Making it happen: managed care considerations in vanquishing hepatitis C

Chronic hepatitis C virus (HCV) infection is an area of medical and economic concern. Studies show a substantial and increasing use of healthcare resources by patients with this disease. However, analysis of available data regarding virologic efficacy, impact on outcomes, and cost-effectiveness in chronic HCV infection appear to justify the initial costs for antiviral treatment, considering the future cost savings generated by prevention of liver disease. To further demonstrate cost-effectiveness, enhanced methods for identifying and treating patients are needed. Greater clinician awareness of available guidelines, patient education, close monitoring of antiviral therapy, emphasis on adherence to therapy, and management of adverse effects are recommended to ensure the best possible care for patients and to maximize outcomes.

Managed care considerations

Managed care issues arising from excessive daytime sleepiness (EDS), which impacts as many as 37% of adults, are widespread. In the United States, insomnia is among the 3 most common complaints. Often it is younger people who have difficulty falling asleep, whereas their elders report more difficulty remaining asleep. Currently, people in the United States sleep 25% fewer hours than they did 100 years ago. Chronic sleep deprivation may be a choice driven by economic or social factors. Industrialized countries engage about 20% of the work force in shifts, and people working night shifts are thought to average 8 fewer hours of sleep each week than day workers. Falling asleep behind the wheel is the single most imminent risk associated with excessive sleepiness.

Patient identification

The homeostatic sleep drive and circadian arousal, each opposing the other, form the neurobiological bases of the sleep and wake states. Many factors can and do disrupt this cycle. Yet, excessive daytime sleepiness is not only common, and it often goes unrecognized. It can contribute to accidents, produce or exacerbate health conditions, reduce efficiency and productivity, interfere with social relationships, and diminish quality of life. The spectrum of common sleep disorders includes circadian rhythm changes, shiftwork requirements, obstructive sleep apnea, narcolepsy, and difficulty in initiating or maintaining sleep, also known as insomnia. In many cases, however, sleep deprivation is the choice of the patient, chosen in response to long commutes, academic rigor, or occupational matters. Regardless of the sleep disorder that a patient has, good sleep behavior or "sleep hygiene" is essential.

Patient-management strategies

An active cortex is necessary for intact cognitive function. In a sleepy individual, the cerebral cortex is to some extent deactivated; a sleep-deprived person will experience reduced physical and mental activity and productivity, more errors on the job, more risk for motor vehicle accidents, and psychosocial problems. Hormone levels can become imbalanced from excessive daytime sleepiness (EDS), and treatments for conditions unrelated to EDS can be hampered. Whether sleep restriction is voluntary or not, those who experience it habitually are at greater risk of obesity and type 2 diabetes. While an accurate history is necessary to diagnose sleep disorders, all too often a patient's chronic daytime sleepiness is never mentioned. EDS will not show up in most blood chemistries either. It is important that primary care providers ask patients about their sleep and its quality. Other screening tools include questionnaires, which are easily administered and can be sensitive. To determine the basis of EDS, formal sleep studies may be necessary.

Pulsed electrochemical detection of thiols and disulfides following capillary electrophoresis

Pulsed electrochemical detection (PED) following capillary electrophoresis (CE) has been applied to the direct detection of thiocompounds. Both reduced and oxidized thiol moieties are detected without the need of derivatization. Thiocompounds can be detected over a wide range of pH conditions (i.e., pH 0-14), and except for pH, their response is relatively unperturbed by buffer composition. Integrated pulsed amperometric detection (IPAD) results in more stable baselines, eliminates oxide-induced artifacts, and yields lower limits of detection than other PED waveforms. Mass detection limits using optimized IPAD waveforms are typically 2 pg (5 fmol) or less. The high selectivity of PED for thiocompounds reduces sample preparation and produces simpler electropherograms of complex samples containing these biologically significant compounds.

Pulsed electrochemical detection of nonchromophoric compounds following capillary electrophoresis

Pulsed electrochemical detection (PED) following capillary electrophoresis (CE) has been applied to the direct detection of polar aliphatic compounds. These compounds typically have poor optical detection properties and are considered to be electroinactive under constant applied potentials. The voltammetric responses at microelectrodes of model compounds were studied under various buffers and pH conditions. The detection of unsubstituted carbohydrates requires highly alkaline conditions, whereas amine-containing compounds (e.g., glycopeptides, peptides, and amino acids) and thiocompounds can best be detected at mildly alkaline (i.e., pH 9.0) and mildly acidic (i.e., pH 5.5) conditions, respectively. In a comparative study of pulsed amperometric detection (PAD) and integrated pulsed amperometric detection (IPAD), IPAD is determined to be better suited to manage the large oxide-formation backgrounds, which accompany oxide-catalyzed detections of amine- and sulfur-containing compounds. IPAD results in more stable baselines, eliminates oxide-induced artifacts, and often yields lower limits of detection. Mass detection limits under optimal conditions are typically 10 fmole or less. This paper delineates PED waveform parameters for the optimal detection of underivatized nonchromophoric compounds of biological significance in various operating buffers and electrolytes.