Measuring patient benefit from botulinum toxin in the treatment of dystonia. Feasibility of cost-utility analysis

The dystonias are a group of movement disorders arising from CNS dysfunction and characterised by involuntary and prolonged spasms of muscle contraction. Recently there has been increasing demand for treatment with botulinum toxin (BT), a relatively expensive neurological paralytic agent. As there has been no systematic assessment of patient benefit from BT, this study was undertaken to develop and test a methodology for assessing the cost utility of BT therapy for patients with dystonias. A generic health status instrument, the EuroQOL, was completed at regular intervals over at least 6 months by 130 patients with a current diagnosis of dystonia. A general population tariff was used to calculate quality-adjusted life-year (QALY) gains from BT treatment, and relevant cost data were obtained from patients and medical records. The cost-per-QALY estimates ranged considerably, depending on the type of dystonia, the duration of BT treatment, type of health-related quality-of-life (HR-QOL) tariff used and baseline characteristics of participants. The study findings reflect the general clinical impression of BT: that it can benefit patients with dystonia, but the benefit may be small compared with many treatments for other diseases. The nature of the disease and its cyclical treatment caused practical difficulties in recruiting participants, administering questionnaires and in estimating QALY gains.     

Neocuproine,a selective Cu(I) chelator,and the relaxation of rat vascular smooth muscle by S-nitrosothiols

1. A study has been made of the effect of neocuproine, a specific Cu(I) chelator, on vasodilator responses of rat isolated perfused tail artery to two nitrosothiols: S-nitroso-N-acetyl-D,L-penicillamine (SNAP) and S-nitroso-glutathione (GSNO).
2. Bolus injections (10 μl) of SNAP or GSNO (10⁻⁷–10⁻³ M) were delivered into the lumen of perfused vessels pre-contracted with sufficient phenylephrine (1–7 μM) to develop pressures of 100–120 mmHg. Two kinds of experiment were made: SNAP and GSNO were either (a) pre-mixed with neocuproine (10⁻⁴ M) and then injected into arteries; or (b) vessels were continuously perfused with neocuproine (10⁻⁵ M) and then injected with either pure SNAP or GSNO.
3. In each case, neocuproine significantly attenuated vasodilator responses to both nitrosothiols, although the nature of the inhibitory effect differed in the two types of experiment. We conclude that the ability of exogenous nitrosothiols to relax vascular smooth muscle in our ex vivo model is dependent upon a Cu(I) catalyzed process. Evidence is presented which suggests that a similar Cu(I)-dependent mechanism is responsible for the release of NO from endogenous nitrosothiols and that this process may assist in maintaining vasodilator tone in vivo.

     

Detection of k-ras mutation in normal and malignant colonic tissues by an enriched PCR method

ras oncogene mutations appear in over 50% of colon tumors in humans. Studies in animal systems have revealed that ras mutations are also present in preneoplastic lesions, suggesting the possibility of early detection of ras mutation in morphologically normal colon tissues for diagnostic purposes. An Enriched PCR, developed by us, eliminates most of the normal ras alleles prior to amplification; subsequent analysis via RFLP enables the detection of one mutant allele within 10(4) normal alleles. Using the Enriched PCR, we have determined the frequency of mutant ras alleles in normal mucosae and in adenomatous polyps of patients with or without adenocarcinoma. Of the 42 patients who had colon tumors, 15 were found to harbor K-ras oncogene mutation (35%). In two of the 14 cases with mutant K-ras in the tumor tissue we were able to identify mutations in tissues that had been obtained from a site at considerable distance from the tumor (13%); Analysis of 7 adenomas identified one as a carrier of the mutant ras allele (14%). Of 11 normal colonic mucosa obtained from patients without neoplasia, one specimen contained K-ras mutation. Thus, mutated alleles of K-ras may be present, at low frequency, throughout the 'normal appearing' tissue. Cells of normal appearance that harbor such mutation, have the potential to undergo further changes and to develop into the transformed phenotype. Overall, our findings suggest that mutant ras alleles can be detected in preneoplastic mucosa that is morphologically normal, and in adenomas, suggesting the occurrence of an initiation event, and possibly enabling the identification of patients who may be at high risk for developing malignant tumors.     

The effect of the illumination time when treating port-wine stains

This paper reports the electron microscopy results obtained from two patients who were treated with 5 W of yellow (578 nm) light from a copper vapour laser with an illumination time of 3.6 ms and a 0.3 mm spot diameter. The endpoint of treatment was transient blanching. Following treatment, erythema was observed. There was minimal damage to the epidermis and non-vascular tissue such as the nerve fibres. There was severe damage to the endothelial cells of the ectatic vessels. Twenty-four hours after treatment, platelet activation and collagen were present, indicating that these vessels were no longer viable. Theoretical calculations are used to determine the flow of heat within and away from a 50m diameter vessel. From this, heating of the entire vessel is shown to occur with illumination times of 4 ms, with minimal heating of the non-vascular tissue. Shorter illuminations do not heat the entire vessel, while the use of longer illumination times will cause excessive damage to the surrounding non-vascular tissue. Illumination times close to 4 ms must be regarded as optimal.     

Estimating treatment cost functions for progressive diseases: a multiproduct approach with an application to breast cancer

Using the theory of multiproduct cost functions, a treatment cost function is derived for diseases which progress through a number of stages. The output classes are conceived as the stages at detection of the disease, with the unit of output within each class being the treated case. The derivation clarifies the assumptions underlying various specific functional forms for the treatment cost function. An empirical application to the treatment of breast cancer is provided, producing evidence on an important issue in the economics of screening programs, viz. whether detection of breast cancer at an earlier stage results in treatment cost savings.     

Perioperative resuscitation knowledge base

PURPOSE: To assess the knowledge base of Canadian anesthesiologists regarding the management of perioperative cardiac arrest. METHODS: A random sample of 200 Canadian Anesthesia Society members were mailed a survey composed of 10 clinical vignettes, each involving a special perioperative resuscitation situation, with six multiple choice options for optimum management. Fourteen possible "lethal errors" (options which are unequivocally harmful to the patient) were identified among the possible choices. Each question had a single correct answer and contributed a single point towards a possible maximum of ten. An arbitrary passing score of 70%, similar to the American Heart Association (AHA) standard for Advanced Cardiac Life Support course (ACLS), was selected. Respondents were asked demographic information including: time since completing residency, time since last ACLS course, provision of cardiac anesthesia and attitude towards utility of AHA protocols in anesthesia practice. RESULTS: A total of 124 surveys were returned. The median score was five with a range of scores from zero to nine. Fifty-eight (56.3%) participants chose at least one "lethal error". Only 17 respondents (13.7%) attained the minimum score of 70% and avoided a "lethal error". Respondents who practiced cardiac anesthesia tended to achieve higher scores (P < 0.05) than generalists. All but one participant indicated that a Continuing Medical Education resource covering this material would be useful. CONCLUSIONS: This survey demonstrates a knowledge deficit concerning special perioperative resuscitation situations. Development of further appropriate research and educational material in this area is justified.