Cost-effectiveness of additional catheter-directed thrombolysis for deep vein thrombosis

BACKGROUND

Additional treatment with catheter-directed thrombolysis (CDT) has recently been shown to reduce post-thrombotic syndrome (PTS).

OBJECTIVES

To estimate the cost effectiveness of additional CDT compared with standard treatment alone.

METHODS

Using a Markov decision model, we compared the two treatment strategies in patients with a high proximal deep vein thrombosis (DVT) and a low risk of bleeding. The model captured the development of PTS, recurrent venous thromboembolism and treatment-related adverse events within a lifetime horizon and the perspective of a third-party payer. Uncertainty was assessed with one-way and probabilistic sensitivity analyzes. Model inputs from the CaVenT study included PTS development, major bleeding from CDT and utilities for post DVT states including PTS. The remaining clinical inputs were obtained from the literature. Costs obtained from the CaVenT study, hospital accounts and the literature are expressed in US dollars ($); effects in quality adjusted life years (QALY).

RESULTS

In base case analyzes, additional CDT accumulated 32.31 QALYs compared with 31.68 QALYs after standard treatment alone. Direct medical costs were $64,709 for additional CDT and $51,866 for standard treatment. The incremental cost-effectiveness ratio (ICER) was $20,429/QALY gained. One-way sensitivity analysis showed model sensitivity to the clinical efficacy of both strategies, but the ICER remained < $55,000/QALY over the full range of all parameters. The probability that CDT is cost effective was 82% at a willingness to pay threshold of $50,000/QALY gained.

CONCLUSIONS

Additional CDT is likely to be a cost-effective alternative to the standard treatment for patients with a high proximal DVT and a low risk of bleeding.

Synergistic cytotoxicity of oncolytic reovirus in combination with cisplatin-paclitaxel doublet chemotherapy

Oncolytic reovirus is currently under active investigation in a range of tumour types. Early phase studies have shown that this agent has modest monotherapy efficacy and its future development is likely to focus on combination regimens with cytotoxic chemotherapy. Indeed, phase I/II clinical trials have confirmed that reovirus can be safely combined with cytotoxic drugs, including a platin-taxane doublet regimen, which is currently being tested in a phase III clinical trial in patients with relapsed/metastatic head and neck cancer. Therefore, we have tested this triple (reovirus, cisplatin, paclitaxel) combination therapy in a panel of four head and neck cancer cell lines. Using the combination index (CI) method, the triple therapy demonstrated synergistic cytotoxicity in vitro in both malignant and non-malignant cell lines. In head and neck cancer cell lines, this was associated with enhanced caspase 3 and 7 cleavage, but no increase in viral replication. In vitro analyses confirmed colocalisation of markers of reovirus infection and caspase 3. Triple therapy was significantly more effective than reovirus or cisplatin-paclitaxel in athymic nude mice. These data suggest that the combination of reovirus plus platin-taxane doublet chemotherapy has significant activity in head and neck cancer and underpin the current phase III study in this indication.

Electron neutrino and antineutrino appearance in the full MINOS data sample

We report on ν(e) and ν(e) appearance in ν(μ) and ν(μ) beams using the full MINOS data sample. The comparison of these ν(e) and ν(e) appearance data at a 735 km baseline with θ13 measurements by reactor experiments probes δ, the θ23 octant degeneracy, and the mass hierarchy. This analysis is the first use of this technique and includes the first accelerator long-baseline search for ν(μ) → ν(e). Our data disfavor 31% (5%) of the three-parameter space defined by δ, the octant of the θ23, and the mass hierarchy at the 68% (90%) C.L. We measure a value of 2sin(2)(2θ13)sin(2)(θ23) that is consistent with reactor experiments.

Differential-effects of viral and cellular oncogenes on the growth factor-dependency of hematopoietic-cells

The effects of different viral and cellular oncogenes on the cytokine-dependency of murine hematopoietic cell lines were compared. The myeloid FDC-P1 cell line was sensitive to abrogation of growth factor-dependency by the constitutive expression of viral oncogenes (v-abl, v-src, v-Ha-ras, and v-fms) and the activated cellular oncogene BCR-ABL and Delta Nraf. The Delta Nraf encoded serine-threonine kinase was approximately 100-fold less efficient in relieving the factor-dependency of FDC-P1 cells than the other oncogenes examined. The synthesis of autocrine cytokines was not detected in the factor-independent FDC-P1 lines, indicating that the oncogene-mediated transformation occurred by a non-autocrine mechanism. A low frequency of cells were isolated after infection with the chronic retrovirus, murine leukemia virus and approximately 40% of these clones synthesized the autocrine lymphokine, granulocyte-macrophage colony stimulating factor. In contrast, only the v-abl and BCR-ABL oncogenes relieved the cytokine-dependency of the lymphoid FL5.12 cell line. In all the transformed cell lines, the rate of glucose transport was elevated above the basal level seen in uninfected cells indicating that this pivotal growth-regulated protein was associated with malignant transformation. In summary, these cell lines varied with respect to abrogation of growth factor-dependency as the myeloid FDC-P1 line was sensitive to transformation by all oncogenes examined whereas only the abl-family members would relieve the cytokine-requirement of lymphoid FL5.12 cells.

Improved measurement of muon antineutrino disappearance in MINOS

We report an improved measurement of ν(μ) disappearance over a distance of 735 km using the MINOS detectors and the Fermilab Main Injector neutrino beam in a ν(μ)-enhanced configuration. From a total exposure of 2.95×10(20) protons on target, of which 42% have not been previously analyzed, we make the most precise measurement of Δm2=[2.62(-0.28)(+0.31)(stat)±0.09(syst)]×10(-3)  eV2 and constrain the ν(μ) mixing angle sin2(2θ)>0.75 (90% C.L.). These values are in agreement with Δm2 and sin2(2θ) measured for ν(μ), removing the tension reported in [P. Adamson et al. (MINOS), Phys. Rev. Lett. 107, 021801 (2011).].

Genetic epilepsy with febrile seizures plus: definite and borderline phenotypes

Generalised epilepsy with febrile seizures plus (GEFS+) is the most studied familial epilepsy syndrome. However, characteristics of UK families have not previously been reported. Among the first 80 families recruited to our families study, four broad subphenotypes were identified: families with classical GEFS+; families with borderline GEFS+; families with unclassified epilepsy; and families with an alternative syndromal diagnosis. Borderline GEFS+ families shared many characteristics of classical GEFS+ families-such as prominent febrile seizures plus and early onset febrile seizures-but included more adults with focal epilepsies (rather than the idiopathic generalised epilepsies predominating in GEFS+) and double the prevalence of migraine. Thus the authors believe that a novel and robust familial epilepsy phenotype has been identified. Subcategorising families with epilepsy is helpful in targeting both clinical and research resources. Most families with GEFS+ have no identified causal mutation, and so predicting genetic homogeneity by identifying endophenotypes becomes more important.

Abstract P318: Vasoprotective Effects of an Apo A-I Mimetic Peptide

Hepatic ischemia/reperfusion (I/R) injury is associated with several pathologic states and contributes to the development of systemic vascular complications. High density lipoprotein (HDL) and apolipoprotein (apo) A-1 possess antioxidant and anti-inflammatory properties and reduce tissue injury in several models of I/R. In the current study, we tested the hypothesis that the synthetic apoA-I mimetic peptide 4F, similar to HDL and apoA-I, exerts cytoprotective effects in a murine model of hepatic I/R injury. C57BL/6 mice were randomized to receive 4F (5 mg/kg, IP) or an equivalent volume of saline vehicle. Mice were then subjected to 45 min of segmental hepatic ischemia, followed by 24 hr reperfusion. Sham-operated mice served as a control. Hepatic I/R injury was associated with an increase in alanine transaminase (ALT: 980±95U/mL) and xanthine oxidase (XO: 700±100U/mL) release compared to sham-operated controls (ALT=27±8U/mL; XO=100±10U/mL). Endothelium-dependent relaxation was impaired in aortae of I/R mice (R max =20%) compared to controls (R max =72%). This response was associated with a decrease in eNOS protein and an increase in iNOS and plasma levels of nitric oxide metabolites (NOx). Further, immunohistochemical studies revealed an increase in the nitration (3-NT) and chlorination (3-CT) of protein tyrosine residues in aortic sections from I/R mice that was associated with an increase in tissue myeloperoxidase (MPO) content. 4F treatment significantly improved the relaxation response in the aorta of I/R mice (R max =60%), prevented the upregulation of iNOS and NOx and reduced tissue protein nitration/chlorination. 4F treatment was further associated with a reduction in hepatocellular injury in I/R mice, as revealed by a decrease in ALT (110±15U/mL) and XO (270±50U/mL) release. Collectively, these data suggest that 4F reduces systemic vascular injury via cytoprotective effects at the level of the liver. ApoA-I mimetic peptide-based therapies may be effective in reducing vascular complications associated with clinical procedures such as transplantation.

Improved search for Muon-neutrino to electron-neutrino oscillations in MINOS

We report the results of a search for ν(e) appearance in a ν(μ) beam in the MINOS long-baseline neutrino experiment. With an improved analysis and an increased exposure of 8.2 × 10(20) protons on the NuMI target at Fermilab, we find that 2 sin(2) (θ(23))sin(2)(2θ(13))<0.12(0.20) at 90% confidence level for δ = 0 and the normal (inverted) neutrino mass hierarchy, with a best-fit of 2sin(2) (θ(23))sin(2)(2θ(13)) = 0.041(-0.031)(+0.047) (0.079(-0.053) (+0.071)). The θ(13) = 0 hypothesis is disfavored by the MINOS data at the 89% confidence level.

First direct observation of muon antineutrino disappearance

This Letter reports the first direct observation of muon antineutrino disappearance. The MINOS experiment has taken data with an accelerator beam optimized for ν(μ) production, accumulating an exposure of 1.71 × 10²⁰ protons on target. In the Far Detector, 97 charged current ν(μ) events are observed. The no-oscillation hypothesis predicts 156 events and is excluded at 6.3σ. The best fit to oscillation yields |Δm²| = [3.36(-0.40)(+0.46)(stat) ± 0.06(syst)] × 10⁻³ eV², sin²(2θ) = 0.86(-0.12)(+0.11)(stat) ± 0.01(syst). The MINOS ν(μ) and ν(μ) measurements are consistent at the 2.0% confidence level, assuming identical underlying oscillation parameters.

Active to sterile neutrino mixing limits from neutral-current interactions in MINOS

Results are reported from a search for active to sterile neutrino oscillations in the MINOS long-baseline experiment, based on the observation of neutral-current neutrino interactions, from an exposure to the NuMI neutrino beam of 7.07×10(20) protons on target. A total of 802 neutral-current event candidates is observed in the Far Detector, compared to an expected number of 754 ± 28(stat) ± 37(syst) for oscillations among three active flavors. The fraction f(s) of disappearing ν(μ) that may transition to ν(s) is found to be less than 22% at the 90% C.L.