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.     

Estimation of genetic risk for type 1 diabetes

The most important gene loci defining risk of type 1 diabetes mellitus (T1DM) are located within the HLA gene region. HLA-DQ molecules are of primary importance but HLA-DR gene products modify the risk conferred by HLA-DQ. The risk associated with an HLA genotype is defined by the particular combination of susceptible and protective alleles. The highest risk is associated with a combination of two different risk haplotypes (7% risk to develop T1DM in Finland) whereas protective genotypes covering 69% of population have a risk of less than 0.2%). The complicated analysis of HLA genotypes is simplified by strong linkage disequilibrium between HLA-DRB1, -DQA1 and -DQB1 loci. In many cases one can deduce the alleles of other loci based on determination of the alleles in one locus. Differences between various populations in the frequency of marker alleles and in the linkages between them has to be taken into account. We have developed PCR based typing methods that utilize blood spot samples, microtiter plate format and lanthanide labeled oligonucleotide probes to define HLA-DQ and -DR alleles relevant for T1DM risk. Typing is run stepwise so that after initial HLA-DQB1 typing only those samples will be further analyzed in which -DQA1 or -DRB1 typing is informative and expected to contribute to the risk estimation. This method has been used to screen more than 50,000 newborn infants in Finland over a time period of 6 years, and it has been able to identify most children who have developed T1D during the follow-up period. The efficiency of the procedure has also been tested in Finnish and Greek populations.     

Fine structure of the carotid body of the midterm human fetus

Summary The human fetal carotid body was studied using both histochemical and electron microscopic methods. The glomus cells of a mid term fetal carotid body evidently contain catecholamines. This was demonstrated both by formaldehyder-induced fluorescence of the cells and by the presence of typical dense-cored vesicles (diameter 1430–3200 Å) in the cytoplasm of the chief cells. The glomus cells were densely innervated and the synapses found on their surface were probably cholinergic in type, containing agranular synaptic vesicles measuring 400–700 Å in diameter with a few dense-cored vesicles measuring 900 to 1300 Å. Synapses were not found in any other cell type within the glomus caroticum. The prominent feature of the glomus cell cytoplasm was the presence of the dense-cored vesicles. The density of the vesicular core varied only slightly from cell to cell. There were no perceptible differences in vesicular size between the different cells. The glomus cells were mostly surrounded by the processes of the sustentacular cells, which usually also surrounded the capillary walls. No glomus cells were ever found in direct contact with the capillary wall. The capillaries were wide and very numerous over the restricted area of the organ. They formed sinusoidal loops, probably anastomosing with each other. Finally, the features of the fine structure are discussed, correlating the present findings with our knowledge about the adult functional carotic body.     

Hemagglutination by BK Virus, a Tentative New Member of the Papovavirus Group

Some characteristics of hemagglutination (HA) by the BK virus, a new candidate for the papovavirus group, have been studied. Hemagglutinin prepared from cell cultures was found to be partially masked by inhibitors which could be dissociated from the virus by incubation at 37 C or by fluorocarbon extraction. Optimal conditions for HA are outlined. In routine tests, 0.5% human erythrocytes were used. The reaction was carried out at pH 7.0 on ice-water slurry. BK hemagglutinin receptors on human erythrocytes were found to be more resistant to neuraminidase than polyoma receptors. By gradient centrifugation analysis, two types of particles were found to be responsible for HA: (i) full, deoxyribonucleic acid-containing particles with a density of 1.325 g/cm(3) and (ii) empty capsids with a density 1.29 g/cm(3). Based on particle counting, one HA unit was calculated to correspond to 3 x 10(6) virus particles.     

Standard sera in solid-phase immunoassays

Solid-phase immunoassay-derived antibody titers are often converted to weight unit concentrations with the aid of standard sera containing known antibody concentrations. Systematic studies justifying this procedure have not yet been published. We therefore investigated the magnitude of errors associated with this conversion. Antibody concentrations of thirteen sera or ascites fluids were determined by quantitative precipitation or equlibrium dialysis, and one was then used as a “standard antibody” for the others in solid-phase radioimmunoassay (SP-RIA) or enzyme-linked immunosorbent (ELISA) assays. Antibody concentrations determined by the conventional solid-phase assay (the “standard serum” has the same specificity as the “sample”) had up to fourfold errors. These errors could be reduced by basing the conversion on the combination of two standard sera instead of one. The possibility was studied of whether the conversion to weight units could be done with the aid of a standard serum directed to a different antigen than the sample antibody. Errors associated with the use of such a heterologous standard were not significantly greater than those found using the conventional conversion. A combination of two reference sera again reduced the errors. The use of such heterologous standard(s), however, requires checking the binding capacity of the antigen coats.     

Physical work capacity in dynamic exercise with differing muscle masses in healthy young and older men

Ten young (aged 23–30 years) and nine older (aged 54–59 years) healthy men with similar estimated limb muscle volumes performed, in random order, three different types of ergometer exercise tests (one-arm cranking, two-arm cranking, and two-leg cycling) up to the maximal level. Values for work load (WL), peak oxygen consumption , peak heart rate (HR), peak ventilation , respiratory gas exchange ratio (R), recovery blood lactate concentration [La^–], and rating of perceived exertion (RPE) were compared between the age-groups in the given exercise modes. No significant age-related differences in WL, peak , peak HR, R, [La^–], or RPE were found in one-arm or two-arm cranking. During one-arm cranking the mean peak was 1.65 (SD 0.26)1 · min^–1 among the young men and 1.63 (SD 0.10)1 · min^–1 among the older men. Corresponding mean peak during two-arm cranking was 2.19 (SD 0.32)1 · min-1 and 2.09 (SD 0.18)1 · min^–1, respectively. During one-arm cranking peak was higher (P < 0.05) among the older men compared to the young men. During two-leg cycling the young men showed higher values in WL (P < 0.001), peak (P < 0.001), and peak HR (P < 0.001). The mean peak was 3.54 (SD 0.24)1 · min^–1 among the young men and 3.02 (SD 0.20)1 · min^–1 among the older men. Corresponding mean peak HR was 182 (SD 5) beats · min^–1 and 170 (SD 8) beats · min^–1, respectively. During two-leg cycling, peak , R, [La^–], and RPE did not differ between the two age-groups. In summary, the older men with similar sizes of estimated arm and leg muscle volumes as the young men had a reduced physical work capacity in two-leg cycling. In one-arm or two-arm cranking, no significant difference in work capacity was found between the age-groups. These results indicate, that in healthy men, age, at least up to the 6th decade of life, is not necessarily associated with a decline in physical work capacity in exercises using relatively small muscle groups, in which the limiting factors are more peripheral than central.     

Cardiorespiratory and thermal effects of wearing gas protective clothing

Summary Six healthy men aged 25 to 37 walked on a treadmill at work levels of 21 and 41% of their for 25 to 30 min wearing gas protective clothing (GPC) consisting of an impermeable suit with a self-contained breathing apparatus (total weight 25 kg) or shorts (control tests, CT) in a temperate environment (t _a 24.3°C ± 1.0°C, rh 30–50%). When the GPC was worn at 21 and 41% , the most prominent increases, compared with the CT, were noted in the heart rate ( ± SE, 120 ± 5 vs 76 ± 3 beats min^–1 and 171 ± 5 vs 103 ± 3 beats min^–1), mean skin temperature (36.1 ± 0.2 vs 31.3° C ± 0.1°C and 36.9 ± 0.3 vs 30.9°C ± 0.4°C) and sweat rate (473 ± 51 vs 70 ± 23 g m^–2 h^–1 and 766 ± 81 vs 135 ± 18 g m^–2 h^–1) indicating a high cardiovascular and thermoregulatory strain, which was not decreased by ventilating the suit with an air flow of 281 min^–1 at 41% . The ventilation, oxygen consumption and production of carbon dioxide increased in relation to the extra weight of the GPC, partly dependent on the dynamic work level. It was concluded that the increase in the physiological load caused by the GPC was so high that the work-rest regimens, workers' level of physical fitness, cardiovascular health and heat tolerance should be considered whenever gas protective clothing is used.