Cost-effectiveness of interferon-gamma release assay testing for the treatment of latent tuberculosis.

The aim of the present study was to assess the cost-effectiveness of the new T-SPOT.TB assay versus the tuberculin skin test (TST) for screening contacts for latent tuberculosis (TB) infection in Switzerland. Health and economic outcomes of isoniazid treatment of 20- and 40-yr-old close contacts were compared in a Markov model over a 20-yr period following screening with TST only (at three cut-off values) and T-SPOT.TB alone or in combination with the TST. T-SPOT.TB-based treatment was cost-effective at (Euro)11,621 and (Euro)23,692 per life-year-gained (LYG) in the younger and older age group, respectively. No TST-based programmes were cost-effective, except at a 15-mm cut-off in the younger group only, where the cost-effectiveness ((Euro)26,451.LYG(-1)) fell just below the willingness-to-pay threshold. Combination of the TST with T-SPOT.TB slightly reduced the total cost compared with the T-SPOT.TB alone by 4.4 and 5.0% in the younger and older groups respectively. The number of contacts treated to avoid one case of TB decreased from 50 (95% confidence interval 32-106) with the TST (10-mm cut-off) to 18 (95%CI 11-43) if T-SPOT.TB was used. Using T-SPOT.TB alone or in combination with the tuberculin skin test for screening of close contacts before latent tuberculosis infection treatment is highly cost-effective in reducing the disease burden of tuberculosis.     

Cost-effectiveness of interferon-gamma release assay screening for latent tuberculosis infection treatment in Germany

OBJECTIVES: To assess the cost-effectiveness of the new QuantiFERON-TB Gold In-Tube (QFT-G) [Cellestis; Carnegie, VIC, Australia] assay for screening and treating of persons who have had close contact with tuberculosis (TB) patients and are suspected of having latent tuberculosis infection (LTBI) [hereafter called close-contacts] in Germany. METHODS: The health and economic outcomes of isoniazid treatment of 20-year-old close-contacts were compared in a Markov model over a period of 20 years, using two different cutoff values for the tuberculin skin test (TST), the QFT-G assay alone, or the QFT-G assay as a confirmatory test for the TST results. RESULTS: QFT-G assay-based treatment led to cost savings of $542.9 and 3.8 life-days gained per LTBI case. TST-based treatment at a 10-mm induration size cutoff gained $177.4 and 2.0 life-days gained per test-positive contact. When the cutoff induration size for the TST was reduced to 5 mm, the incremental cost-effectiveness ratio fell below the willingness-to-pay threshold ($30,170 per life-years gained) but resulted in unnecessary treatment of 77% of contacts owing to false-positive TST results. Combination with the 5-mm induration size TST cutoff value compared to the results of the QFT-G assay alone reduced the total costs per 1,000 contacts by 1.8% to $222,869. The number treated to prevent 1 TB case was 22 for the two QFT-G assay-based procedures, 40 for the TST at a cutoff induration size of 10 mm, and 96 for the TST at a cutoff induration size of 5 mm. When the sensitivity rates of the TST and the QFT-G assay were compounded, the QFT-G assay strategy alone was slightly less costly (0.6%) than the two-step approach. CONCLUSIONS: Using the QFT-G assay, but especially combining the QFT-G assay following the TST screening of close-contacts at a cutoff induration size of 5 mm before LTBI treatment is highly cost-effective in reducing the disease burden of TB.     

Cost-effectiveness of postexposure prophylaxis after sexual or injection-drug exposure to human immunodeficiency virus

BACKGROUND: The cost-effectiveness of interventions that provide human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) to individuals after sexual or injection-drug use exposures depends on the distribution of exposure routes, prevalence of infection among source partners, adherence to PEP regimens, medical care costs, and prevailing epidemiologic contexts, among other factors. OBJECTIVE: To determine the cost-effectiveness of a comprehensive program to prevent HIV infection after sexual or injection-drug use exposure for 401 persons seeking PEP in an urban community. METHODS: We conducted a retrospective cost analysis to evaluate the cost of the PEP intervention, then combined this information with model-based effectiveness estimates to determine the PEP program's "cost-utility ratio," which is the ratio of net program costs to the total number of quality-adjusted life-years (QALYs) saved by the program. RESULTS: The average cost of the PEP regimen was $1222, and the total cost of the program was $450 970. The PEP program prevented an estimated 1.26 HIV infections, saved 11.74 QALYs, and averted $281 323 in future HIV-related medical care costs. The overall cost-utility ratio was $14 449 per QALY saved. When analysis was restricted to men reporting receptive anal intercourse, the savings in averted HIV-related medical care costs exceeded the cost of the program. The results were generally robust to changes in key parameter values but were sensitive to assumptions about the HIV transmission probability for receptive anal intercourse. CONCLUSIONS: For this study population, HIV PEP was cost-effective by conventional standards and cost-saving for persons seeking PEP after male-male receptive anal intercourse.     

肺结核全肺切除近期并发症的治疗

目的 探讨肺结核全肺切除后并发症的诊断和治疗.方法 对北京胸科医院胸外科2000年9月至2010年9月经全肺切除治疗的206例肺结核患者术后近期手术并发症及其治疗效果进行回顾性分析.结果 206例中发生近期手术并发症的26例,术前病变类型:毁损肺12例,肺叶切除后余肺毁损4例,结核性支气管狭窄1例,肺结核合并脓胸2例,肺结核合并支气管胸膜瘘3例(经支气管镜检查证实),空洞型肺结核2例,肺结核合并大咯血2例.26例中左肺15例,右肺11例.入院查痰为痰菌阳性7例.26例中术后14个月内急性呼吸衰竭5例,经呼吸机治疗,3例治愈,2例死亡;术后3个月ARDS 2例,经呼吸机治疗,1例治愈,1例死亡;术后20 d胸腔内出血7例,2例治愈,5例死亡;术后4年脓胸8例,全部治愈;术后50 d支气管胸膜瘘4例,2例治愈,1例未愈,1例死亡.结论 药物治疗是结核病的重要治疗方法,但部分肺结核患者仍需要外科手术治疗,全肺切除可以提高重症肺结核的治愈率,绝大多数手术并发症均可治愈.

Abstract：

Objective To explore the diagnosis and management of short-term complications after pneumonectomy for pulmonary tuberculosis.Methods The clinical data and management of short-term complications in patients with pulmonary tuberculosis after pneumonectomy were retrospectively reviewed and analyzed.Results From September 2000 to September 2010, 206 patients with pulmonary tuberculosis underwent pneumonectomy, of whom 26 experienced complications shortly after the surgery.Postoperative acute type Ⅱ respiratory failure occurred in 5 within 14 months post-operation, acute respiratory distress syndrome (ARDS) in 2 within 3 months post-operation, chest hemorrhage in 7 within 20 days postoperation, empyema in 8 within 4 years post-operation, and bronchopleural fistula in 4 cases within 50 days post-operation.Of the 7 cases with chest hemorrhage, 2 were cured and 5 dead.All the 8 cases with empyema were cured.Of the patients with bronchopleural fistula, 2 were cured, 1 failed, and 1 was dead.Conclusions Pneumonectomy for pulmonary tuberculosis carries a higher risk of developing serious complications such as chest hemorrhage, acute type Ⅱ respiratory failure and bronchopleural fistula.Most complications can be managed successfully if diagnosed and treated early.     

HIV in correctional facilities: role of self-report in case identification

For treatment of HIV/AIDS in jails and prisons to be effective, these institutions must identify as many HIV-positive inmates as they can. We compare HIV status among a drug-addicted jail population determined through a physical examination and a voluntary HIV testing program, with self-reported status in an interview. Of 360 subjects interviewed and given physical examinations, approximately one third (110) took the voluntary HIV test and all were negative, and only 1 was identified as HIV-positive in the physical. However, 7 (2%) stated in the interview that they were HIV positive, none of whom took the HIV test. Five of the 7 also self-reported injection drug use and having shared needles. We conclude that inmate self-report is an important pathway for HIV case finding in correctional institutions.     

不同人群中筛查肺结核病人的效果评价

目的　评价从不同特征的人群中筛检肺结核病人的效果。方法 将受检人群分成肺结核可疑症状组和其他三组,分析比较各组人群中肺结核病人的检出率及其成本效果。结果 肺结核可疑症状组的活动性肺结核检出率为 3590.9/万、涂阳肺结核检出率为 1159.1/万,明显比其他三组人群的检出率高 (P＜0.001)。肺结核可疑症状组检出活动性肺结核的平均费用为 103.0元/例,检出涂阳肺结核的为 319.2元/例,明显比其他三组人群的低。结论 在现有卫生资源的情况下,采取因症就诊为主的发现方式可最大可能地发现肺结核病人。     

Cost-effectiveness of HIV nonoccupational post-exposure prophylaxis in Australia

Objective

The aim of the study was to determine the cost‐effectiveness of HIV nonoccupational post‐exposure prophylaxis (NPEP) in Australia.

Methods

A retrospective cost analysis of a population‐based observational cohort of 1601 participants eligible for NPEP in Australia between 1998 and 2004 was carried out. We modelled NPEP treatment costs and combined them with effectiveness outcomes to calculate the cost per seroconversion avoided. We estimated the cost‐utility of the programme, and sensitivity and threshold analysis was performed on key variables.

Results

The average NPEP cost per patient was A$1616, of which A$848 (52%) was for drugs, A$331 (21%) for consultations, A$225 (14%) for pathology and A$212 (13%) for other costs. The cost per seroconversion avoided in the cohort was A$1 647 476 in our base case analysis, and A$512 410 when transmission rates were set at their maximal values. The cost per quality‐adjusted life‐year (QALY) was between A$40 673 and A$176 772, depending on the risks of HIV transmission assumed.

Conclusions

In our base case, NPEP was not a cost‐effective intervention compared with the widely accepted Australian threshold of A$50 000 per QALY. It was only cost‐effective after receptive unprotected anal intercourse exposure to an HIV‐positive source. Although NPEP was a relatively well‐targeted intervention in Australia, its cost‐effectiveness could be improved by further targeting high‐risk exposures.     

Prevention of venous thromboembolism after general surgery. Cost-effectiveness analysis of alternative approaches to prophylaxis

A number of methods of prophylaxis can reduce the risk of postoperative venous thromboembolism in patients undergoing general surgery. The cost-effectiveness of several of these--low-dose subcutaneous heparin, intermittent pneumatic compression, graduated compression stockings, heparin plus dihydroergotamine, heparin plus stockings, and intermittent pneumatic compression plus stockings--was assessed by pooling data from published reports of randomized controlled trials. Using clinical protocols, costs for prophylaxis, diagnosis, and treatment of venous thromboembolism were determined. The expected outcomes and costs of each strategy were then calculated using techniques of decision analysis. The results indicate that stockings are the only prophylactic method that is actually cost-saving. Costs of care average $34 less per admission for patients using stockings than for those receiving no prophylaxis. Most other methods of prophylaxis further reduce thromboembolic risk, but increase costs by $50 to $88 per patient relative to costs for the use of stockings. Differences in the cost-effectiveness of these prophylaxis are more marked, ranging from about $50,000 to almost $500,000 per additional life saved.     

Use of short-term steroids in the prophylaxis of atrial fibrillation after cardiac surgery

Objectives

To assess the effectiveness of corticosteroids in the prophylaxis of postoperative atrial fibrillation (AF) in patients undergoing elective coronary artery bypass grafting or valvular heart surgery in terms of reducing its incidence and decreasing the length of hospital stay.

初治涂阳肺结核治愈后近期复发预测模型

目的建立初治涂阳肺结核治愈后近期复发的预测模型。方法采用前瞻性追踪研究方法,对2005年1月1日—2006年12月31日广州市初治涂阳肺结核治愈停药的3 293例患者进行2年随访研究,从临床因素、社会因素探讨影响初治涂阳肺结核治愈后复发的相关因素,建立近期复发的logistic回归模型。结果初治涂阳肺结核治愈后细菌学复发率为4.6%。近期复发预测模型:logitP=-9.546+0.586X1+1.959X6+1.449X10+1.118X15+1.027X16+1.525X18+0.674X22+2.042X23,经评价预测效果较好。结论预测模型的建立为减少肺结核复发提供了科学循证依据,能为结核病疫情控制给予针对性指导。     

Active tuberculosis in individuals infected with human immunodeficiency virus after isoniazid prophylaxis.

A review was conducted in Haiti to determine the timing and outcome of active tuberculosis (TB) in human immunodeficiency virus (HIV)-positive patients who had previously received isoniazid (INH) prophylaxis. Of 1005 HIV-seropositive patients who completed INH prophylaxis, 14 (1.4%) subsequently had active TB diagnosed. The median interval between discontinuation of INH prophylaxis and TB diagnosis was 8 months for 6 patients receiving 6 months of INH, 22 months for 5 patients receiving 12-24 months of INH, and 40 months for 3 patients receiving 24-36 months of INH (P = .026). There is a postprophylaxis effect on INH that is dependent upon the duration of therapy.     

Randomized controlled trial of interventions to improve follow-up for latent tuberculosis infection after release from jail

BACKGROUND: Adherence to treatment of persons with latent tuberculosis infection after release from jail has been poor. METHODS: A randomized controlled trial was conducted at the San Francisco City and County Jail, San Francisco, Calif. Subjects undergoing therapy for latent tuberculosis infection who spoke either English or Spanish were randomly allocated to receive education every 2 weeks while in jail; an incentive if they went to the San Francisco County Tuberculosis Clinic within 1 month of release; or usual care. The main outcome measures were completion of a visit to the tuberculosis clinic within 1 month of release and completion of therapy. RESULTS: Of 558 inmates enrolled, 325 were released before completion of therapy. Subjects in either intervention group were significantly more likely to complete a first visit than were control subjects (education group, 37%; incentive group, 37%; and controls, 24%) (adjusted odds ratio based on pooled results for the education and incentive groups, 1.85; 95% confidence interval, 1.04-3.28; P =.02). Those in the education group were twice as likely to complete therapy compared with controls (adjusted odds ratio, 2.2; 95% confidence interval, 1.04-4.72; P =.04). Of those who went to the tuberculosis clinic after release, subjects in the education group were more likely to complete therapy (education group, 65% [24/37]; incentive group, 33% [14/42]; and control group, 48% [12/25]; P =.02). CONCLUSIONS: Education or the promise of an incentive improved initial follow-up. Education was superior to an incentive for the completion of therapy. Fairly modest strategies provided in jail can improve adherence. Further links between jail health services and community care should be explored.     

The role of HLA--G 14-bp polymorphism in allo-HSCT after short-term course MTX for GvHD prophylaxis

HLA-G molecules are HLA class Ib antigens characterized by tolerogenic and immunoinhibitory functions. The HLA-G 14-bp insertion/deletion (ins/del) polymorphism controls protein expression and seems to be implicated in both MTX treatment response and SCT outcome. The aim of our study is to evaluate the role of HLA-G 14?bp polymorphism in subjects affected by hematological malignancies undergoing allo-SCT and receiving MTX therapy for GvHD prophylaxis. We performed a retrospective analysis of HLA-G 14?bp polymorphism using a specific PCR in 47 recipients and in their respective donors, and evaluated the correlation with the incidence of aGvHD, OS and disease-free survival (DFS) after allo-SCT. We did not observe any correlation between this polymorphism and the risk of aGvHD occurrence. On the contrary, we found that the recipients with a 14?bp ins/14?bp ins genotype were characterized by a lower OS and DFS in univariate and multivariate analysis (OS=OR: 3.235; DFS=OR: 3.302). These data indicate a role for recipient HLA-G 14?bp polymorphism in allo-SCT immunotolerance status and follow-up.