Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

Objective: To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice.

Method: Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental costeffectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted.

Results: The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient.

Conclusions: MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

Guidelines for treatment of osteoporosis in men

BACKGROUND: Osteoporosis is associated with significant morbidity and mortality in men. Published randomised controlled trials assessing the benefits of therapy in men with osteoporosis are limited, but those available need to be used to develop management guidelines.

OBJECTIVE: To present evidence based guidelines for the treatment of osteoporosis in men.

DISCUSSION: It is estimated that 30-60% of men presenting with spinal fractures have another illness contributing to their bone disease. Therefore assessment and treatment of coexisting medical conditions is a vital part of management of osteoporosis. While primary prevention of fractures remains crucial, treatment to ensure further fractures do not occur is equally important. Alendronate is the treatment of choice for men with osteoporosis and fractures, with cyclical etidronate an appropriate alternative and testosterone replacement therapy is indicated in hypogonadal men presenting with osteoporosis.

Prevalence, detection and drug treatment of hypertension in a rural Australian population : the Greater Green Triangle Risk Factor Study 2004

Background: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia.

Aim: To assess the prevalence, awareness and treatment of hypertension in a rural South-East Australian population.

Methods: Three cross-sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004–2006 using a random population sample (n = 3320, participation rate 49%) aged 25–74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and/or on antihypertensive drug treatment.

Results: Overall, one-third of participants had hypertension; of these, two-thirds, 54% (95% confidence interval (CI) 47–60) of men and 71% (95% CI 65–77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54–67 and 55%, 95% CI 47–64) compared with men (42%, 95% CI 36–49 and 35%, 95% CI 26–44). Monotherapy was used by 55% (95% CI 48–61) of treated hypertensives. Angiotensin-converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women.

Conclusion: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.

Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640]

Background: Vertebroplasty is a promising but as yet unproven treatment for painful osteoporotic vertebral fractures. It involves radiographic-guided injection of various types of bone cement directly into the vertebral fracture site. Uncontrolled studies and two controlled quasi-experimental before-after studies comparing volunteers who were offered treatment to those who refused it, have suggested an early benefit including rapid pain relief and improved function. Conversely, several uncontrolled studies and one of the controlled before-after studies have also suggested that vertebroplasty may increase the risk of subsequent vertebral fractures, particularly in vertebrae adjacent to treated levels or if cement leakage into the adjacent disc has occurred. As yet, there are no completed randomised controlled trials of vertebroplasty for osteoporotic vertebral fractures. The aims of this participant and outcome assessor-blinded randomised placebo-controlled trial are to i) determine the short-term efficacy and safety (3 months) of vertebroplasty for alleviating pain and improving function for painful osteoporotic vertebral fractures; and ii) determine its medium to longer-term efficacy and safety, particularly the risk of further fracture over 2 years.

Design: A double-blind randomised controlled trial of 200 participants with one or two recent painful osteoporotic vertebral fractures. Participants will be stratified by duration of symptoms (< and ≥ 6 weeks), gender and treating radiologist and randomly allocated to either the treatment or placebo. Outcomes will be assessed at baseline, 1 week, 1, 3, 6, 12 and 24 months. Outcome measures include overall, night and rest pain on 10 cm visual analogue scales, quality of life measured by the Assessment of Quality of Life, Osteoporosis Quality of Life and EQ-5D questionnaires; participant perceived recovery on a 7-point ordinal scale ranging from 'a great deal worse' to 'a great deal better'; disability measured by the Roland-Morris Disability Questionnaire; timed 'Up and Go' test; and adverse effects. The presence of new fractures will be assessed by radiographs of the thoracic and lumbar spine performed at 12 and 24 months.

Discussion: The results of this trial will be of major international importance and findings will be immediately translatable into clinical practice.

Trial registration: Australian Clinical Trial Register # [ACTRN012605000079640]

Nutrition therapy in the prevention and treatment of pressure ulcers

Pressure ulcers are serious problems within hospital and aged care settings and are associated with adverse health outcomes and high treatment costs. Because of a high incidence of pressure ulcers in the health system, attention is now being directed to not just preventing, but also more effectively treating them. Nutrition plays a fundamental part in wound healing, with malnutrition, dehydration and recent weight loss identified as independent risk factors for the development of pressure ulcers. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and vitamins A, C and E have been documented. There is reasonable evidence to show that nutritional support, mostly by high-protein oral nutritional supplements, is effective in significantly reducing the incidence of pressure ulcers in at-risk patients by 25%. Intervention studies using high-protein or specialised disease-specific nutritional supplements support a trend to increased healing of established pressure ulcers. Such specialised supplements are typically based on defined amounts of arginine, vitamin C and zinc. Mechanisms by which nutritional support can aid in pressure ulcer prevention and healing are likely related to addressing macro- and/or micro-nutrient deficiencies arising from either poor oral intake or increased nutrient requirements related to the wound healing process. With much more research still to be done in this area, nutrition support appears an efficacious and costeffective adjunct to current medical and nursing approaches in the prevention and treatment of pressure ulcers.

Mindfulness and the treatment of anger problems

Clinical interventions based on training in mindfulness skills are an increasingly common part of psychological practice. Mindfulness training can lead to reductions in a variety of problematic conditions including pain, stress, anxiety, depressive relapse, psychosis, and disordered eating but to date there have been few attempts to investigate the effectiveness of this approach with problematic anger. In this paper, the literature in relation to the theory and treatment of problematic anger is reviewed, with the aim of determining whether a rationale exists for the use of mindfulness with angry individuals. It is concluded that anger as an emotion seems particularly appropriate for the application of mindfulness-based interventions, and the potential mechanisms for its proposed effects in alleviating the cognitive, affective and behavioral manifestations of anger are discussed.

Personality change and personality disorder : some initial thoughts on the application of McAdams' triarchic model to the treatment of personality disorder

It is increasingly accepted that psychological therapies have an important role to play in the management and treatment of those who are considered to have disorders of personality, particularly those with forensic histories. Whilst there appears to be an emerging evidence base supporting the effectiveness of treatment for this group, there have been relatively few attempts to link treatment approaches to current models of normal personality. In this paper we use McAdams' (1994) triarchic model of personality as a basis for understanding the effective treatment of personality disorders. We conclude that the model may be useful in assisting clinicians to engage patients in treatment, identify innovative methods of intervention, and conceptualise therapeutic progress.

Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age

Nappy dermatitis is a broad term used to describe an acute inflammatory reaction of the skin in the nappy area because of irritation from urine, faeces, moisture or friction. The prevalence is estimated to be between 7% and 35% in infants. Regular application of a barrier preparation at every nappy change may be a valuable component of nappy dermatitis prevention and/or treatment.

The effectiveness of physical activity interventions for the treatment of overweight and obesity and type 2 diabetes

This review summarises current evidence relating to the effectiveness of physical activity (PA) interventions for treating overweight and obesity and type 2 diabetes. Interventions to increase PA for the treatment of overweight and obesity in both children and adults have primarily consisted of health education and behaviour modification strategies in clinical settings or with selected families or individuals. Although evidence is limited, strategies to reduce sedentary behaviours appear to have potential for reducing obesity among children and adolescents. Among adults, strategies that combine diet and PA are more effective than PA strategies alone. Combined lifestyle strategies are most successful for maintained weight loss, although most programs are unsuccessful in producing long-term changes. There is little evidence about compliance to prescribed behaviour changes or the factors that promote or hinder compliance to lifestyle changes. Limited evidence suggests that continued professional contact and self-help groups can help sustain weight loss. Most of the interventions for the treatment of type 2 diabetes have been conducted in clinical settings and have typically required the use of extensive resources. Evidence suggests that interventions can lead to small but clinically meaningful improvements in glycaemic control, even in the absence of weight loss. A recent study demonstrated that a multifactorial intervention (diet, PA and pharmaceutical) can reduce the risk of diabetes complications in individuals with type 2 diabetes. Nevertheless, there is little evidence about the effectiveness of community-based interventions in producing long-term changes in glycaemic control and reduced mortality in people with type 2 diabetes.