Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment: a combined analysis of three mathematical models

Background: WHO's 2013 revisions to its Consolidated Guidelines on antiretroviral drugs recommend routine viral load monitoring, rather than clinical or immunological monitoring, as the preferred monitoring approach on the basis of clinical evidence. However, HIV programmes in resource-limited settings require guidance on the most cost-effective use of resources in view of other competing priorities such as expansion of antiretroviral therapy coverage. We assessed the cost-effectiveness of alternative patient monitoring strategies. Methods: We evaluated a range of monitoring strategies, including clinical, CD4 cell count, and viral load monitoring, alone and together, at different frequencies and with different criteria for switching to second-line therapies. We used three independently constructed and validated models simultaneously. We estimated costs on the basis of resource use projected in the models and associated unit costs; we quantified impact as disability-adjusted life years (DALYs) averted. We compared alternatives using incremental cost-effectiveness analysis. Findings: All models show that clinical monitoring delivers significant benefit compared with a hypothetical baseline scenario with no monitoring or switching. Regular CD4 cell count monitoring confers a benefit over clinical monitoring alone, at an incremental cost that makes it affordable in more settings than viral load monitoring, which is currently more expensive. Viral load monitoring without CD4 cell count every 6—12 months provides the greatest reductions in morbidity and mortality, but incurs a high cost per DALY averted, resulting in lost opportunities to generate health gains if implemented instead of increasing antiretroviral therapy coverage or expanding antiretroviral therapy eligibility. Interpretation: The priority for HIV programmes should be to expand antiretroviral therapy coverage, firstly at CD4 cell count lower than 350 cells per μL, and then at a CD4 cell count lower than 500 cells per μL, using lower-cost clinical or CD4 monitoring. At current costs, viral load monitoring should be considered only after high antiretroviral therapy coverage has been achieved. Point-of-care technologies and other factors reducing costs might make viral load monitoring more affordable in future. Funding: Bill & Melinda Gates Foundation, WHO.

Guidelines of natural zeolites characterization for acid mine drainage treatment. Case study Guayaquil, Ecuador

Zeolites constitute one of the less common groups of tectosilicates. Zeoli1es with pores between -2 to 10 A in their structures have strong sorption capacity and are widely used in industrial and municipal operations to eliminate toxic substances. One of the major environmental problems in the mining activity is the treating of acid mine drainage. In this context, it is very important to search alternatives to manage this challenge. One feasible alternative is using zeolitic tuffs. The results of the physical-chemical characterization of zeolitic tuffs are the c1ue lo continue or not with deeper analysis and tests 01 acid mine drainage treatments. The guidelines to reach this purpose are the main goal of this work. Zeolite 1uff samples (named as XB_01 and XB_02) studied in this work were laken rn the Late Cretaceous Coastal Cayo Arch Ecuador, specifically in the Guaraguao River, showing the most important characteristics of heulandite zeolitic tuffs. X-ray powder diffraction (XRD) tests were developed in order to confirm that the samples belong to the heulandite-type zeoli1ic tuffs. Additionally, Thermogravimetric analysis (TG), Inductively coupled plasma-atomic emission spectroscopy (ICP-AES) and X-ray fluorescence (XRF) of the samples was necessary in order to define the Si/Al ratio and the main mineralogical phases. The XB_01 sample shows a higher ratio Si/Al than XB_02 sample. The cation exchange capacity est was the fundamental step to define the potentiality of the zeolite to use in acid mine drainage treatment Three methodologies were employed to determine the cation exchange capacity. The Cuban standard 626 and the ammonium exchange methodologies reflect results more consistent with each other. This is the starting point to continue with deeper studies such as breakthrough curves for heavy metal ions found in acid mine waters.

Single patient (n-of-1) trials with binary treatment preference

The use of a fully parametric Bayesian method for analysing single patient trials based on the notion of treatment 'preference' is described. This Bayesian hierarchical modelling approach allows for full parameter uncertainty, use of prior information and the modelling of individual and patient sub-group structures. It provides updated probabilistic results for individual patients, and groups of patients with the same medical condition, as they are sequentially enrolled into individualized trials using the same medication alternatives. Two clinically interpretable criteria for determining a patient's response are detailed and illustrated using data from a previously published paper under two different prior information scenarios. Copyright (C) 2005 John Wiley & Sons, Ltd.

Systematic review and analysis of evidences on clinical efficacy and cost-effectiveness of biological drugs for the treatment of Ankylosing Spondylitis

Technology: Infliximab and comparator biological such as adalimumab, etanercept, golimumab. Conditions: Ankylosing spondylitis (AS) Issue: Infliximab is registered to be used in patients with AS. The aim of the Report is to evaluate the clinical efficacy and safety of infliximab and comparator biologicals for the treatment of adult AS. Methods: Systematic literature review and analysis as well as meta-analysis (direct and indirect comparison) of published randomised controlled clinical trials (RCT) were performed, all relevant health economics literature were identified ad analysed. Results: Clinical efficacy of biological therapies is based on good clinical evidences regarding to all clinical efficacy endpoints (ASAS20, ASAS40, ASAS 5/6, and BASDAI 50% response). Altogether, 22 trials are included in our meta-analysis, 12 infliximab, 3 adalimumab studies, 6 etanercept and 1 golimumab. Efficacy of biological treatments for the treatment of AS has been established by clinical scientific evidences, significant improvement at all outcomes considered was confirmed. According to the results of indirect comparison, there were no significant difference between biological treatments and placebo in terms of safety and tolerability endpoints. We found no significant difference between the clinical efficacy and safety of infliximab, adalimumab, etanercept and golimumab therapies. Cost-utility analysis of adalimumab and/or infliximab, etanercept and golimumab treatment for AS were performed in the UK, Canada, The Netherlands, Germany, Spain and France. There are no cost-utility studies from Eastern Central Europe. Implications for decision making: Efficacy of infliximab and comparator biologicals for the treatment of Ankylosing Spondylitis (AS) was proved by clinical evidence, significant improvement at all outcomes considered was confirmed. We found no significant differences in efficacy and safety of different biological treatments. Health economics results suggest that biological therapies are cost-effective alternatives for the treatment of AS in group of developed high income countries. There is a lack of health economics results in Central-Eastern European countries however these data are more and more required by governments and funders as part of the company economic dossiers.

The effects of required/sequenced preparatory courses on academic success and retention at a community college

This dissertation had two purposes: first, to analyze how required sequenced college preparatory courses in mathematics, reading, and writing affect students' academic success and, second, to add to a theoretical model for predicting student retention at a community college. Grade point average, number of degree credits earned, and re-enrollment rate were measured as determinants of academic success. The treatment group had a significantly higher grade point average than the control group. There was no significant difference in the number of degree credits earned or re-enrollment rate for the groups. A series of logistic regressions used the independent variables E-ASSET scores in math, reading, and writing; number of college prep areas required; credits earned; grade point average; students' status; academic restrictions/required course sequencing; sex; race; and socio-economic status to determine the predictor variables for retention. The academic variable that showed the greatest potential as a predictor for retention was grade point average. Overall, receiving financial aid was the greatest predictor for re-enrollment. For a financial aid recipient the odds of re-enrollment were 2.70 times more likely than if no financial aid was received.

The effects of required/sequenced preparatory courses on academic success and retention at a community college

This dissertation had two purposes: first, to analyze how required sequenced college preparatory courses in mathematics, reading, and writing affect students' academic success and, second, to add to a theoretical model for predicting student retention at a community college. Grade point average, number of degree credits earned, and reenrollment rate were measured as determinants of academic success. The treatment group had a significantly higher grade point average than the control group. There was no significant difference in the number of degree credits earned or re-enrollment rate for the groups. A series of logistic regressions used the independent variables E-ASSET scores in math, reading, and writing; number of college prep areas required; credits earned; grade point average; students' status; academic restrictions/required course sequencing; sex; race; and socio-economic status to determine the predictor variables for retention. The academic variable that showed the greatest potential as a predictor for retention was grade point average. Overall, receiving financial aid was the greatest predictor for reenrollment. For a financial aid recipient the odds of reenrollment were 2.70 times more likely than if no financial aid was received.

Do GPs and psychiatrists recommend alternatives when prescribing anti-depressants?

This study explores whether a partial explanation for high antidepressant prescription rates is the failure of prescribers to recommend alternatives. 1,829 New Zealand adults were asked which of six non-pharmacological treatment approaches were recommended when prescribed anti-depressants. The majority (82%) received at least one recommendation and 32% received three or more, most commonly ‘Counsellor/Psychologist/Psychotherapist’ (74%) and Exercise Schedule (43%). It cannot, therefore, be concluded that failing to consider non-pharmacological treatments is a major cause of high prescribing rates. Being younger and more severely depressed were both positively related to number of recommendations. Psychiatrists made significantly more recommendations than GPs.

Minimal Invasive Ostheosintesis For Treatment Of Diaphiseal Transverse Humeral Shaft Fractures.

To evaluate patients with transverse fractures of the shaft of the humerus treated with indirect reduction and internal fixation with plate and screws through minimally invasive technique. Inclusion criteria were adult patients with transverse diaphyseal fractures of the humerus closed, isolated or not occurring within 15 days of the initial trauma. Exclusion criteria were patients with compound fractures. In two patients, proximal screw loosening occurred, however, the fractures consolidated in the same mean time as the rest of the series. Consolidation with up to 5 degrees of varus occurred in five cases and extension deficit was observed in the patient with olecranon fracture treated with tension band, which was not considered as a complication. There was no recurrence of infection or iatrogenic radial nerve injury. It can be concluded that minimally invasive osteosynthesis with bridge plate can be considered a safe and effective option for the treatment of transverse fractures of the humeral shaft. Level of Evidence III, Therapeutic Study.

The Effect Of Pelvic Floor Muscle Training Alone Or In Combination With Electrostimulation In The Treatment Of Sexual Dysfunction In Women With Multiple Sclerosis.

Sexual dysfunction (SD) affects up to 80% of multiple sclerosis (MS) patients and pelvic floor muscles (PFMs) play an important role in the sexual function of these patients. The objective of this paper is to evaluate the impact of a rehabilitation program to treat lower urinary tract symptoms on SD of women with MS. Thirty MS women were randomly allocated to one of three groups: pelvic floor muscle training (PFMT) with electromyographic (EMG) biofeedback and sham neuromuscular electrostimulation (NMES) (Group I), PFMT with EMG biofeedback and intravaginal NMES (Group II), and PFMT with EMG biofeedback and transcutaneous tibial nerve stimulation (TTNS) (Group III). Assessments, before and after the treatment, included: PFM function, PFM tone, flexibility of the vaginal opening and ability to relax the PFMs, and the Female Sexual Function Index (FSFI) questionnaire. After treatment, all groups showed improvements in all domains of the PERFECT scheme. PFM tone and flexibility of the vaginal opening was lower after the intervention only for Group II. All groups improved in arousal, lubrication, satisfaction and total score domains of the FSFI questionnaire. This study indicates that PFMT alone or in combination with intravaginal NMES or TTNS contributes to the improvement of SD.

Impact Of Benign Prostatic Hyperplasia Pharmacological Treatment On Transrectal Prostate Biopsy Adverse Effects.

Background. Benign prostatic hyperplasia (BPH) pharmacological treatment may promote a decrease in prostate vascularization and bladder neck relaxation with theoretical improvement in prostate biopsy morbidity, though never explored in the literature. Methods. Among 242 consecutive unselected patients who underwent prostate biopsy, after excluding those with history of prostate biopsy/surgery or using medications not for BPH, we studied 190 patients. On the 15th day after procedure patients were questioned about symptoms lasting over a week and classified according to pharmacological BPH treatment. Results. Thirty-three patients (17%) were using alpha-blocker exclusively, five (3%) 5-alpha-reductase inhibitor exclusively, twelve (6%) patients used both medications, and 140 (74%) patients used none. There was no difference in regard to age among groups (P = 0.5). Postbiopsy adverse effects occurred as follows: hematuria 96 (50%), hematospermia 53 (28%), hematochezia 22 (12%), urethrorrhagia 19 (10%), fever 5 (3%), and pain 20 (10%). There was a significant negative correlation between postbiopsy hematuria and BPH pharmacological treatment with stronger correlation for combined use of 5-alpha-reductase inhibitor and alpha-blocker over 6 months (P = 0.0027). Conclusion. BPH pharmacological treatment, mainly combined for at least 6 months seems to protect against prostate biopsy adverse effects. Future studies are necessary to confirm our novel results.

Evaluation Of Different Treatment Methods Against Denture Stomatitis: A Randomized Clinical Study.

The aim of this clinical study was to determine the efficacy of Uncaria tomentosa (cat's claw) against denture stomatitis (DS). Fifty patients with DS were randomly assigned into 3 groups to receive 2% miconazole, placebo, or 2% U tomentosa gel. DS level was recorded immediately, after 1 week of treatment, and 1 week after treatment. The clinical effectiveness of each treatment was measured using Newton's criteria. Mycologic samples from palatal mucosa and prosthesis were obtained to determinate colony forming units per milliliter (CFU/mL) and fungal identification at each evaluation period. Candida species were identified with HiCrome Candida and API 20C AUX biochemical test. DS severity decreased in all groups (P < .05). A significant reduction in number of CFU/mL after 1 week (P < .05) was observed for all groups and remained after 14 days (P > .05). C albicans was the most prevalent microorganism before treatment, followed by C tropicalis, C glabrata, and C krusei, regardless of the group and time evaluated. U tomentosa gel had the same effect as 2% miconazole gel. U tomentosa gel is an effective topical adjuvant treatment for denture stomatitis.

Aquatic Toxicity Of Dyes Before And After Photo-fenton Treatment.

This study evaluated the ecotoxicity of five dyes to freshwater organisms before and during their photo-Fenton degradation. EC50 (48h) of the five tested dyes ranged from of 6.9 to >1000mgL(-1) for Daphnia similis. In the chronic tests IC50 (72h) varied from 65 to >100mgL(-1) for Pseudokirchneriella subcapitata and IC50 (8 days) from 0.5 to 410mgL(-1) for Ceriodaphnia dubia. Toxicity tests revealed that although the applied treatment was effective for decolorization of the dye, the partial mineralization may be responsible for the presence of degradation products which can be either more toxic than the original dye, as is the case of Vat Green 3 and Reactive Black 5, lead to initially toxic products which may be further degraded to non toxic products (acid Orange 7 and Food Red 17), or generate non toxic products as in the case of Food Yellow 3. The results highlighted the importance of assessing both acute and chronic toxicity tests of treated sample before effluent discharge.

The Consequences Of Refractory Epilepsy And Its Treatment.

Seizures in some 30% to 40% of patients with epilepsy fail to respond to antiepileptic drugs or other treatments. While much has been made of the risks of new drug therapies, not enough attention has been given to the risks of uncontrolled and progressive epilepsy. This critical review summarizes known risks associated with refractory epilepsy, provides practical clinical recommendations, and indicates areas for future research. Eight international epilepsy experts from Europe, the United States, and South America met on May 4, 2013, to present, review, and discuss relevant concepts, data, and literature on the consequences of refractory epilepsy. While patients with refractory epilepsy represent the minority of the population with epilepsy, they require the overwhelming majority of time, effort, and focus from treating physicians. They also represent the greatest economic and psychosocial burdens. Diagnostic procedures and medical/surgical treatments are not without risks. Overlooked, however, is that these risks are usually smaller than the risks of long-term, uncontrolled seizures. Refractory epilepsy may be progressive, carrying risks of structural damage to the brain and nervous system, comorbidities (osteoporosis, fractures), and increased mortality (from suicide, accidents, sudden unexpected death in epilepsy, pneumonia, vascular disease), as well as psychological (depression, anxiety), educational, social (stigma, driving), and vocational consequences. Adding to this burden is neuropsychiatric impairment caused by underlying epileptogenic processes (essential comorbidities), which appears to be independent of the effects of ongoing seizures themselves. Tolerating persistent seizures or chronic medicinal adverse effects has risks and consequences that often outweigh risks of seemingly more aggressive treatments. Future research should focus not only on controlling seizures but also on preventing these consequences.

[adherence To Statin Treatment And Associated Factors In Female Users From The Unified Health System (sus)].

To identify the adherence rate of a statin treatment and possible related factors in female users from the Unified Health System. Seventy-one women were evaluated (64.2 ± 11.0 years) regarding the socio-economic level, comorbidities, current medications, level of physical activity, self-report of muscular pain, adherence to the medical prescription, body composition and biochemical profile. The data were analyzed as frequencies, Chi-Squared test, and Mann Whitney test (p<0.05). 15.5% of women did not adhere to the medical prescription for the statin treatment, whose had less comorbidities (p=0.01), consumed less quantities of medications (p=0.00), and tended to be younger (p=0.06). Those patients also presented higher values of lipid profile (CT: p=0.01; LDL-c: p=0.02). Musculoskeletal complains were not associated to the adherence rate to the medication. The associated factors to adherence of dyslipidemic women to statin medical prescription were age, quantity of comorbidities and quantity of current medication.

Familial Systemic Mastocytosis With Germline Kit K509i Mutation Is Sensitive To Treatment With Imatinib, Dasatinib And Pkc412.

Mastocytosis are myeloproliferative neoplasms commonly related to gain-of-function mutations involving the tyrosine kinase domain of KIT. We herein report a case of familial systemic mastocytosis with the rare KIT K509I germ line mutation affecting two family members: mother and daughter. In vitro treatment with imatinib, dasatinib and PKC412 reduced cell viability of primary mast cells harboring KIT K509I mutation. However, imatinib was more effective in inducing apoptosis of neoplastic mast cells. Both patients with familial systemic mastocytosis had remarkable hematological and skin improvement after three months of imatinib treatment, suggesting that it may be an effective front line therapy for patients harboring KIT K509I mutation.