Cost effectiveness of olanzapine in prevention of affective episodes in bipolar disorder in the United Kingdom

This study evaluated the cost effectiveness of olanzapine compared with lithium as maintenance therapy for patients with bipolar I disorder (BP1) in the UK. A Markov model was developed to assess costs and outcomes from the perspective of the UK National Health Service over a 1-year period. Patients enter the model after stabilization of a manic episode and are then treated with olanzapine or lithium. Using the findings of a recent randomized clinical trial, the model considers the monthly risk of manic or depressive episodes and of dropping out from allocated therapy. health care resources associated with acute episodes were derived primarily from a recent UK chart review. Costs of maintenance therapy and monitoring were also considered. Key factors influencing cost effectiveness were identified and included in a stochastic sensitivity analysis. The model estimated that, compared to lithium, olanzapine significantly reduced the annual number of acute mood episodes per patient from 0.81 to 0.58 (difference -0.23; 95% CI: -0.34, -0.12). Per patient average annual care costs fell by 799 UK pounds (95% CI: - 1,824 UK pounds, 59 UK pounds) driven by reduced inpatient days--but the cost difference was not statistically significant. Sensitivity analysis found the results to be robust to plausible variation in the model's parameters. The model estimated that using olanzapine instead of lithium as maintenance therapy for BP1 would significantly reduce the rate of acute mood events resulting in reduced hospital costs. Based on available evidence, there is a high likelihood that olanzapine would reduce costs of care compared to lithium.

Eliciting patient preferences for hormonal therapy options in the treatment of metastatic prostate cancer

Treatment choices for metastatic prostate cancer are complex and can involve men balancing survival versus quality of life. The present study aims to elicit patient preferences with respect to the attributes of treatments for metastatic prostate cancer through a discrete choice experiment (DCE) questionnaire. Men with recently diagnosed localized prostate cancer were asked to envisage that they had metastatic disease when completing a survey. As expected, men with prostate cancer placed considerable importance on gains in survival; however, avoiding side effects of treatment was also clearly important. Survival gains should be considered alongside side effects when discussing treatment options in metastatic disease.

Interventions After Artificial Insemination: Conception Rates, Pregnancy Survival, and Ovarian Responses to Gonadotropin-Releasing Hormone, Human Chorionic Gonadotropin, and Progesterone

We hypothesized that increasing concentrations of progesterone (P4) after artificial insemination would increase fertility. Our objective was to assess changes in ovarian structures, incidence of ovulation, and change in serum P4 in response to GnRH, human chorionic gonadotropin (hCG), or exogenous P4 (controlled internal drug release; CIDR insert) treatment beginning 4 to 9 d after artificial insemination (d 0) and again 7 d later (experiment 1). Blood was collected from 753 cows in 3 herds on d 0 and 7. Ovaries of 162 cows were scanned and mapped to confirm the presence of a corpus luteum (CL), and cows were assigned randomly to serve as controls (n = 41) or to receive a CIDR insert for 7 d (n = 41), 100 microg of GnRH (n = 40), or 3,300 IU of hCG (n = 40). More cows were induced to ovulate in response to GnRH (60%) and hCG (78%) compared with controls (2.4%). Compared with controls, cows treated with GnRH or hCG had more induced CL (d 7) and more total CL (d 7), but serum P4 was increased only in response to hCG. Largest follicle diameters on d 7 were less after GnRH and hCG, but total follicular volume on d 7 was reduced by GnRH, hCG, and CIDR, compared with that of controls. Volume of the original luteal structures was increased by hCG but tended to be reduced by CIDR and GnRH compared with luteal volume in controls. Total CL volume was increased by hCG, but reduced by CIDR, compared with CL volume of controls. Conception rates and pregnancy survival were assessed in response to the same treatments described in experiment 1: controls (n = 708), CIDR (n = 711), GnRH (n = 719), and hCG (n = 714). Tendencies for interactions of treatment x herd and treatment x lactation group were detected, but no 3-way interactions were found. Treatment with hCG increased conception rates in second-lactation cows. The CIDR tended to increase, and hCG increased, conception rates in 2 herds, whereas the CIDR decreased conception rates in 1 herd. Pregnancy survival was reduced by GnRH compared with that in controls. We concluded that GnRH and hCG effectively induced ovulation, and increased number of CL, but only increased serum P4 in hCG-treated cows. Further, treatment with the CIDR or hCG increased conception rates but only in some herds.

Health state utilities for metastatic breast cancer

The aim of the study was to obtain United Kingdom-based societal preferences for distinct stages of metastatic breast cancer (MBC) and six common toxicities. Health states were developed based on literature review, iterative cycles of interviews and a focus group with clinical experts. They described the burden of progressive, responding and stable disease on treatment; and also febrile neutropenia, stomatitis; diarrhoea/vomiting; fatigue; hand-foot syndrome (grade 3/4 toxicities) and hair loss. One hundred members of the general public rated them using standard gamble to determine health state utility. Data were analysed with a mixed model analysis. The study sample was a good match to the general public of England and Wales by demographics and current quality of life. Stable disease on treatment had a utility value of 0.72, with a corresponding gain of +0.07 following a treatment response and a decline by 0.27 for disease progression. Toxicities lead to declines in utility between 0.10 (diarrhoea/vomiting) and 0.15 (febrile neutropenia). This study underlines the value that society place on the avoidance of disease progression and severe side effects in MBC. This may be the largest preference study in breast cancer designed to survey a representative general public sample.

"HAIRY CANOLA"--Arabidopsis GL3 induces a dense covering of trichomes on Brassica napus seedlings

Transformation with the Arabidopsis bHLH gene 35S:GLABRA3 (GL3) produced novel B. napus plants with an extremely dense coverage of trichomes on seedling tissues (stems and young leaves). In contrast, trichomes were strongly induced in seedling stems and moderately induced in leaves of a hairy, purple phenotype transformed with a 2.2 kb allele of the maize anthocyanin regulator LEAF COLOUR (Lc), but only weakly induced by BOOSTER (B-Peru), the maize Lc 2.4 kb allele, or the Arabidopsis trichome MYB gene GLABRA1 (GL1). B. napus plants containing only the GL3 transgene had a greater proportion of trichomes on the adaxial leaf surface, whereas all other plant types had a greater proportion on the abaxial surface. Progeny of crosses between GL3+ and GL1+ plants resulted in trichome densities intermediate between a single-insertion GL3+ plant and a double-insertion GL3+ plant. None of the transformations stimulated trichomes on Brassica cotyledons or on non-seedling tissues. A small portion of bHLH gene-induced trichomes had a swollen terminal structure. The results suggest that trichome development in B. napus may be regulated differently from Arabidopsis. They also imply that insertion of GL3 into Brassica species under a tissue-specific promoter has strong potential for developing insect-resistant crop plants.

The effects of ziprasidone on regional c-Fos expression in the rat forebrain

RATIONALE

Typical and atypical antipsychotic drugs produce characteristic patterns of immediate early gene expression in rat forebrain that are considered to reflect their effects in schizophrenia subjects.

OBJECTIVE

To use c-Fos immunohistochemistry to investigate the functional neuroanatomical profile of the newly introduced atypical agent ziprasidone.

MATERIALS AND METHODS

c-Fos immunohistochemistry was performed on paraformaldehyde-fixed cryosections of rat brains obtained, initially, from animals 2, 4, or 6 h after oral administration of 10 mg/kg ziprasidone or vehicle and, subsequently, from animals 2 h after oral administration of 1, 3, or 10 mg/kg ziprasidone or vehicle. The density of immunoreactive nuclei was assessed in pre-determined forebrain regions.

RESULTS

Ziprasidone induced a time-dependent increase in the density of c-Fos-positive nuclei that was maximal at 2 h. At the 2 h time-point, c-Fos expression was significantly (p<0.05) elevated in the shell and core of the nucleus accumbens, lateral and medial caudate putamen, and lateral septum. At 4 h post-dose, c-Fos expression was also significantly increased in the cingulate gyrus. Ziprasidone-induced c-Fos expression was dose-dependent with significant (p<0.05) c-Fos expression observed in the nucleus accumbens (shell and core) and caudate putamen (lateral and medial) at 3 and 10 mg/kg and in the lateral septum at 10 mg/kg.

CONCLUSIONS

Increased c-Fos expression in the nucleus accumbens and lateral septum is considered to be predictive of activity against positive symptoms, in the caudate putamen of motor side effect liability, and in the cingulate gyrus of efficacy against negative symptoms. Thus, the observed pattern of c-Fos expression induced in rat brain by ziprasidone is consistent with its reported clinical effects, namely, efficacy against positive symptoms with a therapeutic window over motor side effects and with some activity against negative symptoms.

Immune response genes in the post-Q-fever fatigue syndrome, Q fever endocarditis and uncomplicated acute primary Q fever

BACKGROUND

The influence of immune response gene variations on the development of chronic complications of Q fever is presently unclear.

AIM

To compare the frequencies of allelic polymorphisms in immune response genes in different Q fever patient groups.

DESIGN

Genetic association study.

METHODS

We measured the frequencies of immune response gene variants in: (i) an expanded group of 31 post-Q-fever fatigue patients (QFS); (ii) 22 Q fever endocarditis patients (QFE); and (iii) 22 patients who made an uncomplicated recovery from their initial attack of primary acute Q fever, comparing them with various standard control panels from the general population.

RESULTS

There were significant differences between the three Q fever groups. QFS patients differed from both QFE and uncomplicated patients and controls in the frequency of carriage of HLA-DRB1*11 and of the 2/2 genotype of the interferon-gamma intron1 microsatellite. Carriage of the HLA DRB1*11 allele was associated with reduced interferon-gamma and IL-2 responses from PBMC stimulated with ligand in short-term culture. QFE showed differences in the IL-10 promoter microsatellites R and G and had higher frequencies of the TNF-alpha receptor II 196R polymorphism. Q fever patients who had made an uncomplicated recovery differed from those with QFS or QFE, but were not significantly different in allelic frequencies to the control panels.

DISCUSSION

These immunogenetic differences support the concept of different immune states in chronic Q fever, determined by genetic variations in host immune responses, rather than by solely properties of Coxiella burnetii.

Pneumococcal pneumonia in the UK--how herd immunity affects the cost-effectiveness of 7-valent pneumococcal conjugate vaccine (PCV)

This study examines the potential clinical and economic benefits for adults arising from paediatric pneumococcal vaccination in the UK. A UK birth cohort model with a 10-year horizon and using a primary 4-dose paediatric 7-valent pneumococcal conjugate vaccine (PCV) schedule was populated with 1999 morbidity and mortality data scaled up to the UK population. Herd immunity effects on adult pneumococcal hospital-treated pneumonia, meningitis and septicaemia, but not on community-treated pneumonia, were calculated using the lower end of the confidence intervals published for the effects in the US. Universal paediatric pneumococcal immunisation would prevent 1168 deaths (1141 adults) and 7147 cases (1791 adults constituted by 32 meningitis, 37 septicaemia and 1722 pneumonia) of serious pneumococcal infection (meningitis, septicaemia, pneumonia) with a resultant direct (payor) cost per life year gained of 4360 pounds. The 7-valent PCV appears to be highly cost effective.

Production of pro-inflammatory cytokines correlates with the symptoms of acute sickness behaviour in humans

BACKGROUND

Elaboration of the concept of cytokine-induced sickness behaviour in recent years has opened new avenues for understanding brain involvement in sickness and recovery processes. Additionally, this has led to much speculation about the role of the immune system in neuropsychiatric syndromes, including depression and chronic fatigue. However, few studies have examined this phenomenon as it naturally occurs in sick humans, and none has attempted to document the quantitative relationships between cytokine levels and non-specific symptoms. The aim of this research was to examine human sickness behaviour and its immunological correlates in documented Epstein-Barr virus (EBV), Q fever or Ross River virus (RRV) infections.

METHOD

We studied two separate samples. The first consisted of 21 patients with acute Q fever. The second included 48 patients with acute RRV or EBV infection. Psychological and somatic symptom profiles were derived from self-report measures completed at enrolment. Quantification of proinflammatory cytokines [interleukin (IL)-1beta and IL-6] in sera and supernatants of peripheral blood mononuclear cell (PBMC) cultures was undertaken by specific ELISAs.

RESULTS

Levels of IL-1beta and IL-6 spontaneously released from PBMC cultures were consistently correlated with reported manifestations of acute sickness behaviour including fever, malaise, pain, fatigue, mood and poor concentration.

CONCLUSIONS

IL-1beta and IL-6 produced as part of the host response represent sensitive markers of sickness behaviour in humans with acute infection. Further work is needed to systematically characterize the spectrum and natural history of sickness behaviour in humans and to elucidate its biological basis.

Fatigue and psychological distress--exploring the relationship in women treated for breast cancer

Disabling fatigue and psychological symptoms of depression or anxiety are commonly reported by women with treated breast cancer. However, most instruments designed to assess fatigue do not assess concurrent psychological symptoms. This study compared the characteristics of two conceptually different, self-report instruments assessing fatigue to determine the extent to which common psychological symptoms co-exist with the symptom of fatigue in women treated for breast cancer. Women attending an oncology day-care facility for adjuvant treatment of breast cancer or ongoing surveillance post-treatment, completed two self-report questionnaires. The Somatic and Psychological Health REport-34 items (SPHERE) and the Functional Assessment of Cancer Therapy-Fatigue (FACT-F subscale-13 items). One hundred and nine women (mean age 52.8 years) completed both questionnaires and total scores on both fatigue assessment scales, FACT-F and SOMA-6, were highly correlated (r = 0.72, P < 0.001). Using the SPHERE case criteria, prolonged fatigue (37% [40/109]) and psychological distress 31% (34/109) were common in women treated for breast cancer. However, those who reported fatigue were much more likely to also report psychological symptoms (22/40 vs. 12/69, X(2) = 16.7: degrees of freedom (df)=1; P < 0.001) and the levels of fatigue on the FACT-F were not significantly different between those who reported "fatigue only" and those who reported "psychological distress only" (18.8 vs. 17.8, P = 0.79). Thus the recent emphasis on recording fatigue during and following treatments for cancer needs to be accompanied by concurrent measurement of psychological symptoms.

Nurse-led education sets out to improve patient concordance and prevent recurrence of leg ulcers

OBJECTIVE

This study evaluated the effects of a structured nurse-led education programme that aimed to improve patient concordance and prevent venous leg ulcer recurrence.

METHOD

The design was quasi-experimental. Subjects (average age: 80) had venous leg ulceration that had healed within the previous two years, and were cared for at home by a district nurse. Data were available on 49 patients with 97 legs, 72 of which had had venous leg ulcers. Patients were divided into two groups: a control group, which received 'usual' care, and experimental group, which was exposed to the education programme. Recurrence rates, the effects of the education on patient behaviour and the effect on recurrence of having both ankle movement and general mobility were measured over one year.

RESULTS

Patients in the experimental group experienced significantly less recurrence over the year (log rank test = 8.28, p = 0.004). To control for differences in mobility and ankle movement in the control and experimental groups at baseline, simultaneous logistic regression analysis was undertaken. This revealed a significant advantage for patients in the experimental group (p = 0.035; OR = 4.45, 95% CI = 1.11-17.74), who spent more time with their legs elevated each day. This difference was sustained throughout the 52 weeks (f = 2.88, p = 0.015). Those who had both full ankle movement (> 60 degrees) and full mobility (without aid) had significantly less recurrence (p = 0.042). Education had no significant effect on the amount of time patients wore compression hosiery (f = 2.1).

CONCLUSION

A structured nurse-led patient concordance programme is effective in preventing venous leg ulcer recurrence and increasing the time patients spend with their legs elevated at heart level. Having both full ankle movement and full mobility reduces the risk of recurrence.

Circulating levels of the chemokines JE and KC in female C3H apolipoprotein-E-deficient and C57BL apolipoprotein-E-deficient mice as potential markers of atherosclerosis development

We have investigated serum chemokines for their suitability as markers of atherosclerosis development in apoE (apolipoprotein E)-deficient (−/−) mice. Female C3H apoE−/− and C57BL apoE−/− mice were fed on either diet W (Western diet; 6 weeks) or normal rodent diet (12 weeks). Serum lipids (0, 6 and 12 weeks) and terminal chemokine levels were measured using commercially available assays, whereas the lesion area was determined using Oil-Red O-stained aortic sections. Serum lipids were higher in C3H apoE−/− mice for both diets throughout the study; however, lesions were significantly larger in C57BL apoE−/− mice fed on either diet. Chemokine levels were significantly lower in C3H apoE−/− mice fed on the normal diet, but no difference was observed between the two groups fed on diet W. We conclude that serum chemokine levels are potential markers for atherosclerosis susceptibility in C3H and C57BL apoE−/− mice fed on a normal rodent diet.

Seroprevalence, correlates, and characteristics of undetected coeliac disease in England

OBJECTIVE

To examine the seroprevalence, correlates, and characteristics of undetected coeliac disease in a large adult population sample in Cambridge, UK.

METHODS

The Cambridge General Practice Health Study invited individuals from 12 general practices, aged 45-76 years, to attend for a health survey that included a bone density measurement, between 1990 and 1995. A total of 7550 participants' serum samples were tested for antiendomysial antibody (EMA). Seroprevalence of undetected coeliac disease was based on EMA positivity. Differences between EMA positive and negative participants of various physiological correlates and reported characteristics were estimated by multivariate logistic and linear regression and adjusted for age, sex, social class, and smoking behaviour.

RESULTS

The seroprevalence of undetected coeliac disease in this general population sample aged 45-76 was 1.2% (95% confidence interval (CI) 0.9-1.4). EMA positive participants (n=87) were on average slightly lighter by 2.2 kg (p=0.08), were more likely to have reported their general health as being "good or excellent" (odds ratio (OR) 1.76 (95% CI 0.90-3.46)), and were less likely to report being a current smoker (OR for current versus never 0.36 (95% CI 0.14-0.90)) than EMA negative participants. EMA positivity was associated with an 8% reduction in mean serum cholesterol (0.5 mmol/l; p<0.01) and reductions in mean haemoglobin (0.3 g/dl; p<0.01), total protein (1.0 g/l; p<0.05), and corrected serum calcium (0.02 mmol/l; p<0.05). There was an increased risk of osteoporosis in EMA positive participants (OR 3.1 (95% CI 1.3-7.2)) and of mild anaemia (OR 4.6 (95% CI 2.5-8.2)) compared with EMA negative participants.

CONCLUSIONS

Undetected coeliac disease is likely to affect approximately 1% of the population of England aged 45-76 years, a value similar to several other countries. Those affected report "better health" but they do have an increased risk of osteoporosis and mild anaemia. In contrast, they have a favourable cardiovascular risk profile that may afford protection from ischaemic heart disease and stroke.

Cost-effectiveness of eformoterol Turbohaler versus salmeterol Accuhaler in children with symptomatic asthma

We conducted an economic evaluation in a UK setting based on a 12-week prospective randomized open-label parallel-group comparison of eformoterol Turbohaler 12 microg b. i.d. with salmeterol Accuhaler 50 microg b. i.d. in children aged 6-17 with symptomatic asthma receiving inhaled corticosteroids and short-acting beta2-agonists. The principal effectiveness measure was percentage of symptom-free days with no short-acting beta2-agonist use during the study period. Asthma-related medication, unscheduled physician contacts and hospitalizations were collected prospectively and cost to the UK NHS calculated using year 2,000 prices. The economic evaluation included 73 patients in the eformoterol group and 72 patients in the salmeterol group. The mean age of patients was 11.6 years (eformoterol) and 11.8 years (salmeterol). The mean percentage of symptom-free days with no short-acting beta2-agonist use was 39% in the eformoterol group and 30% in the salmeterol group. Mean per patient daily cost was 1.15 pounds in the eformoterol group and 1.39 pounds in the salmeterol group. Both cost and effectiveness differences favoured eformoterol (P < 0.05; one-sided). Sensitivity analysis confirmed the results to be robust to changes in effectiveness, price and resource utilisation parameters. Eformoterol delivered by Turbohaler was found to be significantly more effective and less expensive than salmeterol Accuhaler in this study.

Corneal toxicity secondary to inadvertent use of benzalkonium chloride preserved viscoelastic material in cataract surgery

AIMS

To study the long term toxic effects of intraocular benzalkonium chloride (BAC).

METHODS

19 patients exposed to intraocular BAC preserved viscoelastic during cataract surgery in February 1999 developed severe striate keratopathy immediately postoperatively. 16 patients, including two who underwent penetrating keratoplasty, were studied in the period April to June 2000. Ocular symptoms, visual acuity, biomicroscopy, intraocular pressure, dilated funduscopy, specular endothelial microscopy, and corneal pachymetry findings were recorded. The corneal and iris specimens of the two patients who underwent keratoplasty were studied by light, transmission, and scanning electron microscopy.

RESULTS

Six males and 10 females, aged 64-98 years, were studied 14-16 months postoperatively. All patients were symptomatic. 12 patients had best corrected visual acuity of 6/12 or better and four patients of between 6/18 and 6/60. Five patients had corneal epithelial oedema and 11 had Descemet's membrane folds. The central corneal thickness, 620 (SD 71) microm, in affected eyes was significantly higher (p<0.005, two tailed paired t test) than that of the contralateral eyes, 563 (SD 48) microm. The endothelial cell density was significantly lower (p<0.0001, two tailed paired t test) in affected eyes: 830 (SD 280) cells/mm2 v 2017 (SD 446) cells/mm2. The mean average cell area was significantly higher in the BAC treated eyes: 1317 (SD 385) microm2 v 521 (SD 132) microm2. There was no significant difference in the coefficient of variation of cell size between the two eyes (p=0.3, two tailed paired t test). Two corneal specimens displayed morphological features of bullous keratopathy and other non-specific abnormalities. Extracellular melanosomes were present in a portion of the iris of one case.

CONCLUSION

BAC is toxic to the corneal endothelium when used intraocularly, leading to severe striate keratopathy. This cleared in most cases but left varying degrees of residual stromal thickening in all eyes. If penetrating keratoplasty is required the results are excellent.

Continuous monitoring for Cryptosporidium--a novel approach to public health protection

Regulations requiring water utilities in England and Wales to carry out continuous monitoring for Cryptosporidium in treated water were introduced in June 1999. The rationale of the Regulations and the technical basis for the sampling and analysis are reviewed. The results of the first nine months of monitoring are summarised and compared with other equivalent data sets. The impact of the Regulations on water utilities operational practices and the implications for public health protection are discussed.