Cost of illness of the vaccine-preventable diseases influenza, herpes zoster and pneumococcal disease in France

BACKGROUND

The incidence of certain vaccine-preventative diseases, such as influenza, herpes zoster and pneumococcal infection, continues to be high despite the availability of vaccines, resulting in a substantial health and economic burden on society, particularly among older adults aged ≥65 years.

METHODS

A cost calculator was developed to assess the cost of illness of influenza, herpes zoster and pneumococcal disease in France. Direct medical costs related to diagnosis and treatment in the older adult population in both inpatient and outpatient settings were modelled over a 1-year time horizon. Scenario analyses were conducted to determine the impact of hospitalizations on the results by considering only influenza-attributed diagnoses.

RESULTS

In France, influenza has the highest incidence, followed by herpes zoster and pneumococcal disease. Similarly, influenza poses the greatest cost burden among all older adults, while pneumococcal disease poses the greatest cost burden among those aged 65-74 years. When considering only influenza-attributed diagnoses, the number of inpatient visits and associated costs was reduced by 63% in the overall older adult population. In the low-incidence season, the number of inpatient visits and associated costs were reduced by 69%, while in the high-incidence season, the number of inpatient visits and associated costs increased by 63%.

CONCLUSION

Influenza remains a leading vaccine-preventable disease among older adults in France, resulting in a substantial economic burden that could be prevented by increasing vaccine uptake.

Diethyl sinapate-grafted cellulose nanocrystals as nature-inspired UV filters in cosmetic formulations

Inspired by nature’s photoprotection mechanisms, we report an effective UV-blocking nanomaterial based on diethyl sinapate-grafted cellulose nanocrystals (CNC-DES). The colloidal stability and UV-blocking performance of CNC-DES in aqueous glycerol (a common humectant in petroleum-free cosmetic formulations) and in a commercially available moisturizing cream were studied. Grafting the water-insoluble DES onto CNCs renders it dispersible in these water-based formulations, thanks to the excellent water-dispersibility of CNC nanoparticles. Glycerol dispersions containing 0.1 to 1.5 wt% CNC-DES display very high UV-blocking activity owing to the anti-UV DES moieties anchored onto CNCs. A facial cream blended with 1.5 wt% CNC-DES exhibits an SPF of 5.03, which is higher than a commercially available sunscreen with the same active ingredient concentration (SPF = 3.84). DPPH radical scavenging assay also showed the antioxidant potential of CNC-DES, albeit coinciding with a significant reduction in antioxidant activity after grafting DES onto CNCs. Cytotoxicity measurements revealed the CNC-DES not to cause significant cytotoxicity to murine fibroblast cells after 24 h of exposure. Overall, CNC-DES exhibits strong anti-UV and antioxidant properties and is water-dispersible, biocompatible, non-greasy, and lightweight. This study demonstrates the exceptional potential of DES-grafted CNCs as nature-inspired UV filters in the next generation of cosmetic formulations, including those for sensitive skins.

Modelling COVID-19 outbreaks in USA with distinct testing, lockdown speed and fatigue rates

Each state in the USA exhibited a unique response to the COVID-19 outbreak, along with variable levels of testing, leading to different actual case burdens in the country. In this study, via per capita testing dependent ascertainment rates, along with case and death data, we fit a minimal epidemic model for each state. We estimate infection-level responsive lockdown/self-quarantine entry and exit rates (representing government and behavioural reaction), along with the true number of cases as of 31 May 2020. Ultimately, we provide error-corrected estimates for commonly used metrics such as infection fatality ratio and overall case ascertainment for all 55 states and territories considered, along with the USA in aggregate, in order to correlate outbreak severity with first wave intervention attributes and suggest potential management strategies for future outbreaks. We observe a theoretically predicted inverse proportionality relation between outbreak size and lockdown rate, with scale dependent on the underlying reproduction number and simulations suggesting a critical population quarantine 'half-life' of 30 days independent of other model parameters.

Understanding perceptions of nursing professional identity in students entering an Australian undergraduate nursing degree

Developing a professional identity is an essential transition for nursing students as they move through their undergraduate degree. Professional identity is described as a person's perception of themselves within a profession or the collective identity of the profession. The formation of a professional identity is an evolving process, shaped by the media, educational experiences and role modelling. The aim of this study was to develop a greater understanding of the perceptions that students, about to embark on their undergraduate nursing degree, had of the nursing profession. A drawing and mind mapping exercise was conducted with a convenience sample of commencing nursing students to explore how they viewed their future profession. The data underwent thematic analysis and then grouped into sub-themes and themes. Four key themes were identified, 'To be a nurse, I have to look the part', 'To be a nurse, I have to perform in a variety of roles', 'To be a nurse, I have to connect with others', and 'To be a nurse, I have to care for myself.' The formation of a strong pre-professional identity is important for nursing students due to the link between future job satisfaction and the development of a robust nursing workforce.

Patient preferences in Italy: health state utilities associated with attributes of weekly injection devices for treatment of type 2 diabetes

OBJECTIVES

Several glucagon-like peptide-1 receptor agonists are administered as weekly injections for treatment of type 2 diabetes (T2D). These medications vary in their injection processes, and a recent study in the UK found that these differences had an impact on patient preference and health state utilities. The purpose of this study was to replicate the UK study in Italy to examine preferences of an Italian patient sample, while allowing for comparison between utilities in the UK and Italy.

MATERIALS AND METHODS

Participants with T2D in Italy valued health states in time trade-off interviews. All health states had the same description of T2D, but differed in description of the treatment process. As in the original UK study, the first health state described an oral treatment regimen, while additional health states added a weekly injection. The injection health states differed in three injection-related attributes: requirements for reconstituting the medication, waiting during medication preparation, and needle handling.

RESULTS

Interviews were completed by 238 patients (58.8% male; mean age = 60.2 years; 118 from Milan, 120 from Rome). The oral treatment health state had a mean (SD) utility of 0.90 (0.10). The injection health states had significantly (p < 0.0001) lower utilities, which ranged from 0.87 (requirements for reconstitution, waiting, and handling) to 0.89 (weekly injection with none of these requirements). Differences in health state utility scores suggest that each administration requirement was associated with a disutility (ie, negative utility difference): -0.006 (reconstitution), -0.006 (needle handling), -0.011 (reconstitution, needle handling), and -0.022 (reconstitution, waiting, needle handling).

CONCLUSION

Disutilities associated with the injection device characteristics were similar to those reported with the UK sample. Results suggest that injection device attributes may be important to some patients with T2D, and it may be useful for clinicians to consider these attributes when choosing medication for patients initiating these weekly treatments.

Single-use flexible ureteropyeloscopy: a systematic review

PURPOSE

Data assessing the effectiveness of single-use flexible ureteropyeloscopy (FURS) are limited. This study evaluates and compares single-use FURS with conventional reusable FURS.

METHODS

A systematic search using electronic databases (Pubmed and Embase) was performed for studies evaluating single-use FURS in the setting of urinary tract stone disease. Outcome measures included a comparative evaluation of their mechanical, optical and clinical outcomes.

RESULTS

Eleven studies on 466 patients met inclusion criteria. In vitro comparative data were available on three single-use flexible ureteropyeloscopes (LithoVue™, Polyscope™ and SemiFlex™) and clinical data were available on two (LithoVue™ and Polyscope™). The overall stone-free rate and complication rate associated with single-use FURS was 87 ± 15% and 9.3 ± 9%, respectively. There were no significant differences in procedure duration, stone size, stone clearance and complication rates when single-use FURS and reusable FURS were compared (duration: 73 ± 27 versus 74 ± 13 min, p = 0.99; stone size: 1.36 ± 0.2 versus 1.34 ± 0.18 cm, p = 0.93; stone-free rate: 77.8 ± 18 versus 68.5 ± 33%, p = 0.76; complication rate 15.3 ± 10.6 versus 15 ± 1.6%, p = 0.3).

CONCLUSIONS

Single-use FURS demonstrates comparable efficacy with reusable FURS in treating renal calculi. Further studies on clinical efficacy and cost are needed to determine whether single-use FURS will reliably replace its reusable counterpart.

The impact of a structured clinical training course on interns' self-reported confidence with core clinical urology skills

BACKGROUND

Undergraduate training in core urology skills is lacking in many Irish training programmes.

AIMS

Our aim was to assess newly qualified doctors' experience and confidence with core urological competencies.

METHODS

A questionnaire survey covering exposure to urology and confidence with core clinical skills was circulated to all candidates. The group then attended a skills course covering male/female catheterisation, insertion of three-way catheters, bladder irrigation and management of long-term suprapubic catheters. The groups were re-surveyed following the course.

RESULTS

Forty-five interns completed the pre-course questionnaire (group 1) and 27 interns completed the post-course questionnaire (group 2). 24/45 (53%) had no experience of catheter insertion on a patient during their undergraduate training. 26/45 (58%) were unsupervised during their first catheter insertion. 12/45 (27%) had inserted a female catheter. 18/45 (40%) had inserted a three-way catheter. 12/45 (27%) had changed a suprapubic catheter. 40/45 (89%) in group 1 reported 'good' or 'excellent' confidence with male urinary catheterisation, compared to 25/27 (92.5%) in group 2. 18/45 (40%) in group 1 reported 'none' or 'poor' confidence with female catheterisation, compared to 7/27 (26%) in group 2. 22/45 (49%) in group 1 reported 'none' or 'poor' confidence with insertion of three-way catheters, compared to 2/27 (7%) in group 2. 32/45 (71%) in group 1 reported 'none' or 'poor' confidence in changing long-term suprapubic catheters, falling to 3/27 (11%) in group 2.

CONCLUSION

This study raises concerns about newly qualified doctors' practical experience in urology. We suggest that this course improves knowledge and confidence with practical urology skills and should be incorporated into intern induction.

Prospective evaluation of a virtual urology outpatient clinic

BACKGROUND

Outpatient department (OPD) clinics account for a significant proportion of healthcare expenditure. We report on a pilot study of a virtual outpatient clinic (VC) for urology patients as an alternative to a general urology clinic review.

AIMS

The study aims to assess the safety and cost-effectiveness of a virtual clinic as an alternative to general OPD review.

METHODS

A prospective study performed between March 2015 and December 2015 investigated the effectiveness of a VC in our institution. Eligible patients were recruited from general urology outpatient visits, from medical team members and from general practitioners (GP). Data recorded on each VC review included patient demographics, indication for referral to VC, outcome of VC and method of communication with the patient and their GP after the VC.

RESULTS

Three hundred eighty-five patients were registered for the VC. Indications for referral included review of imaging results (n = 136), doctor or patient query (n = 112) and review of laboratory results (n = 67). Outcomes after VC review included general OPD follow-up (n = 134), discharge from urology care (n = 39), referral for urological intervention (n = 29) and referral for radiological investigation (n = 23). VC review prevented 217 OPD clinic visits, saved €17,360 and provided a failsafe mechanism for reviewing investigation results. Two patients booked for OPD review following VC review did not receive appointments.

CONCLUSIONS

Virtual clinic is a safe and cost-effective alternative to general OPD review in appropriately selected patients.

Cost-effectiveness of apixaban versus low molecular weight heparin/vitamin k antagonist for the treatment of venous thromboembolism and the prevention of recurrences

BACKGROUND

Prior analyses beyond clinical trials are yet to evaluate the projected lifetime benefit of apixaban treatment compared to low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA) for treatment of venous thromboembolism (VTE) and prevention of recurrences. The objective of this study is to assess the cost-effectiveness of initial plus extended treatment with apixaban versus LMWH/VKA for either initial treatment only or initial plus extended treatment.

METHODS

A Markov cohort model was developed to evaluate the lifetime clinical and economic impact of treatment of VTE and prevention of recurrences with apixaban (starting at 10 mg BID for 1 week, then 5 mg BID for 6 months, then 2.5 mg BID for an additional 12 months) versus LMWH/VKA for 6 months and either no further treatment or extended treatment with VKA for an additional 12 months. Clinical event rates to inform the model were taken from the AMPLIFY and AMPLIFY-EXT trials and a network meta-analysis. Background mortality rates, costs, and utilities were obtained from published sources. The analysis was conducted from the perspective of the United Kingdom National Health Service. The evaluated outcomes included the number of events avoided in a 1000-patient cohort, total costs, life-years, quality-adjusted life-years (QALYs), and cost per QALY gained.

RESULTS

Initial plus extended treatment with apixaban was superior to both treatment durations of LMWH/VKA in reducing the number of bleeding events, and was superior to initial LMWH/VKA for 6 months followed by no therapy, in reducing VTE recurrences. Apixaban treatment was cost-effective compared to 6-month treatment with LMWH/VKA at an incremental cost-effectiveness ratio (ICER) of £6692 per QALY. When initial LMWH/VKA was followed by further VKA therapy for an additional 12 months (i.e., total treatment duration of 18 months), apixaban was cost-effective at an ICER of £8528 per QALY gained. Sensitivity analysis suggested these findings were robust over a wide range of inputs and scenarios for the model.

CONCLUSIONS

In the UK, initial plus extended treatment with apixaban for treatment of VTE and prevention of recurrences appears to be economical and a clinically effective alternative to LMWH/VKA, whether used for initial or initial plus extended treatment.

Impact of apixaban vs low molecular weight heparin/vitamin k antagonist on hospital resource use in patients with venous thromboembolism

BACKGROUND

The clinical and economic benefits associated with apixaban treatment have been established in clinical trials and published economic evaluations. The benefits associated with apixaban could extend to improving hospital efficiencies, potentially influencing hospital resource use, and bed days. The objective of this study is to estimate the impact of 6-month treatment with apixaban vs low molecular weight heparin/vitamin k antagonist (LMWH/VKA) on hospital resource use among patients with venous thromboembolism (VTE).

METHODS

A model was developed to assess the impact of apixaban vs LMWH/VKA for treatment of VTE and prevention of recurrences on hospital resource use and costs. Resource use items included total hospitalizations, length of stay (LOS), and emergency department (ED) visits, estimated for all incident VTE patients in the UK over a 5-year time horizon. Rates of hospitalizations, ED visits, and LOS associated with recurrent VTE, major, and clinically relevant non-major bleeding were obtained from the AMPLIFY trial; costs were obtained from UK published sources.

RESULTS

Over a 5-year time horizon, the model predicted that, compared to 6 months of LMWH/VKA, 6 months of apixaban led to 3,954 fewer hospitalizations (consisting of 2,341 fewer new admissions and 1,613 fewer re-admissions) and 32,214 fewer bed days, among 332,607 incident VTE patients. ED visits were reduced by 1,582. The reduction in hospital resource use led to a cost saving of ∼£4.5 million in a market of patients treated with apixaban as compared to a market treated with LMWH/VKA. Sensitivity analysis indicated these findings were robust over a wide range of inputs.

CONCLUSIONS

6-month treatment with apixaban for treatment of VTE and prevention of recurrences on hospital resource use led to a reduction in hospitalizations and LOS in comparison to LMWH/VKA. These findings can help the efforts in reducing the growing burden of preventable re-admissions to hospitals.

Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A Prospective Multi-Institutional Study

PURPOSE

Data on urethral catheter related injuries are sparse. To highlight the dangers inherent in traumatic urethral catheterization we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries.

MATERIALS AND METHODS

This prospective study was performed during a 6-month period at 2 tertiary referral teaching hospitals. Recorded data included method and extent of urethral catheterization injury, setting and time of injury, number of catheterization attempts, urological management provided, additional bed days due to urethral injury and clinical outcomes after followup. The additional cost of managing urethral injuries was also calculated.

RESULTS

A total of 37 iatrogenic urethral injuries were recorded during the 6-month period. The incidence of traumatic urethral catheterization was 6.7 per 1,000 catheters inserted. Thirty (81%) patients sustained a complication Clavien-Dindo grade 2 or greater. The additional length of inpatient hospital stay was 9.4 ± 10 days (range 2 to 53). Of these patients 9 (24%) required an indwelling suprapubic catheter and 8 (21%) have an indwelling transurethral catheter. In addition, 9 (24%) are performing self-urethral dilation once weekly and 4 (11%) have required at least 1 urethral dilation due to persistent urethral stricture disease. The additional cost of managing iatrogenic urethral injuries was €335,377 ($371,790).

CONCLUSIONS

Iatrogenic urethral catheterization injuries represent a significant cost and cause of patient morbidity. Despite efforts to educate and train health care professionals on urethral catheterization insertion technique, iatrogenic urethral injuries will continue to occur unless urinary catheter safety mechanics are altered and improved.

Cost-effectiveness of Apixaban Versus Other Oral Anticoagulants for the Initial Treatment of Venous Thromboembolism and Prevention of Recurrence

PURPOSE

To assess the cost-effectiveness of apixaban versus rivaroxaban, low-molecular-weight heparin (LMWH)/dabigatran, and LMWH/vitamin K antagonist (VKA) for the initial treatment and prevention of recurrent thromboembolic events in patients with venous thromboembolism (VTE).

METHODS

A Markov model was developed to evaluate the pharmacoeconomic effect of 6 months of treatment with apixaban versus other anticoagulants over a lifetime horizon. Network meta-analyses were conducted using the results of the Apixaban after the Initial Management of Pulmonary Embolism and Deep Vein Thrombosis with First-Line Therapy (AMPLIFY), EINSTEIN-pooled, and RE-COVER I and II trials for the following end points: recurrent VTE, major bleeds, clinically relevant non-major bleeds, and treatment discontinuations. The analysis was conducted from the perspective of the United Kingdom National Health Service. The outcomes evaluated were the number of events avoided in a 1000-patient cohort, total costs, life years, quality-adjusted life years (QALYs), and cost per QALY gained over a patient's lifetime.

FINDINGS

Treatment for 6 months with apixaban was projected to result in fewer recurrent VTE and bleeding events in comparison to rivaroxaban, LMWH/dabigatran, and LMWH/VKA. Apixaban was cost-effective compared with LMWH/VKA at an incremental cost-effectiveness ratio of £2520 per QALY gained and was a dominant (ie, lower costs and higher QALYs) alternative to either rivaroxaban or LMWH/dabigatran. Sensitivity analysis indicated that results were robust over a wide range of inputs.

IMPLICATIONS

The assessment of the effects and costs of apixaban in this study predicted that apixaban is a dominant alternative to rivaroxaban and LMWH/dabigatran and a cost-effective alternative to LMWH/VKA for 6 months of treatment of VTE and the prevention of recurrence.

Use of Bayesian Markov Chain Monte Carlo Methods to Estimate EQ-5D Utility Scores from EORTC QLQ Data in Myeloma for Use in Cost-Effectiveness Analysis

Background. Patient-reported outcome measures are an important component of the evidence for health technology appraisal. Their incorporation into cost-effectiveness analyses (CEAs) requires conversion of descriptive information into utilities. This can be done by using bespoke utility algorithms. Otherwise, investigators will often estimate indirect utility models for the patient-reported outcome measures using off-the-shelf utility data such as the EQ-5D or SF-6D. Numerous modeling strategies are reported; however, to date, there has been limited utilization of Bayesian methods in this context. In this article, we examine the relative advantage of the Bayesian methods in relation to dealing with missing data, relaxing the assumption of equal variances and characterizing the uncertainty in the model predictions. Methods. Data from a large myeloma trial were used to examine the relationship between scores in each of the 19 domains of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30/QLQ-MY20 and the EQ-5D utility. Data from 1839 patients were divided 75%/25% between derivation and validation sets. A conventional ordinary least squares model assuming equal variance and a Bayesian model allowing unequal variance were estimated on complete cases. Two further models were estimated using conventional and Bayesian multiple imputation, respectively, using the full data set. Models were compared in terms of data fit, accuracy in model prediction, and characterization of uncertainty in model predictions. Conclusions. Mean EQ-5D utility weights can be estimated from the EORTC QLQ-C30/QLQ-MY20 for use in CEAs. Frequentist and Bayesian methods produced effectively identical models. However, the Bayesian models provide distributions describing the uncertainty surrounding the estimated utility values and are thus more suited informing analyses for probabilistic CEAs.

Quality of life, continence and frequency of pouchitis following laparoscopic versus open colectomy and ileal pouch-anal anastomosis: an Irish perspective

BACKGROUND

This study aims to assess quality of life outcomes, continence, rates of pouchitis and predictors of pouchitis for patients undergoing laparoscopic versus open three-stage ileal pouch-anal anastomosis (IPAA) surgery in our institution.

METHODS

Forty-two patients having had three-stage (IPAA) surgery were identified. One was excluded as they had undergone pouchectomy. A postal questionnaire followed by telephone contact was undertaken. The questionnaire was based on The Gastrointestinal Quality of Life Index (GIQLI) and Wexner/Cleveland Clinic Faecal Incontinence Symptom Severity Scoring Systems.

AIMS

Our aim was to assess morbidity, quality of life, incidence of pouchitis and continence following restorative panproctocolectomy and IPAA.

RESULTS

Thirty-five patients completed the response. The median age at colectomy of our patient population was 32 years. 57 % were male and 43 % were female. 54.3 % of cases were carried out laparoscopically. 8/19 patients who had laparoscopic surgery had pouchitis (42.1 %) versus 9/16 patients who had open surgery (56.3 %). The median Wexner score was 0. Nine patients (25.7 %) had a GIQLI score that was within or above the range reported for healthy controls. The rate of complications was 31.7 % for emergency cases and 25.7 % for elective cases. The rate of pouchitis in this group was 48.5 %. Overall pelvic sepsis rate was 12.8 %.

CONCLUSIONS

Ileal pouch-anal anastomosis is a successful and well-tolerated procedure with 94 % of patients opting to have the surgery again. Preliminary results do not show any significant difference in the incidence of pouchitis following laparoscopic surgery.

Selected enteropathogens and clinical course in children hospitalized with severe acute gastroenteritis in Barbados

OBJECTIVES

The primary aim of this study was to determine the prevalence of selected bacterial and viral enteropathogens in children hospitalized with acute gastroenteritis and the secondary aim was to characterize the clinical course and the outcome.

METHODOLOGY

A retrospective audit of children (<15 years) admitted with acute gastroenteritis during January 2008 to October 2010. Stool samples were analyzed for bacterial pathogens and for the Rotavirus. Demographics, clinical presentations, hospital course and outcome were extracted from the admission records.

RESULTS

There were 571 children hospitalized with acute gastroenteritis, which accounted for 11% of all medical hospitalization in children. Overall, 42.9% of these children were ≤12 months in age. Stool test result was documented in 46.6% of children hospitalized with gastroenteritis and an enteropathogen was isolated in 36.8% of cases with documented stool test result. Non-typhoidal Salmonella species was the most commonly isolated enteropathogen accounting for 21.1% of all the documented cases. Rotavirus was identified as an etiological agent in 9.0%. Of the 56 children who had non-typhoidal salmonella gastroenteritis, 54(96.4%) were younger than 5 years. The median duration of hospitalization was 2 days (Range 1 day to 9 days). There were no deaths.

CONCLUSION

Non-typhoidal salmonella was the most common enteropathogen isolated and this was followed by the Rotavirus.

Using daptomycin in hospitalised patients with cSSTI caused by Staphylococcus aureus has an impact on costs

BACKGROUND

The aim was to assess the cost impact of daptomycin compared to vancomycin treatment in patients hospitalised for complicated skin and soft-tissue infection (cSSTI) with suspected methicillin-resistant Staphylococcus aureus infection in the UK.

METHODS

A decision model was developed to estimate the costs associated with cSSTI treatment. Data on efficacy, treatment duration and early discharge from published clinical trials were used, with data gaps on standard clinical practice being filled by means of clinician interviews.

RESULTS

Total health-care costs per patient were GBP 6,214 and GBP 6,491 for daptomycin and vancomycin, respectively. A sensitivity analysis suggested that modifying the parameters within a reasonable range does not impact on the conclusion that the higher cost of daptomycin is likely to be offset by lower costs of monitoring and hospitalisation.

CONCLUSIONS

This study demonstrates that daptomycin not only provides an alternative treatment for multiple resistant infections, but may also reduce National Health Service costs.

A 30-year experience of Millin's retropubic prostatectomy: Has this classic operation derived by a President of the College in Ireland stood the test of time?

INTRODUCTION

In patients with large gland volume, open prostatectomy/adenoma enucleation remains a valuable surgical option in treating large obstructing prostates. We report our series of open prostatectomies spanning 32 years from a single institution.

PATIENTS AND METHODS

We retrospectively reviewed all patients who underwent open prostatectomy between 1980 and 2012. Patient demographical, clinical, pre- and postoperative data and final histology were retrieved from hospital in-patient enquiry system and chart review.

RESULTS

A total of 161 patients underwent Millin's prostatectomy by seven surgeons between 1980 and 2012. The mean blood loss was 1,381 mls (range 300-3,675 mls). One-third (34%) of patients (n = 55) received a blood transfusion. The mean weight of prostate tissue removed was 119 g (median 112 g, range 17-372 g). 6.6 % of pathological specimens revealed incidental prostate cancer, of which 78% were well differentiated (Gleason score ≤ 6). The mean weight of prostate tissue removed in patients who received a transfusion was 124 g. Trial of micturition (TOM) was performed at a mean of 9 days (median 9 days, range 5-25 days) with 94% of patients having a successful trial of voiding. 6% of cases early in the series failed to void initially, but did so at later removal of catheter while still in hospital. 45 patients (28%) of patients developed peri- or postoperative complications. There were three deaths (1.9%).

CONCLUSION

Open Millin's prostatectomy popularized over half a century ago continues to be a valuable option for the surgical treatment of high-volume prostate glands with excellent outcomes for patients.

Estimating quality-adjusted life years from patient-reported visual functioning

PURPOSE

Glaucoma is an important disease, the impacts of which on vision have been shown to have implications for patients' health-related quality of life (HRQoL). The primary aim of this study is to estimate a mapping algorithm to predict EQ-5D and SF-6D utility values based on the vision-specific measure, the 25-item Visual Functioning Questionnaire (VFQ-25), as well as the clinical measures of visual function, that is, integrated visual field, visual acuity, and contrast sensitivity.

METHODS

Ordinary least squares (OLS), Tobit, and censored least absolute deviations were compared using data taken from the Moorfields Eye Hospital in London, to assess mapping functions to predict the EQ-5D and SF-6D from the VFQ-25, and tests of visual function. These models were compared using root mean square error (RMSE), R(2), and mean absolute error (MAE).

RESULTS

OLS was the best-performing model of the three compared, as this produced the lowest RMSE and MAE, and the highest R(2).

CONCLUSIONS

The models provided initial algorithms to convert the VFQ-25 to the EQ-5D and SF-6D. Further analysis would be needed to validate the models or algorithms.

Smoking, alcohol & illicit drug use among young people in a health board region in 1997 and 2002: a comparative study

The objectives of this study were to document and compare patterns of licit and illicit drug use among adolescents in a health board region in 1997 and 2002. 1516 students in 1997 and 1426 in 2002, randomly selected from post-primary schools in the region, completed a questionnaire, incorporating items related to smoking, alcohol and illicit drug use. Lifetime smoking prevalence in 2002 (50.8%) showed a statistically significant decrease from 1997 (57.1%). There was also a statistically significant decrease in regular smoking (1997 - 30.7%; 2002 - 18.2%). There was no significant change in regular alcohol consumption (57.3% - 1997; 53.7% - 2002). However, there was an increase in binge drinking at weekends and reports of feeling drunk more than ten times (24% - 1997; 27.2% - 2002). In 2002, 41.2% had ever taken an illicit drug, a statistically significant increase from 1997 (34.9%); 15.1% were regular users, also a statistically significant increase from 1997 (11.9%). These findings highlight that while the misuse of illicit drugs has increased, smoking has significantly declined since 1997. However, alcohol continues to be a major problem within this age-group. This study has implications for the implementation of services and strategies aimed at reducing smoking, alcohol and drug use within this population.

021.Identification and study of genes important for fetal germ cell biology in mice

We are using a multi-pronged approach to discovering genes and proteins that regulate the allocation, proliferation, migration, differentiation and apoptosis of primordial germ cells (PGCs) in the developing mouse embryo. First, we are using suppression PCR and microarray screening methods to identify genes whose expression is restricted to, or enriched in, gonads of a specific sex or developmental stage. In this way several genes were identified whose expression is restricted to germ cells. Second, we are using a proteomic approach to identify important proteins and the genes that encode them. Protein expression profiles are being compared between different sexes and stages of mouse fetal gonad development. Data so far indicate that this method is a useful adjunct to transcriptional profiling, capable of identifying not only proteins that are differentially expressed, but also those that are differentially modified, for example by phosphorylation. Third, in silico screening of mouse EST databases identified 23 new candidate genes whose expression appears to be limited to pluripotent cells and the germline. Many of these genes are novel uncharacterised transcripts. Preliminary in situ expression analyses show that eight of these genes are indeed limited to the germline and to pluripotent cells. These genes may have important functions in germline specification and function. We are currently developing approaches, including inducible RNAi-based methods, for examining the function of these genes, initially in vitro but also ultimately in vivo.

Atrophoderma of moulin with preceding inflammation

A 16-year-old Vietnamese man presented to the Dermatology Clinic with a 10-year history of bizarre brown patches, which initially started as red asymptomatic "bumps" on the trunk, upper and lower extremities, and face. His past medical history was significant for hypothyroidism and idiopathic urticaria. He was on Eltroxin for hypothyroidism. The family history was noncontributory. Physical examination revealed two types of lesion: erythematous, well-circumscribed papules in a linear configuration along with linear hyperpigmented atrophic patches following Blaschko's lines were noted on the lower extremities (Fig. 1), right upper extremity, right flank (Fig. 2), and right jawline. Initial biopsies taken from the papular lesions on the right thigh and right elbow revealed the following changes. The first biopsy showed a slightly thinned epidermis with prominent dilated blood vessels in the superficial dermis. There also appeared to be a slight increase in the amount of collagen in the deep dermis. The findings were reported as in keeping with "epithelial atrophy." The second biopsy from the lesion on the right elbow revealed an acanthotic epidermis. The granular layer was absent in several areas and there was marked overlying parakeratosis. In the dermis, there was a heavy perivascular lymphocytic infiltrate. The appearances were consistent with a psoriasiform dermatitis (Fig. 3). A biopsy taken from the left thigh approximately 18 months later showed slight irregular acanthosis with dermal edema, dilated blood vessels, and a patchy lymphocytic infiltrate. The appearances were compatible with mild inflammation.

Quality of life following total hip replacement

Orthopaedic surgeons have traditionally used disease-specific scoring systems that focus on relief of pain and improvement in function. However, these allow little scope for patient assessed outcomes such as quality of life. This study assessed quality of life before and after Total Hip Replacement (THR) using the Short Form 36 (SF-36) questionnaire. 100 patients were interviewed pre-operatively and 9 months to one year post-operatively. Data on waiting times/length of stay/complication rates were collected by reviewing clinical notes. The mean length of stay was 22.0 +/- 10.6 days, with a pre-operative length of stay of 5.0 days. 12 patients in all had a post-operative complication, including one post-operative death. There was a statistically significant improvement in overall SF-36 score (+19%) and in 7 out of the 8 parameters that make up the SF-36 score (p < 0.001). Patients undergoing THR in Navan showed a statistically significant improvement in their quality of life post-operatively. Complication rates were in keeping with international norms. It is apparent that patients receive a high quality of care.

Comparison of three commercial assays for the quantification of HIV-1 RNA in plasma from individuals infected with different HIV-1 subtypes

BACKGROUND

Commercial human immunodeficiency virus 1 (HIV-1) ribonucleic acid (RNA) quantification assays vary in their ability to quantify different subtypes of HIV-1, a problem in regions where multipte HIV-1 subtypes may be circulating.

OBJECTIVES

To assess commercial HIV-1 RNA quantification assays on two plasma panels. Panel 1 consisted of HIV-1 seronegative plasma 'spiked' with a known amount of cultured virus of different subtypes, and Panel 2 comprised plasma collected from individuals infected with different HIV-1 subtypes.

STUDY DESIGN

The comparison involved the Amplicor HIV-1 reverse transcriptase-polymerase chain reaction (RT-PCR), Quantiplex branched DNA, and NucliSens HIV-1 QT assays. Panel 1 consisted of 11 plasma 'spiked' with cultured viruses of HIV-1 subtypes A-F, and Panel 2 included 33 plasma samples from 16 patients infected with subtypes A, B, C, E and G.

RESULTS

In Panel 1, the Quantiplex branched deoxyribonucleic acid (bDNA) assay quantified subtypes A-F efficiently, comparable to published results from two other laboratories. The Amplicor RT-PCR assay quantified subtypes B, C, and D but was relatively less efficient with subtypes E, F, and did not or poorly quantified subtype A. Testing of Panel 2 showed some inter-assay differences. In contrast to Panel 1, the Amplicor RT-PCR assay performed variably with subtype A when compared with the Quantiplex bDNA and NucliSens QT assays, and higher viral load levels were generated with subtype E using the Amplicor RT-PCR assay. Subtypes B and C showed some inter-patient differences but the Quantiplex bDNA generally gave a lower quantification than the Amplicor RT-PCR and NucliSens QT assays.

CONCLUSIONS

These studies confirm that commercial HIV-1 load assays vary in their ability to quantify different HIV-1 subtypes. This may be more apparent with individual patient samples than with 'spiked' panels. This variability emphasizes that it is preferable for patient samples to be tested with the same assay, and care should be taken where infection with unusual subtypes is suspected.

Anterior chamber eye anomalies, redundant skin and syndactyly--a new syndrome associated with breakpoints at 2q37.2 and 7q36.3

We report a 34-year-old female with a de novo balanced reciprocal translocation involving 2q37.2 and 7q36.3. She has a unique combination of multiple congenital malformations that include redundant skin, complete tissue syndactyly of the hands and feet, hirsutism, polycystic ovaries and bilateral anterior chamber eye anomalies. Her son has inherited the unbalanced product (46,XY,der(2) t(2;7)(q37.2;q36.3). He has a similar clinical picture with additional features including complex congenital heart disease, post axial polydactyly, hypotonia and global developmental delay. The breakpoints may indicate the location of the gene(s) responsible for this unique combination of features.

Serious criminal offending and mental disorder. Case linkage study

BACKGROUND

A relationship exists between mental disorder and offending behaviours but the nature and extent of the association remains in doubt.

METHOD

Those convicted in the higher courts of Victoria between 1993 and 1995 had their psychiatric history explored by case linkage to a register listing virtually all contacts with the public psychiatric services.

RESULTS

Prior psychiatric contact was found in 25% of offenders, but the personality disorder and substance misuse accounted for much of this relationship. Schizophrenia and affective disorders were also over-represented, particularly those with coexisting substance misuse.

CONCLUSIONS

The increased offending in schizophrenia and affective illness is modest and may often be mediated by coexisting substance misuse. The risk of a serious crime being committed by someone with a major mental illness is small and does not justify subjecting them, as a group, to either increased institutional containment or greater coercion.

Sudden death in psychiatric patients

BACKGROUND

The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner.

METHODS

A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both in-patient and community-based services.

RESULTS

Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders.

CONCLUSIONS

The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.