A novel candidate gene in autosomal dominant facial pruritus

Pruritus is a common and often debilitating symptom that is associated with dermatological conditions including eczema, allergic contact dermatitis, urticaria, some drug eruptions and less commonly systemic diseases and neuropathic causes¹ . We report here an unusual familial centrofacial pruritus without any history or clinical findings of a rash, affecting three siblings and their father. The index patient (ll-1; Figure 1a) was a 62-year-old female with a 20-year history of severe localised pruritus of the nose. Her predominant symptom was debilitating itch on the surface of the skin around her nasal bridge, nasal septum and the nasal alae. She had no associated nasal congestion, rhinorrhea, skin changes nor rash and there was no relation to seasons, being outdoors, time of day, occupation, or food intake. Possible triggers included a warm environment and exercise.

Intradermal testing for autoimmune progesterone dermatitis: should we be basing the diagnosis on it?

Autoimmune progesterone dermatitis (APD) is a rare skin disorder with varying presentations, resulting from hypersensitivity to endogenous progesterone during the luteal phase of the menstrual cycle. The diagnosis has been traditionally confirmed with intradermal progesterone testing (IPT) or intramuscular challenge with progesterone or its derivatives. We present a case of a 31-year-old woman with suspected APD who underwent IPT to progesterone. The patient's cyclical symptoms, positive skin reaction and symptoms following IPT were sufficient to make a diagnosis of APD. However, we also tested 10 healthy female controls without symptoms of APD, and found that 9 of these also developed positive skin reactions to intradermal progesterone at 15 min, 24 and 48 h, albeit to a lesser extent. Therefore, these results raise doubts about the validity of using IPT to make a diagnosis of APD. Further research on appropriate testing is needed.

Potential methanol toxicity and the importance of using a standardised alcohol-based hand rub formulation in the era of COVID-19

OBJECTIVES

Hand sanitisers are urgently needed in the time of COVID-19, and as a result of shortages, some people have resorted to making their own formulations, including the repurposing of distilleries. We wish to highlight the importance of those producing hand sanitisers to avoid methylated spirits containing methanol and to follow WHO recommended formulations.

METHODS

We explore and discuss reports of methanol toxicity through ingestion and transdermal absorption. We discuss the WHO formulations and explain the rationale behind the chosen ingredients.

SHORT CONCLUSION

We advise those producing hand sanitisers to follow WHO recommended formulations, and advise those producing hand sanitisers using methylated spirits, to avoid formulations which contain methanol.

Prevalence of endocrine and genetic abnormalities in boys evaluated systematically for a disorder of sex development

STUDY QUESTION

What is the likelihood of identifying genetic or endocrine abnormalities in a group of boys with 46, XY who present to a specialist clinic with a suspected disorder of sex development (DSD)?

SUMMARY ANSWER

An endocrine abnormality of the gonadal axis may be present in a quarter of cases and copy number variants (CNVs) or single gene variants may be present in about half of the cases.

WHAT IS KNOWN ALREADY

Evaluation of 46, XY DSD requires a combination of endocrine and genetic tests but the prevalence of these abnormalities in a sufficiently large group of boys presenting to one specialist multidisciplinary service is unclear.

STUDY, DESIGN, SIZE, DURATION

This study was a retrospective review of investigations performed on 122 boys.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All boys who attended the Glasgow DSD clinic, between 2010 and 2015 were included in the study. The median external masculinization score (EMS) of this group was 9 (range 1-11). Details of phenotype, endocrine and genetic investigations were obtained from case records.

MAIN RESULTS AND THE ROLE OF CHANCE

An endocrine abnormality of gonadal function was present in 28 (23%) with a median EMS of 8.3 (1-10.5) whilst the median EMS of boys with normal endocrine investigations was 9 (1.5-11) (P = 0.03). Endocrine abnormalities included a disorder of gonadal development in 19 (16%), LH deficiency in 5 (4%) and a disorder of androgen synthesis in 4 (3%) boys. Of 43 cases who had array-comparative genomic hybridization (array-CGH), CNVs were reported in 13 (30%) with a median EMS of 8.5 (1.5-11). Candidate gene analysis using a limited seven-gene panel in 64 boys identified variants in 9 (14%) with a median EMS of 8 (1-9). Of the 21 boys with a genetic abnormality, 11 (52%) had normal endocrine investigations.

LIMITATIONS, REASONS FOR CAUTION

A selection bias for performing array-CGH in cases with multiple congenital malformations may have led to a high yield of CNVs. It is also possible that the yield of single gene variants may have been higher than reported if the investigators had used a more extended gene panel.

WIDER IMPLICATIONS OF THE FINDINGS

The lack of a clear association between the extent of under-masculinization and presence of endocrine and genetic abnormalities suggests a role for parallel endocrine and genetic investigations in cases of suspected XY DSD.

STUDY FUNDING/COMPETING INTEREST(S)

RN was supported by the James Paterson Bursary and the Glasgow Children's Hospital Charity Summer Scholarship. SFA, RM and EST are supported by a Scottish Executive Health Department grant 74250/1 for the Scottish Genomes Partnership. EST is also supported by MRC/EPSRC Molecular Pathology Node and Wellcome Trust ISSF funding. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

None.

An assessment of the quality of the I-DSD and the I-CAH registries - international registries for rare conditions affecting sex development

BACKGROUND

With the proliferation of rare disease registries, there is a need for registries to undergo an assessment of their quality against agreed standards to ensure their long-term sustainability and acceptability.This study was performed to evaluate the I-DSD and I-CAH Registries and identify their strengths and weaknesses.

METHODS

The design and operational aspects of the registries were evaluated against published quality indicators. Additional criteria included the level of activity, international acceptability of the registries and their use for research.

RESULTS

The design of the I-DSD and I-CAH Registries provides them with the ability to perform multiple studies and meet the standards for data elements, data sources and eligibility criteria. The registries follow the standards for data security, governance, ethical and legal issues, sustainability and communication of activities. The data have a high degree of validity, consistency and accuracy and the completeness is maximal for specific conditions such as androgen insensitivity syndrome and congenital adrenal hyperplasia. In terms of research output, the external validity is strong but the wide variety of cases needs further review. The internal validity of data was condition specific and highest for conditions such as congenital adrenal hyperplasia. The shift of the registry from a European registry to an international registry and the creation of a discrete but linked CAH registry increased the number of users and stakeholders as well as the international acceptability of both registries.

CONCLUSIONS

The I-DSD and I-CAH registries comply with the standards set by expert organisations. Recent modifications in their operation have allowed the registries to increase their user acceptability.

High correlation of VAS pain scores after 2 and 6 weeks of treatment with VAS pain scores at 12 weeks in randomised controlled trials in rheumatoid arthritis and osteoarthritis: meta-analysis and implications

Background

Researchers in clinical trials in rheumatoid arthritis (RA) and osteoarthritis (OA) often measure pain levels with a visual analogue scale (VAS). Of interest to clinical practice and future clinical trial design are associations of change from baseline (CFB) between time points with predictive ability of earlier response for long-term treatment benefit. We assessed the association and predictive ability of CFB in VAS pain between 2, 6 and 12 weeks in randomised controlled trials (RCTs) of non-steroidal anti-inflammatory drugs (NSAIDs).

Methods

Aggregated VAS pain data at baseline and CFB at 2, 6 and 12 weeks were collected from a systematic literature review of 176 RCTs in OA and RA. The predictive ability of earlier assessments for longer-term pain reduction was estimated using correlation and regression analyses. Analysis was performed using the R software package for statistical programming, version 3.1.1.

Results

Appropriate data were available from 50 RCTs (22,854 patients). Correlations between time points were high (weighted correlation coefficients between 2 and 6 weeks, 0.84; between 2 and 12 weeks, 0.79; and between 6 and 12 weeks, 0.96). CFB at 6 weeks was highly predictive and close to CFB at 12 weeks (regression coefficient 0.9, 95 % confidence interval 0.9–1.0). CFB at 2 weeks was significantly associated with CFB at 12 (0.8, 0.7–0.8) and 6 weeks (0.9, 0.8–1.0).

Conclusions

The results showed that early analgesic response measured by VAS for pain beyond 2 weeks of treatment with a particular NSAID is likely to be predictive of response at 12 weeks. Failure to achieve desired pain relief in OA and RA after 2 weeks should trigger reassessment of dosage and/or analgesic.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-0972-7) contains supplementary material, which is available to authorized users.

Review and comparison of methodologies for indirect comparison of clinical trial results: an illustration with ranibizumab and aflibercept

AIM

To review and compare methods for indirect comparison of aflibercept and ranibizumab in patients with diabetic macular edema.

METHODS

Post-stratification, inverse probability weighting based on simulated data, weight optimization, and regression model techniques were used to compare pooled individual patient-level data from the RESTORE and RESPOND (ranibizumab 0.5 mg as needed after 3 initial monthly doses) studies with summary-level data from the VIVID and VISTA (aflibercept 2.0 mg every 8 weeks after 5 initial monthly doses, 2q8) studies. The impact of adjusting for up to two baseline characteristics was assessed.

RESULTS

All methods provided similar results. After adjustment for baseline best-corrected visual acuity and central retinal thickness, no statistically significant difference in average gain in baseline best-corrected visual acuity from baseline at month 12 was found between ranibizumab 0.5 mg and aflibercept 2q8.

CONCLUSIONS

Weight optimization and regression methods are useful options to adjust for more than one baseline characteristic.

No evidence of disease activity: indirect comparisons of oral therapies for the treatment of relapsing-remitting multiple sclerosis

Introduction

No head-to-head trials have compared the efficacy of the oral therapies, fingolimod, dimethyl fumarate and teriflunomide, in multiple sclerosis. Statistical modeling approaches, which control for differences in patient characteristics, can improve indirect comparisons of the efficacy of these therapies.

Methods

No evidence of disease activity (NEDA) was evaluated as the proportion of patients free from relapses and 3-month confirmed disability progression (clinical composite), free from gadolinium-enhancing T1 lesions and new or newly enlarged T2 lesions (magnetic resonance imaging composite), or free from all disease measures (overall composite). For each measure, the efficacy of fingolimod was estimated by analyzing individual patient data from fingolimod phase 3 trials using methodologies from studies of other oral therapies. These data were then used to build binomial regression models, which adjusted for differences in baseline characteristics between the studies. Models predicted the indirect relative risk of achieving NEDA status for fingolimod versus dimethyl fumarate or teriflunomide in an average patient from their respective phase 3 trials.

Results

The estimated relative risks of achieving NEDA status for fingolimod versus placebo in a pooled fingolimod trial population were numerically greater (i.e., fingolimod more efficacious) than the estimated relative risks for dimethyl fumarate or teriflunomide versus placebo in each respective trial population. In indirect comparisons, the predicted relative risks for all composite measures were better for fingolimod than comparator when tested against the trial populations of those treated with dimethyl fumarate (relative risk, clinical: 1.21 [95% confidence interval 1.06–1.39]; overall: 1.67 [1.08–2.57]), teriflunomide 7 mg (clinical: 1.22 [1.02–1.46]; overall: 2.01 [1.38–2.93]) and teriflunomide 14 mg (clinical: 1.14 [0.96–1.36]; overall: 1.61 [1.12–2.31]).

Conclusion

Our modeling approach suggests that fingolimod therapy results in a higher probability of NEDA than dimethyl fumarate and teriflunomide therapy when phase 3 trial data are indirectly compared and differences between trials are adjusted for.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0167-z) contains supplementary material, which is available to authorized users.

Variations in the quality and sustainability of long-term glycaemic control with continuous subcutaneous insulin infusion

AIMS

To investigate the pattern of changes in HbA1c in people with Type 1 diabetes managed by long-term Continuous subcutaneous insulin infusion.

METHODS

We studied HbA1c changes using computerized clinic records in 35 adult people with Type 1 diabetes and an elevated HbA1c (≥ 64 mmol/mol, 8.0%) on multiple daily insulin injections, who were then switched to continuous subcutaneous insulin infusion for at least 5 years.

RESULTS

We identified three subgroups with similar baseline HbA1c but different long-term responses to pump therapy: group A--those with improvement followed by deterioration (57%); group B--those with improvement that was sustained throughout the 5 years (31%); and group C-those where HbA1c did not change significantly from baseline (12%). The patients in group C had a higher BMI: 31.0 ± 5.2 vs. 25.9 ± 3.3 vs. 25.2 ± 3.1 kg/m² (group C vs. group A and group B; P = 0.02).

CONCLUSIONS

Improved glycaemic control with continuous subcutaneous insulin infusion was maintained over 5 years by 88% of people with Type 1 diabetes in this study, but there were variations in the long-term efficacy, with some people improving and worsening, others maintaining strict control and a few subcutaneous insulin infusion 'non-responders'.

Benefit-risk assessment in a post-market setting: a case study integrating real-life experience into benefit-risk methodology

PURPOSE

Difficulties may be encountered when undertaking a benefit-risk assessment for an older product with well-established use but with a benefit-risk balance that may have changed over time. This case study investigates this specific situation by applying a formal benefit-risk framework to assess the benefit-risk balance of warfarin for primary prevention of patients with atrial fibrillation.

METHODS

We used the qualitative framework BRAT as the starting point of the benefit-risk analysis, bringing together the relevant available evidence. We explored the use of a quantitative method (stochastic multi-criteria acceptability analysis) to demonstrate how uncertainties and preferences on multiple criteria can be integrated into a single measure to reduce cognitive burden and increase transparency in decision making.

RESULTS

Our benefit-risk model found that warfarin is favourable compared with placebo for the primary prevention of stroke in patients with atrial fibrillation. This favourable benefit-risk balance is fairly robust to differences in preferences. The probability of a favourable benefit-risk for warfarin against placebo is high (0.99) in our model despite the high uncertainty of randomised clinical trial data. In this case study, we identified major challenges related to the identification of relevant benefit-risk criteria and taking into account the diversity and quality of evidence available to inform the benefit-risk assessment.

CONCLUSION

The main challenges in applying formal methods for medical benefit-risk assessment for a marketed drug are related to outcome definitions and data availability. Data exist from many different sources (both randomised clinical trials and observational studies), and the variability in the studies is large.

Reducing blood culture contamination rates: a systematic approach to improving quality of care

Contaminated blood cultures can have a deleterious effect on patient care; they may lead to longer hospital stays, unnecessary antibiotic therapy, needless removal of central lines, and redundant laboratory testing. A multidisciplinary quality improvement team from a western US health care system used an evidence-based process to define a system for obtaining blood culture specimens that subsequently decreased contamination rates from 3.7% to 1.7% with an estimated savings close to 2 million dollars in 2 years.

Methods for covariate adjustment in cost-effectiveness analysis that use cluster randomised trials

Statistical methods have been developed for cost-effectiveness analyses of cluster randomised trials (CRTs) where baseline covariates are balanced. However, CRTs may show systematic differences in individual and cluster-level covariates between the treatment groups. This paper presents three methods to adjust for imbalances in observed covariates: seemingly unrelated regression with a robust standard error, a 'two-stage' bootstrap approach combined with seemingly unrelated regression and multilevel models. We consider the methods in a cost-effectiveness analysis of a CRT with covariate imbalance, unequal cluster sizes and a prognostic relationship that varied by treatment group. The cost-effectiveness results differed according to the approach for covariate adjustment. A simulation study then assessed the relative performance of methods for addressing systematic imbalance in baseline covariates. The simulations extended the case study and considered scenarios with different levels of confounding, cluster size variation and few clusters. Performance was reported as bias, root mean squared error and CI coverage of the incremental net benefit. Even with low levels of confounding, unadjusted methods were biased, but all adjusted methods were unbiased. Multilevel models performed well across all settings, and unlike the other methods, reported CI coverage close to nominal levels even with few clusters of unequal sizes.

Developing appropriate methods for cost-effectiveness analysis of cluster randomized trials

AIM

Cost-effectiveness analyses (CEAs) may use data from cluster randomized trials (CRTs), where the unit of randomization is the cluster, not the individual. However, most studies use analytical methods that ignore clustering. This article compares alternative statistical methods for accommodating clustering in CEAs of CRTs.

METHODS

Our simulation study compared the performance of statistical methods for CEAs of CRTs with 2 treatment arms. The study considered a method that ignored clustering--seemingly unrelated regression (SUR) without a robust standard error (SE)--and 4 methods that recognized clustering--SUR and generalized estimating equations (GEEs), both with robust SE, a "2-stage" nonparametric bootstrap (TSB) with shrinkage correction, and a multilevel model (MLM). The base case assumed CRTs with moderate numbers of balanced clusters (20 per arm) and normally distributed costs. Other scenarios included CRTs with few clusters, imbalanced cluster sizes, and skewed costs. Performance was reported as bias, root mean squared error (rMSE), and confidence interval (CI) coverage for estimating incremental net benefits (INBs). We also compared the methods in a case study.

RESULTS

Each method reported low levels of bias. Without the robust SE, SUR gave poor CI coverage (base case: 0.89 v. nominal level: 0.95). The MLM and TSB performed well in each scenario (CI coverage, 0.92-0.95). With few clusters, the GEE and SUR (with robust SE) had coverage below 0.90. In the case study, the mean INBs were similar across all methods, but ignoring clustering underestimated statistical uncertainty and the value of further research.

CONCLUSIONS

MLMs and the TSB are appropriate analytical methods for CEAs of CRTs with the characteristics described. SUR and GEE are not recommended for studies with few clusters.

Statistical methods for cost-effectiveness analyses that use data from cluster randomized trials: a systematic review and checklist for critical appraisal

INTRODUCTION

The best data for cost-effectiveness analyses (CEAs) of group-level interventions often come from cluster randomized trials (CRTs), where randomization is by cluster (e.g., the hospital attended), not by individual.

METHODS

for these CEAs need to recognize both the correlation between costs and outcomes and that these data may be dependent on the cluster. General checklists and methodological guidance for critically appraising CEA ignore these issues. This article develops a new checklist and applies it in a systematic review of CEAs that use CRTs.

METHODS

The authors developed a checklist for CEAs that use CRTs, informed by a conceptual review of statistical methods. This checklist included criteria such as whether the analysis allowed for both clustering and the correlation between individuals' costs and outcomes. The authors undertook a systematic literature review of full economic evaluations that used CRTs. The quality of studies was assessed with the new checklist and by the "Drummond checklist."

RESULTS

The authors identified 62 papers that met the inclusion criteria. On average, studies satisfied 9 of the 10 criteria for the checklist but only 20% of criteria for the new checklist. More than 40% of studies adopted statistical methods that completely ignored clustering, and 75% disregarded any correlation between costs and outcomes. Only 4 studies employed appropriate statistical methods that allowed for both clustering and correlation.

CONCLUSIONS

Most economic evaluations that use data from CRTs ignored clustering or correlation. Statistical methods that address these issues are available, and their use should be encouraged. The new checklist can supplement generic CEA guidelines and highlight where research practice can be improved.

Bayesian Hierarchical Models for Cost-Effectiveness Analyses that Use Data from Cluster Randomized Trials

Cost-effectiveness analyses (CEA) may be undertaken alongside cluster randomized trials (CRTs) where randomization is at the level of the cluster (for example, the hospital or primary care provider) rather than the individual. Costs (and outcomes) within clusters may be correlated so that the assumption made by standard bivariate regression models, that observations are independent, is incorrect. This study develops a flexible modeling framework to acknowledge the clustering in CEA that use CRTs. The authors extend previous Bayesian bivariate models for CEA of multicenter trials to recognize the specific form of clustering in CRTs. They develop new Bayesian hierarchical models (BHMs) that allow mean costs and outcomes, and also variances, to differ across clusters. They illustrate how each model can be applied using data from a large (1732 cases, 70 primary care providers) CRT evaluating alternative interventions for reducing postnatal depression. The analyses compare cost-effectiveness estimates from BHMs with standard bivariate regression models that ignore the data hierarchy. The BHMs show high levels of cost heterogeneity across clusters (intracluster correlation coefficient, 0.17). Compared with standard regression models, the BHMs yield substantially increased uncertainty surrounding the cost-effectiveness estimates, and altered point estimates. The authors conclude that ignoring clustering can lead to incorrect inferences. The BHMs that they present offer a flexible modeling framework that can be applied more generally to CEA that use CRTs.

Cost-effectiveness of disease-modifying therapies in the management of multiple sclerosis for the Medicare population

OBJECTIVE

To evaluate the cost-effectiveness of disease-modifying therapies (DMTs) for the management of multiple sclerosis (MS) compared to best supportive care in the United States.

METHODS

Cost-effectiveness analysis was undertaken using a state transition model of disease natural history and the impact of DMTs for the representative Medicare beneficiary with MS. Costs and outcomes were evaluated from the health-care payer perspective using a 50-year time horizon. Natural history data were drawn from a longitudinal cohort study. The effectiveness of the DMTs was evaluated through a systematic review. Utility data were taken from a study of patients with clinically definite MS in Nova Scotia. Resource use and cost data were derived from the Sonya Slifka database and associated literature.

RESULTS

When based on placebo-controlled evidence, the marginal cost-effectiveness of interferon beta (IFNβ) and glatiramer acetate compared to best supportive care is expected to be in excess of $100,000 per quality-adjusted life-year gained. When evidence from head-to-head trials is incorporated into the model, the cost-effectiveness of 6 MIU IFNβ-1a is expected to be considerably less favorable. Treatment discontinuation upon progression to Expanded Disability Status Scale 7.0 is expected to improve the cost-effectiveness of all DMTs.

CONCLUSIONS

Further research is required to examine the long-term clinical effectiveness and cost-effectiveness of these therapies. There is no definitive guidance in the United States concerning discontinuation of DMTs; this study suggests that the prudent use of a treatment discontinuation rule may considerably improve the cost-effectiveness of DMTs.

Factors associated with resistance to dementia despite high Alzheimer disease pathology

BACKGROUND

Autopsy series have shown that some elderly people remain with normal cognitive function during life despite having high burdens of pathologic lesions associated with Alzheimer disease (AD) at death. Understanding why these individuals show no cognitive decline, despite high AD pathologic burdens, may be key to discovery of neuroprotective mechanisms.

METHODS

A total of 36 subjects who on autopsy had Braak stage V or VI and moderate or frequent neuritic plaque scores based on Consortium to Establish a Registry for Alzheimer's Disease (CERAD) standards were included. Twelve had normal cognitive function and 24 a diagnosis of AD before death. Demographic characteristics, clinical and pathologic data, as well as antemortem brain volumes were compared between the groups.

RESULTS

In multiple regression analysis, antemortem hippocampal and total brain volumes were significantly larger in the group with normal cognitive function after adjusting for gender, age at MRI, time from MRI to death, Braak stage, CERAD neuritic plaque score, and overall presence of vascular disease.

CONCLUSION

Larger brain and hippocampal volumes were associated with preserved cognitive function during life despite a high burden of Alzheimer disease (AD) pathologic lesions at death. A better understanding of processes that lead to preservation of brain volume may provide important clues for the discovery of mechanisms that protect the elderly from AD.

The distribution of the cost of multiple sclerosis in the UK: how do costs vary by illness severity?

OBJECTIVES

To derive robust estimates for the cost of multiple sclerosis (MS) based on a variety of cost factors across a number of different cost perspectives. This is essential to perform credible pharmacoeconomic evaluations of alternative MS therapies.

METHODS

Here we present a detailed analysis of previously published MS cost data for the UK to which we fit a seemingly unrelated regression. This allows us to assess the size and significance of different cost factors, and account for the covariance between cost perspectives.

RESULTS

We show that disability severity, disease type, relapse status, treatment type and time of treatment, sex, age, educational status, and time since diagnosis, are significant cost factors, with the significance of each dependent on the cost perspective chosen.

CONCLUSIONS

This analysis provides a statistical model that may be used to better estimate individual patient costs across a range of demographic and cost perspectives, for use by health planners and in pharmacoeconomic evaluations.

Multilevel models for estimating incremental net benefits in multinational studies

Multilevel models (MLMs) have been recommended for estimating incremental net benefits (INBs) in multicentre cost-effectiveness analysis (CEA). However, these models have assumed that the INBs are exchangeable and that there is a common variance across all centres. This paper examines the plausibility of these assumptions by comparing various MLMs for estimating the mean INB in a multinational CEA. The results showed that the MLMs that assumed the INBs were exchangeable and had a common variance led to incorrect inferences. The MLMs that included covariates to allow for systematic differences across the centres, and estimated different variances in each centre, made more plausible assumptions, fitted the data better and led to more appropriate inferences. We conclude that the validity of assumptions underlying MLMs used in CEA need to be critically evaluated before reliable conclusions can be drawn.

Modelling the cost effectiveness of TNF-alpha antagonists in the management of rheumatoid arthritis: results from the British Society for Rheumatology Biologics Registry

OBJECTIVE

To evaluate the cost effectiveness of TNF-alpha antagonist therapies for rheumatoid arthritis (RA) in the United Kingdom using data from the British Society for Rheumatology Biologics Registry (BSRBR).

METHODS

A simulation model is constructed to quantify the cost effectiveness of the TNF-alpha antagonist therapies (infliximab, etanercept and adalimumab) as a group versus traditional disease-modifying anti-rheumatic drugs, with a time horizon over the full patient lifetime. Participants are UK NHS patients in the BSRBR with RA who have failed at least two traditional disease-modifying anti-rheumatic drugs. The BSRBR aims to recruit all RA patients starting on a TNF-alpha antagonist agent and follows them 6 monthly via consultant and patient administered questionnaires. Data collected include disease activity scores (DAS28), the Health Assessment Questionnaire and the SF-36. Costs include drug, monitoring and hospitalisations. Benefits are measured in disability and quality of life improvements. The main outcome measure is the incremental cost per quality adjusted life-year gained (discounted).

RESULTS

The basecase cost per quality adjusted life-year gained by using TNF-alpha antagonist therapies is estimated at pound23 882, with probabilistic uncertainty analysis suggesting that the probability that treatments are below 30,000 pounds per QALY is around 84%. The results are most sensitive to assumptions concerning long-term disability progression, discount rates and the validity or otherwise of SF6D derived utility measures. Subgroup analysis, monotherapy versus combination with methotrexate, and a limited analysis of sequential therapy with two TNF-alpha antagonist agents, suggest cost-effectiveness ratios around 20,000 pounds to 30,000 pounds.

CONCLUSIONS

The BSRBR data provide valuable evidence for estimating cost-effectiveness. The analysis concludes that current policies and practice for the use of TNF-alpha antagonist therapies, after RA patients have failed at least two traditional disease-modifying anti-rheumatic drugs, appear cost-effective in the context of the NICE re-appraisal of 2006 for England and Wales, thus supporting their decision to continue their reimbursement. Decision-makers worldwide might adapt this analysis because differential costs, discount rates and other factors could affect results. There remains uncertainty, particularly on long-term disease progression. Further data collection using the BSRBR is recommended, together with a revision to this analysis when data become available.

The efficacy of inhibiting tumour necrosis factor alpha and interleukin 1 in patients with rheumatoid arthritis: a meta-analysis and adjusted indirect comparisons

OBJECTIVE

New treatments that inhibit the cytokines tumour necrosis factor alpha (TNFalpha) and interleukin 1 (IL-1) in the treatment of rheumatoid arthritis have proven clinical effect against placebo and methotrexate (MTX) in several clinical trials in early and late-stage disease and different severity groups. Since there are no head-to-head randomized controlled trials directly comparing the currently available treatments, etanercept, adalimumab, infliximab or anakinra, we perform a meta-analysis that adjusts for differences between study characteristics, and allows indirect comparisons between treatments.

METHODS

Thirteen trials of cytokine antagonists were included from a systematic review of the literature. They reported the primary outcome of American College of Rheumatology (ACR) response criteria at 6 months or beyond. Meta-analytical methods are used to quantify relative treatment effects, using the log odds ratio of an ACR20 or ACR50 response at 6 months, whilst adjusting for study-level variables.

RESULTS

In each of the trials, cytokine treatment was efficacious in comparison with placebo or MTX. For each treatment, the inclusion of MTX in combination improved the response. After adjustment for study-level variables, we found TNFalpha antagonists to be more efficacious compared with anakinra (P < 0.05). Indirect comparisons between the three TNFalpha antagonists indicated no difference in efficacy. Sensitivity analysis using a different statistical model structure confirmed these results.

CONCLUSION

When the outcome of interest is the probability of an ACR20 or ACR50 response at 6 months we found: (i) treatment with the IL-1 antagonist anakinra is better than placebo; (ii) for each treatment, the use of combination MTX improves the probability of response; (iii) treatment with any of the TNFalpha antagonists is better than with the IL-1 antagonist anakinra; and (iv) all drugs in the TNFalpha antagonist class are no different from each other.

Quantitative MRI reveals aging-associated T2 changes in mouse models of Alzheimer's disease

In this study, we used MRI to analyze quantitative parametric maps of transverse (T(2)) relaxation times in a longitudinal study of transgenic mice expressing mutant forms of amyloid precursor protein (APP), presenilin (PS1), or both (PS/APP), modeling aspects of Alzheimer's disease (AD). The main goal was to characterize the effects of progressive beta-amyloid accumulation and deposition on the biophysical environment of water and to investigate if these measurements would provide early indirect evidence of AD pathological changes in the brains of these mice. Our results demonstrate that at an early age before beta-amyloid deposition, only PS/APP mice show a reduced T(2) in the hippocampus and cortex compared with wild-type non-transgenic (NTg) controls, whereas a statistically significant within-group aging-associated decrease in T(2) values is seen in the cortex and hippocampus of all three transgenic genotypes (APP, PS/APP, and PS) but not in the NTg controls. In addition, for animals older than 12 months, we confirmed our previous report that only the two genotypes that form amyloid plaques (APP and PS/APP) have significantly reduced T(2) values compared with NTg controls. Thus, T(2) changes in these AD models can precede amyloid deposition or even occur in AD models that do not deposit beta-amyloid (PS mice), but are intensified in the presence of amyloid deposition.

The effect of disease, functional status, and relapses on the utility of people with multiple sclerosis in the UK

OBJECTIVES

Because published utility estimates in multiple sclerosis (MS) are concentrated in people with moderate to severe disease severity and focus on specific types of MS, we conducted a cross-sectional study of people with MS to estimate the utility associated with disease, functional status as measured by the Adapted Patient Determined Disease Steps (APDDS) Scale, and relapse to enhance knowledge of the association of these factors and utility.

METHODS

The study was conducted by a postal questionnaire sent to 12,968 people in a database managed by a UK charity (the MS Trust). Utility was assessed using the EQ-5D multiattribute utility scale. The APDDS is closely related to the more commonly reported Expanded Disability Status Scale (EDSS).

RESULTS

A total of 2708 (20.9%) questionnaires were returned and 2048 (15.8%) respondents provided data suitable for analysis. The mean age of the sample was 51 years, and 22.5% of people were aged 60 years or more. Disease severity was concentrated in people with moderately severe MS (EDSS 4-6.5), with 21%, 60%, and 19% of people reporting mild, moderate, and severe disease, respectively. Results show that disease severity has an inverse relationship with utility. The mean utility is 0.491. Utility varies between 0.870 and -0.195 for EDSS states 0 and 9. Number of years since diagnosis, type of disease, and recent relapse status are also all significantly associated with utility.

CONCLUSIONS

The results are comparable with previous published utility estimates. We have demonstrated a clear relationship between functional status, disease type, relapse status, duration of illness, and utility. As a set of coefficients, the utility estimates we have calculated may be used to compare the quality of life of people with MS with other illnesses and to inform future economic evaluations in MS.

Costs and quality of life of multiple sclerosis in the United Kingdom

This cost-of-illness analysis for the United Kingdom is part of a Europe-wide study on the costs of multiple sclerosis (MS). The objective was to analyze the costs and quality of life (utility) related to the level of disease severity. People with MS from a database administered by a UK charity (the MS Trust) were asked to participate in the survey by answering a postal questionnaire. In addition to details on the disease (type of disease, relapses, level of functional disability), the questionnaire asked for information on all resource consumption, medical, non-medical, work absence and informal care as well as utility. The response rate was 19%, and a total of 2048 people were included. The mean age of the cohort was 51 years, and 23% of people were > or =60 years of age. Disease severity was concentrated in people with moderately severe MS (Expanded Disability Status Scale [EDSS] score of 4 to 6.5), with 21, 60 and 19% of people reporting mild, moderate and severe disease, respectively. Costs and utility are highly correlated with disease severity. Mean annual costs for all people in the study increase from approximately pound 12.000 at an EDSS score <4 to almost pound 60.000 at an EDSS score > or =7. In particular, employment rates are reduced from 82% in early disease to 2% at an EDSS score of 8, while the costs of inpatient care, investments, informal care and productivity losses increase by more than tenfold between an EDSS score of 0-1 and a score > or =7. Utility decreases from 0.92 at an EDSS score of 0 to a state worse than death in the most severe state (-0.18 at an EDSS score of 9). Compared to the results in an earlier cost study in the United Kingdom using a comparable methodology, costs have substantially increased, by roughly 40%. Part of the increase is due to a higher use of disease-modifying drugs and, possibly linked with this, a higher use of ambulatory care and services. Another part of the increase is most likely due to an increased age in the current sample, with more patients on early retirement due to MS and more intense use of informal care. However, another reason may lie in the methodology, e.g. different unit costs or differences in the sample distribution, despite a similar mean EDSS score of 5.1.

Low rates of cutaneous adverse reactions to alcohol-based hand hygiene solution during prolonged use in a large teaching hospital

We assessed cutaneous adverse reactions (CARs) to alcohol-based hand rub (ABHR) after the introduction of a hand hygiene culture change program at our institution. CARs were infrequent among exposed health care workers (HCWs) (13/2,750; 0.47%; 1 CAR per 72 years of HCW exposure) and were not influenced by the duration or intensity of ABHR use but were associated with the presence of irritant contact dermatitis.

PRNP H187R mutation associated with neuropsychiatric disorders in childhood and dementia

Described is a large family with an autosomal dominant dementia associated with an H187R mutation in the prion protein gene (PRNP). Clinical features include neuropsychiatric disturbances in childhood and adolescence, dementia in young adulthood with frontotemporal manifestations, and long disease duration. Neuropathology revealed atrophy and mild gliosis, whereas prion protein analysis revealed an abnormal conformer with unusual sensitivity to protease digestion. Mutations in PRNP may cause neuropsychiatric disorders that predate dementia by many years.

Parametric modelling of cost data: some simulation evidence

Recently, commentators have suggested that the distributional form of cost data should be explicitly modelled to gain efficiency in estimating the population mean. We perform a series of simulation experiments to evaluate the usual sample mean and the mean estimator of a lognormal distribution, in the context of both theoretical distributions and three large empirical datasets. The sample mean is always unbiased, but is somewhat less efficient when the population distribution is truly lognormal. However the lognormal estimator can perform appallingly when the true distribution is not lognormal. In practical situations, where the true distribution is unknown, the sample mean generally remains the estimator of choice, especially when limited sample size prohibits detailed modelling of the cost data distribution.

Using multilevel models for assessing the variability of multinational resource use and cost data

Multinational economic evaluations often calculate a single measure of cost-effectiveness using cost data pooled across several countries. To assess the validity of pooling international cost data the reasons for cost variation across countries need to be assessed. Previously, ordinary least-squares (OLS) regression models have been used to identify factors associated with variability in resource use and total costs. However, multilevel models (MLMs), which accommodate the hierarchical structure of the data, may be more appropriate. This paper compares these different techniques using a multinational dataset comprising case-mix, resource use and cost data on 1300 stroke admissions from 13 centres in 11 European countries. OLS and MLMs were used to estimate the effect of patient and centre-level covariates on the total length of hospital stay (LOS) and total cost. MLMs with normal and gamma distributions for the data within centres were compared. The results from the OLS model showed that both patient and centre-level covariates were associated with LOS and total cost. The estimates from the MLMs showed that none of the centre-level characteristics were associated with LOS, and the level of spending on health was the centre-level variable most highly associated with total cost. We conclude that using OLS models for assessing international variation can lead to incorrect inferences, and that MLMs are more appropriate for assessing why resource use and costs vary across centres.

Imaging of iron oxide nanoparticles by MR and light microscopy in patients with malignant brain tumours

OBJECTIVE

Ferumoxtran-10 (Combidex), a dextran-coated iron oxide nanoparticle, provides enhancement of intracranial tumours by magnetic resonance (MR) for more than 24 h and can be imaged histologically by iron staining. Our goal was to compare ferumoxtran imaging and histochemistry vs. gadolinium enhancement in malignant brain tumours on preoperative and postoperative MR.

METHODS

Seven patients with primary and metastatic malignant tumours underwent MR imaging with gadolinium and ferumoxtran both pre- and postoperatively. Normalized signal intensities on the ferumoxtran-enhanced scans were determined in representative regions of interest. Resected tissue from six ferumoxtran patients and from three patients who did not receive ferumoxtran was assessed for localization of iron in tumour and reactive brain.

RESULTS

All malignant tumours (all of which enhanced by gadolinium MR) showed ferumoxtran accumulation with T1 and T2 signal changes, even using a 0.15 T intraoperative MR unit in one patient. Iron staining was predominantly in reactive cells (reactive astrocytes and macrophages) and not tumour cells. In five of the seven patients, including two patients who showed additional lesions, areas enhancing with ferumoxtran but not with gadolinium were observed. Comparison of the pre- and postoperative MR revealed residual ferumoxtran-enhancing areas in four of seven cases.

CONCLUSION

In malignant tumours, ferumoxtran may show areas of enhancement, even with a 0.15 T intraoperative MR, that do not enhance with gadolinium. Ferumoxtran-enhancing lesions have persistent increased T1 signal intensity for 2-5 days, which may provide advantages over gadolinium for postoperative imaging. Histochemistry for iron shows uptake of ferumoxtran in reactive cells (astrocytes and macrophages) rather than tumour cells.

Application of a non-linear image registration algorithm to quantitative analysis of T2 relaxation time in transgenic mouse models of AD pathology

Transgenic mouse models have been essential for understanding the pathogenesis of Alzheimer's disease (AD) including those that model the deposition process of beta-amyloid (Abeta). Several laboratories have focused on research related to the non-invasive detection of early changes in brains of transgenic mouse models of Alzheimer's pathology. Most of this work has been performed using regional image analysis of individual mouse brains and pooling the results for statistical assessment. Here we report the implementation of a non-linear image registration algorithm to register anatomical and transverse relaxation time (T2) maps estimated from MR images of transgenic mice. The algorithm successfully registered mouse brain magnetic resonance imaging (MRI) volumes and T2 maps, allowing reliable estimates of T2 values for different regions of interest from the resultant combined images. This approach significantly reduced the data processing and analysis time, and improved the ability to statistically discriminate between groups. Additionally, 3D visualization of intra-regional distributions of T2 of the resultant registered images provided the ability to detect small changes between groups that otherwise would not be possible to detect.

Endocytic disturbances distinguish among subtypes of Alzheimer's disease and related disorders

The endocytic pathway is important in amyloid precursor protein (APP) processing and beta-amyloid formation. Our studies have shown that endocytic pathway activation is a prominent and early feature of neurons in vulnerable regions of the brain in sporadic Alzheimer's disease. We report that endocytic pathway abnormalities are present not only in neurons, but in cerebral endothelia in Alzheimer's disease caused by certain APP mutations. The presence or absence of endocytic abnormalities distinguish subtypes of familial Alzheimer's disease linked to APP mutations from presenilin mutations, supporting the notion that different cellular pathways are involved in the altered processing of APP leading to increased beta-amyloid generation in certain of these different Alzheimer's disease subtypes.

Initial results of a study into the effectiveness of breast cancer screening in a population identified to be at high risk

BACKGROUND

Women are frequently referred to genetic clinics because of a family history of breast or ovarian cancer, conferring a moderate increased risk of the disease, but not sufficient in itself to indicate gene mutation analysis. One possible management strategy is to offer regular mammographic screening, possibly earlier in life and more frequently than in the general population. This strategy is used in many parts of the UK, although it has not been formally evaluated.

METHODS

In this paper we present some early results on the effectiveness of a programme of mammography in 2,998 women aged 19-71 with a moderate family history of breast cancer in Manchester. We estimated the test and programme sensitivity and sojourn time, using different statistical methods.

RESULTS

Fifty breast cancers were diagnosed. The incidence rate observed was 4.46 per thousand person-years. The incidence expected from the segregation analysis of Claus et al. was 3.75 per thousand person-years. Screen-detection rates at first and subsequent screens were 5.00 and 4.93 per thousand respectively. Interval cancer incidence in the first year following a negative screen was 0.91 per thousand person-years. Screening test sensitivity was estimated conservatively as 83%, programme sensitivity as 70%.

CONCLUSIONS

Early indications are that the programme is likely to be effective. Further follow-up, analysis of tumour size, node status and malignancy grade, and subsequent mortality from breast cancer is required to confirm this.

Cutaneous spectrum of coeliac disease

Coeliac disease is characterized by gluten intolerance and immunologically mediated damage to small intestinal mucosa. Patients classically present with gastrointestinal symptoms including chronic diarrhoea, steatorrhoea, weight loss, anorexia and abdominal distension. In a substantial proportion of cases however, gastrointestinal symptoms are minor or absent, and cutaneous manifestations may provide an early clue to diagnosis. Early recognition of coeliac disease, with appropriate implementation of a gluten-free diet, may reduce the incidence of benign and malignant complications associated with this condition.

Occupational skin disease in hairdressers

Hairdressers belong to an occupational group that is commonly affected by occupational skin disease, specifically contact dermatitis, which may be allergic or irritant and, less commonly, contact urticaria. Occupational contact dermatitis predominantly affects apprentices, and atopy is a recognized risk factor associated with a poor prognosis. Repetitive wet work leading to irritant contact dermatitis, followed by exposure to allergens and the development of allergic contact dermatitis, are the main factors contributing to occupational contact dermatitis. Once developed, it is often difficult to manage and is a cause of significant morbidity. Early education, training and prevention is the best approach to the management of this disorder that is endemic among hairdressers.

Reduction of use of latex gloves in food handlers: an intervention study

Frequent latex glove use is a risk factor for the development of latex allergy. With the increase in latex glove use, latex allergy has become more prevalent. There are a number of occupational groups in which the use of latex gloves is both inappropriate and even hazardous, including food handlers, where the hazard relates particularly to their latex-sensitive customers. The aim of this study was to assess both the use of latex gloves by food handlers and the impact of an intervention study on reducing latex glove use. This was done at the Queen Victoria Market in Melbourne, Australia. We found that 10 out of 30 stalls (33%) used latex gloves, and that following a short education program, this was reduced to 1 stall (3%, p=0.006). The potential to reduce latex glove use by using this intervention study was 93% (95% confidence interval of 54%-100%). We recommend that food handlers be educated during their training, not only about hygiene issues, but also about the appropriate type of glove to wear, in order to prevent both the development of a new occupational group at risk of becoming allergic to latex, but more importantly to protect their latex-sensitive customers.

Severe allergic contact dermatitis induced by paraphenylenediamine in paint-on temporary 'tattoos'

Paraphenylenediamine (PPD) is a black dye with well known sensitizing properties. Its increasing use as a skin paint to produce temporary 'tattoos' has led to recent reports of allergic contact dermatitis. Hitherto, such cases of allergic contact dermatitis due to PPD have been localized to the original site of application of the skin paint. We report two cases of severe allergic reactions to paint-on 'tattoos'. Both of these patients had no prior history of sensitivity to PPD, although case 2 had previously used permanent hair dyes. In both cases, the primary eruption at the 'tattoo' site was followed within days by a generalized eruption which ultimately required treatment with oral corticosteroids, because the initially prescribed topical corticosteroids proved ineffective.