The importance of perspective in pharmacoeconomic analyses

Readers of pharmacoeconomic analyses should pay attention to the perspective used in conducting the analyses because very different costs may be included based on the investigators' perspectives. The most common perspectives are those of providers, payers, patients, and society. The societal perspective is broadest and is usually preferred.     

A critical review of continuous infusion H2 receptor therapy

Recent studies suggest that continuous infusions of H2-receptor antagonists may be more effective than intermittent iv therapy to control gastric pH for the prevention of stress ulcers. Infusions of cimetidine, ranitidine, and famotidine have been shown either to have a beneficial clinical effect, to control gastric acid secretion, to maintain gastric pH greater than 4, or to have pharmacokinetic properties similar to intermittent doses. In addition, some evidence suggests that continuous infusions may permit the use of lower doses, leading to cost savings. However, as yet there have been no trials that directly compare continuous and intermittent regimens and show improved outcomes with a continuous regimen. Since candidates for parenteral administration of H2-receptor antagonists are most common in the ICU, several practical issues must be addressed. Patients who receive total parenteral nutrition (TPN) may be suitable candidates for continuous infusions of H2-blockers since these agents can be given in the same container as TPN solutions. These patients also usually have a parenteral access site and infusion pump dedicated to TPN administration. In other patients, drug incompatibilities, limited iv access lines, or a lack of infusion pumps may require frequent interruptions of the infusion in order to administer additional medications, which may lead to a loss of gastric pH control. In most patients, administration of an H2-blocker regimen which maintains consistent pH control after intermittent administration may be the most practical method by which to administer these agents.     

The electrocardiographic manifestations of cyclic antidepressant therapy and overdose: a review

Cyclic antidepressants may cause changes in the electrocardiogram at therapeutic or toxic serum levels. The most serious complications of cyclic antidepressant toxicity are dysrhythmias, hypotension, and seizures. It is predominantly the cardiotoxic effects that cause mortality. Once cardiotoxicity is evident, the treatment of choice is serum alkalinization, preferably by sodium bicarbonate therapy. In order to predict which overdose patients are at high risk for complications, electrocardiographic criteria have been identified as reliable screens. For "first generation" tricyclic antidepressants, QRS prolongation (particularly greater than 100 msec) and a terminal 40-ms frontal plane axis greater than 120 degrees are the most sensitive. This article reviews antidepressant pharmacology, electrocardiographic manifestations of antidepressant cardiotoxicity, and approaches to treatment of antidepressant-induced conduction disturbances and dysrhythmias.     

Medical therapy in the era of percutaneous coronary revascularization: A critical review

Percutaneous coronary revascularization (PCR) frequently results in relief of angina in patients with ischemic heart disease. The aim of this review is to put in perspective the role of PCR in the treatment of patients with coronary artery disease.     

The state of health economic and pharmacoeconomic evaluation research in Zimbabwe: A review

BACKGROUND: Economic evaluation of health care has developed into a substantial body of work, and its contribution to medical decision making is increasingly being recognized.OBJECTIVE: The aim of the study was to describe the characteristics and quality of health economic (including pharmacoeconomic) evaluation research studies related to Zimbabwe.METHODS: A review of the literature was conducted to identify published health economic evaluation studies related to Zimbabwe. HEED, PubMed, MEDLINE, HealthSTAR, EconLit, and PsycINFO databases and sociological and dissertation abstracts were used to search for economic analyses. The searches used the following terms alone and in combination: costs, budgets, fee, economics, health, pharmacy, pharmacy services, medicines, drugs, health economics, cost-effectiveness, cost-benefit, cost-minimization, cost utility analysis, and Zimbabwe. Only original applied economic evaluations addressing a health-related topic pertaining to Zimbabwe and published in full were included. Two reviewers independently evaluated and scored each study in the final sample using the data collection form designed for the study.RESULTS: Fifty-nine studies were identified in the database searches, 18 of which were excluded because they were not about Zimbabwe (3 studies) or were not health related (15). Of the 41 remaining studies, 8 were excluded after further review because they were not original research, 6 because they were not economic analyses, and 1 because it was not about Zimbabwe. The final 26 studies appeared in 13 different journals (based mostly [17 (65%)] outside of Zimbabwe). The mean (SD) number of authors of each study was 3.36 (2.13); most of the authors had medical/clinical training. The number of studies peaked between 1994 and 1997. Based on a 10-point scale, with 10 indicating the highest quality, the mean (SD) quality score for all studies was 5.40 (1.56); 8 of the studies (31%) were considered to be of poor quality (score ≤4). The quality of the studies reviewed was significantly (all, P < 0.05) associated with the country in which the journal was based (non-Zimbabwe = higher), the primary health intervention (services>pharmaceutical interventions), the number of authors (more authors = higher), and year of publication (more recent = higher).CONCLUSION: This study indicated that the use of health economic (including pharmacoeconomic) evaluation research in Zimbabwe was low, and 31 % of the studies were of poor quality. More and better quality health economic research in Zimbabwe is warranted.     

Cyclic antidepressant overdose: A review of current management strategies

Cyclic antidepressant (CA) overdose can produce life-threatening seizures, hypotension, and dysrhythmias. It accounts for up to half of all overdose-related adult intensive care unit admissions and is the leading cause of death from drug overdose in patients arriving at the emergency department alive. Several factors contribute to the significant morbidity and mortality associated with CA overdose. First, CAs are widely prescribed and are dispensed to patients at increased risk for attempting suicide. Second, drugs of this class generally have a low therapeutic toxic ratio. Third, in the majority of fatal cases, the patient dies before reaching a hospital. Finally, and of greatest significance for the clinician, the presenting signs and symptoms of CA overdose may be missed by the physician, even in cases of severe toxicity. Therefore, CAs must be considered early in any case of suspected overdose, and all such cases should be managed as potentially fatal ones. The following case demonstrates the current approach to the patient with significant CA toxicity.     

New developments in antidepressant therapy

Depression is an overwhelmingly common problem in the United States. It is not only life threatening, but also costly, both personally and financially. Following a brief overview of depression, this article presents a variety of treatment modalities. Advantages and dis-advantages of each intervention are explored along with suggestions for evaluating current and future advances in treatment options.     

Meniscal injuries: A critical review

Although once perceived as an unimportant vestigial structure, the menisci of the knee are now known to be a common source of knee pain and disability. The medial meniscus is more vulnerable to injury to due to its intimate attachment to the medial collateral ligament. The moveable lateral meniscus is less prone to tear except when the ACL is injured. The medial and lateral menisci are usually injured as a result of sudden knee flexion with a component of knee internal or external rotation. However, older patients may present without a specific mechanism of injury as their meniscal injuries are often due to degenerative processes. Most meniscal injuries can be diagnosed with a thorough physical examination utilizing the McMurray, Apley, and ``bounce home' maneuvers. Joint line tenderness and the presence of a knee effusion aid in the diagnosis. Magnetic Resonance Imaging (MRI) has become the test of choice in confirming injury. MRI also defines the type, location, and severity of meniscal injury. Some meniscal injuries, particularly peripheral, well-vascularized tears, may be more prone to healing with nonsurgical management. Typical initial management includes reduction of swelling and pain. Rehabilitation stresses tri-planar functional retraining. The final phases of rehabilitation incorporate a functional progression to sports or work specific activities. Arthroscopic knee surgery has become a prevalent treatment method for bucket handle tears and non-vascularized meniscal injuries. Meniscal repair is currently preferred over partial menisectomy to avoid premature osteoarthritis. In sum, clinicians can return patients with meniscal pain to a high level of function with appropriate recognition of injury and functional rehabilitation.     

Photodynamic therapy for herpes simplex: a critical review.

The purpose of this review is to summarize available experimental and clinical data concerning benefits and potential risks of photodynamic therapy for oral and genital herpes simplex virus infections. Since such infections are a source of discomfort and pain, and since recent evidence links the virus itself with carcinogenesis, clinicians have felt an increased need for more effective therapy for herpesvirus infections. In 1973 a human clinical therapeutic procedure based on photodynamic inactivation was developed. The treatment consists of applying a photosensitizing dye to herpesvirus lesions and then exposing them to visible light. A number of human clinical trials have been completed; some of these show reduction of herpesvirus infectivity, whereas others question the efficacy of the procedure. Data from a number of in vitro virus-host cell studies suggest the procedure may be potentially carcinogenic and therefore clinically hazardous. Thus a controversy exists concerning further use of the treatment. This review gives the reader a basis for understanding the controversy and included basic principles of photodynamic inactivation, medical aspects of herpesvirus infections, development of the therapeutic procedure, results of clinical studies, and results of in vitro studies which indicate potential long-term side effects.     

A critical review of interventions targeting prosody

This is a critical review of the research literature pertaining to the treatment of prosody. The studies were located using electronic databases and were analysed with respect to participants, design, treatment methods, outcome measures, and findings. Although only 14 studies met the inclusion and exclusion criteria, there was considerable diversity among the studies with respect to age of participants, type of communication disorder, treatment procedures, and outcomes. Each of the 14 studies reported at least partial success for outcomes such as increased pitch differential, appropriate production of affect in sentences, increased sound pressure level or loudness, and appropriate use of stress. The results were interpreted as supporting the contention that prosody of people with communication impairment can be changed as the result of treatment. However, several concerns about the rigor of the research were offered. For example, there was limited blinding of data analysers, inconsistent presentation of reliability data, assignment to treatment groups involved more matching/counterbalancing than randomization.