Cost Effectiveness of Intracranial Pressure Monitoring in Pediatric Patients with Severe Traumatic Brain Injury: A Simulation Modeling Approach.

OBJECTIVES: To conduct an economic evaluation of intracranial pressure (ICP) monitoring on the basis of current evidence from pediatric patients with severe traumatic brain injury, through a statistical model. METHODS: The statistical model is a decision tree, whose branches take into account the severity of the lesion, the hospitalization costs, and the quality-adjusted life-year for the first 6 months post-trauma. The inputs consist of probability distributions calculated from a sample of 33 surviving children with severe traumatic brain injury, divided into two groups: with ICP monitoring (monitoring group) and without ICP monitoring (control group). The uncertainty of the parameters from the sample was quantified through a probabilistic sensitivity analysis using the Monte-Carlo simulation method. The model overcomes the drawbacks of small sample sizes, unequal groups, and the ethical difficulty in randomly assigning patients to a control group (without monitoring). RESULTS: The incremental cost in the monitoring group was Mex$3,934 (Mexican pesos), with an increase in quality-adjusted life-year of 0.05. The incremental cost-effectiveness ratio was Mex$81,062. The cost-effectiveness acceptability curve had a maximum at 54% of the cost effective iterations. The incremental net health benefit for a willingness to pay equal to 1 time the per capita gross domestic product for Mexico was 0.03, and the incremental net monetary benefit was Mex$5,358. CONCLUSIONS: The results of the model suggest that ICP monitoring is cost effective because there was a monetary gain in terms of the incremental net monetary benefit.

Clinical doses of citalopram or reboxetine differentially modulate passive and active behaviors of female Wistar rats with high or low immobility time in the forced swimming test.

The sensitivity of immobility time (IT) to antidepressant-drugs differs in rats expressing high or low motor activity during the forced swimming test (FST). However, whether this heterogeneity is expressed after the administration of the most selective serotonin and norepinephrine reuptake inhibitors (SSRIs and SNRIs, respectively) is unknown. We compared the influence of either the SSRI citalopram or the SNRI reboxetine with the tricyclic antidepressant amitriptyline on two subgroups of female Wistar rats expressing high IT (HI; at or above the mean value) or low IT (LI; below the mean) during the initial 5 min of the first session of the FST. None of the tested drugs increased motor activity in the open field test. When vehicle was applied to either HI or LI rats, IT increased in the second session of the FST. This increment concurred with a simultaneous climbing time (CT) decrement. When amitriptyline (15 mg/kg) was tested the CT increased for both HI and LI rats. This increment was accompanied by an IT decrement in HI and LI rats. Reboxetine (0.16 or 1 mg/kg) precluded IT and CT changes in both HI and LI rats and produced a swimming time reduction. Citalopram (0.4, 1, and 3 mg/kg) essentially mimicked the influence of reboxetine on the IT and CT in LI rats, as well as in HI rats, but in the latter case only at 3 mg/kg. Yet, at the dose of 10 mg/kg citalopram lacked this effect in both subgroups. No differences were detected when the IT of LI rats was evaluated with citalopram (3 mg/kg) during estrus or diestrus stage. These results show that clinical doses of citalopram produced an antidepressant-like effect selectively in LI rats, while amitriptyline or reboxetine produced this effect in both LI and HI animals.