Australian data on the utilisation and duration on treatment of ibrutinib with a proton pump inhibitor in patients with relapsed or refractory chronic lymphocytic leukaemia

In Australia, over half of patients with relapsed/refractory chronic lymphocytic leukaemia treated with ibrutinib use concomitant proton pump inhibitors (PPIs). High gastric pH reduces the bioavailability of some Bruton tyrosine kinase inhibitors. There was no difference in duration on ibrutinib with or without concomitant PPI (unadjusted P = 0.61; adjusted hazard ratio: 1.23, 95% confidence interval: 0.75-2.02, P = 0.411). PPI use does not affect ibrutinib treatment persistence.

Real-world treatment persistence of four commonly prescribed biologic therapies for moderate to severe psoriasis in Australia

BACKGROUND/OBJECTIVES

Australian data comparing biologic treatments for moderate to severe chronic plaque psoriasis are lacking. We compared persistence on therapy across four biologic therapies (adalimumab, guselkumab, secukinumab and ustekinumab) used to treat chronic plaque psoriasis. The impact of prior biologic use on persistence was also investigated.

METHODS

This retrospective cohort analysis of the Pharmaceutical Benefits Scheme (PBS) 10% sample included data from adult patients prescribed ≥1 biologic of interest by a dermatologist from 1 September 2015 to 31 December 2021. Persistence was defined as continued use until 180 days without a prescription. The index date was the date of the first claim of the biologic. Persistence was evaluated using Kaplan-Meier methods, log-rank tests, adjusted analyses using Cox's regressions, and propensity score matching.

RESULTS

In total, 878 patients, with 1131 index prescriptions, were included. Guselkumab median persistence was not reached in the study period (PBS listed from February 2019). In the adjusted analysis, persistence to guselkumab was significantly greater than to adalimumab (n = 105; median 16 months, HR 2.71 (95% CI 1.94-3.8), p < 0.001), ustekinumab (n = 336; median 19 months, HR 2.91 (95% CI 2.22-3.82), p < 0.001) and secukinumab (n = 305; median 30 months, HR 1.8 (95% CI 1.36-2.38), p < 0.001). Bio-naïve patients had longer persistence on treatment than bio-experienced patients.

CONCLUSIONS

The nationally representative PBS dataset can provide real-world insights into the persistence on biologic therapies for psoriasis in Australia, where eligibility criteria for reimbursed treatment are stringent. Persistence is an indirect marker of sustained treatment effectiveness and tolerability. Both unadjusted and adjusted analyses found longer persistence for guselkumab compared to adalimumab, secukinumab or ustekinumab.

Oncological monitoring after transanal total mesorectal excision (TaTME) for rectal neoplasia

BACKGROUND

The surgical treatment of choice for rectal neoplasia is total mesorectal excision (TME). The transanal approach enables a better approach in male and obese patients and/or those with a narrow pelvis and in patients with small tumors. Short-term results are comparable with those for laparoscopy or the open approach, but the medium- and long-term oncological data are sparse. The aim of the present study was to evaluate our early experience with transanal TME (TaTME).

METHODS

This was a retrospective study conducted on patients who underwent TaTME at our center between August 2013 and April 2017 with a follow-up ≥ 3 years. Histopathology, complications, mortality, neoplastic recurrence and disease-free survival were analyzed.

RESULTS

One hundred patients (68 men and 32 women,, median age 66.8 years [range 29.6-91.2 years]) were included. There were 67 T3 cases (67%) with 74 N0 cases (74%), the mesorectal quality was graded optimal for 87.6% and only 2 cases of radial margin involvement were detected (2%). The median follow-up period was 47.6 months (range 11.8-78.9 months). Eighteen cases of recurrence were diagnosed, of which 3 (3%) recurred locally with an average disease-free period of 43.1 months. Overall survival was 80% and mortality due to progression of disease was 13%.

CONCLUSIONS

TaTME is a safe surgical procedure with surgical, anatomopathological and oncological results at 3 years (medium-term) comparable with those for the laparoscopic and open approaches. Better monitoring is required with studies of the long-term functional and quality of life outcomes, i.e., at 5 or 10 years.

Persistence and adherence to second-generation antipsychotic long-acting injectable medications for schizophrenia: A comparative study in the Australian context

OBJECTIVE

To examine patient characteristics, persistence and adherence to treatment associated with use of second-generation antipsychotic long-acting injectable (SGA LAI) medications in the Australian real-world setting.

METHOD

Five SGA LAIs were compared using a retrospective 10% sample of prescriptions in Australian Pharmaceutical Benefits Scheme (PBS) data: paliperidone palmitate 1-monthly (PP1M), paliperidone palmitate 3-monthly (PP3M), aripiprazole monohydrate (ARI), risperidone (RLAI) and olanzapine pamoate (OLAI).

RESULTS

Patients in the PP3M cohort were more persistent with treatment (p < 0.001). Median months of persistence: PP3M (36 months); ARI (18 months); PP1M (11 months); OLAI (8 months); RLAI (4 months). Patients in the PP3M cohort were more adherent to treatment (p < 0.001): PP3M (78%); ARI (51%); PP1M (46%); OLAI (35%); RLAI (33%).

CONCLUSIONS

Patients on PP3M treatment showed comparatively longer persistence and better adherence. Treatments for schizophrenia with longer dosing intervals may provide patients with symptomatic stability that could allow for reduced hospitalisations/relapse and increased focus on functional recovery.

Real-world experience of Australian and New Zealand patients with chronic lymphocytic leukemia and mantle cell lymphoma accessing ibrutinib through a Named Patient Program

Ibrutinib is a small molecule inhibitor of Bruton's tyrosine kinase indicated for the treatment of relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), and mantle cell lymphoma (MCL). The Named Patient Program in Australia and New Zealand (ANZ NPP) provided access to ibrutinib treatment to 1126 R/R CLL/SLL and 330 R/R MCL patients, prior to Pharmaceutical Benefits Scheme listing. This study aimed to assess the duration of treatment for the ANZ NPP patients, as an indicator of efficacy and tolerability of ibrutinib in the real world. Based on the NPP data, ibrutinib provided a median of 47 months clinical benefit for participants with CLL/SLL and 14 months clinical benefit for those with MCL; outcomes that are consistent with the clinical trial results and further support the well-established efficacy and safety profile of ibrutinib in the real world.

Technological Tools for the Early Detection of Bovine Respiratory Disease in Farms

Simple Summary

The inclusion of remote automatic systems that use continuous learning technology are of great interest in precision livestock cattle farming, since the average size of farms is increasing while time for individual observation is decreasing. Bovine respiratory disease is a main concern in both fattening and heifer rearing farms due to its impact on antibiotic use, loss of performance, mortality, and animal welfare. Much scientific literature has been published regarding technologies for continuous learning and monitoring of cattle’s behavior and accurate correlation with health status, including early detection of bovine respiratory disease. This review summarizes the up-to-date technologies for early diagnosis of bovine respiratory disease and discusses their advantages and disadvantages under practical conditions.

Abstract

Classically, the diagnosis of respiratory disease in cattle has been based on observation of clinical signs and the behavior of the animals, but this technique can be subjective, time-consuming and labor intensive. It also requires proper training of staff and lacks sensitivity (Se) and specificity (Sp). Furthermore, respiratory disease is diagnosed too late, when the animal already has severe lesions. A total of 104 papers were included in this review. The use of new advanced technologies that allow early diagnosis of diseases using real-time data analysis may be the future of cattle farms. These technologies allow continuous, remote, and objective assessment of animal behavior and diagnosis of bovine respiratory disease with improved Se and Sp. The most commonly used behavioral variables are eating behavior and physical activity. Diagnosis of bovine respiratory disease may experience a significant change with the help of big data combined with machine learning, and may even integrate metabolomics as disease markers. Advanced technologies should not be a substitute for practitioners, farmers or technicians, but could help achieve a much more accurate and earlier diagnosis of respiratory disease and, therefore, reduce the use of antibiotics, increase animal welfare and sustainability of livestock farms. This review aims to familiarize practitioners and farmers with the advantages and disadvantages of the advanced technological diagnostic tools for bovine respiratory disease and introduce recent clinical applications.

Understanding the Treatment Preferences of People Living with Schizophrenia in Australia; A Patient Value Mapping Study

PURPOSE

To examine the treatment and long-term outcome preferences for people living with schizophrenia.

PATIENTS AND METHODS

Sixty-six Australian adults, living with schizophrenia completed a novel online survey with six sections: Demographic characteristics; Disease history; Quality-of-life; Patient support programmes; Discrete Choice Experiment, and Best-Worst Scaling exercise.

RESULTS

Participants indicated that they preferred to be involved in treatment decision with their doctor. A minority of participants reported having been previously involved in a patient support programme (28.8%) and only one in six participants had a National Disability Insurance Scheme (NDIS) package (16.7%) with over a third of participants indicating that they were ineligible (37.9%). Participants' average quality-of-life score was 60%.

CONCLUSION

Recent hospitalisation influenced the relative importance of treatment attributes, with effectiveness on hearing voices being the most important treatment attribute. The most important long-term goals were having a stable place to live, being independent, and physical health. People with schizophrenia care about their long-term functional recovery outcomes, rating symptom control and independence as their highest priority. They want to be part of the treatment conversation with their doctors. Therefore, psychiatrists are encouraged to use shared decision-making to establish the treatment course that best aligns with individuals' long-term goals.

Understanding Treatment Preferences of Australian Patients Living with Treatment-Resistant Depression

BACKGROUND

There is evidence of improved adherence and treatment outcomes when patients' treatment preferences are considered, and shared decision making is utilized.

PURPOSE

We aimed to better understand treatment preferences among Australians with treatment-resistant depression (TRD), focusing on the specific treatment attributes that people value (such as effectiveness, risk of side effects and cost) and their relative importance. The risk-benefit trade-offs that characterize treatment choices were also examined.

PATIENTS AND METHODS

An online survey of 75 patients with experience of TRD was conducted, consisting of two discrete choice experiment (DCE) components - a medication DCE and a treatment plan DCE. Participants were able to prioritize and trade off different features of medications and treatment plans. Additional questions aimed to better define this population group, which in Australia is poorly understood.

RESULTS

In both DCEs, two distinct latent classes were identified. In the medication DCE, the classes were distinguished by willingness to consider new treatment alternatives. Participants in class 1 were reluctant to give up current treatment, while those in the slightly larger class 2 preferred new treatment options. In both classes, treatment effectiveness and cost were the greatest contributors to preference. Similar behavior was seen in the treatment plan DCE, with the larger class more likely to choose a new plan over their current treatment arrangement. Participants preferred medications that were low-cost, taken orally, had a high percentage improvement in mood symptoms, high rate of remission and low risk of weight gain. A similar result was found in preferences for treatment plans such that plans with the greatest effectiveness and lowest cost were most favorable.

CONCLUSION

Patient preferences should routinely be considered and discussed to guide informed decisions regarding the value of new and existing medications for TRD and how they sit in the context of treatment plans.

An Australian Real-World Study of Treatment Persistence of Ustekinumab in Crohn's Disease

Introduction

Real-world treatment persistence to ustekinumab for Crohn’s disease (CD) was studied using Australian Pharmaceutical Benefits Scheme (PBS) data. Demographic and treatment pattern characteristics were also investigated.

Methods

Our retrospective cohort analysis included PBS 10% sample data for ustekinumab from September 2017 to March 2020, and for other biologics from October 2007 to capture earlier line(s) of therapy. Included patients received ustekinumab for CD prescribed by a gastroenterologist. Treatment persistence overall and by prior biologic experience, mono- or combination therapy, sex and age were estimated using Kaplan–Meier methods. A Cox proportional hazards regression analysis was performed to assess the effect of age, sex and line of therapy on persistence.

Results

Data were available for 301 patients. Of these, 58.8% were female and 76.7% were aged 26–65 years. Median follow-up from first ustekinumab dispense was 16 months. Median persistence to ustekinumab had not been reached. Twelve-month persistence to ustekinumab was 82.6% (95% CI 78.1–87.5%). Patients receiving ustekinumab as their first biologic therapy had 12-month persistence of 88.0% (80.8–95.9%) compared to 80.6% (75.0–86.6%) for patients who had previously received other biologic therapies (p=0.059). The adjusted analysis showed a trend to longer persistence for patients receiving ustekinumab as their first biologic therapy compared to biologic experienced patients (HR 1.86 (95% CI 0.95–3.63), p=0.070). Males had higher persistence to ustekinumab than females (HR 0.36 (0.20–0.66), p<0.001). Receiving ustekinumab as a monotherapy or in combination with azathioprine, mercaptopurine, 5ASAs, methotrexate, or corticosteroids had no effect on persistence (p=0.22).

Conclusion

In an Australian real-world setting, persistence to ustekinumab was demonstrated to be over 80% at 12 months. Use as monotherapy or in combination with other therapy for CD did not affect persistence. Differences in treatment persistence by gender and previous biologic use warrant further investigation as further long-term data becomes available.

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Envejecimiento, salud y economía. La Encuesta Nacional sobre Salud y Envejecimiento en México

México vive una transición demográfica en la cual el porcentaje de la población mayor de 50 años crece aceleradamente como resultado de un aumento considerable en la esperanza de vida. Dicha población tiene necesidades particulares que deben de ser tomadas en cuenta en la formulación de políticas, sobre todo en materia de acceso a servicios de salud y seguridad social. En este artículo presentamos una descripción general de la Encuesta Nacional de Salud y Envejecimiento (Enasem), un estudio de panel que comenzó en 2001 y que ofrece una oportunidad única para abordar temas demográficos y económicos complejos por medio de la exploración de las características personales, transferencias socioeconómicas e indicadores de salud para una muestra de 15 186 adultos de edad media y avanzada. También presentamos los resultados más relevantes de diferentes estudios que han utilizado la Enasem hasta la fecha. Nuestra revisión indica que México enfrenta desafíos considerables para satisfacer la demanda de servicios médicos para una población que es amenazada por una creciente presencia de enfermedades crónicas, sobre todo para la población de edad avanzada que no cuenta con cobertura de seguro médico.

Preparaciôn y caracterización química y microestructural de surimi de merluza (Merluccius merluccius) y de jurel (Trachurus trachurus) / Preparation and chemical and microstructural characterization of surimi from hake (Merluccius merluccius) and horse mackerel (Trachurus trachurus)

Surimi and kamaboko prepared from hake ( Merluccius merluccius) and horse mackerel ( Trachurus trachurus) were characterized chemically and microstructurally. During the process, protein and lipid values decreased while ash, chloride and free nitrogen extract values increased. Hake surimi and kamaboko had less humidity and a higher value of protein than horse mackerel surimi and kamaboko. In both gels water activity decreased and whiteness increased. Horse mackerel kamaboko was more elastic while hake kamaboko was harder and more brittle. The microstructural study showed that the typical structure of fish muscle was lost, giving rise to a porous protein matrix with regions of high and low protein density, as well as some fragments of muscle fibres.

Cost-Effectiveness of Canagliflozin versus Sitagliptin as Add-on to Metformin in Patients with Type 2 Diabetes Mellitus in Mexico

OBJECTIVE

To assess the cost-effectiveness of canagliflozin versus sitagliptin for the treatment of type 2 diabetes mellitus (T2DM) as an add-on to metformin in Mexico.

METHODS

A validated model (Economic and Health Outcomes [ECHO]-T2DM) was used to estimate the cost-effectiveness of canagliflozin 300 or 100 mg versus sitagliptin 100 mg in patients with T2DM inadequately controlled on metformin monotherapy. Data from a head-to-head, phase III clinical trial, including patients' baseline demographic characteristics, biomarker values, and treatment effects, were used to simulate outcomes and resource use over 20 years from the perspective of the Mexican health care system. Costs of complications and adverse events were tailored to the Mexican setting and discounted at 5%. Cost-effectiveness was assessed using willingness-to-pay thresholds equivalent to 1 times the gross domestic product per capita (locally perceived to be "very cost-effective") and 3 times the gross domestic product per capita (locally perceived to be "cost-effective") on the basis of recommendations of the Mexican government and the World Health Organization.

RESULTS

Owing primarily to better glycated hemoglobin (HbA_1c), body weight, and systolic blood pressure values, canagliflozin 300 and 100 mg were associated with an incremental benefit of 0.16 and 0.06 quality-adjusted life-years (QALYs) versus sitagliptin 100 mg, respectively, over 20 years. The mean differences in cost for canagliflozin 300 and 100 mg versus sitagliptin 100 mg were Mexican pesos (MXP) 1797 (US $134) and MXP 7262 (US $540), respectively, resulting in a cost per QALY gained of MXP 11,210 (US $834) and MXP 128,883 (US $9590), respectively. Both of these cost-effectiveness ratios are below the very cost-effective willingness-to-pay threshold in Mexico. The general finding that canagliflozin is cost-effective versus sitagliptin in Mexico was supported by sensitivity analyses.

CONCLUSION

In Mexico, both doses of canagliflozin are likely to be cost-effective versus sitagliptin in patients with T2DM who have inadequate glucose control on metformin, primarily because of better biomarker control and higher QALYs.

Albuterol and levalbuterol use and spending in Medicare beneficiaries with chronic obstructive pulmonary disease

BACKGROUND

The evidence for the benefits of branded levalbuterol over generic albuterol in patients with chronic obstructive pulmonary disease (COPD) is inconclusive. However, there are significant cost differences between these products.

OBJECTIVES

This study examined use and spending on albuterol and levalbuterol in a nationally representative sample of Medicare beneficiaries with COPD enrolled in Part D in 2006. It also examined differences in patient characteristics and use of other COPD drugs among recipients of these 2 short-acting β-agonists.

METHODS

Data were obtained from the 5% Medicare files for 2005-2006 linked to the 2006 Medicare Part D files. The sample consisted of all fee-for-service beneficiaries with COPD enrolled in stand-alone Part D plans in 2006. Patient characteristics and other COPD medication use were compared across albuterol-only users, levalbuterol-only users, and users of both albuterol and levalbuterol. Multinomial logistic regressions were used to identify factors independently associated with levalbuterol use.

RESULTS

There were 5.5 times more albuterol users than levalbuterol users in 2006; however, mean annual spending on levalbuterol was 18.6 times higher per user in 2006 than spending on albuterol ($1876 vs $101 per user, respectively). Levalbuterol-only users were more likely to be older than albuterol-only users (mean age: 71.5 vs 68.7 years; P < 0.05), as well as sicker (mean prescription drug hierarchical condition category score: 1.72 vs 1.55; P < 0.05) and residing in the South (67.9% vs 41.6%; P < 0.05). Levalbuterol-only users were more likely to use nebulizer forms covered under Part B than inhaler forms covered under Part D (78.6% vs 26.8%, respectively; P < 0.05), whereas albuterol-only users were more likely to use inhaler forms covered under Part D than nebulizer forms covered under Part B (82.2% vs 33.0%, respectively; P < 0.05).

CONCLUSIONS

In this sample of Medicare beneficiaries with COPD enrolled in Part D, mean annual spending in 2006 was significantly higher for levalbuterol than for albuterol. The differences between levalbuterol and albuterol users in terms of patient characteristics, geographic region, and drug formulation/device type, coupled with the inconclusive evidence for efficacy differences in the literature, highlight the need for further comparative clinical and cost-effectiveness studies of these agents.

Impact of the Medicare Modernization Act of 2003 on utilization and spending for medicare part B-covered biologics in rheumatoid arthritis

OBJECTIVE

To examine changes in utilization and expenditures for infliximab in rheumatoid arthritis (RA) patients associated with the 2 changes implemented by the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, specifically 1) reductions in physician reimbursement for Part B drugs between 2003 and 2005 and 2) availability of alternative RA biologics in 2006.

METHODS

Using 2002-2006 5% Medicare files, nationally representative estimates of infliximab use and expenditures were estimated in annual cross-sectional samples of RA beneficiaries. Infliximab initiation and continuation rates were estimated in 2-year longitudinal cohorts (2005-2006 versus 2002-2003, 2003-2004, and 2004-2005).

RESULTS

Total payments (in 2006 dollars) for infliximab increased from $357 million in 2002 to $492 million in 2006. The largest annual increase in infliximab payments occurred in the pre-MMA period from 2002 to 2003, wherein payments per RA patient increased by 31%. From 2003 to 2004, despite the reduction in payments brought by the MMA, there was a 4% increase in total expenditures for infliximab per RA patient driven by an increase in utilization factors. Total payments for infliximab per RA patient actually decreased from 2004 to 2005, when reimbursement was further reduced. Continuation and initiation rates for infliximab use remained unchanged in 2006, as compared with previous years.

CONCLUSION

Infliximab expenditures increased from 2002 to 2006, yet the passage of the MMA was associated with a remarkable slowdown in the rate of increase in expenditures. There was no evidence of significant substitution of infliximab with other biologics made available in 2006.

Assessing quality across healthcare subsystems in Mexico

Recent healthcare reform efforts in Mexico have focused on the need to improve the efficiency and equity of a fragmented healthcare system. In light of these reform initiatives, there is a need to assess whether healthcare subsystems are effective at providing high-quality healthcare to all Mexicans. Nationally representative household survey data from the 2006 Encuesta Nacional de Salud y Nutrición (National Health and Nutrition Survey) were used to assess perceived healthcare quality across different subsystems. Using a sample of 7234 survey respondents, we found evidence of substantial heterogeneity in healthcare quality assessments across healthcare subsystems favoring private providers over social security institutions. These differences across subsystems remained even after adjusting for socioeconomic, demographic, and health factors. Our analysis suggests that improvements in efficiency and equity can be achieved by assessing the factors that contribute to heterogeneity in quality across subsystems.

A randomized, controlled trial of financial incentives for smoking cessation

BACKGROUND

Smoking is the leading preventable cause of premature death in the United States. Previous studies of financial incentives for smoking cessation in work settings have not shown that such incentives have significant effects on cessation rates, but these studies have had limited power, and the incentives used may have been insufficient.

METHODS

We randomly assigned 878 employees of a multinational company based in the United States to receive information about smoking-cessation programs (442 employees) or to receive information about programs plus financial incentives (436 employees). The financial incentives were $100 for completion of a smoking-cessation program, $250 for cessation of smoking within 6 months after study enrollment, as confirmed by a biochemical test, and $400 for abstinence for an additional 6 months after the initial cessation, as confirmed by a biochemical test. Individual participants were stratified according to work site, heavy or nonheavy smoking, and income. The primary end point was smoking cessation 9 or 12 months after enrollment, depending on whether initial cessation was reported at 3 or 6 months. Secondary end points were smoking cessation within the first 6 months after enrollment and rates of participation in and completion of smoking-cessation programs.

RESULTS

The incentive group had significantly higher rates of smoking cessation than did the information-only group 9 or 12 months after enrollment (14.7% vs. 5.0%, P<0.001) and 15 or 18 months after enrollment (9.4% vs. 3.6%, P<0.001). Incentive-group participants also had significantly higher rates of enrollment in a smoking-cessation program (15.4% vs. 5.4%, P<0.001), completion of a smoking-cessation program (10.8% vs. 2.5%, P<0.001), and smoking cessation within the first 6 months after enrollment (20.9% vs. 11.8%, P<0.001).

CONCLUSIONS

In this study of employees of one large company, financial incentives for smoking cessation significantly increased the rates of smoking cessation. (ClinicalTrials.gov number, NCT00128375.)

Microbiological and Sensory Effects of Musts Treated by High-pressure Homogenization

The winemaking sector needs to ensure the microbiological quality of its products to guarantee acceptance and wide commercialization. There are treatments such as high pressure homogenization (HPH) that, apparently, do not affect the final nutritional and sensory food properties. This study is presented to evaluate possibilities of utilizing HPH treatments to reduce the indigenous flora accompanying wine musts, as well as their effects on the fermentative process, oenological parameters, color, aroma, and taste properties. Two different must varieties were used: a white must (Parellada variety) and a red one (Trepat variety). Results showed that the use of HPH at 200 MPa is capable of reducing the microbial load of musts. Residual populations of total bacteria were detected, but neither fungi, nor yeasts, nor lactic acid bacteria were detected after the treatment in either musts. Furthermore, as a result of the decrease of the wild microbiota of the musts, the implantation of the selected yeast for alcoholic fermentation was improved. Sensory assessments of the must and wines showed that there were no significant changes caused by the treatment.

A new decorin-like tetrapeptide for optimal organization of collagen fibres

Decorin interacts with collagen via its protein core and influences collagen fibrillogenesis, thus regulating excessive bundle-like aggregation of collagen. As skin ages, there is lack of functional decorin, which results in disrupted collagen fibres and in a reduction in the tensile strength of the skin. Therefore, a substitute for decorin would make up for the non-functional decorin that is present as we age. Two tetrapeptide sequences have been identified as the specific binding sites of decorin to collagen fibrils. These sequences were engineered to generate new tetrapeptides with improved affinity that would present a decorin-like activity. A focused library of several candidates was synthesized containing only tetrapeptides that mimicked the binding sequences of decorin. The candidates were screened with an in vitro collagen fibrillogenesis assay and the tetrapeptide with International Nomenclature of Cosmetic Ingredients (INCI) name Tripeptide-10 Citrulline achieved the best results. Like decorin, this synthetic tetrapeptide proved, through in vitro tests, to regulate collagen fibrillogenesis and to influence the diameter of collagen fibres, making them thinner and more uniform. Tripeptide-10 Citrulline is a new cosmetic active to target specifically collagen fibre organization. Skin collagen quality is addressed rather than skin collagen quantity. Tripeptide-10 Citrulline ensures uniformity in fibril diameter and increases skin suppleness because of a better cohesion of collagen fibres.

Health insurance coverage and the use of preventive services by Mexican adults

The lack of health insurance coverage could be a potentially important deterrent to the use of preventive health care by older adults with high rates of chronic co-morbidities. We use survey data from 12 100 Mexican adults ages 50 and older who participated in the 2001 Mexican Health and Aging Study (MHAS) to analyze the relation between health insurance coverage and the use of preventive health-care services in Mexico. Uninsured adults were less likely to use preventive screenings for hypertension, high cholesterol, diabetes and (breast, cervical and prostate) cancer than insured adults. After adjusting for other factors affecting preventive care utilization in a logistic regression model, we found that these results still hold for high cholesterol and diabetes screening. Similar results hold for the population not working during the survey week and for adults earning below 200% of the poverty line. Our results suggest that insured adults are in a relatively better position to detect some chronic diseases - and have them treated promptly - than uninsured adults because they have better access to cost-effective preventive screenings. Recent public policy initiatives to increase health insurance coverage rates in Mexico could lead to substantially higher preventive health-care utilization rates and improvements in population health.

Cost-effectiveness of quadrivalent human papillomavirus (HPV) vaccination in Mexico: a transmission dynamic model-based evaluation

We examined the potential health outcomes and cost-effectiveness of quadrivalent human papillomavirus (HPV) 6/11/16/18 vaccination strategies in the Mexican population using a multi-HPV type dynamic transmission model. Assuming similar cervical screening practices, with or without vaccination, we examined the incremental cost-effectiveness of vaccination strategies for 12 year-old females, with or without male vaccination, and temporary age 12-24 catch-up vaccination for females or both sexes. The most effective strategy therein was vaccination of 12-year-olds, plus a temporary 12-24-year-old catch-up program covering both sexes; whereby HPV 6/11/16/18-related cervical cancer, high-grade cervical precancer, and genital wart incidence was reduced by 84-98% during year 50 following vaccine introduction. Incremental cost-effectiveness ratios in the primary analyses ranged from approximately 3000 dollars (U.S.) per quality-adjusted life year (QALY) gained for female vaccination strategies to approximately 16000 dollars /QALY for adding male vaccination with catch-up.

[Ageing, health and economics. National inquest into health and ageing in Mexico]

Mexico is experiencing a demographic transition in which the percentage of the population older than 50 years of age is growing rapidly as a result of increases in life expectancy. This population has special needs that must be taken into account when formulating policy, especially in terms of access to health care services and social security. In this article we present a general description of the Mexican Health and Aging Survey (MHAS), a panel study that began in 2001 and that provides a unique opportunity to study complex demographic and economic issues through the exploration of personal characteristics, socioeconomic transfers and health indicators for a sample of 15 186 middle and older age adults. We also present the most important results from different studies that have used MHAS up to date. Our review shows that Mexico faces substantial challenges in order to be able to satisfy the demand for health services for a population that is being increasingly threatened by chronic disease, particularly the elderly population that lacks health insurance coverage.

[Intraoperative monitoring of the facial nerve: anesthesia and neurophysiology considerations]

Intraoperative monitoring of the motor component of the 7th cranial pair or any other nerve should be routine during any surgical procedure involving risk of neural damage, whether or not the skull is opened. This paper discusses the main indications for monitoring facial and acoustic nerves during ear and neurosurgery involving the pontocerebellar angle (for acoustic neuroma or in surgery on the 8th cranial pair). Intraoperative electromyographic monitoring of the facial nerve should be used routinely in acoustic neuroma surgery to reduce the degree of postoperative neurological impairment and avoid possible malpractice suits. Although such monitoring requires that the muscle remain unblocked, intraoperative neuromuscular relaxants can be used if doses are administered along with appropriate monitoring of the level of peripheral neuromuscular block.

[Osteoma and exostosis of the external auditory meatus: a clinical diagnosis]

Proliferative osseous lesions usually found in the external ear are exostoses and osteomata. In other sites they are clearly different entities, but in this location histopathologic differential features are not so reliable in the study of the specimens. An occlusive osteomata is shown, with the typical clinical presentation demonstrated in a multiplanar CT. Microscopically, the lesion consisted of mature bone trabeculae, separated by medular spaces with fibrovascular tissue, characteristic features of osteomata. However, in the most superficial areas, lines of bone apposition, like those in exostoses, were found. A literature review confirms the lack of specificity of the histopathologic study, so diagnosis is based on clinical data.

[Cervical epidural anesthesia with 0.75% ropivacaine in shoulder surgery]

We present the cases of three patients scheduled for shoulder surgery under cervical epidural anesthesia with 0.75% ropivacaine. The technique was successful and surgery proceeded uneventfully in all three cases. The total doses of ropivacaine infused were 67, 90 and 109 mg. Premedication with intravenous atropine is recommended. Cervical epidural anesthesia offers several advantages over general anesthesia and other regional techniques for shoulder surgery: postoperative analgesia, lower total dose of the local anesthetic and single needle insertion with no need to elicit paresthesias or muscle movements. This technique brings about hemodynamic and respiratory changes in function of the extension and intensity of the block. Extent of the blockade to the upper thoracic sensory segments causes a total or partial sympathetic block with decreased heart rate, blood pressure and cardiac output. Limiting the initial and subsequent doses to restrict the sensory blockade to the surgical area will reduce hemodynamic complications. Ropivacaine provides an effective sensory block and a restricted motor block, reducing the probability of the restrictive pulmonary syndrome associated with cervical epidural anesthesia.

Optimisation and standardisation of a method for detecting and enumerating bacteriophages infecting Bacteroides fragilis

A method for the detection and enumeration of bacteriophages infecting Bacteroides fragilis has been standardised. The recommended host strain is RYC2056 (ATCC 700786) because of the relatively high counts (10(4)-10(5) PFU/100ml) that it recovers in sewage from very different geographical areas. The addition of 0.25% bile to the culture and assay media and the manipulation of the host strain under strict anaerobic conditions resulted in a significant increase (more than 100%) in the number of phages detected. No other changes in the media and culture conditions resulted in changes in the phage counts detected. However, these increases do not justify changing the culture conditions and media described, taking into consideration that bile renders the media cloudy making it difficult to follow the host growth and that most laboratories do not have the facilities to work under strict anaerobic conditions. Nalidixic acid (100 microg/ml) and kanamycin (100 microg/ml) in the assay medium significantly reduce the background flora from polluted samples without affecting the phage counts. Freezing cultures just before the end of the log-phage growth at (-70+/-10) degrees C with BSA-sucrose as cryoprotector, storing of 1-2 ml in glass vials at (-70+/-10) degrees C and using them directly to inoculate fresh broth allows the obtention of cultures ready for phage enumeration in about 2.5 h. All these developments have been incorporated into a procedure that makes the method for detecting phages infecting B. fragilis as workable as the standardised methods available for the detection of coliphages.

Nonepileptic seizures in pregnancy

The authors report five patients with recurrent psychogenic seizures (PS) during pregnancy, with multiple emergency room visits and continued intake of antiepileptic drugs obtained from various sources, despite awareness of the psychogenic nature of their attacks and the risks of antiepileptic drug use in pregnancy. These patients demonstrate that preexisting PS may persist during pregnancy, and there will be patients who continue to take antiepileptic drugs despite awareness of the risks inherent to these treatments. New-onset or persisting PS with pregnancy can be indicative of serious emotional conflicts, and the child should be considered at risk.

Mirtazapine in major depression with comorbid generalized anxiety disorder

BACKGROUND

A high proportion of patients with generalized anxiety disorder (GAD) have comorbid depressive illness. The presence of anxiety in depression has significant prognostic implications. Because of mirtazapine's early anxiolytic effects, the present study was undertaken as a preliminary investigation in patients with a diagnosis of major depression with comorbid GAD.

METHOD

Mirtazapine was administered to 10 patients with DSM-IV major depressive disorder and comorbid GAD in an 8-week open-label study. Mirtazapine was increased from an initial daily dose of 15 mg to a maximum daily dose of 45 mg.

RESULTS

Patients were found to have significant reductions in Hamilton Rating Scale for Depression scores, Hamilton Rating Scale for Anxiety scores, and Beck Depression Inventory scores, with improvement noted after the first week of therapy and continuing improvement over the 8 weeks of study.

CONCLUSION

These positive preliminary findings support the further investigation of mirtazapine's potential value as a treatment for generalized anxiety disorder in addition to its established efficacy as an antidepressant drug.

Diversity of bacteroides fragilis strains in their capacity to recover phages from human and animal wastes and from fecally polluted wastewater

Great differences in capability to detect bacteriophages from urban sewage of the area of Barcelona existed among 115 strains of Bacteroides fragilis. The capability of six of the strains to detect phages in a variety of feces and wastewater was studied. Strains HSP40 and RYC4023 detected similar numbers of phages in urban sewage and did not detect phages in animal feces. The other four strains detected phages in the feces of different animal species and in wastewater of both human and animal origin. Strain RYC2056 recovered consistently higher counts than the other strains and also detected counts ranging from 10(1) to approximately 10(3) phages per ml in urban sewage from different geographical areas. This strain detected bacteriophages in animal feces even though their relative concentration with respect to the other fecal indicators was significantly lower in wastewater polluted with animal feces than in urban sewage.

Cutaneous metastatic adenocarcinoma of gallbladder origin: report of a case and review of the literature

In the English literature, there have only been seven reports of metastasis from cancer of the gallbladder to the skin. This is the report of a 75-year-old woman who developed cutaneous metastasis from an adenocarcinoma of the gallbladder which was confirmed histologically. We report the uncommon metastatic potential of gallbladder carcinoma to the skin.

A 21-kDa C-terminal fragment of protein-disulfide isomerase has isomerase, chaperone, and anti-chaperone activities

A catalyst of disulfide formation and isomerization during protein folding, protein-disulfide isomerase (PDI) has two catalytic sites housed in two domains homologous to thioredoxin, one near the N terminus and the other near the C terminus. The thioredoxin domains, by themselves, can catalyze disulfide formation, but they are unable to catalyze disulfide isomerizations (Darby, N. J. and Creighton, T. E. (1995) Biochemistry 34, 11725-11735). A 21-kDa, C-terminal fragment of PDI (amino acids 308-491), termed weePDI, comprises the C-terminal third of the molecule. The kcat for ribonuclease oxidative folding by weePDI is 0.26 +/- 0.02 min-1, 3-fold lower than the wild-type enzyme but indistinguishable from the activity of a full-length mutant of PDI in which both active site cysteines of the N-terminal thioredoxin domain have been mutated to serine. Eliminating the ability of weePDI to escape easily from covalent complexes with substrate by mutating the active site cysteine nearer the C terminus to serine has a large effect on the isomerase activity of weePDI compared with its effect on the full-length enzyme. weePDI also displays chaperone and anti-chaperone activity characteristic of the full-length molecule. As isolated, weePDI is a disulfide-linked dimer in which the single cysteine (Cys-326) outside active site cross-links two weePDI monomers. The presence of the intermolecular disulfide decreases the activity by more than 2-fold. The results imply that the functions of the core thioredoxin domains of PDI and other members of the thioredoxin superfamily might be modified quite easily by the addition of relatively small accessory domains.

Phages of enteric bacteria in fresh water with different levels of faecal pollution

Levels of somatic and F-specific coliphages, and phages infecting Bacteroides fragilis were measured in 257 samples collected in different freshwater environments with different levels and characteristics of faecal pollution. In samples with recent pollution of domestic origin, the numbers of the three groups of phages were highly correlated, thus showing that their excretion is fairly constant. In this set of samples somatic coliphages, which were the most abundant, and F-specific coliphages outnumbered significantly Bact. fragilis phages. Normalized lines of the numbers of the three groups of phages in water samples and their sediments show that they settle similarly. The correlation between the values of the three groups of phages was not observed in waters with intermediate levels of pollution. An increase in the relative numbers of coliphages with respect to numbers of phages infecting Bact. fragilis was observed. In waters with persistent faecal pollution a dramatic change was recorded in the relative numbers of the different groups of phages. Phages infecting Bact. fragilis suffered the lowest reduction in numbers.

Wastewater from the manufacture of rubber vulcanization accelerators: characterization, downstream monitoring and chemical treatment

The content of wastewater resulting from the manufacture of rubber antioxidants and accelerators by a factory situated in the Ebro basin (Spain) has been determined using gas chromatography-mass spectrometry (GC-MS) and gas chromatography-flame ionization detection (GC-FID). The change in the pollutants was studied in the riverbed via two modules which continuously gathered pollutants on various solid supports (activated carbon and XAD-2 resins). These modules were located in Bocal Station, lying a further 100 km downstream from the factory, and from the Zaragoza water supply. Forty-six different compounds were identified at Bocal Station, the majority resulting from the production of rubber additives. Due to the immunity of different waste substances, and to the toxic nature of some, we studied their reaction when subjected to techniques of chemical oxidation using ozone.

[Patients with chronic airflow limitation: effects of the inspiratory muscle training with threshold load valve, built with appropriate technology, associated to nutritional support]

AIM

To assess prospectively the effects of a controlled program of inspiratory muscle training program and nutritional support in patients with chronic obstructive lung disease (COPD).

PATIENTS AND METHODS

Twenty-three patients with COPD were randomly assigned into four groups. Group I received a 1000 kcal/day nutritional supplement, given as a casein based enteral nutritional formula; group III was subjected to inspiratory muscle training, using an inexpensive pressure threshold load valve constructed according to the Appropriate Technology principles of the WHO, adjusted at 30% of Maximal Inspiratory Mouth Pressure and received also the nutritional supplement; group IV was trained but did not receive the nutritional supplement and group II was not trained nor supplemented. Patients were studied during three months and monthly, inspiratory muscle function, exercise capacity and anthropometry were measured.

RESULTS

A significant improvement in exercise capacity, maximal inspiratory pressure and inspiratory muscle endurance was observed in the four groups throughout the study. Trained subjects had greater improvement in their inspiratory muscle endurance, compared to untrained subjects. Nutritional support had no effect in inspiratory muscle function or exercise capacity. No changes in anthropometric measures were observed.

CONCLUSIONS

The pressure threshold load valve used in this study, improved inspiratory muscle endurance and nutritional support had no effect in patients with COPD.

Simple concentration method for bacteriophages of Bacteroides fragilis in drinking water

A membrane of inorganic material with a honeycomb pore structure was used to concentrate phages infecting Bacteroides fragilis from drinking water. Phages were removed from the membrane with 0.25 M glycine buffer pH 9.5. Phages were not inactivated by storage in this buffer neutralized to pH 7.0 for at least 9 days at 4 degrees C. The method allows recovery of around 50% in drinking water. When the turbidity of the water increased, the efficiency of the concentration decreased markedly. The efficiency of concentration was evaluated versus a presence/absence test in 317 water samples with turbidity level below the threshold of drinking water. Results obtained by concentration of 11 provided data which were significantly more informative than the presence/absence tests carried out on 100 ml. A number of additional tests carried out with both somatic and F-specific coliphages indicated that these conclusions can be extended to these groups of bacteriophages.

Anti-chaperone behavior of BiP during the protein disulfide isomerase-catalyzed refolding of reduced denatured lysozyme

Folding catalysts of the endoplasmic reticulum (ER), such as protein disulfide isomerase (PDI), accelerate the slow chemical steps, such as disulfide bond formation, that accompany protein folding. Molecular chaperones of the ER, notably the heavy chain-binding protein, BiP (grp78), bind and release unfolded proteins in an ATP-dependent fashion. In vitro, the fate of reduced, denatured lysozyme is dependent on whether the substrate interacts first with BiP or PDI. Depending on the ratio of PDI to substrate and order in which the components of the reaction are mixed, PDI can exhibit a foldase/chaperone activity, which increases the rate and extent of lysozyme refolding, or it can function as an anti-chaperone that promotes the formation of inactive, disulfide-linked lysozyme aggregates (Puig, A., and Gilbert, H.F. (1994) J. Biol. Chem. 269, 7764-7771). Reduced, denatured lysozyme, but not the native protein, interacts with BiP and efficiently stimulates its peptide-dependent ATPase activity. When present at substoichiometric amounts, BiP, like PDI, facilitates the formation of large, inactive lysozyme aggregates that are non-covalently associated with BiP. BiP and PDI compete for a limited number of sites in these insoluble aggregates. If BiP is present at a high molar excess, the chaperone binds unfolded lysozyme and inhibits its aggregation by maintaining it in a soluble, yet inactive, conformation, both in the presence or absence of ATP. Increasing concentrations of BiP decrease the extent, but not the initial rate, of refolding, suggesting that BiP and PDI compete for unfolded lysozyme and that the BiP-lysozyme complex is not a very good substrate for PDI either in the presence or absence of ATP. Depending on the BiP and PDI concentrations, unfolded lysozyme may either be efficiently refolded into the native conformation in a PDI-catalyzed reaction, or it may form both soluble and insoluble BiP-lysozyme complexes. In vitro, PDI- and BiP-facilitated aggregation, as well as the competition of the two proteins for substrate, reproduces many of the features of the quality control system of the ER.