A cost-effectiveness analysis of trametinib plus dabrafenib as first-line therapy for metastatic BRAF V600-mutated melanoma in the Swiss setting.

BACKGROUND: The treatment of patients with metastatic melanomas that harbour BRAF V600E or V600K mutations with trametinib plus dabrafenib appears to be superior to treatment with vemurafenib alone. This treatment regimen is likely to become available in Switzerland in the near future. OBJECTIVES: To determine the cost-effectiveness of trametinib plus dabrafenib. METHODS: A Markov cohort simulation was conducted to model the clinical course of typical patients with metastatic melanoma. Information on response rates, clinical condition and follow-up treatments were derived and transition probabilities estimated based on the results of a clinical trial that compared treatment with trametinib plus dabrafenib vs. vemurafenib alone. RESULTS: Treatment with trametinib plus dabrafenib was estimated to cost an additional CHF199 647 (Swiss francs) on average and yield a gain of 0·52 quality-adjusted life years (QALYs), resulting in an incremental cost-effectiveness ratio of CHF385 603 per QALY. Probabilistic sensitivity analyses showed that a willingness-to-pay threshold of CHF100 000 per QALY would not be reached at the current US price of trametinib. CONCLUSIONS: The introduction of trametinib in Switzerland at US market prices for the treatment of metastatic BRAF V600-mutated melanoma with trametinib plus dabrafenib is unlikely to be cost-effective compared with vemurafenib monotherapy. A reduction in the total price of the combination therapy is required to achieve an acceptable cost-effectiveness ratio for this clinically promising treatment.

Impact of robotic dispensing machines in german pharmacies on business performance indicators.

AIMS AND OBJECTIVES: To assess the impact of robotic dispensing machines in community pharmacies on staff efficiency and sales of over-the-counter drugs. SETTING: The study was done on 253 community pharmacies in Germany that use a robotic dispensing machine manufactured by ROWA during 2008. METHOD: Data concerning the financial and economic impact of using a robotic dispensing machine in community pharmacies was gathered using a structured questionnaire and analysed in terms of its financial implications. KEY FINDINGS: The response rate was 29%. In most pharmacies (79%) the robotic dispensing machine was retrofitted. In 59% of the pharmacies additional space was gained for self-service and behind-the-counter display. As a result of using a robotic dispensing machine, personnel costs were reduced by an average of 4.6% during the first 12 months after start-up. Over-the-counter sales increased in the same period by an average of 6.8%. Despite average initial costs of 118,000 euros, total costs within the first 12 months fell in 50% of cases and at least remained the same in 44%. CONCLUSIONS: On average, robotic dispensing machines lead to modest savings in personnel costs and slight increases in sales of over-the-counter drugs. Substantial savings can be achieved only if the staffing level is adapted to the changed personnel requirements.

Comparing centralised and decentralised anaerobic digestion of stillage from a large-scale bioethanol plant to animal feed production.

A comparison of stillage treatment options for large-scale bioethanol plants was based on the data of an existing plant producing approximately 200,000 t/yr of bioethanol and 1,400,000 t/yr of stillage. Animal feed production--the state-of-the-art technology at the plant--was compared to anaerobic digestion. The latter was simulated in two different scenarios: digestion in small-scale biogas plants in the surrounding area versus digestion in a large-scale biogas plant at the bioethanol production site. Emphasis was placed on a holistic simulation balancing chemical parameters and calculating logistic algorithms to compare the efficiency of the stillage treatment solutions. For central anaerobic digestion different digestate handling solutions were considered because of the large amount of digestate. For land application a minimum of 36,000 ha of available agricultural area would be needed and 600,000 m(3) of storage volume. Secondly membrane purification of the digestate was investigated consisting of decanter, microfiltration, and reverse osmosis. As a third option aerobic wastewater treatment of the digestate was discussed. The final outcome was an economic evaluation of the three mentioned stillage treatment options, as a guide to stillage management for operators of large-scale bioethanol plants.

[Medical specialism and academic teaching]. / Arztliche Spezialisierungen und akademischer Unterricht.

Splitting up medical subjects caused remarkable progress in hospital medicine. The most influence on medical education is produced by the organisation itself. As to applied medicine in general much progress will be reached, if applied medicine has become a topic of basic research in hospital medicine.

Alcohol abuse and liver enzymes (AALE): results of an intercompany study of mortality.

Evaluation of applicants for life insurance who have elevations of their liver function tests or an increased probability of alcohol abuse has always been difficult for underwriters. This paper reports the results of an intercompany study in which the pooled mortality experience of a group of insureds with evidence of alcohol abuse, an adverse driving record or elevations of the liver transaminases or gamma-glutamyl transferase is summarized.

[Supporting post of applied medicine]. / Die tragende Säule der angewandten Medizin.

Whilst specialists don't care much about defining themselves, general practitioners repeatedly are trying to describe their role in modern medicine. Nowadays they prefer to present themselves as gate-keepers at the house of medicine. In that paper it is outlined that this isn't a useful idea.

Health status disparities among public and private emergency department patients.

OBJECTIVE: To explore whether patients in a public ED had poorer health than patients in a private ED, the authors compared the physical and mental health statuses of patients seeking emergency care. METHODS: A cross-sectional observational study of all adult patients, regardless of acuity, seen during two 24-hour periods in spring 1997 in an urban county trauma center (68,000 annual visits) and a private community ED (35,000 annual visits). Scores on the Physical Component Summary (PCS) and the Mental Component Summary (MCS) scales of the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) were compared between sites, with published national norms, and with hospital admission. RESULTS: Of 571 eligible patients, 392 (69%) completed the SF-12. Patients in the public ED had a mean PCS score of 40.1, compared with 43.7 for patients in the private ED, for a difference of 3.6 points (p < 0.01; 95% CI = 0.9 to 6.1). After controlling for age, sex, ethnicity, triage acuity, ambulance arrival, and insurance status, this difference increased to 3.9 points (p = 0.02; 95% CI = 0.7 to 7.0). The mean MCS score among public ED patients was 44.1, compared with 46.5 in the private ED population, for a difference of 2.4 (p = 0.08; 95% CI = -0.3 to 5.0); after adjustment this difference increased to 2.5 (p = 0.15; 95% CI = -0.9 to 5.8), but remained statistically not significant. While all scores were significantly lower than national norms (mean PCS 50.1, mean MCS 50.0), patients in the public ED scored consistently lowest. PCS score was significantly inversely correlated with admission, with each point decrease in PCS score increasing the odds of admission by 0.05 (95% CI = 0.01 to 0.08), and conferring an odds ratio of 5.1 (95% CI = 1.2 to 21.1) for admission among the 25th percentile for PCS scores. CONCLUSIONS: Patients seeking care in the public ED had lower adjusted physical health status scores than comparable patients obtaining care in a private ED. The SF-12 is sufficiently responsive to detect hypothesized differences between ED populations, and correlates well with admission decisions.

The effect of legal representation on functional recovery of the hand in injured workers following carpal tunnel release.

A group of 225 patients who underwent surgical release for carpal tunnel syndrome, considered causally related to their jobs, were compared on the basis of one variable: representation by an attorney. Postoperative functional recovery measurements for the represented and the unrepresented workers were reviewed. There is no difference in the functional recovery rates or final functional values in these two groups of workers. We concluded that an attorney representing an injured worker did not influence the functional recovery of the hand in these patients, nor did it affect the medical decision-making process.

Expression of NM23 protein in acquired melanocytic nevi, malignant melanoma and metastases of malignant melanoma: an immunohistological assessment in human skin.

BACKGROUND: It has been suggested that nm23 may exert metastasis suppressor function in human tumors. OBJECTIVE: We have analyzed expression of nm23 polypeptide in acquired melanocytic nevi (n = 19), dysplastic nevi (n = 19), malignant melanomas (n = 22) and metastases of malignant melanomas (n = 47) in situ. METHODS: Nm23 protein was detected immunohistochemically on paraffin sections using the highly sensitive labeled avidin-biotin technique. RESULTS: We found that (1) nm23 polypeptide is predominantly expressed in the cytoplasmic but also in nuclear and membrane compartments of melanocytic human cells, (2) expression of nm23 protein does not correlate with benign or malignant phenotype in melanocytic tumors of human skin. CONCLUSION: Our study challenges the hypothesis that nm23 may function in malignant melanomas as a tumor suppressor gene.

Admission interviews: questions of utility and cost in masters of physical therapy programs in the United States.

PURPOSE: The purpose of this research was twofold. The first purpose was to assess the predictive validity of the interview process in student completion of entry level Masters of Physical Therapy programs on the conventional schedule for the university. The second was to provide a descriptive study of interview formats currently used by these institutions and the cost to the institution, estimated by hours of labor used exclusively for the interview process. METHOD: A questionnaire was mailed to the Director of Admissions of 63 accredited Masters of Physical Therapy programs in the United States. Forty-three responded to the questionnaire for a response rate of 68.3%. Twenty-eight programs (65.1%) performed interviews and fifteen (34.9%) programs did not. RESULTS: A two-tailed t-test revealed that no significant difference existed between programs that interview and those that did not with regards to the attrition rate of students. There was great diversity between the programs in interview content and structure. The cost to the institutions in terms of hours averaged 261 hours per school for faculty and support staff combined. CONCLUSION: The schools of physical therapy that award the Masters of Physical Therapy degree vary markedly in the interview content and format both between schools and with recommendations known to enhance validity and reliability. Since, no difference exists in attrition of students between schools that interview and those that do not, the expense and time invested by both the institution and the students are important considerations. The findings of this study indicate the need for continued investigation of the effectiveness of the interview process and alternative methods of valid and reliable student selection.

Replacement of amalgams with crowns: a cost-effectiveness analysis.

No formal analyses comparing the treatment alternatives of replacing a failed amalgam with either another amalgam or crown have been done to determine the optimum treatment strategy based on lifetime costs to the patient. Using decision analysis, a computer model was developed of the lifetime restorative needs of an adult's posterior tooth. A cost-effectiveness analysis of large amalgams vs crowns was then done to determine the optimum strategy. According to the analyses, the optimum treatment decision is to attempt to replace the failed first amalgam with another amalgam, instead of with a crown. When this amalgam restoration fails, then the subsequent replacement may be with a crown. Potential lifetime cost savings were between 11% and 24% if the first replacement was an amalgam. This study concludes that the technique of decision analysis provides the dental community with an effective evaluation tool for the study of clinical decision-making, taking into account all levels of clinical uncertainty.

Is periodontal disease the primary cause of tooth extraction in adults?

Preventing caries and reducing out-of-pocket costs for dental services are two strategies proposed by the authors to lower the rate of tooth extractions. Efforts also must be made to change public values about the importance of restoring rather than extracting carious teeth.

Comparison of different methods for assessment of rubella infection and immunity.

The different enzyme-linked immunosorbent assays (ELISA), a fluorescence immunoassay (FIAX), and a hemolysis-in-gel test (HIG) were examined for sensitive detection of specific antibodies in sera of persons with acute and previous rubella infection. In comparison to hemagglutination inhibition (HI), all tests were able to detect previously formed rubella antibodies. In sera of patients with acute rubella infection, only the FIAX system showed always positive results. Nevertheless, it remains unclear, if these findings are due to a higher sensitivity of the FIAX system or are possible non-specific results. In some cases, however, this test system failed to detect significant titre rises seen in HI, because it showed high antibody titres already in the first serum sample.