The long-term cost-effectiveness of improving alcohol abstinence with adjuvant acamprosate

A computer model was developed with decision analysis software to explore the long-term clinical and economic outcomes of alcohol abstinence maintenance with either standard counselling therapy or standard therapy plus 48 weeks of adjuvant acamprosate in detoxified alcoholic patients. Important complications of alcoholism were modelled using Markov processes, and included relapse (return to drinking), alcohol-related hepatic disease, acute and chronic pancreatitis, acute and chronic gastritis, oropharyngeal carcinoma, oesophageal carcinoma, alcoholic cardiomyopathy, alcohol-related peripheral neuropathy, alcoholic psychosis, accidental death, and suicide. Probabilities of developing complications were dependent on whether the patients within the cohort remained abstinent or had relapsed. Relapse rates, probabilities, and costs for acamprosate therapy and treatment of complications were taken from published literature. The analysis was performed from the German health insurance perspective. Life expectancy and total lifetime costs (costs of initial abstinence maintenance therapy plus costs of complications) were calculated for a typical male cohort with average age of 41 years, 80% with fatty liver, 15% with cirrhosis, 22% with chronic pancreatitis, and 1% with alcoholic cardiomyopathy at baseline. Life expectancy with and without acamprosate therapy was 15.90 and 14.70 years respectively, and discounted (5% per annum) average total lifetime costs per patient were DEM 46 448 and DEM 49 549 respectively. We conclude that, despite the acquisition costs of DEM 2177, adjuvant acamprosate therapy was both clinically and economically attractive under conservative assumptions.

Applying some UK Prospective Diabetes Study results to Switzerland: the cost-effectiveness of intensive glycaemic control with metformin versus conventional control in overweight patients with type-2 diabetes

OBJECTIVE

The results of the metformin substudy of the United Kingdom Prospective Diabetes Study (UKPDS) were applied through modelling techniques to the Swiss setting, allowing a cost-effectiveness analysis of the management of overweight type-2 diabetes patients with either conventional glycaemic control or intensive control with metformin from the Swiss third-party payer perspective.

METHODS

Occurrence of diabetes-related complications was simulated using a Markov model. Probabilities for complications were taken from the UKPDS, and costs were retrieved from published sources. Total direct costs (costs of diabetes therapy plus costs of treating complications) and survival over an 11-year period were determined for cohorts randomised to either conventional glycaemic control or intensive control with metformin. Changes in life expectancy were calculated for conventional versus intensive control with metformin. Extensive sensitivity analysis was performed.

RESULTS

Mean costs per patient over the 11-year follow-up period (discounted at 5% per annum) were CHF 10,877 and CHF 9950 for patients randomised to either conventional control or intensive control with metformin respectively. Intensive control with metformin led to improved survival (0.43 life-years gained per patient) over the 11-year-period. Outcomes were most sensitive to variations in the acquisition costs of metformin. Changes in the event rates and costs related to myocardial infarction, renal failure, and stroke also had important impacts.

CONCLUSIONS

Within the limitations of the modelling study, intensive glycaemic control with metformin was cost- and life-saving in overweight type-2 diabetes patients in the Swiss setting.

Calcium channel blockers, ACE inhibitors, and the risk of cancer in hypertensive patients: a report from the Department of Health Hypertension Care Computing Project (DHCCP)

OBJECTIVE

Recent studies have shown inconsistent results on the risk of cancer in hypertensive patients using calcium channel blockers (CCBs) and angiotensin-converting enzyme (ACE) inhibitors. We investigated a large number of patients from the Department of Health Hypertension Care Computing Project (DHCCP) observational database treated with these drugs for hypertension to see whether the use of CCBs for hypertension is associated with an increased risk of cancer mortality and the use of ACE inhibitors with a reduction.

DESIGN

Matched case-control study and a longitudinal study of survival from 1 year after presentation.

PATIENTS

A total of 11663 patients treated for hypertension from 1971 through 1987. They were recruited on presentation to one of the hospital hypertension clinics or general practices involved.

MAIN OUTCOME MEASURES

Death with any mention of cancer on the death certificate in patients treated with an Index drug group; CCBs, ACE inhibitors, beta adrenergic blocking drugs (BBs), or receiving a diuretic. The treatment groups were mutually exclusive.

RESULTS

A total of 391 cases of cancer were matched with 1050 controls. In this case-control study the adjusted relative risk estimate in comparison to diuretic treatment for CCBs was 0.79 (95% CI 0.37 to 1.69), and for CCBs plus a diuretic, 1.05 (0.65 to 1.69). Non-significant results were also observed for ACE inhibitors (1.48 (0.43 to 5.1), and 1.40 (0.56 to 3.50) with a diuretic), and also for the BB and methyldopa groups. In the longitudinal survival study, the adjusted relative risk estimate for CCBs was 1.1 (0.60 to 1.94) and 1.0 (0.53 to 1.86) for CCBs plus a diuretic, and for ACE inhibitors 1.33 (0.37 to 4.76) and 1.47 (0.67 to 3.23), respectively.

CONCLUSIONS

In this population there was no increased cancer mortality with the use of CCBs and a relative risk greater than 1.7 to 2.0 was excluded with 95% confidence. The suggestion that ACE inhibitors reduce cancer mortality was not supported with best estimates of relative risk of 1.3 to 1.5 and exclusion of values less than 0.4 to 0.7.

The cost-effectiveness of different management strategies for type I diabetes: a Swiss perspective

AIMS/HYPOTHESIS

A computer model was developed to determine the health outcomes and economic consequences of different combinations of diabetes interventions in newly diagnosed patients with Type I (insulin-dependent) diabetes in Switzerland.

METHODS

We modelled seven complications of diabetes: hypoglycaemia, ketoacidosis, acute myocardial infarction, stroke, lower extremity amputation, nephropathy, and retinopathy. Transition probabilities and costs were taken from published literature. The Swiss health insurance payer perspective was taken. Various combinations of diabetes management strategies, including intensive or conventional insulin therapy and screening and treatment strategies for renal and eye disease were defined. Life expectancy, cumulative incidences of complications, and mean expected total lifetime costs per patient were calculated under six different management strategies. Incremental cost-effectiveness ratios were calculated in terms of costs per life-year gained compared with conventional insulin therapy alone.

RESULTS

The addition of screening for microalbuminuria and retinopathy followed by appropriate treatment, if detected, were cost saving, with reduction in cumulative incidence of end stage renal disease and blindness respectively, and, in the case of microalbulminuria screening and treatment, an improvement in life expectancy. Intensive therapy improved life expectancy but increased total lifetime costs.

CONCLUSION/INTERPRETATION

Optimal management of Type I diabetic patients, including secondary and tertiary prevention, leads to reduced complications and improved life expectancy, with the increased costs of prevention offset to varying degrees by cost savings due to complications avoided.

Association of symptoms of type 2 diabetic patients with severity of disease, obesity, and blood pressure

OBJECTIVE

The symptoms of 430 type 2 diabetic patients were determined by a self-administered questionnaire before entry into the U.K. Prospective Diabetes Study.

RESEARCH DESIGN AND METHODS

Entry into the trial followed 2 months of dietary treatment for newly diagnosed patients with type 2 diabetes. Forty symptoms with five levels of severity were included in the questionnaire. A complaint rate was computed as the sum of symptom scores divided by the number of symptom questions answered.

RESULTS

The complaint rate was independently and positively related to BMI, fasting plasma glucose (FPG), and being a woman. Three symptoms--presence of dry mouth (P < 0.001), thirst (P < 0.01), and stomach pain (P = 0.02)--were related to FPG independent of sex, age, BMI, or blood pressure. Only dry mouth was related to HbA1c (P = 0.05). Complaints of shortness of breath, swollen ankles, headaches, heartburn, sweating, wheezing, nocturia, thirst, and diarrhea increased with BMI independently of other variables. A complaint of cold extremities decreased with BMI. Heartburn, weakness of limbs, and hot flushes were positively related to blood pressure, and unsteadiness was negatively related.

CONCLUSIONS

The symptoms reported by patients with type 2 diabetes increased with FPG and markedly with BMI. The symptoms associated with obesity have been underestimated in the past.

Calcium channel blockers and cardiac mortality in the treatment of hypertension: a report from the Department of Health Hypertension Care Computing Project (DHCCP)

OBJECTIVE

A case control study has reported a 60% higher risk of myocardial infarction in hypertensives treated with a calcium channel blocker (CCB). We examined the Department of Health Hypertension Care Computing Project (DHCCP) data to see if we could confirm or refute this suggestion.

DESIGN

Two case control studies, matched and unmatched, plus two longitudinal studies from 1 year of presentation, one for all subjects given a CCB for more than 1 year compared with those not given this drug, and the second comparing survival on the different drugs initially given between 3 and 12 months of follow-up.

SUBJECTS

A total of 9328 subjects were included in the analyses and 2154 died. Of these, 6406 received one or more of the following index drugs: 26% a calcium channel blocker (CCB); 84% a diuretic; 29% alpha methyldopa; 12% a beta-blocker (BB); and 11% an angiotensin-converting enzyme (ACE) inhibitor. The CCBs were nifedipine, diltiazem or verapamil.

RESULTS

In the case control studies a group given diuretics +/- other treatments (but not including one of the index drugs) provided a reference group with a relative risk (RR) of 1.0. In the matched case control study the adjusted RR for a CCB without a diuretic was 1.32 (95% CI 0.64-2.70) for IHD mortality and 1.05 (95% CI 0.60-1.84) for cardiovascular mortality. Similar results were observed for methyldopa, BBs and ACE inhibitors. The results in the unmatched case control analysis were also similar. The longitudinal study comparing all those treated for over 1 year with a CCB with all other treatments showed a RR for total mortality of 1.03 (95% CI 0.85-1.25). The longitudinal study of total mortality according to treatment initiated at 3-12 months found results of a similar magnitude for CCBs, methyldopa and BBs.

CONCLUSIONS

The reference diuretic group had less severe cardiovascular disease than other groups. Treatment with a CCB, BB or methyldopa was associated with an excess mortality in comparison with this reference group. The excess was similar in the different drug groups.

Efficacy and safety of low molecular weight heparin, unfractionated heparin and warfarin for thrombo-embolism prophylaxis in orthopaedic surgery: a meta-analysis of randomised clinical trials

The efficacy and safety of low molecular weight heparin (LMWH), unfractionated heparin (UFH) and warfarin for prophylaxis of thrombo-embolism in orthopaedic surgery were compared using meta-analysis techniques. Twenty-two studies were included, 2 of which compared LMWH to warfarin. The mean probabilities to develop deep-vein thrombosis (DVT), pulmonary embolism and major and minor bleeding using UFH were: 0.21 (95% confidence interval, CI: 0.18-0.24); 0.01 (95% CI: 0.01-0.02); 0.05 (95% CI: 0.03-0.07), and 0.19 (95% CI: 0.17-0.22), respectively. The relative risk (RR) of DVT for LMWH vs. UFH was 0.76 (95% CI: 0.60-0.91), p < 0.05 and for LMWH vs. warfarin 0.78 (95% CI: 0.69-0.87), p < 0.05. The RR of minor bleeding for LMWH vs. UFH was 0.76 (95% CI: 0.64-0.92), p < 0.05. The RR of minor bleeding for LMWH vs. warfarin was 3.28 (95% CI: 2.21-4.70), p < 0.05.

CONCLUSION

in orthopaedic surgery, LMWH is significantly superior to both UFH and warfarin in the prevention of DVT and results in significantly less minor bleeding complications when compared to UFH, but significantly more minor bleeding when compared to warfarin.

Low molecular weight heparin and unfractionated heparin for prevention of thrombo-embolism in general surgery: a meta-analysis of randomised clinical trials

Low molecular weight heparin (LMWH), unfractionated heparin (UFH) and warfarin were compared with respect to efficacy and safety in the prevention of thrombo-embolism in general surgery. Meta-analysis (MA) with a priori definition of the MA protocol was used to combine the results from randomised trials with patients who underwent general surgery and deep-vein thrombosis (DVT) prophylaxis with LMWH, UFH or warfarin. Forty-four studies were identified for assessment and 33 were included, however, none for warfarin. For efficacy (DVT and pulmonary embolism) and major bleeding, no significant difference between the LMWH- and UFH-treated groups was demonstrated. The relative risk of minor bleedings for LMWH versus UFH was 0.75 (0.64-0.88; 95% confidence interval) and is significant (p < 0.05). Within the limitations of the MA, LMWH and UFH did not differ significantly in terms of prevention of thrombo-embolism, but LMWH had a significantly better safety profile. On this basis, LMWH may be preferable to UFH in the prevention of thrombo-embolism in general surgery.

Acute phase proteins, C-reactive protein and serum amyloid A protein, as prognostic markers in the elderly inpatient

AIM

to study the clinical significance and potential utility of measuring serum amyloid A protein (SAA) compared with the classical acute phase protein, C-reactive protein (CRP).

METHOD

a 3 month prospective study on 66 women, mean age 83 years (range 69-106) and 33 men, mean age 84 years (range 69-95), admitted to the geriatric medicine unit at Hammersmith Hospital. CRP and SAA were determined on admission and at intervals throughout hospital stay; outcome end-points were death during the study, detection of infection, duration of admission and early re-admission to hospital after discharge.

RESULTS

CRP and SAA responses were highly correlated (r = 0.75, P = 0.0001). However, the SAA response was greater than that of CRP in most individuals, with a median ratio of initial SAA to CRP of 2.2 in patients with infective pathology and 1.6 in those with inflammatory pathology. Median (range) SAA on admission was 98 (0.1-940) mg/ml in patients with infection and was twice that observed in patients with other causes of inflammation, median value 50 (0.6-699) mg/l. There was no difference between median CRP on admission in patients with infection or inflammation, median value 53 (0.1-235) and 51.5 (5-246) mg/l respectively. Initial and peak levels of CRP, but not of SAA, were significantly greater in patients who subsequently died, whereas high levels of both proteins predicted length of admission and early re-admission.

CONCLUSION

major elevations of the serum concentrations of CRP and SAA indicated serious disease and predicted poor outcome. Measurement of SAA as well as CRP enhanced the clinical utility of monitoring the acute phase response in 7% of patients with a diagnosis of infection.

Nutritional supplementation in elderly medical in-patients: a double-blind placebo-controlled trial

The aim of this study was to assess the effect of vitamin and/or glucose energy supplementation in elderly medical patients on an intention-to-treat basis. One hundred and six elderly medical in-patients were entered into a double-bind placebo-controlled factorial trial of glucose energy and vitamin supplementation. Supplementation was given for 1 month. This trial was designed to detect a > 2 kg increase in weight and > 3 g/l increase in serum albumin between active and placebo supplementation in 100 patients with 90% power (p < 0.05). Other outcome measures included changes in Barthel activities of daily living, length of stay, and mental test score (MTS). No interaction between vitamin and glucose supplementation was demonstrated. Active energy supplementation with glucose alone was associated with a +0.6 kg change in weight and +0.7 g/l change in albumin [95% confidence interval (CI) -0.8, +2.0 and -1.3, +2.8, respectively]. The respective changes for active vitamin supplementation were -0.6 kg for weight and +0.5 g/l for albumin (95% CI -2.1, +0.8 and -1.5, +2.6, respectively). There were no significant differences in mental test score, Barthel score, or length of stay between the two groups. Compliance with the glucose energy supplementation was poor with only one-third of patients consuming more than 50% of the offered drink. We conclude that the giving of glucose alone and/or vitamin supplementation in elderly patient is of no benefit on an intention-to-treat basis.

Use of surrogate respondents in studies of stroke and dementia

A study was performed to determine the misclassification of information on exposure when surrogate informants are interviewed. Information from nondementia patients admitted to a geriatric ward was compared with that obtained from the patients' family members or friends (informants). Thirty-seven patients were recruited (17 with current or previous stroke, and 20 no history of stroke). Information on past medical and family history, cigarette smoking and alcohol consumption was collected using a questionnaire that was administered independently to patients and informants. For nonstroke patients, agreement on smoking and alcohol consumption at different ages was generally good. Informants reported slightly lower smoking and alcohol intake than patients: 1.3 fewer total pack-years (95% CI, -3.8, +6.5) and 2.7 fewer units/week (95% CI, -1.5, +6.9), respectively. For stroke patients, informants tended to report a greater smoking consumption at all ages, and a slightly higher alcohol consumption. Informants reported an excess of 7.4 total pack-years (95% CI, -1.2, + 16.0) and 2.19 units/week (95% CI, -1.0, +5.3). Agreement for medical history was good, except for hypertension. There was poor agreement for family medical history. The impact of misclassification is discussed.

The cost-effectiveness of four cisplatin-containing chemotherapy regimens in the treatment of stages III B and IV non-small cell lung cancer: an Italian perspective

The cost-effectiveness of four cisplatin-containing chemotherapy regimens used in the treatment of non-small cell lung cancer (NSCLC) stages III B and IV was retrospectively assessed specifically with respect to the situation in Italy and from the third party payer perspective. The chemotherapy regimens compared were gemcitabine+cisplatin (G + C), mitomycin+ifosfamide+cisplatin (MIP), etoposide+cisplatin (E + C), and vinorelbine+cisplatin (V + C). Efficacy and safety data for the regimens were calculated from studies selected from the international literature using formal inclusion and exclusion criteria. In total, one study with one G + C treatment arm (48 patients), one study with one MIP treatment arm (133 patients), three studies with one E + C treatment arm (total 325 patients), and two studies with one V + C treatment arm (total 327 patients) were included. Where efficacy and toxicity results for the same regimen were reported in more than one study, the values were combined using a random effects meta-analysis method. The mean tumour response rates were: 54% (95% confidence intervals (CI) 40-69%); 40% (95% CI 32-49%); 26% (95% CI 20-30%); and 35% (95% CI 24-48) for G + C, MIP, E + C and V + C, respectively. Costs were evaluated for World Health Organization (WHO) grade 3 and 4 toxicities with high impact on medical costs using computer modelling techniques. The official prices of drugs and official reimbursement rates were used to calculate direct medical costs. Average cost-effectiveness analysis demonstrated no significant difference between the treatments. Marginal cost-effectiveness analysis showed that the use of MIP, E + C or V + C instead of G + C would result in additional costs of 7.7, 55.2 (p < 0.05), and 46.2 million lira, respectively, for every patient with a tumour response.

The prevalence of pseudohypertension in the elderly

Pseudohypertension (PHT) could lead to the initiation of unnecessary antihypertensive treatment and potentially adverse consequences. The Finapres is reported to be a reliable alternative to intra-arterial blood pressure (BP) measurements and is unlikely to be distorted by arterial calcification, suggested to be a cause of PHT. Finapres measurements were compared with sphygmomanometric measures of brachial BP. PHT was defined as a systolic pressure (brachial) > or = 190 mm Hg and finger systolic < 160 mm Hg or a diastolic pressure (brachial) > or = 100 mm Hg and finger pressure < 90 mm Hg. One hundred and twenty-five elderly in-patients and out-patients, both hypertensive and normotensive, had a 2.5% prevalence of PHT (1 had diastolic PHT in the left arm, 1 had systolic PHT in the right arm and 1 had systolic PHT in both arms). A group without PHT, but with higher systolic readings with the sphygmomanometer compared with the Finapres (> or = 30 mm Hg) was identified. It was thought that the same factors may affect both pseudohypertensive and non-pseudohypertensive subjects with such large differences. Our data suggest that age plays a role in the presence of higher brachial pressures.

Activity of 2,3-benzodiazepines at native rat and recombinant human glutamate receptors in vitro: stereospecificity and selectivity profiles

The activity and selectivity of the glutamate receptor antagonists belonging to the 2,3-benzodiazepine class of compounds have been examined at recombinant human non-NMDA glutamate receptors expressed in HEK293 cells and on native rat NMDA and non-NMDA receptors in vitro. The racemic 2,3-benzodiazepines GYKI52466, LY293606 (GYKI53405) and LY300168 (GYKI53655) inhibited AMPA (10 microM)-mediated responses in recombinant human GluR1 receptors expressed in HEK293 cells with approximate IC50 values of 18 microM, 24 microM and 6 microM, respectively and AMPA (10 microM) responses in recombinant human GluR4 expressing HEK293 cells with approximate IC50 values of 22 microM, 28 microM and 5 microM, respectively. GYKI 52466, LY293606 and LY300168 were non-competitive antagonists of AMPA receptor-mediated responses in acutely isolated rat cerebellar Purkinje neurons with approximate IC50 values of 10 microM, 8 microM and 1.5 microM, respectively. The activity of racemic compounds LY293606 and LY300168 was established to reside in the (-) isomer of each compound. At a concentration of 100 microM, GYKI52466, LY293606 and LY300168 produced < 30% inhibition of kainate-activated currents evoked in HEK293 cells expressing either human homomeric GluR5 or GluR6 receptors or heteromeric GluR6+KA2 kainate receptors. The activity of the 2,3-benzodiazepines at 100 microM was weak at kainate receptors, but was stereoselective. Similar levels of inhibition were observed for kainate-induced currents in dorsal root ganglion neurons. Intact tissue preparations were also used to examine the stereoselective actions of the 2,3-benzodiazepines. In the cortical wedge preparation, the active isomer of LY300168, LY303070, produced a non-competitive antagonism of AMPA-evoked depolarizations with smaller changes in depolarizations induced by kainate and no effect on NMDA-dependent depolarizations. LY303070 was also effective in preventing 30 microM AMPA-induced depolarizations in isolated spinal cord dorsal roots with an approximate IC50 value of 1 microM. Synaptic transmission in the hemisected spinal cord preparation was stereoselectively antagonized by the active isomers of LY300168 and LY293606. In summary, these results indicate that 2,3-benzodiazepines are potent, selective and stereospecific antagonists of the AMPA subtype of the non-NMDA glutamate receptor.

Alcohol intake and cardiovascular mortality in hypertensive patients: report from the Department of Health Hypertension Care Computing Project

OBJECTIVE

To determine the benefits and risks of drinking alcohol in treated hypertensives.

DESIGN

A prospective study of 6,369 hypertensives (3,161 men) attending primarily hospital clinics in the UK.

METHODS

Relative risks both for drinkers compared with non-drinkers and for level of alcohol consumption were calculated for mortality from ischaemic heart disease, stroke, non-circulatory and all causes.

RESULTS

At presentation 76% of the men and 48% of the women reported recent alcohol consumption. Compared with drinkers, non-drinkers were older, less likely to smoke and had a higher untreated blood pressure. After adjustment for confounding factors, male drinkers had a reduced risk of stroke mortality and possibly of ischaemic heart disease mortality. Similar results were observed in women for stroke mortality but not for ischaemic heart disease mortality. The trend remained after adjustment for previous cardiovascular disease. In men the lowest risk of ischaemic heart disease mortality occurred at intakes of > 21 units per week and stroke mortality was lowest at 1-10 units per week. Men consuming > 21 units per week had a twofold higher non-circulatory mortality. Total mortality was lowest in men who drank 1-10 units per week. Similar effects of alcohol on cardiovascular mortality were observed in women.

CONCLUSIONS

Alcohol intake may reduce stroke mortality in treated hypertensives. Ischaemic heart disease mortality in men may also be reduced, especially at higher intakes ( > 21 units per week). The beneficial effects were offset by increasing incidence of non-circulatory causes of death. Alcohol consumption of 1-10 units per week was associated with the lowest mortality in men.

In vitro and in vivo antagonism of AMPA receptor activation by (3S, 4aR, 6R, 8aR)-6-[2-(1(2)H-tetrazole-5-yl) ethyl] decahydroisoquinoline-3-carboxylic acid

The in vitro and in vivo pharmacology of a structurally novel competitive antagonist for the alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) subtype of excitatory amino acid receptors is described. LY215490, (+/-)(6-(2-(1-H-tetrazol-5-yl)ethyl) decahydroisoquinoline-3-carboxylic acid), was shown to displace selectively 3H-AMPA and 3H-6-cyano-7-nitro- quinoxaline-2,3-dione (3H-CNQX) binding to rat brain membranes. LY215490 potently antagonized quisqualate-and AMPA-induced depolarizations of rat cortical slices in a competitive manner, while requiring higher concentrations to antagonize the effects of N-methyl-D-aspartate (NMDA) and kainate. In slices of rat hippocampus, LY215490 also selectively antagonized AMPA-evoked release of 3H-norepinephrine. These AMPA receptor activities were due to the (-) isomer of the compound. (3S,4aR,6R, 8aR)-6-[2-(1(2)H-tetrazole-5-yl)ethyl] decahydroisoquinoline-3-carboxylic acid (LY293558). LY215490 was centrally active following parenteral administration in mice as demonstrated by protection versus maximal electroshock seizures and decreases in spontaneous motor activity. LY215490 (its active isomer being LY293558) represents a novel pharmacological agent for in vitro and in vivo studies of AMPA receptor function in the CNS.

Proportion of patients with isolated systolic hypertension who have burned-out diastolic hypertension

In a community survey of 3242 subjects, 1663 did not initially have isolated systolic hypertension (ISH) and were re-screened an average of 8 years later. ISH developed in 53 (22%) of untreated patients with previous diastolic hypertension. Similarly, 8% of subjects with transient hypertension and 8% of normotensive controls developed ISH. Of all cases of ISH, 16% had previous diastolic hypertension. These subjects were more likely to have continued to smoke (P = 0.01) and lost more weight (P = 0.001) than patients with ISH who did not have burned-out diastolic hypertension.

Optimal blood pressure control in treated hypertensive patients. Report from the Department of Health Hypertension Care Computing Project (DHCCP)

BACKGROUND

We wished to determine the range of treated systolic (SBP) and diastolic blood pressure (DBP) associated with the best survival in hypertensive patients.

METHODS AND RESULTS

We conducted a cohort study of patients enrolled in the DoH Hypertension Care Computer Project. Five specialist hypertension clinics (95% of patients) and general practitioners (5%) followed 6214 patients (3070 men and 3144 women) with an average age of 52 years for a mean of 107 months. Total, cardiovascular, ischemic heart disease, (IHD) and stroke mortality were the outcome measures. Age-adjusted relative hazard rates were calculated giving the effect on mortality of systolic or diastolic pressure being higher by 1 mm Hg. In men the optimal level of SBP for all four measures of mortality was the lowest pressure range observed, 92 to 133 mm Hg (median 127). For women the treated SBP range of 96 to 148 mm Hg (median 137) was associated with a low total mortality and also with low to moderate rates for IHD and stroke mortality. Relative hazard rates (P < .001) for IHD mortality were 1.010 for men and 1.013 for women and for stroke mortality were 1.018 and 1.021, respectively. The results were similar in men under and over the age of 60. SBP and DBP tended to be more important in younger than older women. For treated DBP in men, a pressure of 55 to 94 mm Hg (median 87) was associated with a low total mortality. The lowest stroke mortality in men was observed for a DBP range of 55 to 83 mm Hg (median 80) but with a tendency for an increase in IHD mortality. For women DBP < 95 mm Hg (range 55 to 94, median 87) also was associated with a low total mortality. IHD mortality in women was not closely related to treated DBP, relative hazard rate = 1.003, [95% confidence index (CI); 0.990,1.017] but the relative hazard rate for men was 1.011, (95% CI; 1.000, 1.022). The relative hazard rates for treated DBP and stroke were high at 1.035 and 1.028 for men and women, respectively (P < .001). IHD mortality increased in the one third of patients with the greatest fall in DBP on treatment, provided they were not initially in the one-third group with highest untreated DBP.

CONCLUSIONS

The best overall survival was associated with a treated SBP of < 134 mm Hg in men and < 149 mm Hg in women and a treated DBP of < 95 mm Hg.

Cough with angiotensin converting enzyme inhibitors: how much of a problem?

PURPOSE

To review the occurrence of angiotensin converting enzyme (ACE) inhibitor-related cough, and to examine its impact on the quality of life.

DATA SOURCES

Data from published reports, postmarketing surveillance studies, hospital case series and randomly allocated controlled trials were reviewed. Data are presented from a nested case-control study examining the effects of ACE inhibitor-related cough in 36 subjects compared with 69 controls on various measures of quality of life.

RESULTS

Low rates of ACE inhibitor-related cough were found in postmarketing studies, ranging from 0.1% (early studies) to 3%. Much higher figures were reported from double-blind randomly allocated controlled trials using self-administered questionnaires; the net increase over baseline was between 13 and 25% compared to 2% with the comparator drug. The nested case-control study suggested that the ACE inhibitor-related cough is associated with some deterioration in well-being. During ACE inhibitor treatment the patients tended to be more fatigued (P = 0.1) and depressed (P < 0.05) than controls. Reports of a sore throat increased by 27% (P < 0.01).

CONCLUSIONS

Cough is a common side effect of ACE inhibitor treatment, with conservative estimates suggesting that around one in 10 patients treated with an ACE inhibitor will develop a dry persistent cough. Half of these may be withdrawn from treatment. This cough is probably associated with some deterioration in well-being, but larger studies are required to confirm this.

The effect of low dose lofepramine in depressed elderly patients in general medical wards

A double-blind randomised controlled trial of the effect of low dose lofepramine (70 mg once daily) against placebo was carried out on depressed elderly inpatients on general medical wards for the elderly, comparing measures of depression and side-effects between the randomised groups. Patients were identified for the study using the Geriatric Depression Scale (GDS) and the Brief Assessment Schedule Depression Cards (BASDEC). Sixty-three subjects were randomised: 46 patients completed the entire trial of 28 days treatment. BASDEC and GDS were administered on day 8 post-admission, and depressed patients were randomised double-blind to either low dose lofepramine (70 mg daily) (n = 23) or placebo (n = 23). Assessment of changes in depressive states were made using the Montgomery Asberg Depression Rating Scale (MADRS) on days 8, 18 and 36 post-admission. Both groups improved by a similar amount during the trial. Lofepramine tended to be more effective than placebo in those patients who were more depressed (GDS > or = 18). On the other hand, subjects who were less depressed (i.e. GDS < 18) improved more on placebo than lofepramine. Low dose lofepramine may prove useful in moderately or severely depressed patients treated for only 4 weeks. However, low dose lofepramine is not indicated for mild (GDS 15-18) depression.

Do acute diseases transiently impair anterior pituitary function in patients over the age of 75? A longitudinal study of the TRH test and basal gonadotrophin levels

Several studies have shown that anterior pituitary function is affected by the ageing process. Little is known, however, about the effect acute diseases have on the anterior pituitary. Should they be associated with a disturbance of anterior pituitary hormone production, they might make anterior pituitary function tests difficult to interpret when they are most needed. To test this hypothesis, we studied the thyrotrophin (TSH) releasing hormone (TRH) test and basal plasma gonadotrophins, taken as indicators of anterior pituitary function and reserve, in 74 consecutive patients (49 women) mean age 82 +/- 5.1 suffering from acute diseases soon after admission to hospital. A total of 44 (30 women) were followed up and retested after 3 disease-free months following recovery and discharge home. Seventy-one age- and sex-matched healthy controls (47 women), mean age 82 +/- 5.0 living in the community were also studied. The mean peak TSH increment after TRH (mean delta max TSH) increased from 5.7 soon after admission, to 7.7 U/l at follow-up (P = 0.01). The mean plasma LH increased from 25 to 35 U/l in women (P = 0.0004) and from 9.7 to 14 U/l in men (P = 0.03). The mean plasma FSH increased from 21 to 25 U/l in women (P = 0.04) and from 7.5 to 9.4 U/l in men (P = 0.01). Controls had greater TSH responses to TRH and higher plasma gonadotrophins levels when compared with acute patients (LH women P = 0.17, for all other tests P < 0.05). We conclude that a transient reduction of anterior pituitary function is a common occurrence in patients over the age of 75 suffering from acute diseases. This has diagnostic relevance and therapeutic implications.

Delta-k lidar acoustic sounding of the atmosphere

A new remote sensing method for temperature sounding of the atmosphere is put forward. The method is based on the Δk-lidar technique, and it detects the modulation of atmospheric lidar backscatter induced by an acoustic wave transmitted collinearly with the lidar. The method is examined as a possible means to extend the range and versatility of atmospheric temperature profiling beyond the limits of the standard radioacoustic sounding method. Performance estimates are carried out which suggest that the method may be feasible for atmospheric temperature profiling to ranges approaching 10 km.

Deltak Lidar sensing of surface waves in a wave tank

The Deltak lidar remote-sensing method is used in a laboratory wave tank demonstration to measure the frequency of surface waves as a function of their wavelength. The results clearly demonstrate the ability of the Deltak lidar method to detect a single surface wave among an ensemble of waves present on the surface with a signal-to-noise ratio that agrees with the theory.

Cyclothiazide reverses AMPA receptor antagonism of the 2,3-benzodiazepine, GYKI 53655

On rat cortical slices, cyclothiazide, 1-100 microM, (ED50 = 7.1 +/- 1.1 microM) enhanced the depolarizing action of alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) but not that of N-methyl-D-aspartate (NMDA). Cyclothiazide 10 microM also reversed the action of a 2,3-benzodiazepine, GYKI 53655, which is a non-competitive AMPA receptor antagonist, but not that of the quinoxalinedione, NBQX, which is a competitive AMPA receptor antagonist.

Quality of life in hypertensives treated with atenolol or captopril: a double-blind crossover trial

AIM

To compare the effects of captopril and atenolol on quality of life of hypertensive patients.

METHODS

In a randomly allocated double-blind crossover trial with two 6-week treatment periods captopril at 25 mg twice a day or atenolol at 50 mg once a day were administered to 265 hypertensive patients (mean age 56 years; 55% men). Of these, 65% were newly treated hypertensives and 35% were previously uncontrolled on a diuretic alone. A seated diastolic blood pressure of 95-115 mmHg was required after a 3-week placebo run-in period. Any previous diuretic therapy was changed to hydrochlorothiazide (25 mg once a day) and the dose was kept constant throughout the trial. Newly diagnosed patients did not take a diuretic at any time. Quality of life was assessed from self-completed questionnaires measuring psychological well-being, symptomatic side effects of treatment, and activity and perceived well-being (a health index). A relative's perception of the patients' mood was also obtained where possible.

RESULTS

Twelve patients withdrew on atenolol and 10 on captopril. No differences between the drugs were observed in quality of life measures, and 95% confidence intervals suggested that important differences were excluded.

CONCLUSION

We conclude that at the doses used in this trial there were no important differences between captopril and atenolol in their effects on quality of life.

Relation between blood pressure and stroke mortality

The relation between stroke mortality and blood pressure was investigated in 10,186 hypertensive patients followed up in the Department of Health Hypertension Care Computing Project for an average of 9 years. An untreated blood pressure measurement was available in 3,472 men and 3,405 women. The age-adjusted risk of stroke death increased by 1% for every 1 mm Hg increase in untreated systolic blood pressure. The relative hazard rate was 1.014 (95% confidence interval [CI], 1.007, 1.021) in men and 1.009 (1.003, 1.016) in women. The corresponding increases for 1 mm Hg for untreated diastolic blood pressure were almost 3% in men and again 1% in women (relative hazard rate 1.026 [95% CI, 1.014, 1.038] in men and 1.010 [1.000, 1.021] in women). Treated blood pressure measurements were available in 3,073 men and 3,148 women. Stroke mortality increased by 2% for a 1 mm Hg increase in treated systolic pressure and 3% for the corresponding increase in diastolic blood pressure. The relation between stroke mortality and blood pressure was similar over and under the age of 65, although the increase in mortality with pressure was greater for treated diastolic blood pressure in women under the age of 65 than over this age. There was no evidence for a J-shaped relation between stroke mortality and either systolic or diastolic pressure in men. In women there was a suggestion of such a relation, but since this relation was also observed for untreated pressures, any increase in risk at lower pressures is unlikely to be a result of treatment.

Methohexitone antagonises kainate and epileptiform activity in rat neocortical slices

Using a grease-seal technique on cortical slices, methohexitone (10-316 microM) dose dependently and reversibly reduced depolarising responses to kainate more than those to alpha-amino-3-hydroxy-4-isoxazolepropionate (AMPA) and N-methyl-D-aspartate (NMDA). The respective pA2 values were 4.9 +/- 0.07, 3.6 +/- 0.03 and 4.0 +/- 0.05 whereas, for 6-nitro,7-sulphamoylbenz[F]quinoxalinedione (NBQX), they were 5.8 +/- 0.06, 6.7 +/- 0.05 and < 4.0. Methohexitone was also more effective than NBQX in reducing the spontaneous epileptiform activity occurring in these cortical slices. Thus 10 and 20 microM of this short-acting barbiturate reduced afterpotentials and burst frequencies respectively by about 50% whereas NBQX 10 microM only reduced burst frequency by some 15%. The results are discussed with respect to a putative methohexitone- and kainate-sensitive autoreceptor which facilitates presynaptic glutamate release.

Relation between treated blood pressure and death from ischaemic heart disease at different ages: a report from the Department of Health Hypertension Care Computing Project

OBJECTIVE

To determine the relation between mortality from ischaemic heart disease (IHD) and treated blood pressure at different ages.

DESIGN

Prospectively, 6216 patients were studied for a mean of 107 months.

SETTING

Of the total patients, 95% were followed in five hospital-based hypertension clinics and the remainder in four group general practices.

PATIENTS

Respectively, 2250 and 2126 hypertensive men and women aged < 60 years and 822 and 1018 aged > or = 60 years.

MAIN OUTCOME MEASURES

Mortality (any mention on the death certificate) from IHD.

RESULTS

Four hundred and sixty-seven patients died with IHD mentioned on the death certificate. The relation between both diastolic blood pressure (DBP) and systolic blood pressure (SBP) during the first 3-12 months of treatment and subsequent IHD mortality was examined. Under the age of 60 years the relative hazard rate (RHR) for death from IHD tended to increase with DBP in both men and women. Above the age of 60 years there was no important or significant relation between IHD mortality and treated DBP. For SBP there was no reduction in the positive relation between IHD mortality and blood pressure in the older age groups. The RHR for SBP ranged between 1.008 and 1.021 in men and women over and under the age of 60 years.

CONCLUSIONS

The positive relation between DBP and IHD mortality decreased with increasing age and, in women aged > or = 60 years, even inverted, partly explaining the negative relation reported between DBP and total mortality in the very old.

Delta-k-lidar sensing of the ocean surface

A new lidar technique for detecting ocean surface waves is analyzed theoretically. The method is based on the Deltak-radar technique and detects the modulation of the low-frequency product of two frequency-separated backscattered laser fields. It is shown that this Deltak-lidar technique can have a much larger signal-to-noise ratio than Deltak-radar, primarily because of its ability to aperture average the speckle noise in the backscattered fields.

Excitatory amino acids: new tools for old stories or pharmacological subtypes of glutamate receptors: electrophysiological studies

Although the N-methyl-D-aspartate (NMDA) subtype of L-glutamate receptor is well characterized, the significance of non-NMDA glutamate-sensitive binding sites is not well documented. In this study, a new tricyclic quinoxalinedione (NBQX) and an arthropod toxin (philanthotoxin) were shown to block responses of spinal neurones in vivo to kainate, quisqualate, and AMPA in parallel but had little effect on responses to NMDA. Philanthotoxin appeared to be a use-dependent antagonist consistent with a channel-blocking mode of action. On cortical wedges in vitro, however, NBQX proved to be a more potent antagonist of AMPA and quisqualate than of kainate (pA2 values of 7.1, 7.0, and 5.6, respectively) with no effect at 10 microM on responses to NMDA. These studies provide evidence that on cortical neurones, but not on spinal neurones. AMPA and kainate depolarize by pharmacologically different mechanisms.

Mortality associated with captopril and enalapril: a report from the DHSS Hypertension Care Computing Project

In 1986, the Committee on Safety of Medicines published a report suggesting that enalapril may have an adverse effect on renal function. The prescription event monitoring scheme subsequently published figures on adverse drug reactions and mortality for patients treated with enalapril. They concluded that enalapril did not have an adverse effect on renal function and survival. Similar data were not available for captopril, as the drug was marketed before prescription event monitoring had been developed. In the Department of Health and Social Security (DHSS) Hypertension Care Computing Project (DHCCP), 368 hypertensive patients treated with captopril and 371 treated with enalapril were followed for an average of 3.1 and 1.6 years, respectively. Thirty-two patients died; none had renal failure as an underlying cause of death. The death rate was similar in both drug groups, at 17.5 (enalapril) and 24.0 (captopril) per 1000 patient-years. The present report shows that, for patients treated for high blood pressure, the relative risk of mortality with captopril compared with enalapril was 1.37, an insignificant difference (95% confidence interval 0.63, 2.98).

Rapid analysis of triacylglycerols using high-performance liquid chromatography with light scattering detection

This paper details a high-performance liquid chromatography (HPLC) method for the separation of triacylglycerols, using a 3-micron, 15 cm x 4.6 mm I.D. Spherisorb ODS column and gradient elution with dichloromethane and acetonitrile. The triacylglycerols are detected using a light scattering detector (mass detector). Separations of a number of different edible oils and fats are reported. The procedure offers a possible method for determining cocoa butter equivalents and the adulteration of edible oils and fats by other non-generic fats and oils.

Qualitative studies on alpha-interferon-2b in prolonged continuous infusion regimes using gradient elution high-performance liquid chromatography

The treatment of home-based cancer patients with continuous infusion chemotherapy requires that complete courses of medication in pre-filled syringes are provided on an out-patient basis. The infusion must remain stable prior to use during refrigerated storage (up to 14 days) and during infusion from holster-worn ambulatory infusion pumps where the temperature of the infusion can reach 37 degrees C. In this study, polypropylene syringes containing interferon alpha-2b infusion (3 mega units in 6 ml) were stored at 4 degrees C. The infusion was analysed during storage by a qualitative gradient-elution high-performance liquid chromatography procedure. Over 14 days storage at 4 degrees C or 24 h storage at 37 degrees C, chromatographic changes occurred indicating interconversion between interferon monomers and possibly oligomer formation. Until further studies are completed we consider interferon alpha-2b unsuitable for inclusion in our home oncology programme.

The formulation and stability of a unit-dose oral vitamin K1 preparation

A unit-dose oral vitamin K1 solution (1 mg ml-1) was developed for administration to neonates as prophylaxis against early haemorrhagic disease of the new-born. Previously, a multidose oral-drop solution was prepared from sterile ampoules of vitamin K1 injection (10 mg ml-1). The unit-dose preparation enabled accurate and convenient dose delivery and was more economical than the multidose solution. Furthermore, the preparation of sterile, single-dose units enabled the elimination of potentially harmful preservatives from the formulation. The unit-dose preparation was shown to be stable for 6 months under refrigerated storage conditions.

Measurement of glucose utilisation with [18F]2-fluoro-2-deoxy-D-glucose: a comparison of different analytical methods

A number of different analytical methods were applied to dynamic scans obtained with [18F]2-fluoro-2-deoxy-D-glucose and positron emission tomography. In particular, methods applying three, four, standard, or no rate constants were compared in four studies on three normal subjects. In addition, regional cerebral blood flow, oxygen utilisation, and blood volume were measured using the oxygen-15 steady-state inhalation technique. There was a large difference between values of glucose utilisation obtained with the various analytical methods, in particular between methods using three or four rate constants. This difference was not due to contamination of the tracer with [18F]2-fluoro-2-deoxy-D-mannose. For dynamic techniques, the separate measurement of regional cerebral blood volume was essential. Static techniques (single scans with standard or no rate constants) were best related to dynamic techniques utilising four rate constants. From the results, it followed, however, that these static techniques can only be applied clinically if relatively large disturbances of glucose metabolism and no changes in rate constants are anticipated. The lumped constant was assessed from the combined measurement of oxygen and glucose utilisation and was higher than previously reported.

A new route for the synthesis of [18F]fluoroaromatic substituted amino acids: no carrier added L-p-[18F]fluorophenylalanine

L-p-[18F]fluorophenylalanine was designed as a potential marker for probing protein synthesis in the human brain by positron emission tomography. This radiotracer has been synthesized using nucleophilic displacement of the activated nitro group of p-nitrobenzaldehyde by NCA 18F- obtained from the 18O (p, n) reaction on enriched water. The L-form of the [18F]fluoroamino acid can be separated on an analytical scale chiral column. A typical production run of 22.2 GBq (600 mCi) of 18F obtained after a 10 microA.h bombardment of 18 MeV protons on 99.8% 18O-enriched water leads to a batch of 1.11 GBq (30 mCi) of NCA L-p-[18F]fluorophenylalanine after a total synthesis time of 120 min.

Inhibition of L-[18F]fluorodopa uptake into human brain by amino acids demonstrated by positron emission tomography

The brain uptake of L-[18F]fluorodopa was measured by positron emission tomography in a healthy male volunteer both under fasting conditions and during intravenous amino acid loading. A significant reduction of tracer uptake into the brain was demonstrated with amino acid loading. This finding represents the first direct evidence for competition between L-dopa and other amino acids for uptake across the blood-brain barrier obtained in vivo in a human subject. It underlines the possible importance of interference by dietary amino acids with the therapeutic actions of L-dopa in Parkinson's disease.

Brain dopamine metabolism in patients with Parkinson's disease measured with positron emission tomography

L-[18F] fluorodopa was administered in trace amounts intravenously to healthy control subjects and to patients with Parkinson's disease. Striatal uptake of radioactivity was measured using positron emission tomography. The capacity of the striatum to retain tracer was severely impaired in patients compared to controls. This may reflect a reduction of striatal dopamine storage in Parkinson's disease. Patients showing the "on/off" phenomenon had an even greater decrease of striatal storage capacity.

Semi-automated preparation of a 11C-labelled antibiotic--[N-methyl-11C]erythromycin A lactobionate

A fast semi-automated method is described for labeling the antibiotic, erythromycin A (1), with the short-lived positron-emitting radionuclide, 11C (t 1/2 = 20.4 min), in order to permit the non-invasive study of its tissue uptake in vivo. Labelling was achieved by the fast reductive methylation of N-demethylerythromycin A (2) with [11C]formaldehyde, itself prepared from cyclotron-produced [11C]-carbon dioxide. Rapid chemical and radiochemical purification of the [N-methyl-11C]erythromycin A (3) were achieved by HPLC and verified by TLC with autoradiography. The purified material was formulated for human i.v. injection as a sterile apyrogenic solution of the lactobionate salt. The preparation takes 42 min from the end of radionuclide production and from [11C]carbon dioxide produces [N-methyl-C11]erythromycin A lactobionate in 1-12% radiochemical yield, corrected for radioactive decay.

In vivo disturbance of the oxidative metabolism of glucose in human cerebral gliomas

Abnormalities in the oxidative metabolism of glucose in human cerebral gliomas have been studied in seven patients using positron emission tomography. Measurements of regional cerebral blood flow and oxygen consumption were obtained using the oxygen-15 steady-state inhalation technique. Values of regional cerebral glucose consumption were obtained using fluorine 18-labeled 2-fluoro-2-deoxy-D-glucose and a simplification of the method of Sokoloff. Functional values were obtained for regions of tumor and brain tissue in the middle cerebral artery territory of the contralateral cortex. Values of regional glucose consumption were calculated for both regions using a value of the lumped constant quoted for normal brain tissue (0.42). Tumor regional cerebral blood flow was comparable to that in the contralateral cortex, whereas regional cerebral oxygen consumption was depressed. This depression resulted in low tumor values of the fractional oxygen extraction ratio (0.21 +/- 0.07), indicating that oxygen supply exceeded the metabolic demand. In contrast, tumor regional cerebral glucose consumption was not depressed and regional glucose extraction ratios were similar for tumor and brain tissue. The metabolic uncoupling between regional oxygen consumption and regional glucose consumption (CMRO2/CMRGlu = 0.24 +/- 0.07 ml of oxygen per milligram of glucose) is indicative of increased aerobic glycolysis.