Challenges with Forecasting Budget Impact: A Case Study of Six ICER Reports

Background

Payers frequently rely on budget impact model (BIM) results to help determine drug coverage policy and its effect on their bottom line. It is unclear whether BIMs typically overestimate or underestimate real-world budget impact.

Analysis of relative effectiveness of high-dose versus standard-dose influenza vaccines using an instrumental variable method

Background

Observational studies of the relative effectiveness of influenza vaccines are essential for public health decision making. Their estimates, however, are subject to bias due to unmeasured confounders. Instrumental variable (IV) methods can control for observed and unobserved confounders.

Phase I trial of doxorubicin-containing low temperature sensitive liposomes in spontaneous canine tumors.

PURPOSE: To determine the maximum tolerated dose, dose-limiting toxicities, and pharmacokinetic characteristics of doxorubicin encapsulated in a low temperature sensitive liposome (LTSL) when given concurrently with local hyperthermia to canine solid tumors. EXPERIMENTAL DESIGN: Privately owned dogs with solid tumors (carcinomas or sarcomas) were treated. The tumors did not involve bone and were located at sites amenable to local hyperthermia. LTSL-doxorubicin was given (0.7-1.0 mg/kg i.v.) over 30 minutes during local tumor hyperthermia in a standard phase I dose escalation study. Three treatments, given 3 weeks apart, were scheduled. Toxicity was monitored for an additional month. Pharmacokinetics were evaluated during the first treatment cycle. RESULTS: Twenty-one patients were enrolled: 18 with sarcomas and 3 with carcinomas. Grade 4 neutropenia and acute death secondary to liver failure, possibly drug related, were the dose-limiting toxicities. The maximum tolerated dose was 0.93 mg/kg. Other toxicities, with the possible exception of renal damage, were consistent with those observed following free doxorubicin administration. Of the 20 dogs that received > or = 2 doses of LTSL-doxorubicin, 12 had stable disease, and 6 had a partial response to treatment. Pharmacokinetic variables were more similar to those of free doxorubicin than the marketed liposomal product. Tumor drug concentrations at a dose of 1.0 mg/kg averaged 9.12 +/- 6.17 ng/mg tissue. CONCLUSION: LTSL-doxorubicin offers a novel approach to improving drug delivery to solid tumors. It was well tolerated and resulted in favorable response profiles in these patients. Additional evaluation in human patients is warranted.     

The vagal nerve as a link between the nervous and immune system in the instance of polymicrobial sepsis

Background The role of the vagal nerve in the autonomic nervous system is widely well known. Recently, an additional function was revealed serving as a connector between the nervous and immune system. This connection is called the “cholinergic inflammatory pathway.” Through stimulation of the acetylcholine receptors located upon the macrophages, the “unspecific” immune system can be directly influenced. Methods The vagal nerve was completely transected directly posterior to its passage through the diaphragm. The effect of complete vagotomy was analyzed using a murine model of polymicrobial peritonitis (colon ascendens stent peritonitis, CASP). Survival and clinical course of vagotomized or sham-operated mice were analyzed in the CASP model. Results After CASP surgery, vagotomy led to a significantly increased mortality (64.7%) in comparison to sham-vagotomized animals (34%). No difference in the bacterial load of various tissues (lung, liver, spleen, blood, lavage fluid, and kidney) from septic animals with or without vagotomy was observed. Vagotomized animals reveal elevated serum cytokine levels (TNF, IL-6, IL-10, and MCP-1) 20 h after the induction of polymicrobial peritonitis. Conclusion The vagal nerve is therefore an important modulator of the immune system. W. Kessler and T. Traeger contributed equally to this work Best of Forum Papers presented at the Annual Meeting of the German Society of Surgery, 2–5 May 2006, Berlin, Germany     

Stereophotogrammetric measurement of the nasolabial fold in repose: a study of age and posture-related changes

The nasolabial fold is a significant facial landmark. Its size, shape, and symmetry are important in facial reanimation surgery, while effacement is an important goal in rejuvenation surgery. However, quantitative data for the nasolabial fold volume (NLFV) and depth is still unavailable. We present a new method of measurement using 3D color speckle stereophotogrammetry and its application in the assessment of NLFV. The VECTRA-3D system was validated to determine its minimum resolution and accuracy. Normal volunteers aged 13–84 years (n = 87) were imaged in repose. Mother–daughter pairs (n = 15, aged 13–61) were imaged in the upright and supine positions. All data were processed using custom software and analyzed by linear regression and nonparametric tests as appropriate. NLFV varied from 0.0026 to 0.2306 ml. There was significant correlation between NLFV and age (r = 0.7269, p < 0.0001). Men had significantly higher NLFV than women across all ages. There was no significant difference between the left and right NLFV. NLFV altered significantly from upright to supine in all subjects (p = 0.0012). However, the mothers increased their NLFV by 32% from supine to upright postures, which was a greater change than observed in their daughters. We have demonstrated a rapid, objective, and non-invasive assessment tool for facial reanimation and rejuvenation surgery. We have quantified the effects of age and posture on NLFV, and the efficacy and longevity of rejuvenation procedures are currently under investigation.     

Study of the localization of radiopacities similar to calcified carotid atheroma by means of panoramic radiography.

OBJECTIVE: To determine the location in soft tissues of the calcifications, similar to calcified carotid atheromas, that can be observed radiographically in the cervical region in panoramic radiographs. STUDY DESIGN: In each anatomic cadaver specimen preserved in formol, consisting of the head and neck, radiopaque spheres (made from gutta-percha) were positioned in anatomic structures of the cervical region that can be sites of calcification. For each anatomic structure marked in this way, panoramic radiography was performed, consisting of 17 radiographs. The images obtained were analyzed by 24 examiners who indicated which radiographs, in their opinion, presented the radiopaque reference projected in the region of bifurcation of the carotid artery. Analysis of 2 proportions from agreement and disagreement was used to determine radiopacities that could be confused in panoramic radiographs with calcified atheromas in the carotid artery. RESULTS: The results showed that 75% (18) of the examiners correctly indicated the reference in the bifurcation of the carotid artery and 79.2% (19) indicated a triticeous cartilage as calcified atheroma of the carotid artery. CONCLUSIONS: Calcified atheromas of the carotid artery are not the only features that can produce radiopaque images lateral to the panoramic radiograph; the presence of calcification in the triticeous cartilage also can induce an erroneous diagnosis of calcified carotid atheroma.     

Defenses of the hamster lung against human neutrophil and porcine pancreatic elastase

Instillation of human neutrophil elastase (HNE) into hamster lungs produces milder emphysema but more pulmonary hemorrhage than an equivalent amount of porcine pancreatic elastase (PPE), whether equivalence is determined by elastolytic units or moles. We undertook a study of the mechanisms of these differences. 125I-HNE or 3H-PPE were instilled intratracheally into hamsters. The partitioning of radioactivity between bronchoalveolar lavage fluid (BAL) and lung tissue was similar for HNE and PPE as were the half-lives, 45 and 51 min, respectively, for uncomplexed, enzymatically active HNE and PPE. In BAL there was preferential binding and inactivation of HNE by the hamsters' alpha-1-protease inhibitor (a-1-PI) whereas PPE was preferentially bound by alpha-2-macroglobulin (a-2-M). This was also observed in vitro when HNE and PPE were incubated with plasma from untreated hamsters. Nevertheless, when the sum of the elastase binding capacity of a-1-PI and a-2-M was considered, hamster plasma had similar binding capacities for HNE and PPE. It is known that the enzymatic activity of elastases is inhibited by formation of a stable complex with a-1-PI. On the other hand, elastases bound to a-2-M are protected against a-1-PI inhibition but can free themselves by proteolysis and exhibit elastolytic activity. Preferential inactivation of HNE by a-1-PI may be one mechanism that accounts for the lesser emphysema-inducing potency of HNE than of PPE.     

A pharmacokinetic comparison of cyclosporin oral solution and cyclosporin capsules in heart and lung transplant recipients

Pharmacokinetic profiles were obtained for 16 heart or lung recipients following the administration of identical doses of cyclosporin as oral solution and capsules on consecutive days. A comparison of pharmacokinetic parameters (AUC, C_max, C_min and t_max) showed that there were no significant differences between the two formulations except for the t_max, which was significantly longer for the capsules. The mean variation in day-to-day trough levels produced by the two different forms was 25.6%. A retrospective study was carried out of consecutive cyclosporin levels in patients at steady state on oral solution. The mean variation in day-to-day trough levels was 32.3%. This was not significantly different from the variation in consecutive trough levels seen in the oral solution/capsule comparison. This study shows that cyclosporin capsules can be substituted for oral solution without causing acute changes in cyclosporin blood levels, and that the pharmacokinetics of the two formulations are similar.This work was carried out in partial fulfillment of the requirements for the Master of Science Degree in Clinical Pharmacy, University of London     

Rural Hospital Nursing as an Elective*

A rural hospital elective in a diploma nursing program is described. A need and opportunity for this unique practicum was identified in a Canadian province where one-third of the acute care beds are in hospitals of under 100 beds, located primarily in towns outside of metropolitan areas. The six week course offers students 35 hours of classroom content focusing on rural health care concepts plus a 150 hour practicum in one of three participating hospitals. The course is seen as unique in that it focuses on rural health care and is offered within the context of a diploma nursing program. Vive student outcomes are identified: awareness of the differences between rural and urban health care; integration of knowledge and experience from previous nursing courses as it relates to the rural context; increasing understanding of how rural population groups affect health care delivery; awareness of rural employment opportunities; and, preparation for the graduate role. A shared vision and collaborative effort on the part of the School of Nursing, the rural hospitals and the host communities has been necessary to establish and maintain such a course.     

Doppler evaluation of normalized peak filling rate in normal children and children with left ventricular outflow obstruction.

To evaluate the early diastolic peak filling rate of the left ventricle, three groups of children (normal children, patients with aortic valvular stenosis, and patients with aortic coarctation) were examined with the peak filling rate normalized to stroke volume calculated from the mitral valve inflow Doppler recording as the peak E velocity divided by the velocity time integral. The normal value for this index in children was 6.78 +/- 0.99 SV/sec and did not vary with age, weight, body surface area, or heart rate. Compared with normal subjects, both patients with aortic stenosis and patients with coarctation had increased left ventricular mass, but patients with aortic stenosis had decreased normalized peak filling rates (5.3 +/- 0.84 SV/sec, p < 0.01), while patients with coarctation had normal rates (6.79 +/- 0.98 SV/sec, p = 0.97). Compared with patients with aortic coarctation, patients with aortic stenosis had higher Doppler gradients. Thus the Doppler index of peak filling rate normalized to stroke volume is particularly useful in children because it is independent of heart rate, age, weight, and body surface area. Patients with coarctation may have normal peak filling rates normalized to stroke volume despite increased left ventricular mass because of milder obstruction or better coronary artery perfusion compared with that of patients with aortic stenosis.