CVA3 Adherence to Hypertension Therapy: The Effect of Initial Drug Choice

Health-care case management places pressure on decision makers to adopt treatment strategies that promote economic efficiency and hence profitability. Traditional costeffectiveness analysis (CEA), where the objective is to calculate cost-effectiveness ratios, can better inform decision making in markets where prices and efficacy vary widely. However, the threshold at which a given therapy becomes economically efficient relative to competing therapies is not evident from cost-effictiveness ratios alone.
OBJECTIVE: To illustrate the use of spatial techniques for identifying efficient treatment options, using statin therapy in secondary prevention of coronary heart disease (CHD) as a case study.
METHODS: We used a Markov model of CHD epidemiology and treatment to estimate cost-effectivness of 13 statin regimens versus no therapy in secondary prevention of CHD. Comparative efficacy was assessed using data from a recent trial (CURVES) that included these regimens. Patients were assumed to have a history of CHD with risk factors similar to those observed in the trial. CHD event risk was estimated using new subsequent-event risk equations from the Framingham Heart Study. Effectiveness was measured alternatively as gain in life expectancy and CHD events averted.
RESULTS: At usual starting doses, atorvastatin therapy provided the largest life expectancy gain and CHD event avoidance at the lowest cost per life-year gained ($12,900 and $23,400 for men and women, respectively), followed by simvastatin ($17,700 and $31,700), lovastatin ($18,800 and $33,700), pravastatin ($22,600 and $40,200), and fluvastatin ($23,800 and $42,000). Any desired level of effectiveness can be obtained at lowest cost with atorvastatin.
CONCLUSION: Economic efficiency is enhanced when atorvastatin is used to treat some or all patients requiring statin therapy in secondary prevention of CHD.     

Enhancing response rates in physician surveys: the limited utility of electronic options

Objective. To evaluate the utility of offering physicians electronic options as alternatives to completing mail questionnaires. Data Source. A survey of colorectal cancer screening practices of Alabama primary care physicians, conducted May–June 2010. Study Design. In the follow‐up to a mail questionnaire, physicians were offered options of completing surveys by telephone, fax, email, or online. Data Collection Method. Detailed records were kept on the timing and mode of completion of surveys. Principal Findings. Eighty‐eight percent of surveys were returned by mail, 10 percent were returned by fax, and only 2 percent were completed online; none were completed by telephone or email. Conclusions. Offering fax options increases response rates, but providing other electronic options does not.     

Challenges for Teaching Injury Prevention in a Juvenile Detention Center

This case study explored the injury related experiences and perceptions of youth in detention and the delivery of first aid education in youth detention contexts. It aimed to develop an understanding of how a mainstream injury prevention intervention could be modified for youth detention populations. Teacher and student reactions to the program were examined and injury checklists, focus groups, and staff interviews were conducted. Analysis revealed serious injuries related to criminal behaviors, violence, dangerous driving, and substance use. Recommendations for youth detention interventions include lesson flexibility, discussions, role-plays, visual materials, peer support strategies, student-teacher relationships, and positive reinforcement.     

Cytokine genotypes correlate with pain and radiologically defined joint damage in patients with juvenile rheumatoid arthritis

OBJECTIVES: Single nucleotide polymorphisms (SNPs) in cytokine genes have been associated with risk of a number of autoimmune diseases. Moreover, some SNPs are associated with variations in rates of in vitro gene expression, and it is therefore possible that these functional polymorphisms may differentially affect inflammatory processes and disease outcome. This project's objective was to determine whether cytokine genotypes correlate with disease outcomes in patients with juvenile rheumatoid arthritis (JRA). METHODS: Genotypes of SNPs of pro-inflammatory cytokines, tumour necrosis factor-alpha -308G -->A, interleukin-6 (IL-6) -174G -->C and interferon-gamma +874G -->A, and anti-inflammatory, immunosuppressive cytokines, interleukin-10 -1082G -->A, -819C -->T and -592A -->C and transforming growth factor-beta1 (TGF-beta1) codon 10T -->C and codon 25G -->C, were determined for patients with JRA who previously participated in a long-term outcome study. Cytokine genotypes and clinical variables showing significant correlations with clinical outcomes at the alpha = 0.100 level in univariate analyses were entered in multivariate tests. RESULTS: In multivariate tests, the IL-6 genotype -174G/G was positively correlated with pain [regression coefficient B = 0.899, 95% confidence intervals (CI) 0.185, 1.612, P = 0.014]. The homozygous TGF-beta1 codon 25G/G genotype showed a protective effect against joint space narrowing on radiographs taken within 2 yr of disease onset, but confidence intervals were wide [odds ratio (OR) 0.176, 95% CI 0.037, 0.837 P = 0.029]. CONCLUSIONS: The correlation of IL-6 genotype with pain and the possible association of the TGF-beta1 codon 25 genotype with short-term radiographic damage (G/C with greater risk and G/G with decreased risk) suggests that both these polymorphisms may be useful early prognostic indicators. Further studies of the relation between cytokine genotypes and outcomes in patients with all forms of juvenile idiopathic arthritis (JIA) are warranted.     

A feedback mechanism regulates monoallelic odorant receptor expression

In olfactory neurons, expression of a single odorant receptor (OR) from a repertoire of >1000 genes is required for odor coding and axonal targeting. Here, we demonstrate a role for OR protein as an essential regulator in the establishment of monoallelic OR expression. An OR-promoter-driven reporter expresses in a receptor-like pattern but, unlike a native OR, is coexpressed with an additional OR allele. Expression of a functional OR from the identical promoter eliminates expression of other OR alleles. The presence of an untranslatable OR coding sequence in the mRNA is insufficient to exclude expression of a second OR. Together, these data identify the OR protein as a critical element in a feedback pathway that regulates OR selection.