Using machine learning with passive wearable sensors to pilot the detection of eating disorder behaviors in everyday life

BACKGROUND

Eating disorders (ED) are serious psychiatric disorders, taking a life every 52 minutes, with high relapse. There are currently no support or effective intervention therapeutics for individuals with an ED in their everyday life. The aim of this study is to build idiographic machine learning (ML) models to evaluate the performance of physiological recordings to detect individual ED behaviors in naturalistic settings.

METHODS

From an ongoing study (Final N = 120), we piloted the ability for ML to detect an individual's ED behavioral episodes (e.g. purging) from physiological data in six individuals diagnosed with an ED, all of whom endorsed purging. Participants wore an ambulatory monitor for 30 days and tapped a button to denote ED behavioral episodes. We built idiographic (N = 1) logistic regression classifiers (LRC) ML trained models to identify onset of episodes (~600 windows) v. baseline (~571 windows) physiology (Heart Rate, Electrodermal Activity, and Temperature).

RESULTS

Using physiological data, ML LRC accurately classified on average 91% of cases, with 92% specificity and 90% sensitivity.

CONCLUSIONS

This evidence suggests the ability to build idiographic ML models that detect ED behaviors from physiological indices within everyday life with a high level of accuracy. The novel use of ML with wearable sensors to detect physiological patterns of ED behavior pre-onset can lead to just-in-time clinical interventions to disrupt problematic behaviors and promote ED recovery.

The representation of authors of color in schizophrenia research articles published in high-impact psychiatric journals

OBJECTIVE

We evaluate how often scholars of color publish papers on schizophrenia in high-impact psychiatric journals, and whether they are more likely than white authors to prioritize race/ethnicity as a primary variable of interest in analyses.

METHODS

Prior work categorized the types of ethnoracial analyses reported in 474 papers about schizophrenia published in high-impact psychiatric journals between 2014 and 2016. In this study, the photographs of the first and last author for each paper were coded as "person of color" (POC) or "white". Additionally, each author was asked to self-report their race and ethnicity. The percentage of papers published by white versus POC authors was calculated. Chi-square analyses tested the hypotheses that (a) white scholars are more likely than POC scholars to conduct any sort of racial analysis; (b) POC scholars are more likely to conduct primary analyses by race/ethnicity; and (c) white scholars are more likely to analyze race/ethnicity as extraneous variables.

RESULTS

Eighteen percent of papers were published by POC first authors, and 17% were published by POC last authors. There were minimal differences in the types of analyses conducted by POC and white authors. Self-reported race/ethnicity showed that Asian scholars were the most highly represented within POC authors (9% of respondents), but only 3% of authors identified as Hispanic/Latinx and none identified as Black or Indigenous American.

CONCLUSIONS

People of color are underrepresented as authors in US-based schizophrenia research published in high-impact journals. Culturally-informed mentorship as well as prioritization of race/ethnicity in funding structures are important to increase representation of POC authors.

Short-chain fatty acids induce tissue plasminogen activator in airway epithelial cells via GPR41&43

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous chronic inflammatory disease generally divided based on the presence or absence of nasal polyps (NPs). One of the features of NPs is excessive fibrin deposition, which is associated with down-regulation of tissue plasminogen activator (t-PA) in NPs. As t-PA is expressed in epithelial cells, and epithelium is readily accessible to topical therapies, identifying compounds that can mediate the induction of t-PA would be a potential new strategy for the treatment of NPs.

OBJECTIVE

The objective of this study was to determine whether short-chain fatty acids (SCFAs) can induce t-PA in airway epithelial cells via their known receptors GPR41 and GPR43.

METHODS

We performed immunohistochemistry (IHC) to determine whether receptors for SCFAs, known as G protein-coupled receptor 41/free fatty acid receptor 3 (GPR41/FFAR3) and GPR43/FFAR2, are expressed in nasal tissue. Primary normal human bronchial epithelial (NHBE) cells were stimulated with different concentrations of SCFAs to test induction of t-PA, which was analysed by expression of mRNA and protein. Mediation of responses by SCFA receptors was evaluated by specific receptor gene silencing with siRNA.

RESULTS

Immunohistochemistry study revealed that airway epithelial cells expressed GPR41 and GPR43. Acetic acid, propionic acid, butyric acid and valeric acid significantly induced t-PA expression from two- to tenfolds. The strongest inducer of t-PA from NHBE cells was propionic acid; cells stimulated with propionic acid released t-PA into the supernatant in its active form. Gene silencing of GPR41 and GPR43 revealed that induction of t-PA by SCFAs was dependent upon both GPR41 and GPR43.

CONCLUSIONS AND CLINICAL RELEVANCE

Short-chain fatty acids were shown to induce airway epithelial cell expression of t-PA via GPR41 and GPR43. Topical delivery of potent compounds that activate these receptors may have value by reducing fibrin deposition and shrinking nasal polyp growth.

Psychologic theories in functional neurologic disorders

In this chapter we review key psychologic theories that have been mooted as possible explanations for the etiology of functional neurologic symptoms, conversion disorder, and hysteria. We cover Freudian psychoanalysis and later object relations and attachment theories, social theories, illness behavior, classic and operant conditioning, social learning theory, self-regulation theory, cognitive-behavioral theories, and mindfulness. Dissociation and modern cognitive neuroscience theories are covered in other chapters in this series and, although of central importance, are omitted from this chapter. Our aim is an overview with the emphasis on breadth of coverage rather than depth.

Elevated presence of myeloid dendritic cells in nasal polyps of patients with chronic rhinosinusitis

BACKGROUND

Although chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2 inflammation, the mechanism underlying the onset and amplification of this inflammation has not been fully elucidated. Dendritic cells (DCs) are major antigen-presenting cells, central inducers of adaptive immunity and critical regulators of many inflammatory diseases. However, the presence of DCs in CRS, especially in nasal polyps (NPs), has not been extensively studied.

OBJECTIVE

The objective of this study was to characterize DC subsets in CRS.

METHODS

We used real-time PCR to assess the expression of mRNA for markers of myeloid DCs (mDCs; CD1c), plasmacytoid DCs (pDCs; CD303) and Langerhans cells (LCs; CD1a, CD207) in uncinate tissue (UT) from controls and patients with CRS as well as in NP. We assayed the presence of DCs by immunohistochemistry and flow cytometry.

RESULTS

Compared to UT from control subjects (n = 15) and patients with CRS without NP (CRSsNP) (n = 16) and CRSwNP (n = 17), mRNAs for CD1a and CD1c were significantly elevated in NPs (n = 29). In contrast, CD207 mRNA was not elevated in NPs. Immunohistochemistry showed that CD1c(+) cells but not CD303(+) cells were significantly elevated in NPs compared to control subjects or patients with CRSsNP. Flow cytometric analysis showed that CD1a(+) cells in NPs might be a subset of mDC1s and that CD45(+) CD19(-) CD1c(+) CD11c(+) CD141(-) CD303(-) HLA-DR(+) mDC1s and CD45(+) CD19(-) CD11c(+) CD1c(-) CD141(high) HLA-DR(+) mDC2s were significantly elevated in NPs compared to UT from controls and CRSsNP, but CD45(+) CD11c(-) CD303(+) HLA-DR(+) pDCs were only elevated in NPs compared to control UT.

CONCLUSION AND CLINICAL RELEVANCE

Myeloid DCs are elevated in CRSwNP, especially in NPs. Myeloid DCs thus may indirectly contribute to the inflammation observed in CRSwNP.

The michigan autism spectrum questionnaire: a rating scale for high-functioning autism spectrum disorders

Although the DSM-5 has recently created a single category of autism spectrum disorder (ASD), delineation of its putative subtypes remains clinically useful. For this process, screening instruments should ideally be brief, simple, and easily available. The aim of this study is to describe the validity of one such instrument. We administered the Michigan Autism Spectrum Questionnaire (MASQ), a 10-item questionnaire, to 42 patients with ASD (age range 6-13 years, mean 9.7 years, SD 2.5, one female) and 18 patients with other psychiatric disorders (age range 6-17 years, mean 11.7 years, SD 3.8, 6 females). Responses to each item were scored from 0 to 4 yielding a total score of 30. Patients with intellectual disability were excluded. As a group, patients with ASD scored higher than those with other psychiatric disorders (Chi-square test with 1 df = 16.019, P < 0.0001). Within the ASD group, a linear discriminant analysis found that the best cut-off points were 22 or above for Asperger syndrome, 14 to 21 for autism/PDDNOS, and less than 14 for those with other psychiatric disorders. We propose that the MASQ can be used as a brief measure to screen high-functioning ASD from other psychiatric disorders and to identify its possible subtypes.

Systematic review of the psychological consequences of false-positive screening mammograms

BACKGROUND

In the UK, women aged 50-73 years are invited for screening by mammography every 3 years. In 2009-10, more than 2.24 million women in this age group in England were invited to take part in the programme, of whom 73% attended a screening clinic. Of these, 64,104 women were recalled for assessment. Of those recalled, 81% did not have breast cancer; these women are described as having a false-positive mammogram.

OBJECTIVE

The aim of this systematic review was to identify the psychological impact on women of false-positive screening mammograms and any evidence for the effectiveness of interventions designed to reduce this impact. We were also looking for evidence of effects in subgroups of women.

DATA SOURCES

MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register for Controlled Trials, Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination (CRD) Database of Abstracts of Reviews of Effects, CRD Health Technology Assessment (HTA), Cochrane Methodology, Web of Science, Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index-Science, Conference Proceeding Citation Index-Social Science and Humanities, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, the International Bibliography of the Social Sciences, the British Library's Electronic Table of Contents and others. Initial searches were carried out between 8 October 2010 and 25 January 2011. Update searches were carried out on 26 October 2011 and 23 March 2012.

REVIEW METHODS

Based on the inclusion criteria, titles and abstracts were screened independently by two reviewers. Retrieved papers were reviewed and selected using the same independent process. Data were extracted by one reviewer and checked by another. Each included study was assessed for risk of bias.

RESULTS

Eleven studies were found from 4423 titles and abstracts. Studies that used disease-specific measures found a negative psychological impact lasting up to 3 years. Distress increased with the level of invasiveness of the assessment procedure. Studies using instruments designed to detect clinical levels of morbidity did not find this effect. Women with false-positive mammograms were less likely to return for the next round of screening [relative risk (RR) 0.97; 95% confidence interval (CI) 0.96 to 0.98] than those with normal mammograms, were more likely to have interval cancer [odds ratio (OR) 3.19 (95% CI 2.34 to 4.35)] and were more likely to have cancer detected at the next screening round [OR 2.15 (95% CI 1.55 to 2.98)].

LIMITATIONS

This study was limited to UK research and by the robustness of the included studies, which frequently failed to report quality indicators, for example failure to consider the risk of bias or confounding, or failure to report participants' demographic characteristics.

CONCLUSIONS

We conclude that the experience of having a false-positive screening mammogram can cause breast cancer-specific psychological distress that may endure for up to 3 years, and reduce the likelihood that women will return for their next round of mammography screening. These results should be treated cautiously owing to inherent weakness of observational designs and weaknesses in reporting. Future research should include a qualitative interview study and observational studies that compare generic and disease-specific measures, collect demographic data and include women from different social and ethnic groups.

Revision of sediment quality triad indicators in Puget Sound (Washington, USA): I. a Sediment Chemistry Index and targets for mixtures of toxicants

The Washington State Department of Ecology annually conducts sediment quality monitoring in Puget Sound as a component of the Puget Sound Ecosystem Monitoring Program. Sediment samples are analyzed to determine the concentrations of about 170 chemical and physical variables. A Sediment Chemistry Index (SCI) was derived using the State of Washington Sediment Management Standards to account for the presence and concentrations of mixtures of toxicants. Mean Sediment Quality Standard quotients (mSQSq) were calculated as the basis for the SCI and compared to the incidence and degree of toxicity in laboratory tests and to metrics of the diversity and abundance of resident benthic assemblages in a database consisting of as many as 664 samples. These data were evaluated with co-occurrence analyses to identify "cut points" (i.e., thresholds) in the index below which the frequency and magnitude of biological effects were relatively low and above which they occurred with increasing frequency or magnitude. Iterative trials of different sets of cut points established the final cut points in mSQSq of 0.1, 0.3, and 0.5. They defined 4 ranges in chemical exposure: Minimum (<0.1), Low (0.1- < 0.3), Moderate (0.3- < 0.5), and Maximum (≥0.5). Across these 4 exposure ranges both the incidence and magnitude of toxicity in some laboratory tests increased, the abundance of most stress-sensitive benthic taxa decreased, and the abundance of most stress-tolerant taxa increased. The mSQSq cut point of 0.1 appears to be the target value for protection of benthic resources, the value below which the probability and magnitude of adverse effects either in the laboratory or the field are the lowest. The mSQSq values are rescaled from 0 to 100 to form the SCI, used by the Puget Sound Partnership and environmental managers as a Dashboard Indicator, with biologically relevant targets selected to monitor ecosystem recovery.

Early and late studies of EMD use in periodontal intrabony defects

BACKGROUND AND OBJECTIVE

The clinical efficacy of EMDs for the treatment of periodontal infrabony defects has been reported. However, recent publications have questioned the validity of results from early findings. Hence, the purpose of this study was to compare the results obtained from early and late studies when EMD was used as an adjunct in treating human intrabony defects during flap surgery. The aim of this meta-analysis was to evaluate the validity of results published from early studies compared with those published from later studies.

MATERIAL AND METHODS

PubMed and MEDLINE searches were performed. The evaluation period was 1997-2010 and it was divided into two groups of equal periods of time: early studies (1997-2003) and late studies (2004-2010). The clinical parameters assessed were clinical attachment level (CAL), probing pocket depth and bone gain (BG; measured as a percentage or in mm).

RESULTS

No statistically significant difference was found between the results obtained from early studies (1997-2003) and late studies (2004-2010) with regards to CAL gain, probing pocket depth reduction and BG. Nonetheless, both study periods showed a benefit for using EMD to treat periodontal infrabony defects when compared with the groups without EMD during open flap surgery.

CONCLUSIONS

The results obtained from this study failed to show any potential differences between the results published from early studies and late studies with regards to the clinical effectiveness of EMD in treating periodontal infrabony defects.

Incidence and risk factors of hepatocellular carcinoma recurrence after liver transplantation in the MELD era

BACKGROUND AND AIMS

Deceased donor liver transplantation (DDLT) rates for candidates with hepatocellular carcinoma (HCC) have significantly increased in the MELD era because of the extra priority given to these candidates. We examined the incidence and pre-DDLT radiological and donor factors associated with post-DDLT HCC recurrence in the MELD era.

METHODS

Outcomes of HCC candidates aged ≥18 years that underwent DDLT between 2/28/02 and 6/30/08 (n = 94) were reviewed. The primary outcome was biopsy-proven post-LT HCC recurrence at any site. Kaplan-Meier analysis was used to calculate the cumulative incidence and Cox regression was used to identify the predictors of post-LT HCC recurrence.

RESULTS

The median age of the 94 candidates who met the study criteria was 54 years, 64% had hepatitis C, median lab MELD was 13, and median pre-LT AFP was 47 ng/dl. Based upon pre-DDLT imaging, 94% candidates met the Milan criteria. The median waiting time to transplant was 47 days and 27% received pre-DDLT loco-regional therapy. Seventeen (18%) developed HCC recurrence after 2.1 median years with a cumulative incidence of 6.8, 12, and 19% at 1, 2, and 3 years post-DDLT. The pre-DDLT number of lesions (p = 0.015), largest lesion diameter (p = 0.008), and higher donor age (p = 0.002) were the significant predictors of HCC recurrence after adjusting for pre-LT loco-regional therapy and waiting time. Post-LT HCC recurrence (p < 0.0001) and higher donor age (p = 0.029) were associated with lower post-LT survival.

CONCLUSIONS

Post-LT HCC recurrence is higher in our MELD era cohort than the reported rate of 8% at 4 years in Mazzaferro et al.'s study. The risk of HCC recurrence was significantly associated with the number of lesions and size of the largest lesion at the time of DDLT as well as with older donor age. Risk stratification using a predictive model for post-LT HCC recurrence based on pre-LT imaging and donor factors may help guide candidate selection and tailoring of HCC surveillance strategies after LT.

Bone-anchored hearing aids (BAHAs) for people who are bilaterally deaf: a systematic review and economic evaluation

BACKGROUND

A bone-anchored hearing aid (BAHA) consists of a permanent titanium fixture, which is surgically implanted into the skull bone behind the ear, and a small detachable sound processor that clips onto the fixture. BAHAs are suitable for people with conductive or mixed hearing loss who cannot benefit fully from conventional hearing aids.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of BAHAs for people who are bilaterally deaf.

DATA SOURCES

Nineteen electronic resources, including MEDLINE, EMBASE and The Cochrane Library (inception to November 2009). Additional studies were sought from reference lists and clinical experts.

REVIEW METHODS

Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Prospective studies of adults or children with bilateral hearing loss were eligible. Comparisons were BAHAs versus conventional hearing aids [air conduction hearing aid (ACHA) or bone conduction hearing aid (BCHA)], unaided hearing and ear surgery; and unilateral versus bilateral BAHAs. Outcomes included hearing measures, validated measures of quality of life (QoL), adverse events and measures of cost-effectiveness. For the review of cost-effectiveness, full economic evaluations were eligible.

RESULTS

Twelve studies were included (seven cohort pre-post studies and five cross-sectional 'audiological comparison' studies). No prospective studies comparing BAHAs with ear surgery were identified. Overall quality was rated as weak for all included studies and meta-analysis was not possible due to differences in outcome measures and patient populations. There appeared to be some audiological benefits of BAHAs compared with BCHAs and improvements in speech understanding in noise compared with ACHAs; however, ACHAs may produce better audiological results for other outcomes. The limited evidence reduces certainty. Hearing is improved with BAHAs compared with unaided hearing. Improvements in QoL with BAHAs were identified by a hearing-specific instrument but not generic QoL measures. Studies comparing unilateral with bilateral BAHAs suggested benefits of bilateral BAHAs in many, but not all, situations. Prospective case series reported between 6.1% and 19.4% loss of implants. Most participants experienced no or minor skin reactions. A decision analytic model was developed. Costs and benefits of unilateral BAHAs were estimated over a 10-year time horizon, applying discount rates of 3.5%. The incremental cost per user receiving BAHA, compared with BCHA, was £ 16,409 for children and £ 13,449 for adults. In an exploratory analysis the incremental cost per quality-adjusted life-year (QALY) gained was between £ 55,642 and £ 119,367 for children and between £ 46,628 and £ 100,029 for adults for BAHAs compared with BCHA, depending on the assumed QoL gain and proportion of each modelled cohort using their hearing aid for ≥ 8 or more hours per day. Deterministic sensitivity analysis suggested that the results were highly sensitive to the assumed proportion of people using BCHA for ≥ 8 hours per day, with very high incremental cost-effectiveness ratio values (£ 500,000-1,200,000 per QALY gained) associated with a high proportion of people using BCHA. More acceptable values (£ 15,000-37,000 per QALY gained) were associated with a low proportion of people using BCHA for ≥ 8 hours per day (compared with BAHA).

LIMITATIONS

The economic evaluation presented in this report is severely limited by a lack of robust evidence on the outcome of hearing aid provision. This has lead to a more restricted analysis than was originally anticipated (limited to a comparison of BAHA and BCHA). In the absence of useable QoL data, the cost-effectiveness analysis is based on potential utility gains from hearing, that been inferred using a QoL instrument rather than measures reported by hearing aid users themselves. As a result the analysis is regarded as exploratory and the reported results should be interpreted with caution.

CONCLUSIONS

Exploratory cost-effectiveness analysis suggests that BAHAs are unlikely to be a cost-effective option where the benefits (in terms of hearing gain and probability of using of alternative aids) are similar for BAHAs and their comparators. The greater the benefit from aided hearing and the greater the difference in the proportion of people using the hearing aid for ≥ 8 hours per day, the more likely BAHAs are to be a cost-effective option. The inclusion of other dimensions of QoL may also increase the likelihood of BAHAs being a cost-effective option. A national audit of BAHAs is needed to provide clarity on the many areas of uncertainty surrounding BAHAs. Further research into the non-audiological benefits of BAHAs, including QoL, is required.

Negative predictive value of positron emission tomography and computed tomography for stage T1-2N0 non-small-cell lung cancer: a meta-analysis

BACKGROUND

Nodal staging of non-small-cell lung cancer (NSCLC) is crucial in evaluation of prognosis and determination of therapeutic strategy. This study aimed to determine the negative predictive value (NPV) of combined positron emission tomography and computed tomography (PET-CT) in patients with stage I (T1-2N0) NSCLC and to investigate the possible risk factors for occult nodal disease.

METHODS

Studies investigating the performance of PET in conjunction with CT in the nodal staging of stage I NSCLC were identified in the MEDLINE database. The initiative of standards for reporting of diagnostic accuracy (STARD) was used to ensure study quality. Pathologic assessments through mediastinoscopy or thoracotomy were required as the reference standard for evaluation of PET-CT accuracy. Stata-based meta-analysis was applied to calculate the individual and pooled NPVs.

RESULTS

Ten studies with a total of 1122 patients with stage I (T1-2N0) NSCLC were eligible for analysis. The NPVs of combined PET and CT for mediastinal metastases were 0.94 in T1 disease and 0.89 in T2 disease. Including both T1 disease and T2 disease, the NPVs were 0.93 for mediastinal metastases and 0.87 for overall nodal metastases. Adenocarcinoma histology type (risk ratio [RR], 2.72) and high fluorine-18 (18F) fluorodeoxyglucose (FDG) uptake in the primary lesion were associated with greater risk of occult nodal metastases.

CONCLUSIONS

Although overall occult nodal metastases in clinical stage T1-2N0 NSCLC is not infrequent, combined PET and CT provide a favorable NPV for mediastinal metastases in T1N0 NSCLC, suggesting a low yield from routine invasive staging procedures for this subgroup of patients.

The clinical effectiveness and cost-effectiveness of long-term weight management schemes for adults: a systematic review

OBJECTIVE

To assess the long-term clinical effectiveness and cost-effectiveness of multicomponent weight management schemes for adults in terms of weight loss and maintenance of weight loss.

DATA SOURCES

Bibliographic databases were searched from inception to December 2009, including the Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), and MEDLINE In-Process & Other Non-Indexed Citations. Bibliographies of related papers were screened, key conferences and symposia were searched and experts were contacted to identify additional published and unpublished references.

REVIEW METHODS

For the clinical effectiveness review, two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text of retrieved papers by one reviewer and checked by a second reviewer using a pre-piloted inclusion flow chart. The studies were long-term randomised controlled trials (RCTs) of adult participants who were classified by body mass index as overweight or obese. Interventions were multicomponent weight management programmes (including diet, physical activity and behaviour change strategies) that assessed weight measures. Programmes that involved the use of over-the-counter medicines licensed in the UK were also eligible. For the cost-effectiveness review two reviewers independently screened studies for inclusion. Cost-effectiveness, cost-utility, cost-benefit or cost-consequence analyses were eligible. Data were extracted using a standardised and pre-piloted data extraction form. The quality of included studies was assessed using standard criteria. Studies were synthesised through a narrative review with full tabulation of results.

RESULTS

A total of 3358 references were identified, of which 12 were included in the clinical effectiveness review. Five RCTs compared multicomponent interventions with non-active comparator groups. In general, weight loss appeared to be greater in the intervention groups than in the comparator groups. Two RCTs compared multicomponent interventions that focused on the diet component. In these studies there were no statistically significant differences in weight loss between interventions. Four RCTs compared multicomponent interventions that focused on the physical activity component. There was little consistency in the pattern of results seen, in part owing to the differences in the interventions. In one RCT the intervention focused on the goal-setting interval and it appeared that weight loss was greatest in those given daily goals compared with weekly goals. Overall, where measured, it appeared that most groups began to regain weight at further follow-up. Of the 419 studies identified in the cost-effectiveness searches, none met the full inclusion criteria. Two economic evaluations are described in our review; however, caution is required in their interpretation, as they did not meet all inclusion criteria. Lifetime chronic disease models were used in these studies and the models included the costs and benefits of avoiding chronic illness. Both studies found the interventions to be cost-effective, with estimates varying between -£473 and £7200 (US$12,640) per quality-adjusted life-year gained; methodological omissions from these studies were apparent and caution is therefore required in the interpretation of these results.

CONCLUSIONS

Long-term multicomponent weight management interventions were generally shown to promote weight loss in overweight or obese adults. Weight changes were small however and weight regain was common. There were few similarities between the included studies; consequently an overall interpretation of the results was difficult to make. There is some evidence that weight management interventions are likely to be cost-effective, although caution is required as there were some limitations in the two cost-evaluation studies described.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Enabling measurements of low-conductance single molecules using gold nanoelectrodes

A high resistance nanogap platform was used to trap and electrically characterize 30 nm thiolated double-stranded DNA molecules. High resolution scanning electron microscopy was also used to image the trapped DNA strands. It was found that the surface state of the electrodes and underlying substrate could influence the measurements of trapped molecules when the measured resistances were on the order of TΩ or greater. Hydrophilic surfaces gave rise to larger leakage currents that could potentially mask the underlying signals from molecules positioned in the nanogap. Finally, the careful handling of the samples and control of the environment is essential to avoid surface charging of the oxide substrate layer as these parasitic charges affect electrical measurements of the nanogap. The presented results thus outline some important considerations when making low-conductance measurements on molecules and should prove useful for the characterization of molecules in molecular electronics or sensors employing nanogap platforms.

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.

Outcomes of therapy: vancomycin-resistant enterococcal bacteremia in hematology and bone marrow transplant patients

PURPOSE

The purpose of this study was to evaluate the risk factors associated with the treatment failure and 30-day mortality in hematology and bone marrow transplant patients treated with daptomycin or linezolid for vancomycin-resistant enterococci (VRE) bacteremia. The safety and tolerability of therapy was also assessed.

METHODS

This single-center, retrospective study included adult patients admitted to the hematology or bone marrow transplant service with documented vancomycin-resistant Enterococcus faecium or Enterococcus faecalis bacteremia and received at least 48 h of either linezolid or daptomycin as primary treatment. Clinical and microbiologic outcomes were assessed at day 7, 14, and 30 of hospital stay.

RESULTS

A total of 72 patients were included in the analysis. Forty-three patients received daptomycin as primary treatment and 29 received linezolid as primary treatment. Overall success rate at day 7 was 81.9%, day 14 success rate was 79.2%, and day 30 success rate was 76.4% for all patients. Forty-one patients (57.0%) had high-grade bacteremia defined as greater than one positive blood culture for VRE. The mortality rate was significantly higher if high-grade bacteremia was present (34.1% vs. 7.0%; p = 0.009).

CONCLUSIONS

This study suggests that linezolid and daptomycin are both reasonable options for treating VRE bacteremia in hematology and bone marrow transplant patients; however, patients with high-grade VRE bacteremia may be at increased risk for treatment failure.

Assessment of a nanoparticle bridge platform for molecular electronics measurements

A combination of electron beam lithography, photolithography and focused ion beam milling was used to create a nanogap platform, which was bridged by gold nanoparticles in order to make electrical measurements and assess the platform under ambient conditions. Non-functionalized electrodes were tested to determine the intrinsic response of the platform and it was found that creating devices in ambient conditions requires careful cleaning and awareness of the contributions contaminants may make to measurements. The platform was then used to make measurements on octanethiol (OT) and biphenyldithiol (BPDT) molecules by functionalizing the nanoelectrodes with the molecules prior to bridging the nanogap with nanoparticles. Measurements on OT show that it is possible to make measurements on relatively small numbers of molecules, but that a large variation in response can be expected when one of the metal-molecule junctions is physisorbed, which was partially explained by attachment of OT molecules to different sites on the surface of the Au electrode using a density functional theory calculation. On the other hand, when dealing with BPDT, high yields for device creation are very difficult to achieve under ambient conditions. Significant hysteresis in the I-V curves of BPDT was also observed, which was attributed primarily to voltage induced changes at the interface between the molecule and the metal.

Systematic review of the effectiveness and cost-effectiveness of weight management schemes for the under fives: a short report

OBJECTIVE

To search for, review and synthesise studies of the effectiveness and cost-effectiveness of weight management schemes for the under fives.

DATA SOURCES

MEDLINE [Ovid], MEDLINE In-Process [Ovid], EMBASE [Ovid], CAB [Ovid], Health Management Information Consortium [Ovid], The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, Science Citation Index Expanded [Web of Science], Conference Proceedings Citation Index [The Web of Science], Database of Abstract Reviews [CRD; Centre for Reviews and Dissemination], HTA [CRD], PsycINFO [Ebsco], NHS CRD. These databases were searched from 1990 to February 2009. Supplementary internet searches were additionally conducted.

REVIEW METHODS

Relevant clinical effectiveness studies were identified in two stages. Titles and abstracts returned by the search strategy were examined independently by three researchers and screened for possible inclusion. Disagreements were resolved by discussion. Full texts of the identified studies were obtained. Three researchers examined these independently for inclusion or exclusion, and disagreements were again resolved by discussion.

RESULTS

One of the randomised controlled trials (RCTs) was from the UK. It measured the effects of a physical activity intervention for children in nurseries combined with home-based health education for their parents; this was compared to usual care. The main outcome measure was body mass index (BMI); secondary measures were weight and physical activity. At the 12-month follow-up, no statistically significant differences were found between the groups on any measure. However, a trend, favouring the intervention, was found for BMI and weight. The other two RCTs were from the USA. The larger trial investigated the effects of a combined preschool and home intervention in African American and Latino communities. Nutrition education and physical activity programmes were aimed at under fives in preschool. The home component consisted of related health education and homework for the parents, who received a small financial reward on completion. The 1- and 2-year results for the African American sites showed a significantly slower rate of increase in BMI than for results at baseline, for the intervention group than for the control group. However, in the Latino communities no such differences were found. The second US trial was a much smaller home-based parental education programme in Native American communities in the USA and Canada. The intervention consisted of a parental skills course for parents to improve their children's diet and physical activity. This was compared with a course providing skills to improve child behaviour. Follow-up was at 16 weeks and showed no significant differences between groups in BMI.

CONCLUSIONS

No controlled trials addressing the issue of treating obesity or evidence of cost-effectiveness studies in the under fives' population were found. From the three prevention studies, apart from the larger US trial, the interventions showed no statistically significant differences in BMI and weight between the intervention and control groups (although there was some evidence of positive trends for BMI and weight). It should also be noted that these conclusions are based on only three dissimilar studies, thereby making the drawing of firm conclusions difficult. Research is urgently needed in further well-designed UK-based RCTs of weight management schemes aimed at the prevention of obesity, that combine with cost-effectiveness studies targeted at preschool children with long-term follow-up.

Renal outcomes after liver transplantation in the model for end-stage liver disease era

The proportion of patients undergoing liver transplantation (LT) with renal insufficiency has significantly increased in the Model for End-Stage Liver Disease (MELD) era. This study was designed to determine the incidence and predictors of post-LT chronic renal failure (CRF) and its effect on patient survival in the MELD era. Outcomes of 221 adult LT recipients who had LT between February 2002 and February 2007 were reviewed retrospectively. Patients who were listed as status 1, were granted a MELD exception, or had living-donor, multiorgan LT were excluded. Renal insufficiency at LT was defined as none to mild [estimated glomerular filtration rate (GFR) >or= 60 mL/minute], moderate (30-59 mL/minute), or severe (<30 mL/minute). Post-LT CRF was defined as an estimated GFR < 30 mL/minute persisting for 3 months, initiation of renal replacement therapy, or listing for renal transplantation. The median age was 54 years, 66% were male, 89% were Caucasian, and 43% had hepatitis C. At LT, the median MELD score was 20, and 6.3% were on renal replacement therapy. After a median follow-up of 2.6 years (range, 0.01-5.99), 31 patients developed CRF with a 5-year cumulative incidence of 22%. GFR at LT was the only independent predictor of post-LT CRF (hazard ratio = 1.33, P < 0.001). The overall post-LT patient survival was 74% at 5 years. Patients with MELD >or= 20 at LT had a higher cumulative incidence of post-LT CRF in comparison with patients with MELD < 20 (P = 0.03). A decrease in post-LT GFR over time was the only independent predictor of survival. In conclusion, post-LT CRF is common in the MELD era with a 5-year cumulative incidence of 22%. Low GFR at LT was predictive of post-LT CRF, and a decrease in post-LT GFR over time was associated with decreased post-LT survival. Further studies of modifiable preoperative, perioperative, and postoperative factors influencing renal function are needed to improve outcomes following LT.

Sunitinib and bevacizumab for first-line treatment of metastatic renal cell carcinoma: a systematic review and indirect comparison of clinical effectiveness

Background:

Two new agents have recently been licensed for use in the treatment of metastatic renal cell carcinoma (RCC) in Europe. This paper aims to systematically review the evidence from all available randomised clinical trials of sunitinib and bevacizumab (in combination with interferon-α (IFN-α)) in the treatment of advanced metastatic RCC.

Methods:

Systematic literature searches were performed in six electronic databases. Bibliographies of included studies were searched for further relevant studies. Individual conference proceedings were searched using their online interfaces. Studies were selected according to the predefined criteria. All randomised clinical trials of sunitinib or bevacizumab in combination with IFN for treating advanced metastatic RCC in accordance with the European licensed indication were included. Study selection, data extraction, validation and quality assessment were performed by two reviewers with disagreements being settled by discussion. The effects of sunitinib and bevacizumab (in combination with IFN-α) on progression-free survival were compared indirectly using Bayesian Markov Chain Monte-Carlo (MCMC) sampling in Win BUGS, with IFN as a common comparator.

Results:

Three studies were included. Median progression-free survival was significantly prolonged with both interventions (from approximately 5 months to between 8 and 11 months) compared with IFN. Overall survival was also prolonged, compared with IFN, although the published data are not fully mature. Indirect comparison suggests that sunitinib is superior to bevacizumab plus IFN in terms of progression-free survival (hazard ratios 0.796; 95% CI 0.63–1.0; P=0.0272).

Conclusion:

There is evidence to suggest that treatment with sunitinib and treatment with bevacizumab plus IFN has clinically relevant and statistically significant advantages over treatment with IFN alone in patients with metastatic RCC.

Impact of fatness, insulin, and gynecological age on luteinizing hormone secretory dynamics in adolescent females

OBJECTIVE

To study the link between fatness and gonadotropin secretion. Overweight status is linked to polycystic ovary syndrome (PCOS) in adolescents. We postulated that heavier adolescents without symptoms would secrete LH with: [1] increased pulse frequency (LHPF) and [2] exaggerated integrated concentrations (LHAUC).

DESIGN

Cross-sectional.

SETTING

General clinical research center.

PATIENT(S)

Eighty-seven postmenarcheal cyclic adolescents from lean to overweight recruited during the follicular phase.

INTERVENTION(S)

Luteinizing hormone sampling: [1] every 10 minutes/24 hours; [2] at 20-minute intervals after a GnRH challenge.

MAIN OUTCOME MEASURE(S)

The LHPF and LHAUC (calculated by the CLUSTER algorithm). Hormonal and metabolic covariates included percent body fat (PercentBF), insulin-like growth factor-I (IGF-I), fasting insulin, and the insulin resistance index HOMA-IR. The SAS software was used for analyses.

RESULT(S)

The PercentBF and younger gynecological age predicted faster LHPF. Fatness was negatively linked to LHAUC, which was best predicted by PercentBF and IGF-1 in multivariate modeling (R(2) = 0.25). The PercentBF and insulin predicted a lower 20-minute LH response to GnRH.

CONCLUSION(S)

[1] Higher adiposity and younger gynecological age predict rapid LHPF. [2] The early years after menarche represent a vulnerable window for an exaggerated LHPF with weight gain. [3] In healthy adolescents, higher adiposity is linked to lower LHAUC, thereby preserving pituitary stores.

Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs

OBJECTIVES

To review the evidence on the clinical effects and associated treatment costs of surgical procedures and non-surgical devices for the management of non-apnoeic snoring.

DATA SOURCES

Major electronic databases were searched for relevant studies published between 1980 and 2007. All treatment costs were estimated based on data from NHS reference costs, device manufacturers and clinical opinion.

REVIEW METHODS

Studies were screened, data extracted and quality assessed according to standard methods. Results were broadly grouped according to the intervention and comparator when applicable, and further subgrouped according to the specific intervention type and study design. Results were combined using a narrative synthesis with relevant quantitative results tabulated. Differences between studies assessing the same intervention were explored narratively by examining differences in the intervention, study duration and study quality.

RESULTS

The systematic review included 27 studies (three randomised controlled trials, two controlled clinical trials and 22 pre-post studies) reported in 30 publications assessing uvulopalatopharyngoplasty (UP3) versus laser-assisted uvulopalatoplasty (LAUP), UP3 alone, LAUP alone, palatal stiffening techniques (Pillar implants and injection snoreplasty), radiofrequency ablation (RFA) of the soft palate or tongue base, continuous positive airway pressure (CPAP) devices and mandibular advancement splints (MAS). Studies were generally of a low methodological quality with small sample sizes. A total of 1191 patients was included. Both UP3 and LAUP reduced the number of snores per hour and produced a modest reduction in snoring loudness. UP3 was effective in reducing a number of subjectively reported snoring indices, but results on objective measures were equivocal. Limited evidence indicates that subjectively assessed snoring is improved after LAUP; no objective measures were assessed. RFA was associated with a reduction in partner-assessed snoring intensity, though evidence for an objective reduction in snoring sound levels was mixed. Pillar implants were moderately effective at reducing partner-rated snoring intensity, but had no effect on objective snoring indices. Use of CPAP reduced the number of snores per hour; no subjective measures were evaluated. Use of MAS improved objective snoring outcomes, including the maximal snoring sound volume, the mean snoring sound volume and the percentage of time spent in loud snoring; no subjective measures were evaluated. The cost for UP3 ranges from approximately 1230 pounds to approximately 1550 pounds. For LAUP the cost varies from 790 pounds to 2070 pounds depending on the number of stages of the procedure. The treatment costs associated with the use of Pillar implants range from 1110 pounds to 1160 pounds. The approximate annual treatment costs associated with the use of a CPAP machine and MAS are 220 pounds and 130 pounds respectively.

CONCLUSIONS

This study highlighted the paucity and poor quality of the evidence available on the effects of both surgical procedures and non-surgical devices for the management of primary snoring. Any conclusions to be drawn from the results are therefore somewhat tentative. There was no procedure that was clearly the least-cost option. Further research should focus on standardising methods of measuring outcomes and reporting, undertaking active controlled trials, and investigating the longer-term effects of treatments.

Time to full publication of studies of anti-cancer medicines for breast cancer and the potential for publication bias: a short systematic review

OBJECTIVES

To identify the expected delay between publication of conference abstracts and full publication of results from trials of new anti-cancer agents for breast cancer and to identify whether there are any apparent biases in publication and reporting.

DATA SOURCES

Major electronic databases were searched to identify randomised controlled trials (RCTs) of the selected interventions for the treatment of breast cancer.

REVIEW METHODS

A systematic review was conducted according to standard methods. Data were extracted from the included studies using a predesigned and piloted data extraction template.

RESULTS

Six anti-cancer treatments for breast cancer were included in the review: docetaxel, paclitaxel, trastuzumab, gemcitabine, lapatinib and bevacizumab. The literature searches generated 1556 references, from which 71 publications were retrieved and screened for inclusion. Screening identified 41 publications of 18 RCTs with at least one arm of treatment meeting the inclusion criteria for the review. Of the 18 included RCTs, only four publications (from three RCTs) reported the same outcomes in both an abstract and a full publication. Time between the abstract and full publication was 5 months in two cases, 7 months in one case and 19 months in one case (overall mean delay = 9 months). Eleven trials were identified that have not currently published in a full publication the data presented in an abstract or conference proceeding. The duration between publication of the abstracts and the end of August 2007 varied from 3 months to 38 months (mean delay 16.5 months). The longest delays in publication were for trials investigating gemcitabine (38 months) or bevacizumab (33 months). Observational analysis of the published and unpublished trials did not indicate any particular biases in terms of whether positive results were more likely to be fully published than non-significant ones.

CONCLUSIONS

It was surprising that only three of the 18 relevant RCTs had one or more full papers that reported the same outcome measures (and stage of analysis) as an earlier conference abstract. However, a limitation of this review is the small number of studies included. With a larger sample size than that in the present report, investigation into the effect of publication delay on decision-making might be feasible. Future research should include extension of this work to other anti-cancer drugs and investigation into the reasons for lengthy delays to full publication noted for some trials.

Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta2 agonists for the treatment of chronic asthma in children under the age of 12 years

OBJECTIVES

To assess the clinical and cost-effectiveness of inhaled corticosteroids (ICS) alone and ICS used in combination with a long-acting beta2 agonist (LABA) in the treatment of chronic asthma in children aged under 12 years.

DATA SOURCES

Major electronic bibliographic databases, e.g. MEDLINE and EMBASE, were searched up to February/March 2006 (and updated again in October 2006).

REVIEW METHODS

A systematic review of clinical and cost-effectiveness studies and economic analyses were carried out. A flexible framework was used to allow different types of economic analyses as appropriate, with either a cost comparison or cost-consequence comparison conducted.

RESULTS

Of 5175 records identified through systematic literature searching, 34 records describing 25 studies were included (16 were fully published randomised controlled trials, six were systematic reviews, and three were post-2004 conference abstracts). The most frequently reported relevant outcomes in the 16 RCTs were peak expiratory flow rate (13 trials), FEV1 (13 trials), symptoms (13 trials), adverse events or exacerbations (13 trials), use of rescue medication (12 trials), markers of adrenal function (e.g. blood or urine cortisol concentrations) (13 trials), height and/or growth rate (seven trials) and markers of bone metabolism (two trials). In the trials that compared low-dose ICS versus ICS and high-dose ICS versus ICS, no consistent significant differences or patterns in differential treatment effect among the outcomes were evident. Where differences were statistically significant at high doses, such as for lung function and growth, they favoured formoterol fumarate (FF), but this was generally in studies that did not compare the ICS at the accepted clinically equivalent doses. Differences between the drugs in impact on adrenal suppression were only significant in two studies. At doses of 200, 400 and 800 microg/day, beclometasone dipropionate (BDP) appears to be the current cheapest ICS product both with the inclusion and exclusion of chlorofluorocarbon (CFC)-propelled products. In the trials comparing ICS at a higher dose with ICS and LABA in combination, most outcomes favoured the combined inhaler. Only the combination inhaler, Seretide Evohaler, is slightly cheaper than the weighted mean cost of all types of ICS at increased dose except BDP 400 microg/day (including CFC-propelled products). Both the combination inhalers, Seretide Accuhaler and Symbicort Turbohaler, are more expensive than the weighted mean cost for all types of ICS at a two-fold increased dose. Compared with the lowest cost preparation for each ICS drug, all the combination inhalers are always more expensive than the ICS products at increased dose.

CONCLUSIONS

The limited evidence available indicates that there are no consistent significant differences in effectiveness between the three ICS licensed for use in children at either low or high dose. BDP CFC-propelled products are often the cheapest ICS currently available at both low and high dose, and may remain so even when CFC-propelled products are excluded. Exclusion of CFC-propelled products increases the mean annual cost of all budesonide (BUD) and BDP, while the overall cost differences between the comparators diminish. There is very limited evidence available for the efficacy and safety of ICS and LABAs in children. From this limited evidence, there appear to be no significant clinical differences in effects between the use of a combination inhaler versus the same drugs in separate inhalers. There is a lack of evidence comparing ICS at a higher dose with ICS and LABA in combination and comparing the combination products with each other. In the absence of any evidence concerning the effectiveness of ICS at higher dose with ICS and LABA, a cost-consequence analysis gives mixed results. There are potential cost savings with the use of combination inhalers compared to separate inhalers. At present prices, the BUD/FF combination is more expensive than those containing FP/SAL, but it is not known whether there are clinically significant differences between them. A scoping review is required to assess the requirements for additional primary research on the clinical effectiveness of treatment for asthma in children under 5 years old. Such a review could also usefully include all treatment options, pharmacological and non-pharmacological, for asthma. A direct head-to-head trial that compares the two combination therapies of FP/SAL and BUD/FF is warranted, and it is important to assess whether the addition of a LABA to a lower dose of ICS could potentially be as effective as an increased dose of ICS alone, but also be steroid sparing. There is also a need for the long-term adverse events associated with ICS use to be assessed systematically. Future trials of treatment for chronic asthma in children should aim to standardise further the way in which outcome measures are defined. There should be a greater focus on patient-centred outcomes to provide a more meaningful estimation of the impact of treatment on asthma control. Methods of reporting also require standardisation.

Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta2 agonists for the treatment of chronic asthma in adults and children aged 12 years and over

OBJECTIVES

To assess the clinical and cost-effectiveness of inhaled corticosteroids (ICS) alone and ICS used in combination with a long-acting beta2 agonist (LABA) in the treatment of chronic asthma in adults and children aged over 12 years.

DATA SOURCES

Major electronic bibliographic databases, e.g. MEDLINE and EMBASE, were searched up to February/March 2006 (and updated again in October 2006).

REVIEW METHODS

A systematic review of clinical and cost-effectiveness studies was conducted. Cost comparison and cost-consequence analyses were performed where appropriate.

RESULTS

The assessment of clinical effectiveness was based on the 67 randomised controlled trials selected from the 5175 reports identified through the systematic literature search. The most frequently reported relevant outcomes were lung function, symptoms, use of rescue medication and adverse events. The trials varied considerably. In the trials that compared low-dose ICS versus ICS and high-dose ICS versus ICS, there were few significant differences in clinical effectiveness, although a few of the trials had assessed non-inferiority between the comparators rather than superiority. At doses of 400, 800 and 'high-level' doses of 1500 or 1600 microg/day, beclometasone dipropionate (BDP) appears to be the current cheapest ICS product both with the inclusion and exclusion of chlorofluorocarbon (CFC)-propelled products. A significant treatment benefit for combination ICS/LABA therapy across a range of outcomes compared with ICS alone was identified [when the ICS was double the accepted clinically equivalent dose of the ICS in the combination inhaler, and dry powder inhalers (DPIS) were used to deliver the drugs]. When a formoterol fumarate (FF)/salmeterol (SAL) combination inhaler and a budesonide (BUD)/FF combination inhaler were each compared with their constituent drugs delivered in separate inhalers, there were very few statistically significant differences between the treatments across the various efficacy outcomes and the rate of adverse events. Combination inhalers were more often cheaper than doubling the dose of ICS alone. However, the costs were highly variable and dependent on both the dose required and the preparation used in the trials. The estimated mean annual cost of FP/SAL combination varied from being 94 pounds cheaper to 109 pounds more expensive than the alternative of BUD at a higher dose. The BUD/FF combination varied from being 163 pounds cheaper to 66 pounds more expensive than the higher dose of either BUD or FP. When the combination inhalers were compared to each other, the results were mixed, with the FP/SAL combination significantly superior on some outcomes and the BUD/FF combination superior on others; however, meta-analysis showed that there were no significant differences between the two treatments in the rate of adverse events. Taking an ICS with a LABA as either of the two currently available combination products, FP/SAL and BUD/FF, is usually cheaper than taking the relevant constituent drugs in separate inhalers. At very high doses of BUD (1600 microg/day), however, the BUD/FF combination inhaler can be up to 156 pounds more expensive than having the same drugs in separate inhalers. In terms of the relative costs associated with taking one of the combination inhalers, at low dose (400 microg BUD or 200 microg FP/day) the cheapest combination inhaler is FP/SAL as a pressurised metered dose inhaler (pMDI) (Seretide Evohaler). However, this is only slightly cheaper than using BUD/FF as a DPI (Symbicort Turbohaler). At higher dose levels (800 microg BUD or 500 microg FP/day) FP/SAL as either pMDI aerosol (Seretide Evohaler) or a DPI (Seretide Accuhaler) is the cheapest combination product available, but again only slightly cheaper than the DPI BUD/FF combination (Symbicort Turbohaler). It should be highlighted, however, that the three head-to-head trials that compared the effects of FP/SAL with BUD/FF used the FP/SAL DPI combination inhaler, Seretide Accuhaler.

CONCLUSIONS

The evidence indicates that there are few consistent significant differences in effects between the five ICS licensed for use in adults and adolescents over the age of 12 years, at either low or high dose. On average, BDP products currently tend to be the cheapest ICS available and tend to remain so as the daily ICS dose required increases. There is evidence that the addition of a LABA to an ICS is potentially more clinically effective than doubling the dose of ICS alone, although consistent significant differences between the two treatment strategies are not observed for all outcome measures. The cost differences between combination therapy compared with ICS monotherapy are highly variable and dependent on the dose required and the particular preparations used. For the combination therapies of ICS/LABA there are potential cost savings with the use of combination inhalers compared with separate inhalers, with few differences between the two treatment strategies in terms of effects. The only exception to this cost saving is with BUD/FF at doses higher than 1200 microg/day, where separate inhaler devices can become equivalent to or cheaper than combination inhalers. Neither of the two combination inhalers (FP/SAL or BUD/FF) is consistently superior in terms of treatment effect. A comparison of the costs associated with each combination therapy indicates that at low dose FP/SAL delivered via a pMDI is currently the cheapest combination inhaler but only marginally cheaper than BUD/FF delivered as a DPI. At higher doses, both the FP/SAL combination inhalers (PMDI and DPI) are marginally cheaper than BUD/FF (DPI). Future trials of treatment for chronic asthma should standardise the way in which outcome measures are defined and measured, with a greater focus on patient-centred outcomes. For informing future cost-utility and cost-effectiveness analyses from a UK NHS perspective, there is a need for longitudinal studies that comprehensively track the care pathways followed when people experience asthma exacerbations of different severity. Further research synthesis, quantifying the adverse effects of the different ICS, is required for treatment choices by patients and clinicians to be fully informed.

Chronic sepsis mortality characterized by an individualized inflammatory response

Late mortality in septic patients often exceeds the lethality occurring in acute sepsis, yet the immunoinflammatory alterations preceding chronic sepsis mortality are not well defined. We studied plasma cytokine concentrations preceding late septic deaths (days 6-28) in a murine model of sepsis induced by polymicrobial peritonitis. The late prelethal inflammatory response varied from a virtually nonexistent response in three of 14 to a mixed response in eight of 14 mice to the concurrent presence of nearly all measured cytokines, both proinflammatory and anti-inflammatory in three of 14 mice. In responding mice a consistent prelethal surge of plasma MIP-2 (1.6 vs 0.12 ng/ml in survivors; mean values), MCP-1 (2.0 vs 1.3 ng/ml), soluble TNF receptor type I (2.5 vs 0.66 ng/ml), and the IL-1 receptor antagonist (74.5 vs 3.3 ng/ml) was present, although there were infrequent increases in IL-6 (1.9 vs 0.03 ng/ml) and IL-10 (0.12 vs 0.04 ng/ml). For high mobility group box 1, late mortality was signaled by its decrease in plasma levels (591 vs 864 ng/ml). These results demonstrate that impeding mortality in the chronic phase of sepsis may be accurately predicted by plasma biomarkers, providing a mechanistic basis for individualized therapy. The pattern of late prelethal responses suggest that the systemic inflammatory response syndrome to compensatory anti-inflammatory response syndrome transition paradigm fails to follow a simple linear pattern.

Childhood body mass index and perioperative complications

BACKGROUND

Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children.

METHODS

This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children.

RESULTS

There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children.

DISCUSSION

Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.

The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation

OBJECTIVES

To establish the effectiveness and cost-effectiveness of cinacalcet for the treatment of secondary hyperparathyroidism (SHPT) for people on dialysis due to end-stage renal disease (ESRD).

DATA SOURCES

Electronic databases were searched up to February 2006.

REVIEW METHODS

Included randomised controlled trials (RCTs) on the clinical effectiveness of cinacalcet for SHPT in ESRD were critically appraised, had relevant data extracted and were summarised narratively. A Markov (state transition) model was developed that compared cinacalcet in addition to current standard treatment with phosphate binders and vitamin D to standard treatment alone. A simulated cohort of 1000 people aged 55 with SHPT was modelled until the whole cohort was dead. Incremental costs and quality-adjusted life-years (QALYs) were calculated. Extensive one-way sensitivity analysis was undertaken as well as probabilistic sensitivity analysis.

RESULTS

Seven trials comparing cinacalcet plus standard treatment with placebo plus standard treatment were included in the systematic review. A total of 846 people were randomised to receive cinacalcet. Cinacalcet was more effective at meeting parathyroid hormone (PTH) target levels (40% vs 5% in placebo, p < 0.001). In those patients meeting PTH targets, 90% also experienced a reduction in calcium-phosphate product levels, compared with 1% in placebo. Significantly fewer people treated with cinacalcet were hospitalised for cardiovascular events, although no difference was seen in all-cause hospitalisation or mortality. Significantly fewer fractures and parathyroidectomies were also seen with cinacalcet. Findings on all patient-based clinical outcomes were based on small numbers. The authors' economic model estimated that, compared to standard treatment alone, cinacalcet in addition to standard care costs an additional 21,167 pounds and confers 0.34 QALYs (or 18 quality-adjusted weeks) per person. The incremental cost-effectiveness ratio (ICER) was 61,890 pounds/QALY. In most cases, even extreme adjustments to individual parameters did not result in an ICER below a willingness-to-pay threshold of 30,000 pounds/QALY with probabilistic analysis showing only 0.5% of simulations to be cost-effective at this threshold. Altering the assumptions in the model through using different data sources for the inputs produced a range of ICERs from 39,000 pounds to 92,000 pounds/QALY.

CONCLUSIONS

Cinacalcet in addition to standard care is more effective than placebo plus standard care at reducing PTH levels without compromising calcium levels. However, there is limited information about the impact of this reduction on patient-relevant clinical outcomes. Given the short follow-up in the trials, it is unclear how data should be extrapolated to the long term. Together with the high drug cost, this leads to cinacalcet being unlikely to be considered cost-effective. Recommendations for future research include obtaining accurate estimates of the multivariate relationship between biochemical disruption in SHPT and long-term clinical outcomes.

Circulating cytokine/inhibitor profiles reshape the understanding of the SIRS/CARS continuum in sepsis and predict mortality

Mortality in sepsis remains unacceptably high and attempts to modulate the inflammatory response failed to improve survival. Previous reports postulated that the sepsis-triggered immunological cascade is multimodal: initial systemic inflammatory response syndrome (SIRS; excessive pro-, but no/low anti-inflammatory plasma mediators), intermediate homeostasis with a mixed anti-inflammatory response syndrome (MARS; both pro- and anti-inflammatory mediators) and final compensatory anti-inflammatory response syndrome (CARS; excessive anti-, but no/low proinflammatory mediators). To verify this, we examined the evolution of the inflammatory response during the early phase of murine sepsis by repetitive blood sampling of septic animals. Increased plasma concentrations of proinflammatory (IL-6, TNF, IL-1beta, KC, MIP-2, MCP-1, and eotaxin) and anti-inflammatory (TNF soluble receptors, IL-10, IL-1 receptor antagonist) cytokines were observed in early deaths (days 1-5). These elevations occurred simultaneously for both the pro- and anti-inflammatory mediators. Plasma levels of IL-6 (26 ng/ml), TNF-alpha (12 ng/ml), KC (33 ng/ml), MIP-2 (14 ng/ml), IL-1 receptor antagonist (65 ng/ml), TNF soluble receptor I (3 ng/ml), and TNF soluble receptor II (14 ng/ml) accurately predicted mortality within 24 h. In contrast, these parameters were not elevated in either the late-deaths (day 6-28) or survivors. Surprisingly, either pro- or anti-inflammatory cytokines were also reliable in predicting mortality up to 48 h before outcome. These data demonstrate that the initial inflammatory response directly correlates to early but not late sepsis mortality. This multifaceted response questions the use of a simple proinflammatory cytokine measurement for classifying the inflammatory status during sepsis.

Spatial extent of degraded sediment quality in Puget Sound (Washington State, U.S.A.) based upon measures of the sediment quality triad

A survey was designed and conducted to determine the severity, spatial patterns, and spatial extent of degraded sediment quality in Puget Sound (Washington State, USA). A weight of evidence compiled from results of chemical analyses, toxicity tests, and benthic infaunal analyses was used to classify the quality of sediments. Sediment samples were collected from 300 locations within a 2363 km(2) area extending from the US/Canada border to the inlets of southern Puget Sound and Hood Canal. Degraded conditions, as indicated with a combination of high chemical concentrations, significant toxicity, and adversely altered benthos, occurred in samples that represented about 1% of the total area. These conditions invariably occurred in samples collected within urbanized bays and industrial waterways, especially near the urban centers of Everett, Seattle, Tacoma, and Bremerton. Sediments with high quality (as indicated by no toxicity, no contamination, and the presence of a relatively abundant and diverse infauna) occurred in samples that represented a majority (68%) of the total study area. Sediments in which results of the three kinds of analyses were not in agreement were classified as intermediate in quality and represented about 31% of the total area. Relative to many other estuaries and marine bays of the USA, Puget Sound sediments ranked among those with minimal evidence of toxicant-induced degradation.

Viscoelastic characterization of compacted pharmaceutical excipient materials by analysis of frequency-dependent mechanical relaxation processes

A newly developed method for determining the frequency-dependent complex Young's modulus was employed to analyze the mechanical response of compacted microcrystalline cellulose, sorbitol, ethyl cellulose and starch for frequencies up to 20 kHz. A Debye-like relaxation was observed in all the studied pharmaceutical excipient materials and a comparison with corresponding dielectric spectroscopy data was made. The location in frequency of the relaxation peak was shown to correlate to the measured tensile strength of the tablets, and the relaxation was interpreted as the vibrational response of the interparticle hydrogen and van der Waals bindings in the tablets. Further, the measured relaxation strength, holding information about the energy loss involved in the relaxation processes, showed that the weakest material in terms of tensile strength, starch, is the material among the four tested ones that is able to absorb the most energy within its structure when exposed to external perturbations inducing vibrations in the studied frequency range. The results indicate that mechanical relaxation analysis performed over relatively broad frequency ranges should be useful for predicting material properties of importance for the functionality of a material in applications such as, e.g., drug delivery, drug storage and handling, and also for clarifying the origin of hitherto unexplained molecular processes.

Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria

STUDY OBJECTIVE

We determine whether the use of an emergency medical services (EMS) protocol for selective spine immobilization would result in appropriate immobilization without spinal cord injury associated with nonimmobilization.

METHODS

A 4-year prospective study examined EMS and hospital records for patients after the implementation of an EMS protocol for selective spine immobilization. EMS personnel were trained to perform and document a spine injury assessment for out-of-hospital trauma patients with a mechanism of injury judged sufficient to cause a spine injury. The assessment included these clinical criteria: altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness. The protocol required immobilization for patients with a positive assessment on any of those criteria. Outcome characteristics included the presence or absence of spine injury and spine injury management.

RESULTS

The study collected data on 13,483 patients; 126 of the patients were subsequently excluded from the study because of incomplete data, leaving a study sample of 13,357 patients with complete data. Spine injuries were confirmed in the hospital records for 3% (n=415) of patients, including 50 patients with cord injuries and 128 patients with cervical injuries. Sensitivity of the EMS protocol was 92% (95% confidence interval [CI] 89.4 to 94.6%) resulting in nonimmobilization of 8% of the patients with spine injuries (33 of 415). None of the nonimmobilized patients sustained cord injuries. The specificity was 40% (95% CI 38.9 to 40.5%).

CONCLUSION

The use of our selective immobilization protocol resulted in spine immobilization for most patients with spine injury without causing harm in cases in which spine immobilization was withheld.