Treatment Outcome and Cost-Effectiveness of Different Highly Active Antiretroviral Therapy Regimens in the Uk (1996–2002)

The aim of this study was to estimate the outcome and cost-effectiveness per life-year-gained (LYG) of first-, second- and third-line non-nucleoside reverse transcriptase inhibitors (NNRTI) versus protease inhibitor (PI) containing highly active antiretroviral therapy regimens. Hospital care costs (2002 US dollars discounted 3.5% per annum) were linked to treatment failure times. Results show that the median time-to-treatment failure for first-line (nucleoside reverse transcriptase inhibitors) 2NRTIs + NNRTI was substantially longer than that for 2NRTIs + PIboosted, 2NRTIs + PI and 2NRTIs + 2PIs, whereas for second- and third-line they were similar. Comparing first-line 2NRTIs + NNRTI with 2NRTIs + PIboosted cost per LYG was US$ 12,375; US$ 12,139 per LYG when compared with 2NRTIs + PI and US$ 2948 per LYG when compared with 2NRTIs + 2PIs. For second-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PIboosted was US$ 19,501; US$ 18,364 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. For third-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PIboosted was US$ 2708; US$ 11,559 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. In conclusion, first-line 2NRTIs + NNRTI was cost-effective or cost-saving when compared with PI-containing regimens for all lines of therapy. Such information is required by clinicians and managers of HIV services to make appropriate treatment decisions based on clinical and financial grounds, and given the increasing number of people living with HIV, such information will become more important over time.

An open, pharmacokinetic (PK) and mass balance study of 14C-AZD2171, incorporating DCE-CT evaluations

14140

Background: AZD2171 is an oral, highly potent and selective VEGF signaling inhibitor in clinical development. Methods: Patients with solid metastatic tumors received a single radiolabeled oral dose of 14C- AZD2171 45 mg; blood samples and all excretions were collected for evaluating the PK and metabolic profiles. After sufficient radioactivity recovery, patients started once-daily oral dosing with AZD2171 30 mg. The primary objective of the study was to determine the rates and routes of excretion of AZD2171 using 14C-AZD2171. Efficacy (RECIST), safety and tolerability were secondary objectives. The potential effects of AZD2171 on DCE-CT vascular parameters were also explored. Results: Six patients received treatment and remained on study for 64–171 days. In 5/6 patients, the amount of radioactivity recovered in the urine and feces samples within 168-hours post- dosing ranged from 84.8–93.0%; the analogous amount in the remaining patient was only 34.1%. In all patients, mean radioactivity recovered was 58.8% in feces and 20.8% in urine. Radioactivity appeared to be confined to plasma. Three patients (2 renal cell carcinoma; 1 mesothelioma) had a best RECIST response of stable disease (SD); 1 patient had a confirmed reduction in max tumor diameter of 10% to <30%. Two patients had progressive disease and 1 patient was non-evaluable. The most common adverse events (AEs) were diarrhea (n=5) and hypertension (n=3); no grade 3 or 4 AEs occurred more than once. There was evidence of reductions in DCE-CT parameters post treatment, particularly perfusion, permeability surface product (PSP) and positive enhancement integral. For each of these parameters, a decrease from baseline outside the baseline reference range was recorded for 3 patients (including 2 with SD) at 1 month after the start of daily dosing of AZD2171. Overall, within-patient variability (W-PV) was generally low for all DCE-CT parameters measured and was consistently lower than between-patient variability. The W-PV was largest for PSP (18%) and lowest for mean transit time (7%). Conclusions: The primary route of AZD2171 elimination appears to be hepatic. AZD2171 was well tolerated and clinically meaningful disease stabilization was seen. Changes in tumor vascular parameters were detected by DCE-CT.

[Table: see text]

Prevalence of asymptomatic intracranial atherosclerosis in high-risk patients

We used transcranial Doppler to screen 3,057 patients who had at least one vascular risk factor of hypertension, diabetes, or hyperlipidemia and found 385 (12.6%) had middle cerebral artery stenosis. Elderly, hypertension, diabetes, and hyperlipidemia were associated factors. The prevalence escalated quadratically with increasing number of associated factors: from 7.2% for one, to 29.6% for four associated factors. Asymptomatic middle cerebral artery stenosis is common in patients with vascular risk factors.

A door-to-door survey of intracranial atherosclerosis in Liangbei County, China

We studied 590 asymptomatic villagers aged > or =40 years in Liangbei County in central rural China and found 41 subjects (prevalence 6.9%) with intracranial atherosclerosis. In a multivariate analysis, the significant risk factors for intracranial stenosis were hypertension (OR 2.53; 95% CI 1.12 to 5.72), glycosuria (OR 3; 1.19 to 7.97), heart disease (OR 4; 1.39 to 11.6), and family history of stroke (OR 5.2; 1.38 to 20). Intracranial atherosclerosis is not uncommon among asymptomatic Chinese subjects.

Quality of life is predictive of survival in patients with unresectable hepatocellular carcinoma

BACKGROUND

Patients with unresectable hepatocellular carcinoma (HCC) have a dismal prognosis. The objective of this study was to evaluate whether patient-reported baseline quality of life (QoL) measured by the EORTC QLQ-C30 instrument is predictive of survival for these patients.

MATERIALS AND METHODS

Two hundred and thirty-three patients with unresectable HCC (mainly hepatitis B-associated) who were recruited into two separate randomized phase III clinical studies, based on palliative chemotherapy and palliative hormonal therapy, respectively, gave consent and received pretreatment QoL assessment. EORTC QLQ-C30 scores and clinical variables at the time of study entry were analyzed to identify factors that influenced survival by applying multivariate analysis. Independent prognostic factors for survival were studied by Cox regression analysis.

RESULTS

Median survival of the 233 patients was 5.5 months (95% CI 4.2-6.5 months). Significant independent predictors of shorter survival were advanced Okuda staging (P = 0.0030; HR = 2.058), high baseline total bilirubin (P = 0.0008; HR = 1.013) and worse QoL score in the appetite score domain (P = 0.0028; HR for 10 point increase = 1.070). Patients who were entered into the chemotherapy trial (P = 0.0002; HR = 0.503), those who scored better in the physical functioning domain (P = 0.0034; HR for 10 point decrease = 0.911) and the role functioning domain (P = 0.0383; HR for 10 point decrease = 0.944) of the QoL questionnaire, were associated with longer survival.

CONCLUSIONS

In the studied HCC population, patient-reported baseline QoL provides additional prognostic information that supplements traditional clinical factors, and is a new prognostic marker for survival for patients with unresectable HCC.

A phase I study of BIBF 1120, an orally active triple angiokinase inhibitor (VEGFR, PDGFR, FGFR) given continuously to patients with advanced solid tumours, incorporating dynamic contrast enhanced magnetic resonance imaging (DCE-MRI)

3015

Background: BIBF 1120 is a potent inhibitor of VEGFR, PDGFR, FGFR kinases, and of members of the Src family of tyrosine kinases (Src, Lck, Lyn). Methods: Patients (Pts) with advanced solid tumours were enrolled. BIBF 1120 was administered orally once daily (q.d.) continuously, starting at 100 mg/day. Dosing was later amended to twice daily (b.i.d.) in view of transaminitis seen with q.d. dosing. DCE-MRI studies were performed at baseline, days 2 and 28. All pts underwent pharmacokinetic (PK) sampling. Results: 51 pts (26M/25F; median age 57 y, range 22–78 y; ECOG PS 0/1 = 22/27) were treated at: 100 mg q.d. (n = 6), 200 mg q.d. (n = 6), 300 mg q.d. (n = 7), 400 mg q.d. (n = 16), 450 mg q.d. (n = 5); 250 mg b.i.d. (n = 11). Median treatment duration was 57 days (range: 1 day– 22 m). The most common toxicities were nausea, vomiting, diarrhoea, abdominal pain and fatigue, all ≤ grade (G)2. Asymptomatic, reversible elevation of liver enzymes which was dose limiting in 2/5 pts at 450 mg q.d. defined the MTD at 400 mg q.d. At 250 mg b.i.d., 2/11 pts had DLT (G3 elevation in liver enzymes: n = 1; G3 abdominal pain: n = 1). 44 pts treated for ≥2 m were assessable for response: 13 pts had SD for ≥3 m (median 7m, range 3–22 m; renal, prostate, colorectal, chondrosarcoma, leiomyomatosis, fibromatosis). 3 pts with renal cancer had SD for 8, 14+ and 22 m respectively. PK evaluations generally showed increasing gMean Cmax and AUC values with increasing doses, with high inter-patient variability. Tmax was ∼2h post-dosing. gMean t1/2 values ranged from 6.8–26.4h. DCE-MRI of target lesions in 35 pts showed significant antivascular/antiangiogenic effects in some patients and dose cohorts, particularly at 200 mg q.d. and ≥400 mg q.d. DCE-MRI effects were most pronounced at 28 days, especially in metastatic liver lesions. Conclusions: BIBF 1120 is well-tolerated in patients with advanced solid malignancies and induces in vivo antiangiogenic effects detectable by DCE-MRI. Some patients experienced clinically meaningful disease stabilisation. The recommended dose for future Phase II studies was determined to be 250 mg b.i.d.

[Table: see text]

Comparative effects of ventricular resynchronization therapy in heart failure patients with or without coronary artery disease

In patients with advanced heart failure, intraventricular conduction delay (IVCD) and left ventricular systolic dysfunction (LVSD), multisite cardiac pacing can be proposed as an additive treatment. The aim of this study was to assess the clinical effectiveness of atrioventricular pacing according to the etiology of LVSD, by comparing the outcome of patients with and without coronary artery disease. Between August 1997 and November 1998, 103 patients were included in the InSync trial and received a biventricular pacemaker and a specifically designed left ventricular pacing lead. Baseline evaluation (12 lead ECG, New York Heart Association Class, quality of life (QOL) and distance walked during the 6 min walk test) was repeated in survival patients at 1, 3, 6 and 12 months after pacemaker implantation. Patients were split in two groups, ischemic (N = 48) and non-ischemic (N = 55), according the result of a recent coronary angiography, the existence of coronary angioplasty or coronary artery bypass or the history of a prior myocardial infarction.

RESULTS

The mortality rate was similar in the two groups with a mean 12 months actuarial survival rate of 78%. Nevertheless, the delay between the death and the pacemaker implantation was significantly higher in the non-ischemic group. A significant reduction in QRS duration and a significant improvement in NYHA class (-1.5). QOL score (-50%) and 6 min walking test (+18%) were observed similarly in the two groups.

CONCLUSION

This study shows that biventricular pacing improves significantly functional status of patients with LVSD, IVCD and advanced heart failure, regardless the etiology of the cardiomyopathy, ischemic or not, without over-mortality in ischemic patients.

T-cell response to adenovirus hexon and DNA-binding protein in mice

The successful development of adenovirus vectors for vaccines and gene therapy will require a better understanding of the host immune response. Using the ELISPOT assay to measure IFN-gamma-secreting CD8(+) cells, we identify immunodominant epitopes of the adenovirus hexon and DNA-binding protein in BALB/c and C57BL/6 mice. The T-cell response to the intramuscular administration of adenovirus serotype 5 peaks within a few weeks and gradually declines but is still detectable after 12 weeks. A second administration did not substantially increase the number of reactive T cells. The CD8(+) T-cell response was also similar between wild type and E1-deleted adenovirus. When B-cell-deficient mice were injected with adenovirus encoding the gene for secreted alkaline phosphatase, sera phosphatase activity was reduced more quickly in mice pre-exposed to adenovirus. These results add to the evidence that cell-mediated immunity is a substantial barrier to therapeutic adenoviral vectors and provide more quantitative tools to measure cellular immune responses to adenovirus.

Long-term outcome of carpal tunnel syndrome after conservative treatment

The purpose of this study was to investigate the long-term prognosis of patients with carpal tunnel syndrome (CTS). We prospectively followed-up patients with CTS for 80 weeks. Thirty cases had been treated with a single injection of methylprednisolone acetate and another 30 with a 10-day course of prednisolone. At the end of the follow-up period, there were no significant differences in symptoms as measured by global symptom score and in the proportion of patients who progressed to decompressive surgery. Few patients who were not operated on (11.4%) remain asymptomatic.

Have a nice day -- do a wart audit

We performed an audit of the treatment of genital warts at our clinic by reviewing the case notes of 302 patients who presented with a first episode of genital warts. 186 were suitable for inclusion, of whom over 90% were clear of warts within three months. However, even after just one month of treatment, 84.9% of men and 60.2% of women were clear of warts. On the basis of this information, we can be more optimistic when advising patients about the likely duration of treatment.

Intravenous bolus somatostatin after diagnostic cholangiopancreatography reduces the incidence of pancreatitis associated with therapeutic endoscopic retrograde cholangiopancreatography procedures: a randomised controlled trial

BACKGROUND

Previous studies suggested that somatostatin given before endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. However, the routine use of somatostatin in all patients undergoing ERCP is not likely to be cost effective. This study evaluated whether intravenous bolus somatostatin given after diagnostic cholangiopancreatography could reduce the incidence of pancreatitis in a group of patients undergoing therapeutic ERCP procedures.

METHODS

In a randomised, double blind, controlled trial, the effect of intravenous bolus somatostatin 250 microg given immediately after diagnostic cholangiopancreatography was compared with that of placebo in patients who required endoscopic sphincterotomy or other therapeutic procedures. The primary end point was the incidence of post-ERCP clinical pancreatitis, and a secondary end point was the incidence of hyperamylasemia.

RESULTS

A total of 270 patients were randomised. The somatostatin group (n=135) and the placebo group (n=135) were comparable in age, sex, indications for treatment, and types of procedure. The frequencies of clinical pancreatitis (4.4% v 13.3%; p=0.010) and hyperamylasemia (26.0% v 38.5%; p=0.036) were both significantly lower in the somatostatin group compared with the placebo group.

CONCLUSIONS

A single dose of intravenous bolus somatostatin, given immediately after diagnostic cholangiopancreatography, is effective in reducing the incidence of pancreatitis after therapeutic ERCP. This novel approach of administering prophylactic somatostatin may offer a cost effective prophylaxis for post-ERCP pancreatitis.

Sexually transmitted infections in a young offenders institution in the UK

According to the recently published National Strategy for Sexual Health and HIV, prisoners need targeted sexual health information. However, there is a paucity of published data on incidence of sexually transmitted infections (STIs) among prisoners in the UK. The aim of this study was to assess the sexual behaviour and spectrum of STI in a young offenders institution (YOI) in the UK. Case notes of all patients seen in a male YOI in Reading over a one-year period were reviewed. All were either self-referrals or referred by the prison staff. Age- and sex-matched patients attending the genitourinary medicine (GUM) clinic at the Royal Berkshire Hospital Reading during the same period served as a control group. A total of 177 patients aged 17-20 were seen in the YOI during the study period. Ninety (51.72%) had STI vs 95 (54.91%) in the control group (P = 0.5942). Three YOI patients and four GUM attendees declined STI screening. Twenty-nine (16.38%) patients in the YOI had >or=2 sexual partners in the preceding three months vs 41 (23.16%) in the control group (P = 0.0811). Fourteen (7.90%) YOI patients had a previous history of STI vs 25 (14.12%) in the GUM clinic population (P = 0.0618). Thirty-five (20.11%) YOI patients gave a history of having injected drugs vs none amongst GUM clinic attendees. Of the 35 patients with a history of intravenous drug use four were hepatitis C-antibody positive. This study showed high rates of STI in a YOI. Past history of high risk behaviour was common and a significant number had been intravenous drug users. This study strongly supports the need for immediate care, targeted sexual health information and STI prevention in YOI in the UK.

n-p short-range correlations from (p,2p+n) measurements

We studied the 12C(p,2p+n) reaction at beam momenta of 5.9, 8.0, and 9.0 GeV/c. For quasielastic (p,2p) events p(f), the momentum of the knocked-out proton before the reaction, was compared (event by event) with p(n), the coincident neutron momentum. For |p(n)|>k(F)=0.220 GeV/c (the Fermi momentum) a strong back-to-back directional correlation between p(f) and p(n) was observed, indicative of short-range n-p correlations. From p(n) and p(f) we constructed the distributions of c.m. and relative motion in the longitudinal direction for correlated pairs. We also determined that 49+/-13% of events with |p(f)|>k(F) had directionally correlated neutrons with |p(n)|>k(F).

Naively changing HAART

BACKGROUND

Few UK studies have systematically investigated which antiretroviral therapy (ART) combinations HIV-infected people are commenced on, when they start and reasons for stopping or changing their regimens.

OBJECTIVE

To describe when HIV-infected ART-naive patients started first-, second- or third-line triple ART, classes of drugs prescribed and whether stopping ART was associated with virological, immunological or clinical indicators of treatment failure.

DESIGN

A multicentre prospective open cohort study, employing the National Prospective Monitoring System on the use, cost and outcome of HIV service provision in UK hospitals-HIV Health-economics Collaboration (NPMS-HHC).

SETTING

Five hundred and eighty-five ART-naive patients seen in one London and two non-London HIV clinics between 1 January 1998 and 31 December 1999.

RESULTS

Of 4,044 HIV-infected individuals seen, 585 (15%) were ART naive. Median time interval (interquartile range, IQR) between HIV diagnosis and starting triple ART was 800 (63-2,094) days. Median CD4 count when first diagnosed with HIV infection was 278 (IQR 127-481) cells/ micro L which dropped to 190 (IQR 86-297) cells/ micro L when starting triple ART. Of these 585 patients, 162 started second-line and 46 third-line ART during the study period. Of those patients who stopped ART, 51% did not have evidence of virological, immunological or clinical indicators of therapy failure.

CONCLUSIONS

Reasons for the delay between diagnosis of HIV infection and starting ART are varied. The large proportion of individuals who stopped ART for reasons other than virological, immunological or clinical indicators of therapy failure, are most likely due to drug-associated toxicity. Both of these findings need to be elucidated in greater detail through prospective studies.

Efficacy and safety of penile biopsy in a GUM clinic setting

The UK National Guidelines on Sexually Transmitted Infections recommend penile biopsy in patients with persistent balanitis and balanitis of uncertain aetiology. Many GUM clinics perform penile biopsy. However, few studies have looked at the usefulness and safety of penile biopsy in a GUM clinic setting. We assessed the spectrum of dermatological conditions seen in a penile dermatoses clinic and looked at the usefulness and safety of penile punch biopsy in a GUM clinic setting. We reviewed the case notes of patients who attended the penile dermatoses clinic at the GUM department, Royal Berkshire Hospital, Reading over a period of 18 months. A total of 87 patients were seen in the penile dermatoses clinic. Their ages ranged from 17 to 73 and 70 (80%) were uncircumcised. Twenty-four (28%) patients had biopsies and five (6%) declined. Forty-nine (56%) patients did not have a biopsy either because of a clinically apparent diagnosis (45) or lesions were close to the urethral meatus (4). Five were referred for circumcision and one was referred to a dermatologist. Three patients were lost to follow-up. Penile biopsy was performed to exclude malignancy in 17 (71%) cases and due to diagnostic uncertainty in seven (29%) cases. Histological diagnoses were consistent with initial clinical diagnoses in 17 (71%) cases. Four (17%) had minor complications following biopsy, two had wound dehiscence, one had bleeding and another had a wound infection. In conclusion, a wide spectrum of penile skin disorders were seen in the penile dermatoses clinic. The majority of patients had a clinically apparent diagnosis. The histological diagnosis was consistent with initial clinical diagnosis in most of the biopsied patients. The main indications for biopsy were to exclude malignancy and for diagnostic dilemma. Penile biopsy is a safe procedure with minimal complications.

Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome

OBJECTIVE

Sonographic examination of the median nerve has been suggested as a useful alternative to electrophysiologic study in the diagnosis of carpal tunnel syndrome. To determine its usefulness and the best diagnostic criterion, sonograms of patients with the disease were compared with sonograms of healthy subjects in a case-control study.

METHODS

Patients with carpal tunnel syndrome and asymptomatic controls who were matched for age and sex were enrolled and underwent sonography of the wrists. Eight separate sonographic criteria were analyzed in each wrist. Data from the patient group and the control group were compared to establish optimal diagnostic criteria for carpal tunnel syndrome, using receiver operating characteristic analytic techniques.

RESULTS

Thirty-five patients with carpal tunnel syndrome and 35 asymptomatic controls were examined. Increased cross-sectional area of the median nerve was found to be the most predictive measure of carpal tunnel syndrome, proximal to the tunnel inlet, at the tunnel inlet, and at the tunnel outlet, with significant differences between patients and controls. Using a receiver operating characteristic curve, a cut-off value >0.098 cm(2) at the tunnel inlet provided a diagnostic sensitivity of 89% and a specificity of 83%.

CONCLUSION

Sonographic measurement of the median nerve cross-sectional area is both sensitive and specific for the diagnosis of carpal tunnel syndrome.

Meta-analysis of randomised controlled trials of the effectiveness of antiarrhythmic agents at promoting sinus rhythm in patients with atrial fibrillation

OBJECTIVE

To conduct a meta-analysis of randomised controlled trials to estimate the effectiveness of antiarrhythmic drugs at promoting sinus rhythm in patients with atrial fibrillation.

DESIGN

Articles were identified by using a comprehensive search of English language papers indexed in Medline from 1966 to August 2001. For the outcomes of sinus rhythm and death, a random effects model was used to model repeated assessments within a study at different time points.

SETTING

Emergency departments and ambulatory clinics.

PATIENTS

Patients with atrial fibrillation.

INTERVENTIONS

Antiarrhythmic agents grouped according to their Vaughan-Williams class.

MAIN OUTCOME MEASURES

Sinus rhythm and mortality.

RESULTS

91 articles met a priori criteria for inclusion in the analysis. Median duration of follow up was one day (range 0.04-1096, mean (SD) 46 (136) days). The median proportion of patients in sinus rhythm at follow up was 55% (range 0-100%) and 32% (range 0-90%) receiving active treatment and placebo, respectively. Median survival was 99% (range 55-100%) and 99% (range 55-100%). Compared with placebo, the following drug classes were associated with increased sinus rhythm at follow up: IA (treatment difference 21.5%, 95% confidence interval (CI) 16.3% to 26.8%); IC (treatment difference 33.1%, 95% CI 23.3% to 42.9%); and III (treatment difference 17.4%, 95% CI 11.5% to 23.3%). Class IC drugs were associated with increased sinus rhythm at follow up compared with class IV drugs (treatment difference 43.2%, 95% CI 11.5% to 75.0%). There was no significant difference in mortality between any drug classes.

CONCLUSIONS

Class IA, IC, and III drugs are associated with increased sinus rhythm at follow up compared with placebo. It is unclear whether any antiarrhythmic drug class is associated with increased or decreased mortality.

pH regulation of renal gene expression

The increase in intracellular pH (pHi) associated with various tumour cells triggers changes in gene expression. Similar adaptations also occur as part of the physiological response to changes in acid base balance. For example, during metabolic acidosis, increased renal ammoniagenesis and bicarbonate synthesis are sustained by the increased expression of various transport proteins and key enzymes of glutamine metabolism. In rat kidney, increased expression of the mitochondrial glutaminase (GA) and glutamate dehydrogenase (GDH) results from stabilization of their respective mRNAs. The 3'-untranslated region (UTR) of the GA mRNA contains a direct repeat of an 8-base AU sequence that functions as a pH-response element. This sequence exhibits a high affinity and specificity for z-crystallin. The same protein binds to two separate, but homologous, 8-base AU sequences within the 3'-UTR of the GDH mRNA. The apparent binding activity of z-crystallin is increased significantly during onset of metabolic acidosis. Thus, increased binding of z-crystallin may initiate the pH-responsive stabilization of the two mRNAs. In contrast, induction of the phosphoenolpyruvate carboxykinase (PEPCK) gene occurs at the transcriptional level. In LLC-PK1-FBPase+ kidney cells, a decrease in pHi leads to activation of the p38 stress-activated protein kinase and subsequent phosphorylation of ATF-2. This transcription factor binds to the CRE-1 element within the promoter of the PEPCK gene to enhance transcription. Similar mechanisms may contribute to altered gene expression in tumour cells.