Economic evaluation of Nootropil in the treatment of acute stroke in France

Investigation into stereoselective pharmacological activity of phenotropil

Phenotropil [N-carbamoylmethyl-4-aryl-2-pyrrolidone (2-(2-oxo-4-phenyl-pyrrolidin-1-yl) acetamide; carphedon)] is clinically used in its racemic form as a nootropic drug that improves physical condition and cognition. The aim of this study was to compare the stereoselective pharmacological activity of R- and S-enantiomers of phenotropil in different behavioural tests. Racemic phenotropil and its enantiomers were tested for locomotor, antidepressant and memory-improving activity and influence on the central nervous system (CNS) using general pharmacological tests in mice. After a single administration, the amount of compound in brain tissue extracts was determined using an ultra performance liquid chromatography-tandem mass spectrometry (UPLC/MS/MS) method in a positive ion electrospray mode. In the open-field test, a significant increase in locomotor activity was observed after a single administration of R-phenotropil at doses of 10 and 50 mg/kg and S-phenotropil at a dose of 50 mg/kg. In the forced swim test, R-phenotropil induced an antidepressant effect at doses of 100 and 50 mg/kg, and S-phenotropil was active at a dose of 100 mg/kg. R-phenotropil significantly enhanced memory function in a passive avoidance response test at a dose of 1 mg/kg; the S-enantiomer did not show any activity in this test. However, the concentrations of R- and S-phenotropils in brain tissue were similar. In conclusion, the antidepressant and increased locomotor activity relies on both R- and S-phenotropils, but the memory-improving activity is only characteristic of R-phenotropil. These results may be important for the clinical use of optically pure isomers of phenotropil.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

Pharmacological treatment for aphasia following stroke

BACKGROUND

Aphasia describes language impairment associated with a brain lesion.

OBJECTIVES

The objective of this review was to assess the effects of drugs on language abilities when given to people with aphasia following stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Register (last searched: May 2001), and reference lists of relevant articles to December 1998. We also contacted academic institutions and other researchers to identify further published and unpublished trials. MEDLINE was searched from 1966-1998, and CINAHL from 1982-1998. We searched the International Journal of Disorders of Communication by hand (known by other names in the past), from 1969 to 1998.

SELECTION CRITERIA

Randomised controlled trials comparing: ~bullet~Any drug given to improve language, versus no treatment, or versus placebo ~bullet~Any drug given to improve language versus speech and language therapy ~bullet~One drug given to improve language versus another drug given with the same aim

DATA COLLECTION AND ANALYSIS

The principal reviewer collected the data, and assessed the quality of the trials with independent data checking and methodological advice. If we could not perform a statistical combination of different studies, we sought missing data. Failing that we provided a description. We sought missing data from authors, or where appropriate, a drug company.

MAIN RESULTS

We considered fifty two studies in detail, from which we identified ten trials suitable for the review. In most cases the methodological quality was unassessable, and only one trial reported sufficient detail for us to complete a description and analysis. This study did lose a large number of patients during its course. Drugs used in the trials identified were piracetam, bifemalane, piribedil, bromocriptine, idebenone, and Dextran 40. We found weak evidence that patients were more likely to have improved on any language measure at the end of the trial if they had received treatment with piracetam (odds ratio 0.46, 95% confidence interval 0.3 to 0.7). The evidence is considered weak because of the large numbers of drop outs from the trials identified, who were lost to follow up. Patients who were treated with piracetam were no more likely (considering statistical significance) than those who took a placebo to experience unwanted effects, including death (odds ratio 1.29, 95% confidence interval for difference 0.9 to 1.7). However, the differences in death rates between the two groups, even though not not statistically significant, do give rise to some concerns that there may be an increased risk of death from taking piracetam. We could not determine if drug treatment is more effective than speech and language therapy. We could not determine whether one drug is more effective than another.

REVIEWER'S CONCLUSIONS

The main conclusion of this review is that drug treatment with piracetam may be effective in the treatment of aphasia after stroke. Further research is needed to explore the effects of drugs for aphasia, in particular piracetam. If a trial is done, this must be large enough to have adequate statistical power. The safety of the drug should be of primary interest. Researchers should examine the long term effects of this treatment, and whether it is more effective than speech and language therapy.

Economic evaluation in stroke research : a systematic review

BACKGROUND AND PURPOSE

The purpose of this review is to provide insight into the quality of economic evaluation in the field of cerebrovascular diseases (CVD) on the basis of a systematic analysis.

METHODS

A literature search was performed using several sources. Trial-based full economic evaluation studies, were included in this review. The quality of the studies was independently assessed by 2 reviewers using a checklist.

RESULTS

Twenty-three articles were found to comply with our inclusion and exclusion criteria. Only a few studies mentioned the perspective of the study, and in these cases it was always the societal perspective. The majority of the studies were cost-minimization and cost-effectiveness analyses based on cohort studies. All studies included healthcare costs, and in some instances patient and family costs were considered. Costs were usually measured by tariffs. Clinical end points and mortality were used to measure effects. Cost and effect measurements were based on hospital records.

CONCLUSIONS

Only a few full economic evaluations have been undertaken in the domain of CVD. In most of the studies, the technical execution and methodology were limited.