Detection of Cryptosporidium species and sources of contamination with Cryptosporidium hominis during a waterborne outbreak in north west Wales

As part of investigations into the cause of a waterborne outbreak of Cryptosporidium hominis infection linked to a mains water supply, surface waters and wastewater treatment plants were tested for Cryptosporidium spp. Oocyst counts in base flow surface water samples ranged from nil to 29 per 10 l. Oocyst counts in effluent from a community wastewater treatment plant were up to 63 fold higher and breakout from one septic tank five logs higher. There were no peak (storm) flow events during the investigation. C. hominis, four named genotypes (cervine, muskrat II, rat, W19) and six new small subunit ribosomal RNA gene sequences were identified. Four of the new sequences were closely related to Cryptosporidium muskrat genotype I, one was closely related to the fox genotype and one to Cryptosporidium canis. C. hominis was found extensively in the catchment, but only at sites contaminated by wastewater, and in the treated water supply to the affected area. All were gp60 subtype IbA10G2, the outbreak subtype. Multiple routes of contamination of the reservoir were identified, resulting in persistent detection of low numbers of oocysts in the final water. This work demonstrates the utility of genotyping Cryptosporidium isolates in environmental samples during outbreak investigations.

Evaluating the operational utility of a Bacteroidales quantitative PCR-based MST approach in determining the source of faecal indicator organisms at a UK bathing water

Microbial source tracking techniques are used in the UK to provide an evidence-base to guide major expenditure decisions and/or regulatory action relating to sewage disposal. Consequently, it is imperative that the techniques used robustly index faecal indicator organisms (FIOs) that are the regulatory parameters for bathing and shellfish harvesting areas. This study reports a 'field-scale' test of microbial source tracking (MST) based on the quantitative PCR analyses of Bacteroidales 16S rRNA genetic marker sequences. The project acquired data to test the operational utility of quantitative Bacteroidales MST data, comparing it with FIO concentrations in streams, effluents and bathing waters. Overall, the data did not exhibit a consistent pattern of significant correlations between Bacteroidales MST parameters and FIOs within the different sample matrices (i.e. rivers, bathing waters and/or effluents). Consequently, there was little evidence from this study that reported concentrations and/or percentages of human and/or ruminant faecal loadings (that are based on Bacteroidales MST gene copy numbers) offer a credible evidence-base describing FIO contributions to receiving water 'non-compliance'. The study also showed (i) there was no significant attenuation of the Bacteroidales gene copy number 'signal' through the UV disinfection process; and (ii) single non-compliant samples submitted for Bacteroidales MST analysis, do not reliably characterise the balance of faecal loadings due to the high variability in the MST signal observed. At this stage in the development of the MST tool deployed, it would be imprudent to use the percentage human and/or ruminant contributions (i.e. as indicated by MST data acquired at a bathing water) as the sole or principal element in the evidence-base used to guide major expenditure decisions and/or regulatory action.

Low rates of transmission of SRV-2 and STLV-I to juveniles in a population of Macaca fascicularis facilitate establishment of specific retrovirus-free colonies

BACKGROUND

Prevalence of simian retrovirus-2 (SRV-2) and simian T lymphotropic virus type I (STLV-I), was unknown in 337 captive cynomolgus macaques.

METHODS AND RESULTS

Molecular assays identified 29% of animals as SRV-2 mono-infected, 4% of animals as STLV-I mono-infected and 9% of animals as dual-infected. Of 108 juvenile animals, 83% were SRV-2-negative and no juvenile animal was STLV-I-positive. A subsequent study of juvenile macaques over a period of 2.5 years detected no STLV-I and 10 SRV-2 infections, six of which occurred between testing and day of colony formation. The study also highlighted that an anti-SRV-2 serological response does not presuppose infection. Tissue reservoirs of latent SRV-2 were not identified in suspected SRV-2 infections.

CONCLUSIONS

Low transmissibility of the viruses present in the parental cohort and improved knowledge of the host response to SRV-2 has facilitated the creation of specific-retrovirus-free colonies of cynomolgus macaques.

Expression of somatostatin and dopamine 2 receptors in neuroendocrine tumours and the potential role for new biotherapies

INTRODUCTION

Somatostatin and dopamine receptors are both G-protein-coupled receptors. Somatostatin receptor (SSTR) expression in neuroendocrine tumours has been well characterised, and there is evidence of dopamine receptor expression in neuroendocrine tumours. In this study, we examined expression of D2R, SSTR-2 and SSTR-5 using immunohistochemistry in patients with neuroendocrine tumours.

METHODS

Consecutive samples of formalin-fixed paraffin-embedded tumour tissue were available from 56 patients with a histologically confirmed diagnosis of neuroendocrine tumour (NET). The study population was divided into low-grade (n = 29), intermediate-grade (n = 18) and high-grade NET (n = 9). Immunohistochemical evaluation was performed for the expression of SSTR-2a, SSTR-5 and D2 receptors (D2R).

RESULTS

Both SSTR-2 and SSTR-5 were expressed in 100% of low-grade, 94.4% of intermediate-grade and 66.7% of high-grade NET. D2R was expressed in 93.1% of low-grade, 77.8% of intermediate-grade and 44.4% of high-grade tumours. Co-expression of all 3 receptors was present in 93.1% of low-grade tumours. There was an inverse correlation of SSTR-2 (r = -0.380, p < 0.005) and SSTR-5 (r = -0.472, p < 0.0001) with tumour grade. D2R was positively correlated with SSTR-2 (r = 0.269, p = 0.041) and SSTR-5 (r = 0.267, p = 0.045). Also, D2R expression was inversely correlated with grade of tumour (r = 0.395, p = 0.006). Octreoscan correlated with SSTR-2, SSTR-5 and D2R expression.

CONCLUSION

D2R is expressed in the majority of low and intermediate grade tumours. It is co-expressed with SSTR-2 and SSTR-5 in the majority of cases. The advent of new chimeric molecules that bind both somatostatin and dopamine receptors may provide a new therapeutic option in the management of neuroendocrine patients.

Single photon emission computerized tomography in the evaluation of the osteoblastic activities of a new bone regeneration technique: analysis of 12 mandibular sites in six experimental pigs

OBJECTIVES

To utilize single photon emission computerized tomography performed in sequence to determine the osseo-integrating capabilities and osteoblastic activities of a new bone regeneration technique called the membrane--sandwich technique (Ogunsalu sandwich bone regenerating technique) and to compare the quality and quantity of bone formed by this bone regeneration unit to bone regeneration obtained by using the same particulate bone grafting material covered with interceed (another type of bio-resorbable membrane).

DESIGN AND METHOD

Single photon emission computerized tomography bone imaging was performed in sequence on the mandible of a total of 6 pigs on both the right and left side (total of 12 sites) at two and a half hours following the injection of technetium 99m methylene diphosphate. Imaging was performed using a Siemen Orbitar II gamma camera. The projection data was acquired in a 128 x 128 matrix over 180 arc and SPECT reconstruction was performed using a filtered back projector method with a Shepp-Logan Hanning filter and a cut-off frequency of 0.4. The surgical defect on one side of the jaw was treated with the sandwich unit with Bio-oss particulate bone within it, while the other side contained the same quantity of Bio-oss as in the left side but just covered with interceed membrane. The osteoblastic uptake on the side with the classical sandwich was compared to the side with the particulate bone covered with interceed membrane for dynamic physiological activities. The average activity for both sides was calculated and compared.

RESULT

For all the 12 sites, osteoblastic activities were recorded and indicated that vascularized bone was formed at all the experimental sites. Autogenous bone graft was confirmed to be superior to xenograft using this sandwich technique. Furthermore, the osteoblastic activities on the sandwich side were seen to be more when compared with the control side (Interceed side).

CONCLUSION

The Ogunsalu sandwich bone regeneration technique has been successfully evaluated with SPECT which shows osteoblastic activity with formation of vascularized bone which integrates with the surrounding bone.

Farmyards, an overlooked source for highly contaminated runoff

Summer sampling of storm runoff generated from areas of roofs and hardstanding situated on four dairy/beef farms has provided novel information regarding its microbiological and chemical quality. All farm hardstandings generated runoff that was contaminated with respect to those pollutants (faecal coliforms, FC, and faecal streptococci, FS, major nutrients, organic carbon) that are ubiquitously associated with faecal matter and urine. The separate analysis of roof runoff indicated that these can contribute significant concentrations of FS, phosphorus (P) and potentially toxic elements such as zinc (Zn), and suggests a level of 'background' contamination originating from wash-off of bird droppings and in the case of Zn galvanised surfaces. On average hardstanding runoff showed enhanced concentrations of >4 orders of magnitude for FC and 2-3 for major nutrients and carbon relative to roof runoff. Organic forms of nitrogen (N) and P contributed significantly (averaging >40%) to the total dissolved fraction in both roof and hardstanding runoff. Part of the substantial variability in composition of runoff samples could be attributed to differences between farms as well as the timing of sample collection during individual storms. Where situations allowed, a comparison of water upstream and downstream of the farmyard demonstrated they acted as a source of multiple contaminants not only during hydrologically active storm events but also during dry periods. Contamination pathways included a combination of both point (e.g., septic overflows) and non-point (e.g., seepage from livestock housing) sources. Farmyards situated within intensive livestock farming areas such as SW Scotland, would be expected to have significant local and accumulated downstream impacts on the aquatic environment. Localised impacts would be particularly important for headwaters and low order streams.

Results of field investigations into the impact of intermittent sewage discharges on the microbiological quality of wild mussels (Mytilus edulis) in a tidal estuary

Field surveys were designed to examine the effects of sewage contamination from storm overflow effluent on faecal coliform and Escherichia coli concentrations in the flesh of wild mussels (Mytilus edulis). Bags containing 30 mussels each were fixed at known inter-tidal locations and retrieved at intervals following discharge from a nearby combined sewer overflow (CSO). Concentrations of faecal coliform bacteria and E. coli were measured in the shellfish flesh and in samples of overlying water prior to collection of the mussel samples. Faecal coliform and E. coli concentrations in shellfish increased rapidly after CSO discharge. E. coli concentrations exceeded the European shellfish hygiene class C limit of 46,000 100g(-1), and decayed during subsequent CSO discharge-free periods. The concentration and depuration response was independent of the magnitude of CSO spill volume. First-order exponential decay functions were fitted to the data. Decay rates were lower than those found in corresponding microcosm experiments. This relates to the repeated pattern of inundation and exposure associated with the tidal cycles in the estuary. Relationships between E. coli and faecal coliform concentrations in the shellfish and overlying water samples were relatively weak (r<0.60), a pattern often seen with data from uncontrolled environmental experiments.

Quantitative catchment profiling to apportion faecal indicator organism budgets for the Ribble system, the UK's sentinel drainage basin for Water Framework Directive research

Under the EU Water Framework Directive (WFD) 20/60/EC and the US Federal Water Pollution Control Act 2002 management of water quality within river drainage basins has shifted from traditional point-source control to a holistic approach whereby the overall contribution of point and diffuse sources of pollutants has to be considered. Consequently, there is a requirement to undertake source-apportionment studies of pollutant fluxes within catchments. The inclusion of the Bathing Water Directive (BWD), under the list of 'protected areas' in the WFD places a requirement to control sources of faecal indicator organisms within catchments in order to achieve the objectives of both the BWD (and its revision - 2006/7/EC) and the WFD. This study was therefore initiated to quantify catchment-derived fluxes of faecal indicator compliance parameters originating from both point and diffuse sources. The Ribble drainage basin is the single UK sentinel WFD research catchment and discharges to the south of the Fylde coast, which includes a number of high profile, historically non-compliant, bathing waters. Faecal indicator concentrations (faecal coliform concentrations are reported herein) were measured at 41 riverine locations, the 15 largest wastewater treatment works (WwTWs) and 15 combined sewer overflows (CSOs) across the Ribble basin over a 44-day period during the 2002 bathing season. The sampling programme included targeting rainfall-induced high flow events and sample results were categorised as either base flow or high flow. At the riverine sites, geometric mean faecal coliform concentrations showed statistically significant elevation at high flow compared to base flow. The resultant faecal coliform flux estimates revealed that over 90% of the total organism load to the Ribble Estuary was discharged by sewage related sources during high flow events. These sewage sources were largely related to the urban areas to the south and east of the Ribble basin, with over half the load associated with the relatively small subcatchment of the River Douglas. The majority of this load was attributed to two WwTWs that discharge through a common outfall close to the tidal limit of this catchment. Budgets adjusted to accommodate the impact of proposed UV disinfection of these effluents showed that the load from these sources would be reduced significantly during base flow conditions. However, during high flow events loads would still remain high due to the operation of storm sewage overflows from stormwater retention tanks. The study identified untreated storm sewage spills from urban infrastructure and WwTW stormwater retention tanks as the dominant component of the high flow flux of faecal indicators to receiving waters of the Fylde coast and the associated bathing waters.

Characteristics and significance of liquid effluent from woodchip corrals in Scotland

Woodchip corrals are increasingly used as cost effective means of over-wintering livestock in temperate regions but there is little information on their potential environmental impact. Four woodchip corrals of varying characteristics were instrumented to capture and quantify the flows reaching the base, where pollutant fluxes may move either vertically to groundwater, or laterally to a water course. Samples for chemical analysis were collected daily by auto-sampler. Samples for bacterial analysis were aseptically hand-sampled. Sampling frequency was increased during high flow events and sampling was conducted over a 12-month period. Microbiological samples were analysed for total coliform (TC), presumptive Escherichia coli (EC) and intestinal enterococci (IE). Leachate was also analysed for total phosphorus, phosphate, total nitrogen, ammonium, total oxidised nitrogen, nitrite and nitrate. Each corral had a recording rain gauge sited within 10 m of the corral surface. Mean total nitrogen concentration in leachate was 339.5 mg l(-1), of which ammoniacal-N comprised approximately 57%. Mean total phosphorus concentration was 94.7 mg l(-1). Geometric mean concentrations of TC, EC and IE were 95,461, 94,983 and 55,552 cfu100 ml(-1), respectively. Significant flows of leachate occurred at the base of the corrals on most days during the 1-year sampling period and flow rate increased with stocking density. Strong positive linear relationships were found between the concentrations of the nutrient parameters and discharge. Strong positive curvilinear relations were found between faecal indicator concentrations and discharge. Different relationships were observed in the stocked and unstocked corrals. The resulting fluxes are sufficient to give concern and to indicate that corral development is worthy of regulatory attention.

Faecal indicator organism concentrations and catchment export coefficients in the UK

Characterisation of faecal indicator organism (FIO) concentrations and export coefficients for catchments with particular combinations of land use and under specific climatic regimes is critical in developing models to predict daily loads and apportion sources of the microbial parameters used to regulate water quality. Accordingly, this paper presents a synthesis of FIO concentration and export coefficient data for the summer bathing season, with some comparative winter data, for 205 river/stream sampling points widely distributed across mainland UK. In terms of both geometric mean (GM) FIO concentrations and export coefficients (expressed as cfu km(-2) h(-1)), the results reveal (1) statistically significant elevations at high flow compared with base flow, with concentrations typically increasing by more than an order of magnitude and export coefficients by about two orders; (2) significantly higher values in summer than in winter under high-flow conditions; and (3) extremely wide variability between the catchments (e.g. four orders of magnitude range for GM faecal coliform concentrations), which closely reflects land use-with urban areas and improved pastures identified as key FIO sources. Generally, these two most polluting land uses are concentrated in lowland areas where runoff (m3 km(-2) h(-1)) is low compared with upland areas, which in the UK are dominated by rough grazing and forestry. Consequently, contrasts in export coefficients between land use types are less than for FIO concentrations. The GMs reported for most land use categories are based on 13 sites and exhibit quite narrow confidence intervals. They may therefore be applied with some confidence to other catchments in the UK and similar geographical regions elsewhere. Examples are presented to illustrate how the results can be used to estimate daily summer base- and high-flow FIO loads for catchments with different land use types, and to assess the likely effectiveness of certain strategies for reducing FIO pollutant loadings in areas with extensive areas of lowland improved pasture.

Single photon emission computerized tomography and histological evaluation in the validation of a new technique for closure of oro-antral communication: an experimental study in pigs

Various bone regeneration techniques have evolved recently but controversies regarding vascularization and integration of such bone grafting techniques have led occasionally to animal experiment to validate such techniques. The objective of this study was to evaluate the evidence of vascularization and osseo-integration of a new bone regeneration technique utilized for the closure of oro-antral communication (OAC) by an experimental model in which Single Photon Emission computerized Tomography and histological studies were conducted in pigs. We conclude that the sandwich technique used for the closure of OAC results in a vascularized new bone formation which eventually osseo-integrate with the surrounding bone. Also, this experimental study confirmed that autogeneous bone graft was superior to xenografts when used within the sandwich unit.

Faecal indicator organism concentrations in sewage and treated effluents

The importance of faecal indicator organism (FIO) fluxes within drainage basins is increasing as the European Union (EU) Water Framework Directive and the United States Clean Water Act place requirements on regulators to manage point and diffuse sources of microbial pollution causing non-compliance (EU) or impairment (US) of receiving waters. Central to this management task is knowledge of the likely FIO concentrations in raw sewage and treated effluents, but few empirical data have been published in the peer-reviewed literature. Accordingly, this paper presents results for 1933 samples from 162 different sewage discharge sites in the UK and Jersey, which encompass 12 types of sewage-related discharge, representative of untreated sewage and primary-, secondary- and tertiary-treated effluents. Geometric means (GMs) and 95% confidence intervals (CIs) have been used to characterise base- and high-flow FIO concentrations. The data sets and sub-sets are mostly quite large (n 40) and may therefore be applied with some confidence to comparable discharge sites in similar geographical regions. Very marked, statistically significant reductions in GM FIO concentrations result from secondary and tertiary treatment, and there are statistically significant differences between some secondary and some tertiary treatments. Flow conditions are also shown to be important: untreated sewage and effluent from primary treatment plant have lower concentrations at high flow, due to dilution within combined sewerage systems, whereas some treated effluents (e.g. from activated sludge plant) have higher concentrations at high flow because of the shorter residence time within the plant. Under base-flow conditions, secondary treatments result in estimated GM FIO reductions of 95.22-99.29% (cf. primary-treated effluent). Corresponding figures for tertiary treatment plants (cf. secondary-treated effluent) are 93.24-96.59% for reedbed/grass plots and 99.71-99.92% for UV disinfection. Results suggest that secondary and tertiary treatment plants are less effective under high-flow conditions, but further high-flow sampling is required to confirm this.

The microbiological quality of seven large commercial private water supplies in the United Kingdom

Some 1% of the UK population derives their potable water from 140,000 private water supplies (PWSs) regulated by Local Authorities. The overwhelming majority of these are very small domestic supplies serving a single property or a small number of properties. Treatment for such supplies is rudimentary or non-existent and their microbiological quality has been shown to be poor in every published study to date. Private water supplies serving commercial enterprises such as hotels, restaurants, food production premises and factories are more frequently treated and subject to closer regulation in the United Kingdom. As a result, it has been assumed that these larger commercial supplies are less likely to experience elevated faecal indicator and pathogen concentrations at the consumer tap which have been observed at small domestic supplies.This paper reports on intensive monitoring at seven commercial private water supplies (six of which were treated) spread throughout the UK serving hotels, holiday parks and food production enterprises. Daily sampling of 'potable' water, both at the consumer tap and using large volume filtration for Giardia and Cryptosporidium spp. was conducted over two six week periods in the spring and autumn of 2000. This allowed the effects of short term episodic peaks in faecal indicator and pathogen concentration to be quantified. All the supplies experienced intermittent pathogen presence and only one, a chlorinated deep borehole supply, fully complied with UK water quality regulations during both periods of sampling.Poor microbiological water quality typically followed periods of heavy rainfall. This suggests that the design and installation of such systems should be undertaken only after the likely range of raw water quality has been characterised, which requires a thorough understanding of the effects of flow and seasonality on raw water quality. There is no reason to suspect that the monitored sites are uncharacteristic of other commercial supplies and the results reinforce public health concerns related to domestic supplies. Furthermore, the pattern of contamination is highly episodic, commonly lasting only a few days. Thus, the relatively infrequent regulatory monitoring of such supplies would be unlikely to identify the poor water quality episodes and does not provide the data necessary for public health protection. Although some statistical relationship was found between faecal indicator organisms and the presence of pathogens, the use of FIOs in assessments of regulatory compliance may not always provide a reliable measure of public health risk, i.e. indicator absence does not preclude pathogen presence. The results of this study suggest that a risk assessment system similar to the WHO 'Water Safety Planning' approach might offer a more appropriate regulatory paradigm for private water supplies.

Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices--budget impact analysis

OBJECTIVES

There is growing recognition that a comprehensive economic assessment of a new health-care intervention at the time of launch requires both a cost-effectiveness analysis (CEA) and a budget impact analysis (BIA). National regulatory agencies such as the National Institute for Health and Clinical Excellence in England and Wales and the Pharmaceutical Benefits Advisory Committee in Australia, as well as managed care organizations in the United States, now require that companies submit estimates of both the cost-effectiveness and the likely impact of the new health-care interventions on national, regional, or local health plan budgets. Although standard methods for performing and presenting the results of CEAs are well accepted, the same progress has not been made for BIAs. The objective of this report is to present guidance on methodologies for those undertaking such analyses or for those reviewing the results of such analyses.

METHODS

The Task Force was appointed with the advice and consent of the Board of Directors of ISPOR. Members were experienced developers or users of budget impact models, worked in academia, industry, and as advisors to governments, and came from several countries in North America, Oceana, Asia, and Europe. The Task Force met to develop core assumptions and an outline before preparing a draft report. They solicited comments on the outline and two drafts from a core group of external reviewers and more broadly from the membership of ISPOR at two ISPOR meetings and via the ISPOR web site.

RESULTS

The Task Force recommends that the budget impact of a new health technology should consider the perspective of the specific health-care decision-maker. As such, the BIA should be performed using data that reflect, for a specific health condition, the size and characteristics of the population, the current and new treatment mix, the efficacy and safety of the new and current treatments, and the resource use and costs for the treatments and symptoms as would apply to the population of interest. The Task Force recommends that budget impact analyses be generated as a series of scenario analyses in the same manner that sensitivity analyses would be provided for CEAs. In particular, the input values for the calculation and the specific cost outcomes presented (a scenario) should be specific to a particular decision-maker's population and information needs. Sensitivity analysis should also be in the form of alternative scenarios chosen from the perspective of the decision-maker. The primary data sources for estimating the budget impact should be published clinical trial estimates and comparator studies for efficacy and safety of current and new technologies as well as, where possible, the decision-maker's own population for the other parameter estimates. Suggested default data sources also are recommended. These include the use of published data, well-recognized local or national statistical information and in special circumstances, expert opinion. Finally, the Task Force recommends that the analyst use the simplest design that will generate credible and transparent estimates. If a health condition model is needed for the BIA, it should reflect health outcomes and their related costs in the total affected population for each year after the new intervention is introduced into clinical practice. The model should be consistent with that used for the CEA with regard to clinical and economic assumptions.

CONCLUSIONS

The BIA is important, along with the CEA, as part of a comprehensive economic evaluation of a new health technology. We propose a framework for creating budget impact models, guidance about the acquisition and use of data to make budget projections and a common reporting format that will promote standardization and transparency. Adherence to these proposed good research practice principles would not necessarily supersede jurisdiction-specific budget impact guidelines, but may support and enhance local recommendations or serve as a starting point for payers wishing to promulgate methodology guidelines.

Quality of clinical and economic evidence in dossier formulary submissions

OBJECTIVE

To investigate the quality and completeness of clinical and economic data in dossiers submitted by drug companies to a health plan using Academy of Managed Care Pharmacy guidelines (the Format) for formulary submissions.

STUDY DESIGN

We reviewed the quality of economic analyses in dossiers submitted to Premera Blue Cross Health Plan (Mountlake Terrace, Washington; enrollment 1.6 million) between January 2002 and September 2005. For dossiers submitted in 2003, we examined the clinical studies included.

METHODS

Dossiers were audited with a data collection form to judge the types of clinical studies used to support labeled and off-label indications, and the quality and transparency of economic analyses. We compared economic analyses for high-cost (30-day treatment cost > $1000) versus low-cost products, and for "innovative" versus "me-too" drugs.

RESULTS

Evidence to support off-label indications often was included in 2003 dossiers, but the information was less extensive and of poorer quality than data for labeled indications. Of 115 dossiers submitted between 2002 and 2005, 53 (46%) included economic analyses. The economic analyses had low levels of compliance with standards: only 43% performed sensitivity analysis; 38% stated the study perspective; 37% discussed relevant treatment alternatives; 20% stated assumptions clearly; and 18% mentioned caveats to conclusions. Economic analyses of high-cost products and innovative products had higher compliance with recommended practices.

CONCLUSIONS

Drug companies are submitting dossiers of evidence to formulary committees. Dossiers often included clinical data to support off-label indications, but concerns persist about their quality. About half of dossiers included economic analyses, but these analyses had relatively low levels of compliance with recommended practices.

To determine the cost-effectiveness of pemetrexed (PEM) compared to current standards of care in 2nd-line advanced non-small cell lung cancer (NSCLC) from the UK National Health Service (NHS) perspective

6540

Objective: To assess the clinical and cost-effectiveness of pemetrexed (PEM) compared with current standards of care (SOC) in 2nd-line advanced NSCLC from a UK perspective. The SOC selected for the evaluation were: (i) docetaxel (DOC) as it is the standard active therapy in the UK and is recommended by the National Institute for Health and Clinical Excellence (NICE) and (ii) best supportive care (BSC) as the majority patients in the UK who fail 1st-line therapy do not receive further chemotherapy. Methods: The analytic technique used was a cost-utility analysis (CUA) in the form of a Markov model. Utilities were generated from 100 members of the general public, considering tumor response status and toxicity, in accordance with the standard NICE appraisal methodology. Clinical inputs were derived from a pooled analysis phase III clinical trial data. Costs were taken from the British National Formulary and UK national databases. The incremental cost-effectiveness ratios (ICERs) are presented for both life-years gained (LYG) and quality-adjusted life- years (QALY) gained. Conclusions: The incremental cost per LY and cost per QALY for pemetrexed in 2nd-line NSCLC are below £20,000, compared to docetaxel and BSC. Based on its survival and toxicity benefits PEM is a cost-effective option in within the UK.

No significant financial relationships to disclose.

[Table: see text]

Cross-sectional analysis of adult diabetes type 1 and type 2 patients with diabetic microvascular complications from a German retrospective observational study

OBJECTIVE

To obtain epidemiological data on the prevalence of predefined stages of diabetic microvascular complications from a representative cross-section of patients with existing microvascular complications of type 1 or type 2 diabetes in Germany.

RESEARCH DESIGN AND METHODS

A cross-sectional, retrospective study of medical records of 705 type 1 and 1910 type 2 adult diabetic patients with a diagnosis of retinopathy and/or peripheral neuropathy and/or nephropathy before 2002 and treated in 2002 in Germany.

RESULTS

Of 376 patients with type 1 diabetes having retinopathy, 59.3% had mild or moderate non-proliferative retinopathy without macular oedema, 27.1% had macular oedema, and 13.6% had severe retinopathy without macular oedema. In 862 patients with type 2 diabetes, the distribution of retinopathy/maculopathy classes was 56.8%, 35.5%, and 7.7%, respectively. Of 381 type 1 diabetes patients with observed peripheral neuropathy, 81.4% had sensorimotor neuropathy, 8.9% had diabetic foot conditions, and 9.7% had lower extremity amputations because of diabetes. In 1005 patients with type 2 diabetes, the distribution of neuropathy classes was 78.2%, 12.1%, and 9.7%, respectively. The proportions of patients with renal insufficiency in type 1 and type 2 diabetes groups were 15.3% versus 13.5%, respectively.

CONCLUSIONS

The study suggests that there are considerable proportions of patients with progressive stages of microvascular complications related to type 1 and type 2 diabetes in Germany. This underlines the importance of improvement of optimal quality of care and frequent screening for preventing late diabetic microvascular complications and the necessity of effective intervention strategies to tackle this major public health problem.

Reducing fluxes of faecal indicator compliance parameters to bathing waters from diffuse agricultural sources: the Brighouse Bay study, Scotland

The European Water Framework Directive requires the integrated management of point and diffuse pollution to achieve 'good' water quality in 'protected areas'. These include bathing waters, which are regulated using faecal indicator organisms as compliance parameters. Thus, for the first time, European regulators are faced with the control of faecal indicator fluxes from agricultural sources where these impact on bathing water compliance locations. Concurrently, reforms to the European Union (EU) Common Agricultural Policy offer scope for supporting on-farm measures producing environmental benefits through the new 'single farm payments' and the concept of 'cross-compliance'. This paper reports the first UK study involving remedial measures, principally stream bank fencing, designed to reduce faecal indicator fluxes at the catchment scale. Considerable reduction in faecal indicator flux was observed, but this was insufficient to ensure bathing water compliance with either Directive 76/160/EEC standards or new health-evidence-based criteria proposed by WHO and the European Commission.

Does social cohesion modify the association between area income deprivation and mental health? A multilevel analysis

BACKGROUND

Despite the increasing belief that the places where people live influence their health, there is surprisingly little consistent evidence for their associations with mental health. We investigated the joint effect of community and individual-level socio-economic deprivation and social cohesion on individual mental health status.

METHODS

Multilevel analysis of population survey data on 10,653 adults aged 18-74 years nested within the 325 census enumeration districts in Caerphilly county borough, Wales, UK. The outcome measure was the Mental Health Inventory (MHI-5) subscale of the SF-36 instrument. A social cohesion subscale was derived from a factor analysis of responses to the Neighbourhood Cohesion scale and was modelled at individual and area level. Area income deprivation was measured by the percentage of low income households.

RESULTS

Poor mental health was significantly associated with area-level income deprivation and low social cohesion after adjusting for individual risk factors. High social cohesion significantly modified the association between income deprivation and mental health: the difference between the predicted mean area mental health scores at the 10th and 90th centiles of the low income distribution was 3.7 in the low cohesion group and 0.9 in the high cohesion group (difference of the difference in means = 2.8, 95% CI: 0.2, 5.4).

CONCLUSIONS

Income deprivation and social cohesion measured at community level are potentially important joint determinants of mental health. Further research on the impact of the social environment on mental health should investigate causal pathways in a longitudinal study.