A randomized trial of single versus double high-level disinfection of duodenoscopes and linear echoendoscopes using standard automated reprocessing

BACKGROUND AND AIMS

In a pilot study, we demonstrated that current guidelines for duodenoscope and linear echoendoscope (DLE) reprocessing using a single cycle of high-level disinfection (HLD) in an automated reprocessor may be inadequate. In August 2015, the U.S. Food and Drug Administration offered double HLD as a possible response to address this concern. As a result, Providence Health and Services adopted double HLD as standard procedure for DLEs, but no rigorous clinical studies supported this practice. We undertook a quality improvement study to compare single HLD versus double HLD at 4 of our 34 hospitals.

METHODS

HLD of DLE was randomized, separately in each facility, to either single HLD or double HLD on weekdays, with standard double HLD on weekends or holidays. There was 99.7% compliance with the randomization scheme. Daily qualitative surveillance cultures of dried, post-HLD DLEs were collected for 6 months (1 swab sample from the elevator mechanism and 1 combined brush sample from the suction and working channels for each encounter), and each sample was incubated for 48 hours. Positivity rates of any microbial growth and growth of high-concern pathogens (potentially pathogenic enteric flora) were compared between the 2 study arms.

RESULTS

Altogether, 5850 surveillance culture specimens were obtained during 2925 encounters from the 45 DLEs in clinical use in the participating hospitals. Of these, 3052 (52.2%) were from endoscopes cleaned by double HLD. Double HLD demonstrated no benefit over single HLD because similar positivity rates were observed (all P > .05). The elevator mechanism was more frequently colonized than the biopsy channel (5.2% vs 2.9%, P < .001). Among the 224 encounters with positive growth, 140 (62.5%) recovered microbes from only the elevator mechanism specimens, 73 (32.6%) recovered microbes from only the channel specimens, and 11 (4.9%) recovered microbes from both types of specimens. Double HLD failed to improve contamination rates for either sample site at any of the 4 endoscopy facilities, although there were significant overall differences in contamination rates among the facilities (P < .001), as observed in our previous study. Only 8 high-concern pathogens were recovered from 5 DLEs, all from the elevator mechanism. Persistent growth was observed on 2 duodenoscopes. One grew Enterococcus spp (not vancomycin-resistant enterococci) on 3 occasions, and Escherichia coli was present on 2 of these occasions, 1 of which was a multidrug-resistant organism. The other grew different enteric flora on 2 specimens.

CONCLUSIONS

Our prospectively randomized study, involving 4 separate endoscopy facilities and standard automated endoscope reprocessing, showed that double HLD did not reduce culture positivity rates compared with single HLD in facilities with an already low positive culture rate. Alternative risk mitigation strategies will be assessed in an ongoing effort to reduce endoscope contamination.

Surveillance of guideline practices for duodenoscope and linear echoendoscope reprocessing in a large healthcare system

BACKGROUND AND AIMS

To assess the adequacy of currently recommended duodenoscope and linear echoendoscope (DLE) automatic endoscope reprocessing (AER) and high-level disinfection (HLD), we collected daily post-reprocessing surveillance cultures of 106 DLEs in 21 Providence and Affiliate Hospitals.

METHODS

Daily qualitative surveillance of dried, post-HLD DLEs was conducted for a minimum of 30 days at each facility. Positivity rates for any microbial growth and growth of high-concern pathogens were reported. Potential effects of DLE manufacturer, age, and AER processor on culture-positivity rate were assessed.

RESULTS

Microbial growth was recovered from 201 of 4032 specimens (5%) or 189 of 2238 encounters (8.4%), including 23 specimens (.6%) or 21 encounters (.9%) for a high-concern pathogen. Wide variations in culture-positivity rate were observed across facilities. No striking difference in culture-positivity rate was seen among 8 DLE models, 3 DLE manufacturers, DLE age, manual or bedside cleanser, or automatic flushing system use. However, there was suggestive evidence that Custom Ultrasonics AER (Warminster, Pa, USA) had a lower culture-positivity rate than Medivators AER (Cantel Medical Corp., Little Falls, NJ, USA) for high-concern pathogen growth (0/1079 vs 21/2735 specimens or 0/547 vs 20/1582 encounters). Two endoscopes grew intestinal flora on several occasions despite multiple HLD. No multidrug-resistant organism was detected.

CONCLUSIONS

In this multicenter DLE surveillance study, microbial growth was recovered in 5.0% of specimens (8.4% of encounters), with most being environmental microbes. Enteric bacterial flora was recovered in .6% of specimens (.9% of encounters), despite compliance with 2014 U.S. guidelines and manufacturers' recommendations for cleaning and HLD process. The observed better performance of Custom Ultrasonics AER deserves further investigation.

Sample acceptance time criteria, electronic issue and alloimmunisation in thalassaemia

OBJECTIVES

To determine the safety of a 1-week acceptance criteria of sample receipt in laboratory to transfusion commencement in transfusion dependent thalassaemia with respect to alloimmunisation. To determine the safety of electronic issue of blood components in such a setting.

METHODS

Retrospective audit of alloimmunisation (1999-2012) and blood exposure in registered thalassaemia patients at a central London thalassaemia centre where the acceptance criteria for the group and save sample from arrival in the laboratory to the time of issue of blood for transfusion for someone who has been transfused in the last 28 days was 1 week, and there was electronic issue protocol for patients who have always had a negative antibody screen (other than temporary positivity in pregnant women receiving prophylactic anti-D or anti Le-a, Anti Le-b and Anti P1 that are no longer detectable).

RESULTS

There were 133 patients with thalassemia variants regularly attending UCLH for review. A total of 105 patients had transfusion dependent thalassaemia (TDT) (7 E-beta thalassaemia, 98 beta thalassaemia major). Ten of the 84 patients who received their transfusions at UCLH were alloimmunised. Seven of them had been alloimmunised prior to arrival at UCLH. Only two patients developed antibodies at UCLH during this period.

CONCLUSION

The prevalence of alloantibody formation of 2% in UCLH transfused patients, with presumptive incidence of 0.01 alloantibodies per 100 units or 0·001 immunisations per person per year compares favourably with other reported series and suggests that 1 week interval with appropriate electronic issue is acceptable practice.

Calcium dysregulation in relation to Alzheimer-type pathology in the ageing brain

AIMS

Calcium dyshomeostasis is implicated in the pathogenesis of several neurodegenerative disorders including Alzheimer's disease. However, much of the previous research has focused on changes in neuronal calcium signalling. In a recent microarray study we identified dysregulation of several key signalling pathways including the Ca(2+) signalling pathway in astrocytes as Alzheimer-type pathology developed. In this study we sought to determine the expression of calpain-10 and calcium/calmodulin-dependent kinase alpha (CamKIIα) in relation to Alzheimer-type pathology in a population-based study.

METHODS

Using post mortem temporal cortex samples derived from the Medical Research Council Cognitive Function and Ageing Study (MRC-CFAS) ageing brain cohort we examined calpain-10 and CamKIIα gene and protein expression using quantitative polymerase chain reaction and immunohistochemistry.

RESULTS

We demonstrate that astrocytic expression of calpain-10 is up-regulated, and CamKIIα down-regulated with increasing Braak stage. Using immunohistochemistry we confirm protein expression of calpain-10 in astrocytes throughout the temporal cortex and demonstrate that calpain-10 immunoreactivity is correlated with both local and global measures of Alzheimer-type pathology. In addition, we identify a subpopulation of calpain-10 immunoreactive interlaminar astrocytes that extend processes deep into the cortex. CamKIIα is predominantly neuronal in localization and is associated with the presence of diffuse plaques in the ageing brain.

DISCUSSION

Dysregulated expression of key calcium signalling molecules occurs with progression of Alzheimer-type pathology in the ageing brain, highlighting the need for further functional studies of astrocytic calcium signalling with respect to disease progression.

Clinical effectiveness and cost-effectiveness of depth of anaesthesia monitoring (E-Entropy, Bispectral Index and Narcotrend): a systematic review and economic evaluation

BACKGROUND

It is important that the level of general anaesthesia (GA) is appropriate for the individual patient undergoing surgery. If anaesthesia is deeper than required to keep a patient unconscious, there might be increased risk of anaesthetic-related morbidity, such as postoperative nausea, vomiting and cognitive dysfunction. This may also prolong recovery times, potentially increasing health-care costs. If anaesthesia is too light, patients may not be fully unconscious and could be at risk of intraoperative awareness.

OBJECTIVE

The objective of this report is to assess the clinical effectiveness and cost-effectiveness of Bispectral Index (BIS), E-Entropy and Narcotrend technologies, each compared with standard clinical monitoring, to monitor the depth of anaesthesia in surgical patients undergoing GA.

DATA SOURCES

A search strategy was developed and run on a number of bibliographic electronic databases including MEDLINE, EMBASE, The Cochrane Library and the Health Technology Assessment (HTA) database. For the systematic review of patient outcomes, databases were searched from the beginning of 2009 to November 2011 for studies of BIS (and then updated in February 2012), and from 1995 to November 2011 (and then updated in February 2012) for studies of E-Entropy and Narcotrend. For the systematic review of cost-effectiveness, searches were from database inception to November 2011 (an update search was performed in February 2012).

REVIEW METHODS

The systematic review of patient outcomes followed standard methodology for evidence synthesis. A decision-analytic model was developed to assess the cost-effectiveness of depth of anaesthesia monitoring compared with standard clinical observation. A simple decision tree was developed, which accounted for patients' risk of experiencing short-term anaesthetic-related complications in addition to risk of experiencing intraoperative awareness.

RESULTS

Twenty-two randomised controlled trials comparing BIS, E-Entropy and Narcotrend with standard clinical monitoring were included in the systematic review of patient outcomes, alongside evidence from a recent Cochrane review. Six trials of patients classified with risk factors for intraoperative awareness were combined in a fixed-effect meta-analysis. The overall pooled Peto's odds ratio was 0.45 (95% confidence interval 0.25 to 0.81) in favour of BIS. However, there was statistically significant heterogeneity. The base-case cost per quality-adjusted life-year (QALY) for BIS compared with standard clinical monitoring ranged from £22,339 to £44,198 depending on patient subgroups (type of GA received; level of risk for awareness). For E-Entropy, base-case estimates ranged from £14,421 to £31,430. For Narcotrend, estimates varied from a cost per QALY of £8033 to Narcotrend dominating standard clinical monitoring.

LIMITATIONS

The analysis was limited by lack of clinical effectiveness data, particularly for E-Entropy and Narcotrend.

CONCLUSIONS

The available evidence on the impact of the technologies on reducing the likelihood of intraoperative awareness is limited. However, there were reductions in general anaesthetic consumption and anaesthetic recovery times. The cost-effectiveness of depth of anaesthesia monitoring appears to be highly dependent on a number of factors, including probability of awareness.

STUDY REGISTRATION

PROSPERO registration number CRD42011001834.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Reliability analysis of the resting state can sensitively and specifically identify the presence of Parkinson disease

Parkinson disease (PD) is characterized by a number of motor and behavioral abnormalities that could be considered deficits of a "no task" or "resting" state, including resting motor findings and defects in emerging from a resting state (e.g., resting tremor, elevated resting tone, abulia, akinesia, apathy). PET imaging, and recently, the MRI technique of continuous arterial spin labeling (CASL) have shown evidence of changes in metabolic patterns in individuals with PD. The purpose of this study was to learn if the presence of PD could be "predicted" based on resting fluctuations of the BOLD signal. Participants were 15 healthy controls, 14 subjects with PD, and 1 subject who presented as a control but later developed PD. The amplitude of the low frequency fluctuation (ALFF) was used as an index of brain activity level in the resting state. Participants with PD using this index showed a reliable decrease in activity in a number of regions, including the supplementary motor cortex, the mesial prefrontal cortex, the right middle frontal gyrus, and the left cerebellum (lobule VII/VIII) as well as increased activity in the right cerebellum (lobule IV/V). Using a cross validation approach we term "Reliability Mapping of Regional Differences" (RMRD) to analyze our sample, we were able to reliably distinguish participants with PD from controls with 92% sensitivity and 87% specificity. Our "pre-diagnostic" subject segregated in our analysis with the PD group. These results suggest that resting fMRI should be considered for development as a biomarker and analytical tool for evaluation of PD.

Peginterferon alfa and ribavirin for chronic hepatitis C in patients eligible for shortened treatment, re-treatment or in HCV/HIV co-infection: a systematic review and economic evaluation

OBJECTIVE

to assess the clinical effectiveness and cost-effectiveness of peginterferon alfa and ribavirin for the treatment of chronic hepatitis c virus (HCV) in three specific patient subgroups affected by recent licence changes: those eligible for shortened treatment courses [i.e. those with low viral load (LVL) and who attained a rapid virological response (RVR) at 4 weeks of treatment], those eligible for re-treatment following previous non-response or relapse, and those co-infected with human immunodeficiency virus (HIV).

DATA SOURCES

Fourteen electronic bibliographic databases, including the Cochrane Library, MEDLINE and EMBASE, were searched up to October 2009. Key hepatitis C resources and symposia, bibliographies of related papers and manufacturer submissions to the National Institute for Health and Clinical Excellence were also searched and clinical experts were contacted.

REVIEW METHODS

A systematic review and economic evaluation were carried out. Titles and abstracts were screened for eligibility by one reviewer. Inclusion criteria were defined a priori and applied independently by two reviewers to the full text of retrieved references. For the clinical effectiveness review, studies were included if they were randomised controlled trials (RCTs) of adults with chronic HCV, restricted to the patient groups described above. The intervention was standard peginterferon and ribavirin combination therapy compared with shortened duration courses (24 weeks for genotype 1, 16 weeks for genotype 2/3) or best supportive care (BSC). Outcomes included sustained virological response (SVR), relapse rate and adverse events. In addition, full economic evaluations and studies of health-related quality of life were sought for this subgroup of patients. Data extraction and quality assessment were undertaken by two reviewers independently. Studies were synthesised through a narrative review with tabulation of results. Our previously published Markov state-transition model was adapted to estimate the cost-effectiveness of treatment strategies in subgroups of adults with chronic HCV who were eligible for shortened treatment and re-treatment and those with HCV/HIV co-infection. The model extrapolated the impact of SVR on life expectancy, quality-adjusted life expectancy and lifetime costs for each subgroup of patients with HCV. Categories of costs included in the model were drug acquisition, patient management, on-treatment monitoring, management of adverse events, and health-state costs for disease progression.

RESULTS

In total, 2400 references were identified. Six RCTs were included in the review of clinical effectiveness, all reporting peginterferon alfa and ribavirin therapy in patients eligible for shortened treatment. In general, these RCTs were of good quality. No RCTs comparing peginterferon and ribavirin with BSC were identified for the re-treatment or co-infection populations. The results suggest that chronic HCV patients who have LVL at baseline and who achieve an RVR can be treated with shortened courses of therapy (24 weeks for genotype 1, 16 weeks for genotype 2/3) and achieve SVR rates that are comparable to those who receive the standard duration of treatment (ranges 84%-96% vs 83%-100%, respectively). However, patient numbers in the LVL/RVR subgroups were small and none of the trials was powered for this subgroup analysis, so results should be interpreted with caution. In the one trial reporting virological relapse rates in the subgroup of patients with LVL/RVR, rates were low and not statistically significantly different between those treated for 24 versus 48 weeks [3.6% vs 0%, respectively, difference 3.6%, 95% confidence interval (CI) -7.2% to 6.6%, p = 1.000]. In the cost-effectiveness analysis of shortened treatment with peginterferon alfa-2a, incremental cost-effectiveness ratios (ICERs) ranged from £35,000 to £65,000 for patients with genotype 1, whereas in patients with genotypes 2 and 3 shortened treatment dominated standard treatment. For patients with genotype 1 with LVL/RVR, shortened treatment with peginterferon alfa-2b dominated standard treatment. In patients with genotype 1 and those with genotype non-1 who were re-treated with peginterferon alfa-2a, the ICERs were £9169 and £2294, respectively. In patients with genotypes 1 and 4, who were re-treated with peginterferon alfa-2b, the ICER was £7681, whereas re-treatment dominated BSC for patients with genotypes 2 and 3. In patients co-infected with HCV/HIV, who were receiving peginterferon alfa-2a, the ICER was £7941 per quality-adjusted life-year (QALY) gained in patients with genotypes 1 and 4, whereas in patients with genotypes 2 and 3 peginterferon alfa-2a dominated BSC. In co-infected patients receiving peginterferon alfa-2b the ICER was £11,806 in genotypes 1 and 4, and £2161 in genotypes 2 and 3.

CONCLUSIONS

The clinical trial evidence indicates that patients may be successfully treated with a shorter course of peginterferon combination therapy without compromising the likelihood of achieving an SVR. The economic evaluation shows that treatment with peginterferon alfa in the specified subgroups of patients with LVL/RVR will yield QALY gains, without excessive increases in costs, and may be cost saving in some situations. However, a judgement is required on the value of the QALY loss that may result from adopting a shorter treatment regimen, if shorter treatment is associated with a lower SVR than standard treatment duration. There is a need for further RCT evidence, particularly in people who have not responded to, or relapsed following, treatment. Phase II and Phase III trials are currently in progress, evaluating the safety and efficacy of protease inhibitors and nucleoside analogues for treatment-naive and treatment-experienced people with chronic HCV.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Apathy, depression, and motor symptoms have distinct and separable resting activity patterns in idiopathic Parkinson disease

Apathy and depression are heterogeneous syndromes with symptoms that overlap clinically. This clinical overlap leads to problems with classification and diagnosis in clinical populations. No functional imaging study has attempted to separate brain regions altered in apathy from those altered in depression in a clinical population. Parkinson disease (PD) is a disorder in which apathy and depression co-exist in a single population. We evaluate the relationship between apathy, depression, and motor severity of disease in PD, focusing on the relationship between these factors and the amplitude of the low frequency fluctuation (ALFF) in the resting state. We first evaluated if the resting ALFF signal is a reliable measure for our clinical question. For this, we develop and introduce a cross validation approach we term the "Regional Mapping of Reliable Differences" (RMRD) method to evaluate reliability of regions of interest deemed "significant" by standard voxel-wise techniques. Using this approach, we show that the apathy score in this sample is best predicted by ALFF signal in the left supplementary motor cortex, the right orbitofrontal cortex, and the right middle frontal cortex, whereas depression score is best predicted by ALFF signal in the right subgenual cingulate. Disease severity was best predicted by ALFF signal in the right putamen. A number of additional regions are also statistically (but not reliably) correlated with our neuropsychological measures and disease severity. Our results support the use of resting fMRI as a means to evaluate neuropsychiatric states and motor disease progression in Parkinson disease, and the clinical and epidemiologic observation that apathy and depression are distinct pathological entities. Our finding that "significance" and "reliability" are dissociated properties of regions of interest identified as significant using standard voxel-wise techniques suggests that including reliability analyses may add useful scientific information in neurobehavioral research.

Recombinant human growth hormone for the treatment of growth disorders in children: a systematic review and economic evaluation

BACKGROUND

Recombinant human growth hormone (rhGH) is licensed for short stature associated with growth hormone deficiency (GHD), Turner syndrome (TS), Prader-Willi syndrome (PWS), chronic renal insufficiency (CRI), short stature homeobox-containing gene deficiency (SHOX-D) and being born small for gestational age (SGA).

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of rhGH compared with treatment strategies without rhGH for children with GHD, TS, PWS, CRI, SHOX-D and those born SGA.

DATA SOURCES

The systematic review used a priori methods. Key databases were searched (e.g. MEDLINE, EMBASE, NHS Economic Evaluation Database and eight others) for relevant studies from their inception to June 2009. A decision-analytical model was developed to determine cost-effectiveness in the UK.

STUDY SELECTION

Two reviewers assessed titles and abstracts of studies identified by the search strategy, obtained the full text of relevant papers, and screened them against inclusion criteria.

STUDY APPRAISAL

Data from included studies were extracted by one reviewer and checked by a second. Quality of included studies was assessed using standard criteria, applied by one reviewer and checked by a second. Clinical effectiveness studies were synthesised through a narrative review.

RESULTS

Twenty-eight randomised controlled trials (RCTs) in 34 publications were included in the systematic review. GHD: Children in the rhGH group grew 2.7 cm/year faster than untreated children and had a statistically significantly higher height standard deviation score (HtSDS) after 1 year: -2.3 ± 0.45 versus -2.8 ± 0.45. TS: In one study, treated girls grew 9.3 cm more than untreated girls. In a study of younger children, the difference was 7.6 cm after 2 years. HtSDS values were statistically significantly higher in treated girls. PWS: Infants receiving rhGH for 1 year grew significantly taller (6.2 cm more) than those untreated. Two studies reported a statistically significant difference in HtSDS in favour of rhGH. CRI: rhGH-treated children in a 1-year study grew an average of 3.6 cm more than untreated children. HtSDS was statistically significantly higher in treated children in two studies. SGA: Criteria were amended to include children of 3+ years with no catch-up growth, with no reference to mid-parental height. Only one of the RCTs used the licensed dose; the others used higher doses. Adult height (AH) was approximately 4 cm higher in rhGH-treated patients in the one study to report this outcome, and AH-gain SDS was also statistically significantly higher in this group. Mean HtSDS was higher in treated than untreated patients in four other studies (significant in two). SHOX-D: After 2 years' treatment, children were approximately 6 cm taller than the control group and HtSDS was statistically significantly higher in treated children. The incremental cost per quality adjusted life-year (QALY) estimates of rhGH compared with no treatment were: 23,196 pounds for GHD, 39,460 pounds for TS, 135,311 pounds for PWS, 39,273 pounds for CRI, 33,079 pounds for SGA and 40,531 pounds for SHOX-D. The probability of treatment of each of the conditions being cost-effective at 30,000 pounds was: 95% for GHD, 19% for TS, 1% for PWS, 16% for CRI, 38% for SGA and 15% for SHOX-D.

LIMITATIONS

Generally poorly reported studies, some of short duration.

CONCLUSIONS

Statistically significantly larger HtSDS values were reported for rhGH-treated children with GHD, TS, PWS, CRI, SGA and SHOX-D. rhGH-treated children with PWS also showed statistically significant improvements in body composition measures. Only treatment of GHD would be considered cost-effective at a willingness-to-pay threshold of 20,000 to 30,000 pounds per QALY gained. This analysis suggests future research should include studies of longer than 2 years reporting near-final height or final adult height.

The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity.

DATA SOURCES

Seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references.

REVIEW METHODS

Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) > or = 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI > or = 40; BMI > or = 30 and < 40 with Type 2 diabetes at baseline; and BMI > or = 30 and < 35. Models were applied with assumptions on costs and comorbidity.

RESULTS

A total of 5386 references were identified of which 26 were included in the clinical effectiveness review: three randomised controlled trials (RCTs) and three cohort studies compared surgery with non-surgical interventions and 20 RCTs compared different surgical procedures. Bariatric surgery was a more effective intervention for weight loss than non-surgical options. In one large cohort study weight loss was still apparent 10 years after surgery, whereas patients receiving conventional treatment had gained weight. Some measures of QoL improved after surgery, but not others. After surgery statistically fewer people had metabolic syndrome and there was higher remission of Type 2 diabetes than in non-surgical groups. In one large cohort study the incidence of three out of six comorbidities assessed 10 years after surgery was significantly reduced compared with conventional therapy. Gastric bypass (GBP) was more effective for weight loss than vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). Laparoscopic isolated sleeve gastrectomy (LISG) was more effective than AGB in one study. GBP and banded GBP led to similar weight loss and results for GBP versus LISG and VBG versus AGB were equivocal. All comparisons of open versus laparoscopic surgeries found similar weight losses in each group. Comorbidities after surgery improved in all groups, but with no significant differences between different surgical interventions. Adverse event reporting varied; mortality ranged from none to 10%. Adverse events from conventional therapy included intolerance to medication, acute cholecystitis and gastrointestinal problems. Major adverse events following surgery, some necessitating reoperation, included anastomosis leakage, pneumonia, pulmonary embolism, band slippage and band erosion. Bariatric surgery was cost-effective in comparison to non-surgical treatment in the reviewed published estimates of cost-effectiveness. However, these estimates are likely to be unreliable and not generalisable because of methodological shortcomings and the modelling assumptions made. Therefore a new economic model was developed. Surgical management was more costly than non-surgical management in each of the three patient populations analysed, but gave improved outcomes. For morbid obesity, incremental cost-effectiveness ratios (ICERs) (base case) ranged between 2000 pounds and 4000 pounds per QALY gained. They remained within the range regarded as cost-effective from an NHS decision-making perspective when assumptions for deterministic sensitivity analysis were changed. For BMI > or = 30 and 40, ICERs were 18,930 pounds at two years and 1397 pounds at 20 years, and for BMI > or = 30 and < 35, ICERs were 60,754 pounds at two years and 12,763 pounds at 20 years. Deterministic and probabilistic sensitivity analyses produced ICERs which were generally within the range considered cost-effective, particularly at the long twenty year time horizons, although for the BMI 30-35 group some ICERs were above the acceptable range.

CONCLUSIONS

Bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.

Adefovir dipivoxil and pegylated interferon alpha for the treatment of chronic hepatitis B: an updated systematic review and economic evaluation

OBJECTIVE

To update and extend a 2006 report on the clinical effectiveness and cost-effectiveness of adefovir dipivoxil (ADV) and pegylated interferon alpha (PEG-alpha) for the treatment of chronic hepatitis B (CHB).

DATA SOURCES

Thirteen bibliographic databases were searched including MEDLINE, EMBASE and the Cochrane Library. Searches were run from the beginning of 2005 to September 2007.

REVIEW METHODS

For the clinical effectiveness review, randomised controlled trials (RCTs) comparing ADV, PEG-alpha-2a and PEG-alpha-2b with currently licensed treatments for CHB, including non-pegylated interferon alpha (IFN-alpha) and lamivudine (LAM), were included. Outcomes included biochemical, histological and virological response to treatment, drug resistance and adverse effects. A systematic review of economic evaluations of antiviral treatments for CHB was conducted. The economic Markov model used in the 2006 report was updated in terms of utility values, discount rates and costs.

RESULTS

Of the 82 papers retrieved for detailed screening, eight RCTs were included. Three evaluated ADV, four evaluated PEG-alpha-2b and one (from the original literature search) compared PEG-alpha-2b plus LAM with PEG-alpha-2b monotherapy. No RCTs of PEG-alpha-2a were identified. One ADV trial showed a statistically significant difference between ADV and placebo in terms of ALT response and HBV DNA levels, favouring ADV. Following withdrawal of ADV, levels were similar to those in placebo patients. In the ADV versus ADV plus LAM trial, there was a statistically significant difference in favour of the combination treatment. In the PEG-alpha trials, there were statistically significant differences favouring PEG-alpha-2b plus LAM compared with either one of the drugs given as monotherapy. For the comparison between PEG-alpha-2b and IFN-alpha and the comparison between different staggered regimens of the commencement of PEG-alpha-2b and LAM, there were no statistically significant differences between groups. Four full economic evaluations were identified, in addition to one identified in the original report. Two assessed PEG-alpha-2a; the remainder assessed ADV. PEG-alpha-2a was associated with increased treatment costs and gains in quality-adjusted life expectancy. In a UK study, the incremental cost-effectiveness ratio (ICER) for PEG-alpha-2a was 10,444 pounds per QALY gained compared with LAM. Evaluations of ADV found that LAM monotherapy was dominated; the ICER for ADV monotherapy compared with 'doing nothing' was $19,731. The results of the updated analysis were generally robust to changes in deterministic sensitivity analysis. In a probabilistic sensitivity analysis, the same sequence of treatments was identified as optimal. In a probabilistic sensitivity analysis, PEG-alpha-2b had a probability of being cost-effective of 79% at a willingness-to-pay threshold of 20,000 pounds per QALY, and 86% at a willingness-to-pay threshold of 30,000 pounds per QALY.

CONCLUSIONS

Both ADV and PEG-alpha are beneficial for patients with CHB in terms of suppressing viral load, reducing liver damage-associated biochemical activity, inducing HBeAg seroconversion, and reducing liver fibrosis and necroinflammation. The effects of long-term treatment with ADV are generally durable, with relatively low rates of resistance. In most cases, cost-effectiveness estimates were within acceptable ranges. Further research should assess the clinical effectiveness and cost-effectiveness of newer antiviral agents in relation to existing drugs, including the role of initiating treatment with combination therapy.

Non-occupational postexposure prophylaxis for HIV: a systematic review

OBJECTIVES

To review the evidence on the clinical effectiveness and cost-effectiveness of non-occupational postexposure prophylaxis (PEP) for HIV.

DATA SOURCES

Eleven electronic databases were searched from inception to December 2007.

REVIEW METHODS

Selected studies were assessed, subjected to data extraction using a standard template and quality assessment using published criteria. Studies were synthesised using a narrative approach with full tabulation of results from all included studies.

RESULTS

One clinical effectiveness study meeting the inclusion criteria was identified, a cohort study of PEP in a high-risk HIV-negative homosexual male cohort in Brazil. The quality of the study was generally weak. Seroincidence in the cohort as a whole (2.9 per 100 person-years) was very similar to that expected in this population (3.1 per 100 person-years, p > 0.97), despite the seroconversion to HIV being 1/68 in the PEP group and 10/132 in the group not receiving PEP. High-risk sexual activities declined over time for both PEP and non-PEP users. Four economic evaluations met the inclusion criteria of the review. The methodological quality of the studies was mixed. The studies are constrained by a lack of published data on the clinical effectiveness of PEP after non-occupational exposure, with effectiveness data derived from one study of occupational PEP. Their generalisability to the UK is not clear. Results suggest that PEP following non-occupational exposure to HIV was cost saving for men who have unprotected receptive anal intercourse with men, whether the source partner is known to be HIV positive or not; heterosexuals after unprotected receptive anal intercourse; and intravenous drug users sharing needles with a known HIV-positive person. PEP following non-occupational exposure to HIV was cost-effective for all male-male intercourse (unprotected receptive and insertive anal intercourse, unprotected receptive oral sex, and 'other') and was possibly cost-effective for intravenous drug users and high-risk women. Four additional studies were identified giving further information about adverse events associated with PEP after non-occupational exposure to HIV. The majority of participants experienced adverse events with the most common being nausea and fatigue. Rates were generally higher in participants receiving triple therapy than in participants receiving dual therapy. Completion of PEP therapy was variable, ranging from 24% to 78% of participants depending on type of therapy. Toxicity was the main reason for discontinuation of treatment.

CONCLUSIONS

It is not possible to draw conclusions on the clinical effectiveness of non-occupational PEP for HIV because of the limited evidence available. The review of cost-effectiveness suggests that non-occupational PEP may be cost-effective, especially in certain population subgroups; however, the assumptions made and data sources used in the cost-effectiveness studies mean that their results should be used with caution.

The mechanism of cyanide intoxication and its antagonism

The mechanism of cyanide intoxication has been attributed to the inhibition of cytochrome oxidase, thereby decreasing the tissue utilization of oxygen. One mechanism of cyanide antagonism is by sequestering cyanide with methaemoglobin to form cyanmethaemoglobin and another mechanism is detoxifying with a sulphur donor to thiocyanate. Questions have been raised with regard to these classical mechanisms. Oxygen with nitrite-thiosulphate antagonizes the lethal effects of cyanide. Theoretically, increased oxygen should serve no useful purpose, as it is the tissue utilization of oxygen which is inhibited. In the nitrite-thiosulphate antidotal combination, the proposal is made that the predominate antidotal action of nitrite is a vasogenic action, rather than methaemoglobin formation, because when methaemoglobin formation is inhibited by methylene blue the protective action of sodium nitrite persists. This suggests that methaemoglobin formation plays only a small part, if any, in the therapeutic antagonism of the lethal effects of cyanide. The roles and implications of sodium thiosulphate and non-rhodanese substrates in the detoxification mechanism are compared. Lastly, a new approach to cyanide antagonism has been initiated which involves the erythrocyte encapsulation of thiosulphate and sulphurtransferase as an antidote and prophylaxis against cyanide.

Cardioprotection against the toxic effects of anthracyclines given to children with cancer: a systematic review

OBJECTIVES

To evaluate the technologies used to reduce anthracycline-induced cardiotoxicity in children. Also to evaluate cardiac markers to quantify cardiotoxicity, and identify cost-effectiveness studies and future research priorities.

DATA SOURCES

Eight electronic databases were searched from inception to January 2006. Bibliographies of related papers were assessed for relevant studies and experts contacted to identify additional published references.

REVIEW METHODS

A systematic review of the evidence was undertaken using a priori methods.

RESULTS

Four randomised controlled trials (RCTs) met the inclusion criteria of the review, each considering a different cardioprotective intervention; all trials included children with acute lymphoblastic leukaemia, and one also included children with non-Hodgkin's lymphoma. However, all had methodological limitations. No cost-effectiveness studies were identified. One RCT and six cohort studies on the use of cardiac markers met the inclusion criteria of the review, but also had methodological limitations. Of the two RCTs that considered continuous infusion versus bolus (rapid) infusion, one found that continuous infusion of doxorubicin did not offer any cardioprotection over bolus; the other suggested that continuous infusion of daunorubicin had less cardiotoxicity than bolus. Two studies considered cardioprotective agents, one concluded that dexrazoxane prevents or reduces cardiac injury without compromising the antileukaemic efficacy of doxorubicin and the other reported a protective effect of coenzyme Q10 on cardiac function during anthracycline therapy. One RCT suggested that cardiac troponin T can be used to assess the effectiveness of the cardioprotective agent dexrazoxane. Two cohort studies considering atrial natriuretic peptide and two considering brain (B-type) natriuretic peptide suggested that these chemicals are elevated in some subgroups of children treated with anthracyclines for cancer. N-terminal B-type natriuretic peptide levels were significantly elevated in children treated with anthracyclines who had cardiac dysfunction. One cohort study found that serum lipid peroxide was higher in younger children treated with doxorubicin than correspondingly aged children not receiving doxorubicin. No differences in carnitine levels were found in children treated with doxorubicin and a group of healthy children in one cohort study.

CONCLUSIONS

It is difficult to draw conclusions about the effectiveness of technologies for reducing or preventing cardiotoxicity and about the use of cardiac markers in children as the evidence is limited in quantity and quality. The lack of standardisation for monitoring and reporting cardiac performance is problematic. Not all studies report effectiveness in terms of cardiac outcomes and event-free survival with supporting statistical analyses. Studies are mostly small and of short duration, making generalisation difficult. Increasing numbers of survivors of childhood cancer treated with anthracyclines will experience cardiac damage and require long-term surveillance and management. This will have an impact on cardiac services and costs. Diverse medical problems and other late sequelae that affect cardiac outcome will have an impact on other specialist services. Mechanisms to reduce or prevent cardiotoxicity from anthracycline therapy and cardiac markers to improve monitoring could alter the extent of this impact on service provision. RCTs of the different methods for reducing or preventing cardiotoxicity in children treated with anthracyclines for cancer with long-term follow-up are needed to determine whether the technologies influence the development of cardiac damage. Cost-effectiveness research is also required.

Use of cardiac markers to assess the toxic effects of anthracyclines given to children with cancer: a systematic review

AIM

To evaluate the effectiveness of cardiac markers to quantify anthracycline-induced cardiotoxicity in children with cancer.

METHODS

Systematic review using a priori methods.

RESULTS

Seven studies, all with methodological limitations, were identified. One RCT suggests that cardiac troponin can be used to assess the effectiveness of the cardio-protective agent dexrazoxane. Cohort studies suggest that atrial natriuretic peptide and brain (B-type) natriuretic peptide are elevated in some subgroups of patients compared with healthy children; NT-pro-BNP levels are significantly elevated in children with cardiac dysfunction compared with those without; serum lipid peroxide is higher in children who have received doxorubicin compared with children not receiving doxorubicin; there are no differences in carnitine levels between children treated with doxorubicin and a healthy control group.

CONCLUSIONS

The limited evidence makes conclusions difficult. Research is needed to fill this important evidence gap and link short-term changes in cardiac markers to longer-term cardiac damage.

Recombinant growth hormone for idiopathic short stature in children and adolescents

BACKGROUND

Idiopathic short stature (ISS) refers to children who are very short compared with their peers for unknown or hereditary reasons. Recombinant human growth hormone (GH) has been used to increase growth and final height in children with ISS.

OBJECTIVES

To assess the effects of recombinant human GH on short-term growth and final height in children with ISS.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE, The Cochrane Library, Science Citation Index, BIOSIS and Current Controlled Trials. Article reference lists were assessed for trials and experts and pharmaceutical companies were contacted.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with ISS with normal GH secretion. GH had to be administered for a minimum of six months and be compared with placebo or no treatment. A growth or height outcome measure had to be assessed.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. Data were extracted by one reviewer and checked by a second. The primary outcome was final height and secondary outcomes included short term growth, health related quality of life and adverse effects. To estimate summary treatment effects, data were pooled, when appropriate using a random effects model.

MAIN RESULTS

Ten RCTs were included. One trial reported near final height in girls and found that girls treated with GH were 7.5 cm taller than untreated controls (GH group, 155.3 cm +/- 6.4; control, 147.8 cm +/- 2.6; P = 0.003); another trial which reported adult height standard deviation score found that children treated with GH were 3.7 cm taller than children in a placebo-treated group (95% confidence intervals 0.03 to 1.10; P < 0.04). The other trials reported short term outcomes. Results suggest that short-term height gains can range from none to approximately 0.7 SD over one year. One study reported health related quality of life and showed no significant improvement in GH treated children compared with those in the control group, whilst another found no significant evidence that GH treatment impacts psychological adaptation or self-perception in children with ISS. No serious adverse effects of treatment were reported.

AUTHORS' CONCLUSIONS

GH therapy can increase short-term growth and improve (near) final height. Increases in height are such that treated individuals remain relatively short when compared with peers of normal stature. Large, multicentre RCTs are required which should focus on final height and address quality of life and cost issues.

Clinical and cost-effectiveness of cardioprotection against the toxic effects of anthracyclines given to children with cancer: a systematic review

This review systematically assessed the evidence on the clinical and cost-effectiveness of cardioprotection against the toxic effects of anthracyclines given to children with cancer. We searched eight electronic databases, including Medline and the Cochrane Library, from inception to January 2006 for systematic reviews and randomised controlled trials that reported death, heart failure, arrhythmias or measures of cardiac performance associated with cardioprotective technologies compared with standard treatment in children treated for cancer with anthracyclines. Economic evaluations were also sought. Inclusion criteria, data extraction and quality assessment were undertaken by standard methodology. Four randomised controlled trials met the inclusion criteria of the review; each had methodological limitations. No economic evaluations were identified. Studies were combined through narrative synthesis. One trial found that continuous infusion of doxorubicin did not offer any cardioprotection over rapid infusion. One suggested that continuous infusion of daunorubicin provoked less cardiotoxicity than rapid infusion. One concluded that dexrazoxane reduces cardiac injury during doxorubicin therapy and one reported a protective effect of coenzyme Q₁₀ on cardiac function during anthracycline therapy. The evidence on the effectiveness of cardioprotective technologies in children is limited in quality and quantity thus making conclusions difficult. This is surprising given the importance of anthracycline use in children with cancer. Further long-term research, which includes relevant outcome measures, is needed to determine whether technologies influence the development of cardiac damage without limiting the antitumour efficacy of anthracyclines.

Recombinant growth hormone for children and adolescents with Turner syndrome

BACKGROUND

Turner syndrome (TS) affects about one in 1500 to 2500 live-born females. One of the most prevalent and salient features of the syndrome is extremely short stature. Untreated women are approximately 20 to 21 cm shorter than normal women within their respective populations. Recombinant human growth hormone (hGH) has been used to increase growth and final height in girls who have Turner syndrome.

OBJECTIVES

To assess the effects of recombinant growth hormone in children and adolescents with TS.

SEARCH STRATEGY

MEDLINE, EMBASE, The Cochrane Library, LILACS, BIOSIS, Science Citation Index and reference lists were used to identify relevant trials.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with TS before achieving final height. Growth hormone had to be administered for a minimum of six months and compared with a placebo or no treatment control condition.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. The primary outcomes were final height and growth. Secondary outcomes included bone age, quality of life, cognitive performance, and adverse effects.

MAIN RESULTS

Four RCTs that included 365 participants after one year of treatment were included. Only one trial reported final height in 61 treated women to be 148 cm and 141 cm in 43 untreated women (mean difference (MD) seven cm, 95% CI 6 to 8). Short-term growth velocity was greater in treated than untreated girls after one year (two trials, MD three cm per year, 95% CI 2 to 4) and after two years (one trial, MD two cm per year, 95% CI 1 to 2.3). Skeletal maturity was not accelerated by treatment with recombinant growth hormone (hGH). Adverse effects were minimally reported.

AUTHORS' CONCLUSIONS

Recombinant human growth hormone (hGH) doses between 0.3 to 0.375 mg/kg/wk increase short-term growth in girls with Turner syndrome by approximately three (two) cm in the first (second) year of treatment. Treatment in one trial increased final height by approximately six cm over an untreated control group. Despite this increase, the final height of treated women was still outside the normal range. Additional trials of the effects of hGH carried out with control groups until final height is achieved would allow better informed decisions about whether the benefits of hGH treatment outweigh the requirement of treatment over several years at considerable cost.

The transcriptional landscape of the mammalian genome

This study describes comprehensive polling of transcription start and termination sites and analysis of previously unidentified full-length complementary DNAs derived from the mouse genome. We identify the 5' and 3' boundaries of 181,047 transcripts with extensive variation in transcripts arising from alternative promoter usage, splicing, and polyadenylation. There are 16,247 new mouse protein-coding transcripts, including 5154 encoding previously unidentified proteins. Genomic mapping of the transcriptome reveals transcriptional forests, with overlapping transcription on both strands, separated by deserts in which few transcripts are observed. The data provide a comprehensive platform for the comparative analysis of mammalian transcriptional regulation in differentiation and development.

Traumatic brain injury and grey matter concentration: a preliminary voxel based morphometry study

BACKGROUND

Magnetic resonance imaging (MRI) studies have shown diffuse cerebral atrophy following traumatic brain injury. In the past, quantitative volumetric analysis of these changes was carried out by manually tracing specific regions of interest. In contrast, voxel based morphometry (VBM) is a fully automated technique that allows examination of the whole brain on a voxel by voxel basis.

OBJECTIVE

To use VBM to evaluate changes in grey matter concentration following traumatic brain injury.

METHODS

Nine patients with a history of traumatic brain injury (ranging from mild to severe) about one year previously were compared with nine age and sex matched healthy volunteers. T1 weighted three dimensional MRI images were acquired and then analysed with statistical parametric mapping software (SPM2). The patients with traumatic brain injury also completed cognitive testing to determine whether regional grey matter concentration correlated with a measure of attention and initial injury severity.

RESULTS

Compared with controls, the brain injured patients had decreased grey matter concentration in multiple brain regions including frontal and temporal cortices, cingulate gyrus, subcortical grey matter, and the cerebellum. Decreased grey matter concentration correlated with lower scores on tests of attention and lower Glasgow coma scale scores.

CONCLUSIONS

Using VBM, regions of decreased grey matter concentration were observed in subjects with traumatic brain injury compared with well matched controls. In the brain injured patients, there was a relation between grey matter concentration and attentional ability.

Expression of interleukin-6 and its effects on growth of HP75 human pituitary tumor cells

The role of IL-6 in the pathogenesis of pituitary adenomas is unclear, as tumor biology is difficult to study in primary culture. We have shown here that the human pituitary cell line HP75 synthesizes IL-6 mRNA and expresses and secretes IL-6 (6167 +/- 56 pg/ml/72 h for 30,000 cells). IL-6 receptor (IL-6R) mRNA was identified by in situ hybridization and RT-PCR. Exogenous IL-6 in low dose (1 ng/ml) stimulated, whereas higher doses (100 ng/ml) inhibited, growth. This diverse effect occurs in other cell types as a result of receptor down-regulation. Cell growth was inhibited by IL-6-blocking antibody (76 +/- 6.5% inhibition; P < 0.0001). This demonstrates that IL-6 is an important growth regulator in HP75 cells, having an autocrine growth stimulatory effect under basal conditions. IL-1alpha and dibutyryl cAMP stimulated and dexamethasone inhibited IL-6 secretion; however, bacterial lipopolysaccharide, forskolin, and cholera toxin had no effect. This implies that there is a defect in the control of IL-6 secretion. Soluble IL-6R was not detected, but soluble gp130 receptor was present in the conditioned medium. Stimulation of cleavage of soluble IL-6R from the membrane-bound IL-6R could not be induced by phorbol ester or dexamethasone. Whether IL-6 has a similar effect in human pituitary adenomas requires further investigation.

IL-8 mRNA expression by in situ hybridisation in human pituitary adenomas

Several cytokines have been shown to be expressed in normal and adenomatous pituitary tissue. Recently, interleukin-8 (IL-8) mRNA was identified by reverse transcription (RT)-PCR in each of a series of 17 pituitary tumours examined. We have investigated further the presence of IL-8 mRNA, using in situ hybridisation in two normal human anterior pituitary specimens and 25 human pituitary adenomas. IL-8 mRNA was not identified in either of the two normal pituitary specimens. Only three of the 25 adenomas were positive for IL-8 mRNA. In these three tumours, which included two null cell adenomas and one gonadotrophinoma, the majority of tumour cells (>90%) were positive for IL-8 mRNA. The remaining 22 adenomas were completely negative. There was no difference in tumour size or type between the IL-8 positive and the IL-8 negative tumours, and immunocytochemistry for von Willebrandt factor showed that the two groups were also similar in their degree of vascularisation. In conclusion, IL-8 mRNA was found in 12% of pituitary adenomas studied and was histologically identified within the tumour cells. In situ hybridisation is a more appropriate technique for assessing cytokine mRNA production by human pituitary tumours because RT-PCR may be too sensitive, identifying very small, possibly pathologically insignificant, quantities of mRNA that could be produced by supporting cells such as fibroblasts, endothelial cells or macrophages.

When staff training isn't enough: an evaluation of a collaborative approach

This paper describes an evaluation of a training workshop for staff working with people who have severe physical and learning disabilities and who need extensive support with eating and drinking. Training involved joint input from speech and language therapy, dietetics, occupational therapy and physiotherapy and was evaluated at three levels: participants' satisfaction, gains in knowledge and video-tapes of mealtimes pre- and post-training to assess changes in practice. Results indicated very positive staff perceptions of the workshops and highly significant increases in knowledge, both immediately (p < 0.001) and after six months (p < 0.001). However there was no evidence of significant change in practice. Results are discussed in the context of bringing about changes in staff behaviour.

Role of the hippocampus in sex differences in verbal memory: memory outcome following left anterior temporal lobectomy

The authors examined the neural and cognitive bases for sex differences in verbal memory in 57 patients who underwent left anterior temporal lobectomy (ATL) for the treatment of intractable seizures. On the California Verbal Learning Test (D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1987), women recalled more words than men both before and after surgery, regardless of the extent of hippocampal damage. Extent of hippocampal sclerosis was related to memory loss in both men and women. Women's superiority in verbal memory appears to result in part from their use of an efficient encoding strategy. Women were more likely than men to use semantic clustering both before and after ATL, and sex differences in word recall were attenuated after scores were adjusted for semantic clustering. There was no effect of ATL on semantic clustering. Taken together, these results suggest that sex differences in verbal memory are not due to differences in the integrity of the left hippocampus.

Role of the hippocampus in sex differences in verbal memory: memory outcome following left anterior temporal lobectomy

The authors examined the neural and cognitive bases for sex differences in verbal memory in 57 patients who underwent left anterior temporal lobectomy (ATL) for the treatment of intractable seizures. On the California Verbal Learning Test (D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1987), women recalled more words than men both before and after surgery, regardless of the extent of hippocampal damage. Extent of hippocampal sclerosis was related to memory loss in both men and women. Women's superiority in verbal memory appears to result in part from their use of an efficient encoding strategy. Women were more likely than men to use semantic clustering both before and after ATL, and sex differences in word recall were attenuated after scores were adjusted for semantic clustering. There was no effect of ATL on semantic clustering. Taken together, these results suggest that sex differences in verbal memory are not due to differences in the integrity of the left hippocampus.

Pattern of interictal hypometabolism in PET scans with fludeoxyglucose F 18 reflects prior seizure types in patients with mesial temporal lobe seizures

BACKGROUND

Interictal hypometabolism is routinely used as an indicator of the epileptogenic zone in patients with complex partial seizures (CPSs). However, the regional pattern of hypometabolism varies without obvious reasons, even among patients with identical epileptogenic zones and causes.

OBJECTIVE

To investigate whether this pattern may be related to the electroencephalographic and clinical features of the seizure that precedes the positron emission tomographic (PET) scan with fludeoxyglucose F 18.

PATIENTS AND METHODS

Fifty-three patients with CPSs were first classified into 4 groups, depending on the features of the seizure that preceded the PET scan (determined from findings from electroencephalography and videotelemetry). In 14 patients, this seizure was focal limbic (characterized by aurae or staring spells); in 18, the CPS was widespread limbic (including automatisms). Ten patients had a CPS with posturing, and 11 had a secondarily generalized CPS. Regions with a hemisphere-normalized concentration of fludeoxyglucose F 18 below the 95% confidence interval of values from 8 control subjects were defined as hypometabolic. The location of these regions was then compared among the 4 groups, and the degree of hypometabolism was related to the time from the seizure to the PET scan with fludeoxyglucose F 18.

RESULTS

The hypometabolic area was limited to the epileptogenic zone if the preceding seizure was focal limbic, whereas in patients with widespread limbic seizures, it included one or several additional areas of the limbic cortex (P = .03). Patients with posturing differed from both previous groups by having hypometabolism in the extralimbic frontal lobe (P < .001), and subjects with secondarily generalized seizures differed from all others because of cerebellar (P < .001) and parietal lobe (P < .05) reductions. The time between the seizure and the performance of the PET scan did not correlate with the degree or extent of hypometabolism.

CONCLUSIONS

Mechanisms involved in the generation of a seizure that precedes a PET scan with fludeoxyglucose F 18 seem to influence the "interictal" hypometabolic pattern. Therefore, caution should be used when interpreting scans that are preceded by a nonhabitual seizure.

Localized cerebellar hypometabolism in patients with complex partial seizures

PURPOSE

We sought to determine the cause of cerebellar dysfunction in epilepsy and whether this dysfunction was directly related to seizures.

METHODS

Cerebellar metabolism was evaluated in 48 patients with a well-defined region of seizure onset and with corresponding hypometabolism. Regions of interest (ROI) were drawn according to a standardized template. If the ROI/nonepileptogenic cortex count rate ratio was outside the 95% confidence interval (CI) of controls, the ROI was defined as abnormal. The ratios from cerebellar hemispheres (defined as ipsi- or contralateral to the seizure onset region), were compared among controls (n = 8); patients who had seizure onsets and corresponding hypometabolism mesially in a temporal lobe (patient group 1, n = 19); patients whose seizures had onset mesially in a temporal lobe but spread rapidly to the ipsilateral frontal lobe and who had hypometabolism both in the affected temporal lobe and frontal lobe (patient group 2, n = 23); and patients who had seizure onsets and corresponding hypometabolism in the frontal lobe (patient group 3, n = 6).

RESULTS

Significant hypometabolism was noted in the contralateral cerebellum of patients in group 2 and 3 [p = 0.007 and p = 0.008, respectively; two-way analysis of variance (ANOVA)]. In contrast, patients in group 1 tended to have lower values in the ipsilateral cerebellum (p = 0.057).

CONCLUSIONS

The observed cerebellar changes are consistent with animal data showing that cerebellar connections to frontal lobes are numerous and crossed, whereas the connections to mesial temporal lobes are less abundant, bilateral, with an ipsilateral predominance. The difference between the two groups of patients with mesial temporal seizures suggests that cerebellar dysfunction in partial epilepsy, at least to a certain extent, is related to mechanisms involved in seizure generation and spread.

Antagonism of the lethal effects of cyanide by a synthetic water-soluble cobalt(III) porphyrin compound

Efficacy of hydroxocobalamin (vitamin B12) as a cyanide antidote is limited by its high molecular weight (1355 g/mol) and by the competitive binding of the cobalamin dimethylbenzimidazole. The present study describes experiments with a lower molecular weight cobalt porphyrin that has a high affinity for cyanide, Co(III)-5,10,15,20-tetrakis(4-sulfonatophenyl) porphyrin (CoTPPS), which was prepared by the method of Herrmann et al. (1978). CoTPPS was synthesized and its efficacy as an antidote to the lethal effects of cyanide either alone or in various combinations with NaNO2 and/or Na2S2O3 was determined. The LD50 value for CoTPPS was found to be 334 mg/kg. These studies were conducted using the CoTPPS LD01, 200 mg/kg. The cyanide antagonists NaNO2 (0.1 g/kg, sc), Na2S2O3 (1.0 g/kg, ip), and CoTPPS (0.2 g/kg, ip) were administered at 45, 15, and 10 min respectively prior to graded doses of KCN (sc). The LD50 values for KCN in male Swiss-Webster mice were calculated by probit analysis at the 95% confidence level and the various treatments were compared by potency ratios. These results indicated that the administration of CoTPPS alone protects against the lethal effects of cyanide. Moreover, CoTPPS adds to the protection provided by Na2S2O3 and/or NaNO2. Efficacy of this antidote is probably related to the binding equilibrium between CoTPPS and cyanide.

Normal thyroid function in desipramine nonresponders converted to responders by the addition of L-triiodothyronine

The results of complete thyroid function testing were normal in four desipramine nonresponders who were converted to responders by addition of L-triiodothyronine (T3). These findings suggest that the effectiveness of T3 is not due to correction of subtle thyroid deficiencies.

Dexamethasone suppression test and Axis I diagnoses of inpatients with DSM-III borderline personality disorder

To determine the relationship of Axis I diagnoses to the DSM-III diagnosis of borderline personality disorder, 100 consecutive admissions to an inpatient service were studied. Of the 27 patients labeled borderline, 14 were given an Axis I diagnosis of major depression (unipolar) compared with 8 of 73 nonborderlines; 73% (19 of 26) of all borderlines tested but only 46% (18 of 39) of nonborderlines had a positive DST (p less than .05). Few borderline patients received concomitant nonaffective diagnoses, and even fewer were given bipolar or schizoaffective diagnoses.

Positron emission tomographic study of affective disorders: problems and strategies

Because anatomical studies of psychiatric disorders in humans have been largely unsuccessful, and because pharmacological interventions in patients with mental illness can be analyzed by means of biochemical assay techniques, positron emission tomography (PET) provides an exciting new means to study mental illness. Using fluorine-18-labeled fluorodeoxyglucose and PET to measure local cerebral glucose utilization, the investigators examined patients with affective disorders and normal age-matched controls. Patients with unipolar depression were studied in a drug-free baseline state following short-term administration of methylphenidate and in a euthymic state in long-term follow-up. Patients with bipolar disorders were studied in either the manic or depressed phases of illness and again in a euthymic state in long-term follow-up. Age-matched controls were studied both with and without methylphenidate administration. The results demonstrate that metabolic subgrouping of patients may be possible. Mood changes produced by pharmacological agents resulted in changes in the patterns of metabolism when compared with the baseline state. Problems associated with the use of PET to study mental illness fall into the categories of patient classification (diagnosis, state, trait, ambient conditions, and mental processes) and data analysis (anatomical and statistical). These problems, the limitations of the present techniques, and strategies for their improvement are discussed. Despite these difficulties, PET should prove to be a fruitful means of exploring the human biochemical abnormalities associated with mental illness.