Deep Brain Stimulation Compared With Contingency Management for the Treatment of Cocaine Use Disorders: A Threshold and Cost-Effectiveness Analysis

ObjectivesCocaine is the second most frequently used illicit drug worldwide (after cannabis), and cocaine use disorder (CUD)-related deaths increased globally by 80% from 1990 to 2013. There is yet to be a regulatory-approved treatment. Emerging preclinical evidence indicates that deep brain stimulation (DBS) of the nucleus accumbens may be a therapeutic option. Prior to expanding the costly investigation of DBS for treatment of CUD, it is important to ensure societal cost-effectiveness.AimsWe conducted a threshold and cost-effectiveness analysis to determine the success rate at which DBS would be equivalent to contingency management (CM), recently identified as the most efficacious therapy for treatments of CUDs.Materials and MethodsQuality of life, efficacy, and safety parameters for CM were obtained from previous literature. Costs were calculated from a societal perspective. Our model predicted the utility benefit based on quality-adjusted life-years (QALYs) and incremental-cost-effectiveness ratio resulting from two treatments on a one-, two-, and five-year timeline.ResultsOn a one-year timeline, DBS would need to impart a success rate (ie, cocaine free) of 70% for it to yield the same utility benefit (0.492 QALYs per year) as CM. At no success rate would DBS be more cost-effective (incremental-cost-effectiveness ratio <$50,000) than CM during the first year. Nevertheless, as DBS costs are front loaded, DBS would need to achieve success rates of 74% and 51% for its cost-effectiveness to exceed that of CM over a two- and five-year period, respectively.ConclusionsWe find DBS would not be cost-effective in the short term (one year) but may be cost-effective in longer timelines. Since DBS holds promise to potentially be a cost-effective treatment for CUDs, future randomized controlled trials should be performed to assess its efficacy.     

Epidural anaesthesia for Caesarean section in patients with active recurrent genital herpes simplex infections: a retrospective review

The safety of epidural anaesthesia in patients with active, recurrent genital herpes simplex (HSV) infections is controversial. We reviewed the six-year experience of the use of epidural anaesthesia in this patient population in two institutions. Eighty-nine parturients with active genital HSV were administered epidural anaesthesia for Caesarean section. No patient suffered an adverse outcome related to either the anaesthetic or the virus. The theoretical risks of regional anaesthesia in the parturient with active herpes genitalis are reviewed. We conclude from available data that the risk of an adverse outcome is small and does not contraindicate the use of epidural anaesthesia in patients with recurrent infection.     

An analysis of the role of stimulus removal in taste adaptation by means of simulated drinking

Human multiple sip drinking was simulated by repeated, alternate application of a NaCl solution and a second liquid to the anterior portion of the tongue. Judged intensity of the NaCl solution remained constant during alternation with artificial saliva, increased during alternation with water, and decreased during alternation with an identical NaCl solution or with no second liquid. Relative change in concentration on the tongue may determine constancy, facilitation, or adaptation during drinking.     

Colonization with methicillin-resistant Staphylococcus aureus after liver transplantation.

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection after orthotopic liver transplantation (OLT). Colonization with MRSA is associated with a higher risk of infection. Previous studies have shown a high prevalence of MRSA colonization among OLT candidates. However, the risk of colonization with MRSA after OLT is still unclear. The objective of this study was to estimate the incidence and the factors associated with colonization with MRSA after OLT. This was a prospective cohort study including patients submitted to OLT between the years 2000 and 2002. Surveillance cultures of nasal swab specimens were performed within the 1st 72 hours of hospital admission and, subsequently, on weeks 2, 6, 13, and 26. Patients whose baseline cultures revealed nasal carriage of MRSA were excluded. A total of 60 patients were included in the study. The median follow-up was 72 days. A total of 9 patients (15%) became colonized. In multiple logistic regression analyses, the use of a urinary catheter for > or =5 days (P = .006), postoperative bleeding at the surgical site (P = .009), and preoperative use of fluoroquinolones (P = .08) were associated with a higher risk of colonization. Patients without any of these risk factors did not become colonized. In conclusion, nasal carriage of MRSA is frequently acquired after OLT. Periodic postoperative screening for MRSA carriage should be an integral component in programs designed to reduce nosocomial MRSA transmission in these patients. Further studies are needed to set up and validate a predictive model that could allow targeting postoperative screening to high-risk OLT recipients.     

In vitro methodology for resistance arteries.

Two commonly used methods for examining the physiological and pharmacological properties of isolated resistance arteries are the ring-mounted preparation and the cannulated, pressurized vessel. Each technique is discussed and consideration given to limitations and advantages. Also presented are examples of comparative differences between them, and practical experimental schemes for calibrating cannulae and for perfusing resistance arteries. Although both methods are valuable, the cannulated approach may better reflect the in vivo properties of the arteries.     

Observations on blood pressure measurements in high-school athletes

The purpose of this study is to identify possible evidence of hypertension in athletic adolescents. In addition to sex and age, the effects of various physical factors that may influence blood pressure are measured. The data were collected from the annual screening physicals of local high-school athletic program participants. Nine of the 11 measured physical factors account for 10 percent to 20 percent of the variability in blood pressure measurements. These include age, weight, height, pulse, quadriceps girth, heel cord flexibility, jump reach, hang time, and grip strength. These variables are incorporated into formulae that adjust the range of "normal" values of systolic and diastolic blood pressure to reduce the effects of these confounding factors, thereby increasing the accuracy of the "normal" or "hypertensive" determination for each individual.     

Chemoarchitecture and afferent connections of the "olfactostriatum": a specialized vomeronasal structure within the basal ganglia of snakes

The olfactostriatum, a portion of the striatal complex of snakes, is the major tertiary vomeronasal structure in the ophidian brain, receiving substantial afferents from the nucleus sphericus, the primary target of accessory olfactory bulb efferents. In the present study, we have characterized the olfactostriatum of garter snakes (Thamnophis sirtalis) on the basis of chemoarchitecture (distribution of serotonin, neuropeptide Y and tyrosine hydroxylase) and hodology (afferent connections). The olfactostriatum is densely immunoreactive for serotonin and neuropeptide Y and shows moderate-to-weak immunoreactivity for tyrosine hydroxylase. In addition to afferents from the nucleus sphericus, the olfactostriatum receives inputs from the dorsal and lateral cortices, nucleus of the accessory olfactory tract, external and dorsolateral amygdalae, dorsomedial thalamic nucleus, ventral tegmental area and raphe nuclei. Double labeling experiments demonstrated that the distribution of serotonin and neuropeptide Y in this area almost completely overlaps the terminal field of projections from the nucleus sphericus. Also, serotonergic and dopaminergic innervation of the olfactostriatum likely arise, respectively, from the raphe nuclei and the ventral tegmental area, whereas local circuit neurons originate the neuropeptide Y immunoreactivity. These results indicate that the olfactostriatum of snakes could be a portion of the nucleus accumbens, with features characteristic of the accumbens shell, devoted to processing vomeronasal information. Comparative data suggest that a similar structure is present in the ventral striatum of amphibians and mammals.