that blockade of fatty acid amide hydrolase is the primary determinant of the effects of genistein on cellular anandamide uptake.

A SELDI-TOF MS study of the genetic and post-translational molecular heterogeneity of eosinophil cationic protein

Eosinophil cationic protein (ECP), a secretory protein of the eosinophil granulocyte, is a basic and highly heterogeneous protein. This heterogeneity is dependent on polymorphisms in the ECP gene and post-translational modifications, and it affects the functional properties of the protein in terms of cytotoxicity. The aim of this study was to further investigate the molecular heterogeneity, hence, an affinity capture assay based on an antigen-antibody interaction with the surface-enhanced laser desorption/ionization-time of flight mass spectrometry (SELDI-TOF MS) technique was developed. Of three monoclonal antibodies tested, that is, EG2, 614, and 652, the 614 mab was chosen for the experiments. ECP heterogeneity of single individuals was studied in extracts of purified blood eosinophils, and the presence of approximately 5 major molecular species was demonstrated in each subject. ECP from subjects with different ECP 434(G>C) genotypes (arg97thr) showed mass differences corresponding to the amino acid shift from arginine to threonine. ECP purified from pooled leukocytes of large numbers of healthy blood donors demonstrated an extensive mass heterogeneity with approximately 10 major molecular species. By the use of a variety of glucosidases it was shown that this heterogeneity was mainly due to N-linked oligosaccharides on which sialic acid, galactose, and acetylglucosamine was positioned. We conclude that the SELDI-TOF MS technique using specific monoclonal antibodies is a convenient and versatile tool; by means of this technique, we could detect both genetic and post-translational causes of the molecular heterogeneity of the eosinophil cationic protein.

Glucose metabolism in human adipose tissue studied by 13C-glucose and microdialysis

OBJECTIVE

Microdialysis can be used to monitor carbohydrate metabolism and lipolysis in adipose tissue. This method, however, does not discriminate between local metabolite production and delivery from other tissues. Our aim was to study glucose metabolism by direct delivery of 13C-labelled glucose into adipose tissue by microdialysis.

MATERIAL AND METHODS

Seven healthy adults were studied after an overnight fast. In three of them the effect of physical activity on glucose metabolism was tested. Microdialysis catheters were introduced into abdominal adipose tissue and 25 mM 13C-labelled glucose was added to the perfusion fluid. An extraction procedure for separating lactic acid from glucose and glycerol in the microdialysate samples was developed. After derivatization, the 13C enrichment of the compounds was analysed by gas chromatography-mass spectrometry.

RESULTS

13C-labelled lactate was detected in the first 15-min eluate fraction following that in which 13C-glucose had reached the microdialysis probe. In the different subjects, 22-35 % of adipose tissue lactate was produced locally. During exercise there was an increase in the lactate concentration and a decrease in 13C enrichment of lactate. Although lactate production in the adipose tissue increased during exercise, most adipose tissue lactate resulted from inflow. The administered 13C-labelled glucose also rapidly converted to 13C-glycerol. The 13C enrichment of glycerol was lower than that of lactate. During exercise the 13C enrichment of glycerol increased, indicating that newly synthesized depot fat was preferentially hydrolysed during physical activity.

CONCLUSIONS

Metabolism of glucose to lactate and glycerol in subcutaneous adipose tissue is a rapid process that can be monitored in vivo by administration of stable isotope labelled glucose into the microdialysis probe. In adults at rest about one-fourth of adipose tissue lactate is produced locally.

The 434(G>C) polymorphism within the coding sequence of Eosinophil Cationic Protein (ECP) correlates with the natural course of Schistosoma mansoni infection

Schistosomiasis is a chronic parasitic infection with over 200 million people infected worldwide. In Schistosoma mansoni infections, parasite-derived eggs get trapped in the liver, causing the formation of granulomas, which may develop into periportal fibrosis and portal hypertension, and thus severe morbidity. Eosinophil cationic protein (ECP) is a secretory protein of eosinophil granulocytes that efficiently kills the larval stage of S. mansoni, but also affects fibroblast functions. We have investigated the prevalence of the ECP gene polymorphism 434(G>C) in two African populations, from an S. mansoni endemic area in Uganda (n=297) and from a non-endemic area in Sudan (n=78), and also compared these with a Swedish population (n=209). The genotype frequencies in the Ugandan population differed significantly from both the Sudanese and Swedish populations (P<0.001). In the Ugandan population there was a significant association between genotype and prevalence of infection (P=0.03), with lower prevalence in subjects with the GG genotype compared with GC (P=0.02) and CC (P=0.03). There was also a trend towards an association with periportal fibrosis (P=0.08) in the Ugandan population. This suggested association was confirmed when the predominant tribe (n=212) was analysed separately (P=0.004). Our results suggest that ECP may be an important protein, both in the immune response against S. mansoni and in the development of periportal fibrosis. The results also suggest genetic selection towards the ECP 434CC genotype in populations living in S. mansoni endemic areas.

Fate of heavy metals after application of sewage sludge and wood-ash mixtures to short-rotation willow coppice

Short-rotation willow coppice (SRWC), grown on farmland in Sweden for energy-biomass production, was fertilised with sewage sludge and wood-ash mixtures on the basis of the permitted annual phosphorus supply. Two identical experiments were conducted in central Sweden, on two newly harvested commercial SRWC fields. The maximum legally permitted amount of the sludge-ash mixture, sludge only, ash only, and twice the maximum permitted sludge-ash amount, were applied. The aim was to assess the effect of pH changes following treatment, on the ability of SRWC to take up large amounts of Cd and other metals. The remediation effect of SRWC was also studied. Under the experimental conditions applied, uptake by SRWC was unaffected by pH changes. The differences between the amounts of metals experimentally applied, less the uptake by SRWC after a potential harvest, were broadly within the permitted limits. For Cd, a reduction of total amounts in soil was observed.

Resolving the challenges of producing small-bore tubing

Experience shows that sufficient time and resources must be allocated to writing a specification. It is essential to be clear about the intended use of the tubing. Once the preliminary specification has been compiled, trial and error is often a necessary part of the process of making a successful product. Finally, all polymers are affected by the environment and their previous history.

Nuclear insertions help and hinder inference of the evolutionary history of gorilla mtDNA

Numts are fragments of mitochondrial DNA (mtDNA) that have been translocated to the nucleus, where they can persist while their mitochondrial counterparts continue to rapidly evolve. Thus, numts represent 'molecular fossils' useful for comparison with mitochondrial variation, and are particularly suited for studies of the fast-evolving hypervariable segment of the mitochondrial control region (HV1). Here we used information from numts found in western gorillas (Gorilla gorilla) and eastern gorillas (Gorilla beringei) to estimate that these two species diverged about 1.3 million years ago (Ma), an estimate similar to recent calculations for the divergence of chimpanzee and bonobo. We also describe the sequence of a gorilla numt still possessing a segment lost from all contemporary gorilla mtDNAs. In contrast to that sequence, many numts of the HV1 are highly similar to authentic mitochondrial organellar sequences, making it difficult to determine whether purported mitochondrial sequences truly derive from that genome. We used all available organellar HV1 and corresponding numt sequences from gorillas in a phylogenetic analysis aimed at distinguishing these two types of sequences. Numts were found in several clades in the tree. This, in combination with the fact that only a limited amount of the extant variation in gorillas has been sampled, suggests that categorization of new sequences by the indirect means of phylogenetic comparison would be prone to uncertainty. We conclude that for taxa such as gorillas that contain numerous numts, direct approaches to the authentication of HV1 sequences, such as amplification strategies relying upon the circularity of the mtDNA molecule, remain necessary.