The innate immune response, clinical outcomes, and ex vivo HCV antiviral efficacy of a TLR7 agonist (PF-4878691)

Hepatitis C virus (HCV) infection is an issue of global concern, and studies are ongoing to identify new therapies that are both effective and safe. PF-4878691 is a Toll-like receptor 7 (TLR7) agonist modeled so as to dissociate its antiviral activities from its inflammatory activities. In a proof-of-mechanism study in healthy volunteers who received doses of 3, 6, and 9 mg of PF-4878691 twice a week for 2 weeks, PF-4878691 induced biomarkers of the immune and interferon (IFN) responses in a dose-dependent and dose-frequency-related manner. A novel finding was induction of TLR7 expression in vivo in response to PF-4878691, leading to an amplified biomarker response. A nonresponder at the 9-mg dose had a polymorphism in the IFN-α receptor 1 subunit (Val168Leu). Two subjects who had received 9-mg doses experienced serious adverse events (SAEs), characterized by flu-like symptoms, hypotension, and lymphopenia, leading to early termination of the study. TLR7 stimulation results in a pharmacologic response at levels commensurate with predicted antiviral efficacy, but these doses are associated with SAEs, raising concerns about the therapeutic window of this class of compounds for the treatment of HCV infection.

Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review

Non-opioid analgesics, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), or cyclo-oxygenase 2 (COX-2) inhibitors are often given along with morphine as part of multimodal analgesia after major surgery. We have undertaken a systematic review and a mixed treatment comparison (MTC) analysis in order to determine explicitly which class of non-opioid analgesic, paracetamol, NSAIDs, or COX-2 inhibitors is the most effective in reducing morphine consumption and morphine-related adverse effects. Sixty relevant studies were identified. The MTC found that when paracetamol, NSAIDs, or COX-2 inhibitors were added to patient-controlled analgesia (PCA) morphine, there was a statistically significant reduction in morphine consumption: paracetamol [mean difference (MD) -6.34 mg; 95% credibility interval (CrI) -9.02, -3.65], NSAIDs (MD -10.18; 95% CrI -11.65, -8.72), and COX-2 inhibitors (MD -10.92; 95% CrI -12.77, -9.08). There was a significant reduction in nausea and postoperative nausea and vomiting with NSAIDs compared with placebo (odds ratio 0.70; 95% CrI 0.53, 0.88) but not for paracetamol or COX-2 inhibitors, nor for NSAIDs compared with paracetamol or COX-2 inhibitors. There was no statistically significant difference in sedation between any intervention and comparator. On the basis of six trials (n=695), 2.4% of participants receiving an NSAID experienced surgical-related bleeding compared with 0.4% with placebo. The MTC found that there is a decrease in 24 h morphine consumption when paracetamol, NSAID, or COX-2 inhibitors are given in addition to PCA morphine after surgery, with no clear difference between them. Similarly, the benefits in terms of reduction in morphine-related adverse effects do not strongly favour one of the three non-opioid analgesics.

Capecitabine for the treatment of advanced gastric cancer

This paper presents a summary of the evidence review group (ERG) report into capecitabine for advanced gastric cancer (aGC). Capecitabine is an oral prodrug of 5-fluorouracil (5-FU). The decision problem addressed was the use of capecitabine (X) compared to 5-FU (F), in combination regimens with platinum agents [cisplatin (C) or oxaliplatin (O)] with or without epirubicin (E), in patients with inoperable aGC. Approximately 7000 new cases of gastric cancer are diagnosed in England and Wales every year. Of these, 80% are candidates for palliative chemotherapy and around 2900 receive such treatment. The standard UK practice for patients with aGC who are considered fit enough has consisted of a triplet regimen comprising intravenous 5-FU in combination with a platinum agent (capecitabine or oxaliplatin) and epirubicin. The manufacturer's submission (MS) focused on direct evidence from two phase III non-inferiority randomised controlled trials (RCTs), REAL-2 (Randomized ECF for Advanced and Locally advanced oesophagogastric cancer-2; n = 1002) and ML17032 (n = 316). REAL-2 randomised patients to four regimens (ECF, ECX, EOF and EOX) to compare 5-FU with capecitabine and cisplatin with oxaliplatin, whereas ML17032 compared CX with CF. Efficacy outcomes from these trials were pooled in an individual patient data (IPD) meta-analysis. Both RCTs demonstrated statistically significant non-inferiority of capecitabine on the outcome of overall survival (OS) assessed in the per-protocol population; equivalent results were also demonstrated for progression-free survival (PFS). The IPD meta-analysis found a statistically significant benefit in OS for capecitabine compared with 5-FU [unadjusted hazard ratio (HR): 0.87; 95% confidence interval (CI) 0.77 to 0.98, p = 0.027]. There was no evidence of a poorer safety profile for capecitabine overall, nor of any difference in quality of life (QoL) between the two fluoropyrimidines. The MS included a de novo economic evaluation based on a cost-minimisation analysis (CMA), where the costs of capecitabine-based regimens were compared with their equivalent 5-FU-based regimens in aGC. A time horizon of 5.5 cycles (each lasting for 21 days) was used in the base-case analysis, representing the duration of treatment. The results of the manufacturer's base-case analysis showed that capecitabine regimens are associated with mean net cost savings of 1620 pounds (ECX vs ECF), 1572 pounds (EOX vs EOF) and 4210 pounds (CX vs CF). The manufacturer failed to comment explicitly on the uncertainty around the estimates of efficacy and on the fact that the IPD meta-analysis suggests that capecitabine may actually be more effective on average. Further analyses exploring additional costs incurred by the UK NHS from extending survival duration showed that these are unlikely to have a material effect on conclusions. A full probabilistic analysis was not performed; however, the evidence explored by the MS and ERG is consistent in suggesting that capecitabine has a lower mean cost than 5-FU-based regimens. The submission was considered to contain convincing evidence of the non-inferiority of capecitabine to 5-FU on survival; this evidence was considered to be applicable to UK practice. Although some uncertainty remains, the ERG deemed CMA to be an appropriate framework with which to analyse this decision problem. Overall cost estimates for the CMA were generated appropriately and were robust to uncertainties regarding assumptions and sources. At the time of writing, the guidance document issued by NICE on 28 July 2010 states that capecitabine in combination with a platinum-based regimen is recommended for the first-line treatment of inoperable advanced gastric cancer.

Capecitabine for the treatment of advanced gastric cancer

This paper presents a summary of the evidence review group (ERG) report into capecitabine for advanced gastric cancer (aGC). Capecitabine is an oral prodrug of 5-fluorouracil (5-FU). The decision problem addressed was the use of capecitabine (X) compared to 5-FU (F), in combination regimens with platinum agents [cisplatin (C) or oxaliplatin (O)] with or without epirubicin (E), in patients with inoperable aGC. Approximately 7000 new cases of gastric cancer are diagnosed in England and Wales every year. Of these, 80% are candidates for palliative chemotherapy and around 2900 receive such treatment. The standard UK practice for patients with aGC who are considered fit enough has consisted of a triplet regimen comprising intravenous 5-FU in combination with a platinum agent (capecitabine or oxaliplatin) and epirubicin. The manufacturer’s submission (MS) focused on direct evidence from two phase III non-inferiority randomised controlled trials (RCTs), REAL-2 (Randomized ECF for Advanced and Locally advanced oesophagogastric cancer-2; n = 1002) and ML17032 (n = 316). REAL-2 randomised patients to four regimens (ECF, ECX, EOF and EOX) to compare 5-FU with capecitabine and cisplatin with oxaliplatin, whereas ML17032 compared CX with CF. Efficacy outcomes from these trials were pooled in an individual patient data (IPD) meta-analysis. Both RCTs demonstrated statistically significant non-inferiority of capecitabine on the outcome of overall survival (OS) assessed in the per-protocol population; equivalent results were also demonstrated for progression-free survival (PFS). The IPD meta-analysis found a statistically significant benefit in OS for capecitabine compared with 5-FU [unadjusted hazard ratio (HR): 0.87; 95% confidence interval (CI) 0.77 to 0.98, p = 0.027]. There was no evidence of a poorer safety profile for capecitabine overall, nor of any difference in quality of life (QoL) between the two fluoropyrimidines. The MS included a de novo economic evaluation based on a cost-minimisation analysis (CMA), where the costs of capecitabine-based regimens were compared with their equivalent 5-FU-based regimens in aGC. A time horizon of 5.5 cycles (each lasting for 21 days) was used in the base-case analysis, representing the duration of treatment. The results of the manufacturer’s base-case analysis showed that capecitabine regimens are associated with mean net cost savings of £1620 (ECX vs ECF), £1572 (EOX vs EOF) and £4210 (CX vs CF). The manufacturer failed to comment explicitly on the uncertainty around the estimates of efficacy and on the fact that the IPD meta-analysis suggests that capecitabine may actually be more effective on average. Further analyses exploring additional costs incurred by the UK NHS from extending survival duration showed that these are unlikely to have a material effect on conclusions. A full probabilistic analysis was not performed; however, the evidence explored by the MS and ERG is consistent in suggesting that capecitabine has a lower mean cost than 5-FU-based regimens. The submission was considered to contain convincing evidence of the non-inferiority of capecitabine to 5-FU on survival; this evidence was considered to be applicable to UK practice. Although some uncertainty remains, the ERG deemed CMA to be an appropriate framework with which to analyse this decision problem. Overall cost estimates for the CMA were generated appropriately and were robust to uncertainties regarding assumptions and sources. At the time of writing, the guidance document issued by NICE on 28 July 2010 states that capecitabine in combination with a platinum-based regimen is recommended for the first-line treatment of inoperable advanced gastric cancer.

HIV stigma, disclosure and psychosocial distress among Thai youth living with HIV

The objective of the present paper is to assess stigma and to create an abbreviated 12-item Stigma Scale based on the 40-item Berger's Stigma Scale for Thai youth living with HIV (TYLH). TYLH aged 16-25 years answered the 40-item Stigma Scale and the questionnaires on mental health, social support, quality of life and alcohol/substance use. Sixty-two (88.6%) of 70 TYLH reported at least one person knowing their serostatus. Men having sex with men were more likely to disclose the diagnosis to friends (43.9% versus 6.1%, P < 0.01) and less likely to disclose to families (47.6% versus 91.8%, P < 0.01). Women were more likely to disclose to families (90.2% versus 62.1%, P < 0.01) and less likely to disclose to friends (7.3% versus 31%, P < 0.05). The 12-item Stigma Scale was reliable (Cronbach's alpha, 0.75) and highly correlated with the 40-item scale (r = 0.846, P < 0.01). Half of TYLH had mental health problems. The 12-item Stigma Scale score was significantly associated with mental health problems (beta = 0.21, P < 0.05). Public attitudes towards HIV were associated with poorer quality of life (beta = -1.41, P < 0.01) and mental health problems (beta = 1.18, P < 0.01). In conclusion, the12-item Stigma Scale was reliable for TYLH. Increasing public understanding and education could reduce stigma and improve mental health and quality of life in TYLH.

Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review

OBJECTIVES

To determine which class of non-opioid analgesics - paracetamol (acetaminophen), NSAIDs or COX-2 inhibitors - is the most effective at reducing morphine consumption and associated adverse effects when used as part of multimodal analgesia following major surgery.

DATA SOURCES

A systematic literature review was conducted using MEDLINE, EMBASE and CENTRAL databases, searched from January 2003 to February 2009 and updating an earlier review.

REVIEW METHODS

Randomised controlled trials comparing paracetamol, NSAIDs or COX-2 inhibitors to each other or placebo, in adults receiving patient-controlled analgesia (PCA) with morphine following major surgery, were included. The COX-2 inhibitors rofecoxib and valdecoxib were excluded. Only trials that reported 24-hour morphine consumption were included. Other outcomes of interest were morphine-related adverse effects and adverse effects related to the non-opioids. Adequacy of randomisation, concealment of allocation, double blinding, and the flow of patients within the trial was assessed. The main analysis was a mixed treatment comparison (MTC) evaluating the relative effects of the four treatment classes. Four main outcomes were prioritised: 24-hour morphine consumption, sedation, nausea and vomiting, and surgical bleeding. Studies reporting nausea alone were pooled with studies reporting postoperative nausea and vomiting (PONV). Comparisons were described as statistically significant (at 5% level) when the credibility interval (CrI) did not cross 1 for odds ratio (OR) and zero for mean difference (MD). Trials making direct comparisons between the active interventions were also pooled in a meta-analysis using a random effects model. Sensitivity analyses were performed to assess the effects of study quality, individual drugs, and baseline morphine consumption.

RESULTS

Sixty relevant studies were identified. When paracetamol, NSAIDs or COX-2 inhibitors were added to PCA morphine, there was a statistically significant reduction in morphine consumption: paracetamol (MD -6.34 mg; 95% CrI -9.02 to -3.65); NSAIDs (MD -10.18; 95% CrI -11.65 to -8.72); and COX-2 inhibitors (MD -10.92; 95% CrI -12.77 to -9.08). NSAIDs and COX-2 inhibitors were both significantly better than paracetamol, and there was no significant difference between NSAIDs and COX-2 inhibitors (MD -0.74; 95% CrI -3.03 to 1.56). There was a significant reduction in nausea and PONV with NSAIDs compared to placebo (OR 0.70; 95% CrI 0.53 to 0.88) but not for paracetamol or COX-2 inhibitors, nor for NSAIDs compared to paracetamol or COX-2 inhibitors.

CONCLUSIONS

24-hour morphine consumption decreased by 6.3 mg to 10.9 mg, compared to placebo, when paracetamol, NSAID or COX-2 inhibitors were added to PCA morphine following surgery. Differences in effect between the three drug classes were small and unlikely to be of clinical significance. There does not appear to be a strong case for recommending routine addition of any of the three non-opioids to PCA morphine in the 24 hours immediately after surgery, or for favouring one drug class above the others.

Recent incidence trends and sociodemographic features of oesophageal and gastric cancer types in an English region

BACKGROUND

Oesophageal and gastric cancers comprise various common tumour types with possible different aetiology and historically different incidence trends.

AIM

To enhance and update evidence about the descriptive epidemiology of oesophageal and gastric cancers.

METHODS

Population-based information from the East of England was available on 16 319 (65% male) incident cases of oesophago-gastric cancer (ICD-10 C150-169) diagnosed during 1995-2006. Age-standardized incidence trends by gender and deprivation groups and sex ratios were compared for four different tumour types [oesophageal squamous cell carcinoma (OSCC), oesophageal adenocarcinoma (OAC), junctional/cardia adenocarcinoma (JCA), and non-cardia gastric adenocarcinoma (NCGA)].

RESULTS

Between 1995-1997 and 2004-2006, the age-standardized incidence of OAC and JCA increased slightly (by 4% and 6% in men and 17% and 8% in women respectively), with a sex ratio >4 for both. Conversely, OSCC and NCGA incidence decreased (-20% and -32% in men and -15% and -26% in women respectively), with sex ratio of <2 for both. In men, OSCC and NCGA incidence was associated with increasing deprivation.

CONCLUSIONS

Within the study context, there was a modest rise in OAC and JCA incidence. OAC and JCA share common incidence trends and sociodemographic features (contrasting with those of OSCC and NCGA cancers).

Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews

Background

There is increasing pressure to tackle the wider social determinants of health through the implementation of appropriate interventions. However, turning these demands for better evidence about interventions around the social determinants of health into action requires identifying what we already know and highlighting areas for further development.

Methods

Systematic review methodology was used to identify systematic reviews (from 2000 to 2007, developed countries only) that described the health effects of any intervention based on the wider social determinants of health: water and sanitation, agriculture and food, access to health and social care services, unemployment and welfare, working conditions, housing and living environment, education, and transport.

Results

Thirty systematic reviews were identified. Generally, the effects of interventions on health inequalities were unclear. However, there is suggestive systematic review evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, particularly interventions in the fields of housing and the work environment.

Conclusion

Intervention studies that address inequalities in health are a priority area for future public health research.

Prognosis and comorbidities in stage III and IV endometrial cancer

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Background: While endometrial cancer may be associated with many comorbid conditions, none have been characterized as changing overall prognosis. The aim of this study was to identify medical conditions or laboratory values, that may serve as prognostic factors in stage III and IV endometrial cancer. Methods: A retrospective chart review identified 112 women with stage III or IV endometrial cancer between years 1993–1998. Information about medical comorbidities and presenting lab values were collected using electronic medical records. Progression free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier survival method and the log rank test. Results: The average age was 64.9 yrs. 79 women (70.5%) had stage III disease and 33 women (29.5%) had stage IV disease. For those with a baseline creatinine <1.2 (n = 91), the PFS and OS were not significantly different from those with a baseline creatinine ≥1.2 (n = 17; p = 0.554 and p = 0.487, respectively). There was a non-significant trend toward worse PFS for the 41 patients with hypertension (HTN) compared to the 62 without (48.0 and 61.2 months, p = 0.191). The overall survival was significantly worse for those with HTN (38.7 months vs. 56.0 months p = 0.046). For those with known coronary artery disease, no significant difference in PFS or OS was found (p = 0.792 and p = 0.312 respectively). Those with diabetes (n = 15) did not have a significantly different PFS compared to those who did not (n = 88; p = 0.728). The OS was worse at 20.1 months for those with diabetes compared to 54.3 months for those without (p = 0.001). Baseline albumin had a significant effect on both PFS and OS. Those with an albumin <3.5 (n = 54) had a PFS of 46.2 months compared to 94.0 months for those with an albumin ≥3.5 (n = 23; p = 0.007), and the OS for those with low albumin was 44.8 months compared to 83.4 months for those with the higher albumin (p = 0.005). Conclusions: These results suggest that past medical history and some baseline laboratory values may be important in considering prognosis. In particular, patients with a history of HTN or diabetes have a worse overall survival. Those with a baseline albumin of <3.5 have a worse PFS and OS.

No significant financial relationships to disclose.

Working for health? Evidence from systematic reviews on the effects on health and health inequalities of organisational changes to the psychosocial work environment

OBJECTIVE

To map the health effects of interventions which aim to alter the psychosocial work environment, with a particular focus on differential impacts by socio-economic status, gender, ethnicity, or age.

METHODS

A systematic approach was used to identify, appraise and summarise existing systematic reviews (umbrella review) that examined the health effects of changes to the psychosocial work environment. Electronic databases, websites, and bibliographies, were searched from 2000-2007. Experts were also contacted. Identified reviews were critically appraised and the results summarised taking into account methodological quality. The review was conducted in the UK between October 2006 and December 2007.

RESULTS

Seven systematic reviews were identified. Changes to the psychosocial work environment were found to have important and generally beneficial effects on health. Importantly, five reviews suggested that organisational level psychosocial workplace interventions may have the potential to reduce health inequalities amongst employees.

CONCLUSION

Policy makers should consider organisational level changes to the psychosocial work environment when seeking to improve the health of the working age population.

Transtheoretical model and risky sexual behaviour in HIV + youth in Thailand

The purpose of the study was to determine the applicability of the Transtheoretical Model for predicting unprotected intercourse in HIV+ Thai youth. Questionnaires and interviews about sexual behaviour, readiness to change, self-efficacy, substance use, emotional distress and social support were obtained from 70 HIV+ Thai youth (ages 17 to 25). Path analysis suggested the model was an excellent fit with the data. Readiness to change but not self-efficacy was directly related to unprotected intercourse acts. This differed from HIV+ youth in the US where self-efficacy fully mediated the relationship between readiness to change and condom use. In the Thai sample, social support and self-efficacy were indirectly related to unprotected intercourse through stage of change. Substance use was unrelated to unprotected intercourse, but rates of use were low. Potential cultural differences in the construct of self-efficacy and its relationship to risky behaviours in Thailand require further study. However, results highlight the potential of prevention interventions that increase readiness to change through boosting self-efficacy and social support specific to practicing safer sex while addressing mental health concerns.

Development and validation of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with Type 2 diabetes

AIMS

To develop and validate an easy-to-use questionnaire to identify obstacles to self management in Type 2 diabetes.

METHODS

The Diabetes Obstacles Questionnaire (DOQ) was developed from earlier research and the literature. It was completed by 180 people with Type 2 diabetes, recruited from 22 general practices in the UK. Responders also completed a quality-of-life questionnaire (ADDQoL) and the Problem Areas in Diabetes (PAID) scale.

RESULTS

From analysis of the 176 usable questionnaires, 36 items of the original 113 items were deemed redundant. The remaining 77 items were assembled into eight sub-scales covering Medication, Self Monitoring, Knowledge and Beliefs, Diagnosis, Relationships with Health-Care Professionals, Lifestyle Changes, Coping, and Advice and Support. Each sub-scale had a factor structure of no more than three factors, had Cronbach's alpha of more than 0.75, and a Kaiser-Meyer-Olkin of more than 0.75. Each sub-scale correlated significantly with the PAID scale (P < 0.01), demonstrating criterion validity. Construct validity was shown by significant correlation between HbA(1c) and the sub-scales which relate to managing blood glucose levels: Self Monitoring, Relationship with Health-Care Professionals, Lifestyle Changes and Coping. Construct validity was further shown by significant correlation between QoL scores and Medication, Lifestyle Changes and Coping.

DISCUSSION

The DOQ, comprising eight sub-scales, is a usable, valid instrument for both clinical and research settings. It helps to identify in detail the obstacles which an individual finds in living with Type 2 diabetes.

The nurse's role in day surgery: a literature review

AIM

This paper reports a literature review to synthesize the evidence on day surgery, demonstrating its usefulness for innovative nurses.

BACKGROUND

Day surgery growth has developed rapidly in recent years. Such a rapid growth has triggered a shift in nursing roles and interventions. Nursing roles are taking shape within modern day surgical units but have not been widely reviewed in developing countries.

METHODS

The RCN library, BNI, CINAHL and Medline databases were searched using the terms 'day surgery and technological advantages', 'financial/economic benefits', 'patient experiences/satisfaction', 'day surgery/international comparisons', 'day surgery and developing countries'. Only papers in the English language from 1990 to 2005 were reviewed, with a predominantly adult focus. The papers examined mainly used research techniques and some opinion papers, policy documents and textbooks were examined for additional information.

FINDINGS

The key strengths of day surgery are cost-effectiveness, increased patient satisfaction and low infection rates. Patients indicated that effective information provision and psychological preparation helped them cope with the experience. The use of music, story telling and distraction reduced pre-operative anxiety. Contrastingly, the deficits included poor information giving and psychological preparation resulting in high anxiety levels. Many patients encountered variable pain and nausea management and education strategies.

CONCLUSION

This review highlights the importance of adequate preparation and continuous psychological support for patients undergoing day surgery. The challenges faced by practitioners involved with innovation are also emphasized.

A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease

OBJECTIVES

To determine the diagnostic accuracy and cost-effectiveness of duplex ultrasound (DUS), magnetic resonance angiography (MRA), and computed tomography angiography (CTA), as alternatives to contrast angiography (CA), for the assessment of lower limb peripheral arterial disease (PAD).

DATA SOURCES

Ten electronic databases were searched in April 2004, with an update in May 2005. Six key journals and bibliographies of included studies were also searched and experts in the field were consulted.

REVIEW METHODS

Data extraction and quality assessment were performed in duplicate. Data were analysed according to test type and diagnostic threshold. For the economic analysis, a decision tree was developed and a probabilistic sensitivity analysis performed to incorporate statistical uncertainty into the cost-effectiveness analysis.

RESULTS

A total of 113 studies met the inclusion criteria (including six economic evaluations). For the detection of stenosis greater than 50% in the whole leg, contrast-enhanced (CE) MRA (14 studies) had the highest diagnostic accuracy, with sensitivity ranging from 92 to 99.5% and specificity from 64 to 99%. Two-dimensional (2D) time-of-flight (TOF) MRA (11 studies) was less accurate, with sensitivity ranging from 79 to 94% and specificity from 74 to 92%. 2D phase-contrast (PC) MRA (one study) had a sensitivity of 98% and specificity of 74%. CTA (seven studies) also appeared slightly inferior to CE MRA, with a sensitivity ranging from 89 to 99% and specificity from 83 to 97%, but better than DUS (28 studies), which had a sensitivity ranging from 80 to 98% and specificity from 89 to 99%. There was some indication that CE MRA and DUS were more accurate for detecting stenoses/occlusions above the knee than below the knee or in the pedal artery. The four studies of patient attitudes strongly suggested that patients preferred CE MRA to CA. CA was considered the most uncomfortable test, followed by CE MRA, with CTA being the least uncomfortable. Half of the patients (from a sample who did not suffer from claustrophobia and had no metallic implants) expressed no preference between undergoing TOF MRA or DUS; most of those who did express a preference favoured TOF MRA. In the 55 studies identified for adverse events, MRA was associated with the highest reported proportion. However, the most severe adverse events were more common in patients undergoing CA; although these were rare for both tests. The economic evaluation showed DUS dominated the other alternatives when the whole leg was assessed, by presenting higher effectiveness at a lower cost per quality-adjusted life-year (QALY; i.e. 13,646 pounds per QALY). When the assessment was limited to a section of the leg, either above the knee or below the knee, 2D TOF MRA was the most cost-effective preoperative diagnostic strategy. The incremental cost per QALY for below-the-knee comparisons was equal to 37,024 pounds when 2D TOF MRA was compared with DUS. For above-the-knee comparisons, 2D TOF MRA presented the lowest cost and slightly lower effectiveness compared with CE MRA, with a cost per QALY equal to 13,442 pounds.

CONCLUSIONS

The results of the review suggest that CE MRA has a better overall diagnostic accuracy than CTA or DUS, and that CE MRA is generally preferred by patients over CA. Where available, CE MRA may be a viable alternative to CA. The only controlled trial suggested that the results of DUS were comparable to those of CA, in terms of surgical planning and outcome. This finding conflicts with the results of diagnostic accuracy studies, which reported poor estimates of accuracy for DUS in comparison with CA. There was insufficient evidence to evaluate the usefulness of CTA for the assessment of PAD, particularly newer techniques. The results of the economic modelling suggest that for PAD patients for whom the whole leg is evaluated by a preoperative diagnostic test, DUS dominates the other alternatives by presenting higher effectiveness at a lower cost per QALY. However, when the analysis of stenosis is limited to a section of the leg, either above the knee or below the knee, 2D TOF MRA appears to be the most cost-effective preoperative diagnostic strategy. Further research is needed into a number of areas including the relative clinical effectiveness of the available imaging tests, in terms of surgical planning and postoperative outcome.

Transtheoretical Model and substance use in HIV-positive youth

The purpose of the study was to test constructs of the Transtheoretical Model (TTM) for predicting alcohol and other drug use in HIV-positive youth (ages 16-25). Questionnaires and interviews about alcohol and other drug use, stage of change, self-efficacy, emotional distress and social support were obtained from 64 HIV-positive youth. Structural equation modeling with standard errors determined by methods appropriate to small samples, demonstrated that self-efficacy mediated the relationship between stage of change and alcohol use and between social support and alcohol use. The same pattern of results emerged for marijuana use. The models predicted 47% of the variance in alcohol use and 69% of the variance in marijuana use. Results supported the TTM and highlight the potential of interventions that seek to boost self-efficacy and social support specific to reducing substance use.

Ancillary services and retention of youth in HIV care

The purpose of this prospective study was to test the relationship between receipt of ancillary services (case management, advocacy, counseling) over six months and retention of youth in HIV care in the subsequent six months. Medical records of 75 youth (ages 16-25) enrolled in a comprehensive HIV care program at a university-affiliated medical center in Detroit, Michigan were reviewed for receipt of services in a 12-month period. The youth program offered medical and ancillary services in a one-stop-shopping model. The expectation for medical care for youth was at least quarterly medical appointments. A three-point scale was constructed with a score of '0' indicating no gaps (at least one medical care appointment every three months in a six-month period), a score of '1' indicating one gap (no appointment in one of the two quarters) and a score of '2' indicating two gaps (no appointments in six months). Increased receipt of ancillary services in the first six months predicted lower gap scores in the second six months, even controlling for gap scores in the first six months. Counseling appointments were the strongest predictor. Preliminary results suggest the continued need for resources allocated to ancillary services to support retention in care.

The effect of changes in the treatment paradigm for chronic lymphocytic leukemia: A tumor registry study

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Background: In the early 1990s, several new agents became available for treatment of chronic lymphocytic leukemia (CLL), leading to a shift in the treatment paradigm with the hope of improving long-term survival. To determine if that outcome has been achieved, we performed a retrospective analysis of survival of patients in our community. Methods: The hospital tumor registry was queried to identify patients with CLL diagnosed 1980 to 2004. Zip code at diagnosis was used to assign a median household income based on census data. Survival was estimated by the method of Kaplan and Meier. Comparisons between the two groups were made by chi square. Hazard ratios for mortality were calculated in a Cox proportional hazard model using a backward stepping procedure retaining factors having a p-value < 0.1. Results: There were 192 patients with a diagnosis of CLL for analysis. The study cohort was comprised of 58% males and 42% females of median age 67 years (range, 39–96 years) at diagnosis. Fifty-three (28%) were <60 years of age, 29% were 60–69 years old, 26% were 70–79 years old, and 18% were >79 years at diagnosis. The group was 71% caucasian and 29% African American. Seventy-five (39%) patients had a household income greater than the median for the state, and the remainder had lesser incomes. There was a significant increase in the proportion of African Americans diagnosed >1990 compared to those diagnosed ≤1990 (40% vs 19%, p = 0.002), but there were no differences between time periods in gender, age, age category or income category. On multivariate analysis, factors predicting mortality differed between time periods as shown in the table. Median survival was 4.0 years for all patients, 3.9 years for the early group and 4.1 years for the later group (p = NS). Conclusion: We conclude that with changes in the treatment paradigm for CLL, gender and race are no longer prognostic for mortality, and the relative hazard for death is less amongst those 60–69 years and >79 years old, but there is no difference in survival for patients overall.

[Table: see text]

No significant financial relationships to disclose.