Cost-effectiveness analysis of additional docetaxel for metastatic hormone-sensitive prostate cancer treated with androgen-deprivation therapy from a Chinese perspective.

The E3805 (CHAARTED) study found that docetaxel combined with androgen-deprivation therapy (ADT) significantly improved overall survival of patients with metastatic hormone-sensitive prostate cancer. This study aims to determine whether docetaxel combined with ADT is a cost-effective strategy for advanced prostate cancer in China. According to the E3805 study, two groups (docetaxel + ADT and ADT alone) and three health states [progression-free survival (PFS), progressive disease (PD) and death] were analysed in a Markov model. All medical costs were calculated from the Chinese societal perspective. Quality-adjusted life year (QALY) and incremental cost-effectiveness ratios (ICERs) were applied as the primary outcome. Overall, the addition of docetaxel was estimated to increase the cost by $12 816.93, with a gain of 0.48 QALY. Additionally, for patients with high-volume disease, the increased cost and effectiveness were $14 627.75 and 0.69 QALYs in docetaxel + ADT group versus the ADT alone group, and the ICER was $21 199.63 per QALY. These ICERs are far more than the commonly accepted willingness-to-pay (WTP) threshold of $20 301 per QALY in China. In spite of longer survival time, docetaxel combined with ADT is not a recommended cost-effective treatment for metastatic hormone-sensitive prostate cancer in the Chinese setting.

Adenomas as a risk factor in familial colorectal cancer: implications for screening and surveillance in the UK.

Colorectal cancer (CRC) develops from normal epithelium, through dysplastic adenoma to invasive carcinoma. In addition to familial adenomatous polyposis and Lynch syndrome, approximately 10-35% of CRCs are familial in nature. CRC screening and surveillance programmes are based on an understanding of the natural history of polyps and rely on the ability to remove premalignant lesions endoscopically before they are capable of developing invasion. There are, however, significant differences in these guidelines between the UK and the USA in relation to the weight attributed to a family history of polyps. Here, using publicly available national data sets, we show that these differences in guidelines unexpectedly generate inadequate screening recommendations for second-degree relatives of patients with CRC in the UK. We validate our simple mathematical modelling of the clinical problem on a regional data set as well as previously published study data to demonstrate the correct interpretation. We further discuss the implications of a family history of adenoma formation in the current climate of the Bowel Cancer Screening Programme and suggest a re-evaluation of the UK guidelines in the light of this developing issue.

Assessment of hydroxylated metabolites of polychlorinated biphenyls as potential xenoestrogens: a QSAR comparative analysis∗.

Alternative methods, including quantitative structure-activity relationships (QSAR), are being used increasingly when appropriate data for toxicity evaluation of chemicals are not available. Approximately 40 mono-hydroxylated polychlorinated biphenyls (OH-PCBs) have been identified in humans. They represent a health and environmental concern because some of them have been shown to have agonist or antagonist interactions with human hormone receptors. This could lead to modulation of steroid hormone receptor pathways and endocrine system disruption. We performed QSAR analyses using available estrogenic activity (human estrogen receptor ER alpha) data for 71 OH-PCBs. The modelling was performed using multiple molecular descriptors including electronic, molecular, constitutional, topological, and geometrical endpoints. Multiple linear regressions and recursive partitioning were used to best fit descriptors. The results show that the position of the hydroxyl substitution, polarizability, and meta adjacent un-substituted carbon pairs at the phenolic ring contribute towards greater estrogenic activity for these chemicals. These comparative QSAR models may be used for predictive toxicity, and identification of health consequences of PCB metabolites that lack empirical data. Such information will help prioritize such molecules for additional testing, guide future basic laboratory research studies, and help the health/risk assessment community understand the complex nature of chemical mixtures.

Responsivity to criminogenic need in forensic intellectual disability services.

BACKGROUND: Research has shown for some time that addressing criminogenic need is one of the crucial aspects of reducing reoffending in all types of offenders. Criminogenic need such as anger or inappropriate sexual interest is considered to be crucial in the commission of the offence. The aim of the present study is to investigate the extent to which forensic services address the needs of those accepted into services. METHOD: This study reviews the treatment for 197 offenders with intellectual disability accepted into a range of services. Participants' case files were examined to ascertain the extent to which need was addressed through recognised therapies. A standard pro forma was used on which we had established good reliability across four research assistants. RESULTS: The most frequently referred problems were violence and sexual offending. Specialist forensic intellectual disability community services were significantly more likely to provide treatment specifically designed to address index behaviours when compared to generic community services and secure services. CONCLUSIONS: Various possible explanations of these findings are explored including staffing levels, diagnosed mental illness, expertise of staff and clarity of purpose in services.

Vaccine policy and Arkansas childhood immunization exemptions: a multi-year review.

BACKGROUND: An increase in total vaccine exemptions (medical, philosophic, and religious) occurred in Arkansas after a 2003 legislation added a philosophic category and used a new process for vaccine exemptions. By legislative requirement, the Arkansas Department of Health monitored exemptions through the 2009-2010 school year. PURPOSE: The goal of the study was to determine the prevalence of vaccine exemption in 2003-2010 compared to the number of requests prior to the legislation enacted in 2003. METHODS: Exemptions were calculated by school-age category using raw numbers of exemptions, total estimates of the population by age level, enrollment numbers for students in public and private schools, and in enrolled college students born after 1957. Exemptions also were analyzed by school district, grade level, type of exemption, and particular vaccine exemption requested. RESULTS: Overall exemptions continued to rise each year, with an average increase of 23.1% annually. Medical exemptions declined from an average of 21.3% of all exemptions before to an average of 4.8% thereafter. The greatest increase in number of exemptions was observed among college students. The highest total rate of exemptions per precollegiate student population was <1.3%. When exemption requests were categorized, most (79%) were for exemptions from "all vaccines." The most common single exempted vaccine was MMR (measles, mumps, rubella). CONCLUSIONS: Since philosophic exemptions were codified in 2003 in Arkansas, the number and rate of vaccine exemptions continue to progressively increase. However, vaccine-preventable disease clusters have not yet been linked to or identified in any population with a high rate of vaccine exemptions.

Treatment for tobacco dependence for rural, lower-income smokers: outcomes, predictors, and measurement considerations.

PURPOSE: Outcomes from a statewide program that delivered evidence-based, intensive treatment for tobacco dependence to a rural population of lower socioeconomic status (SES) were evaluated. Factors that predicted success and measurement considerations were examined. DESIGN AND ANALYSES: Data were collected at intake, at all treatment sessions, and at 3- and 12-months posttreatment. Abstinence rates were calculated using complete-case analysis and intention-to-treat analysis, and they were estimated for all participants. Logistic regression was used to evaluate the predictive significance of demographic and clinical factors. SETTING: Twenty health care sites across Arkansas. PARTICIPANTS: A total of 2,350 predominantly rural, lower SES, Arkansas residents. INTERVENTION: Evidence-based, six-session, multi-component cognitive-behavioral therapy with relapse prevention. RESULTS: The estimated percent abstinent was 26.47% at 3-months and 21.73% at 12-months posttreatment; 51.02% of patients completed treatment and demonstrated markedly higher quit rates. Although numerous factors predicted outcomes at different points, self-efficacy and dependence levels at intake were robust predictors across time and methods of calculating outcomes. Sex, partner smoking status, and educational level were significant predictors of long-term abstinence. CONCLUSIONS: This study demonstrates that intensive, evidence-based treatment for tobacco dependence can be successfully delivered in a statewide program and can yield long-term outcomes that approximate those seen in more controlled settings. Overall sample estimates may be more appropriate for the assessment of outcomes in this context.

Smoke-free medical facility campus legislation: support, resistance, difficulties and cost.

Although medical facilities restrict smoking inside, many people continue to smoke outside, creating problems with second-hand smoke, litter, fire risks, and negative role modeling. In 2005, Arkansas passed legislation prohibiting smoking on medical facility campuses. Hospital administrators (N=113) were surveyed pre- and post-implementation. Administrators reported more support and less difficulty than anticipated. Actual cost was 10-50% of anticipated cost. Few negative effects and numerous positive effects on employee performance and retention were reported. The results may be of interest to hospital administrators and demonstrate that state legislation can play a positive role in facilitating broad health-related policy change.

Making hospital grounds smoke-free: a case study of Arkansas Act 134 of 2005.

The impact of tobacco use and environmental tobacco smoke (ETS) has been well documented. Many policies have been implemented to curb tobacco use and to reduce exposure to ETS. The purpose of this article is to describe the development and passage of Arkansas Act 134 of 2005, the first state law to prohibit the use of tobacco products on the grounds of all nonfederal community (nonpsychiatric) hospital facilities in the state. Efforts to bring this and other tobacco control policies to the attention of policy makers will be discussed in the context of several agenda-setting strategies. The strategy used by stakeholders in Arkansas to bring out Act 134 as well as the other agenda-setting strategies described in the article provide insight into the ways other states and communities seeking to adopt smoking bans and related public health policies can bring such policies to the attention of policy makers.

Defining distinct caregiver subpopulations by intensity of end-of-life care provided.

Interventions designed to assist informal caregivers who serve individuals at or near the end of life have predominantly focused on caregiving spouses. Can we define other caregiver subpopulations--by intensity of care provided--so as to enable better a) identification of caregiver needs and b) targeting of support to caregivers? The Health Omnibus Survey, an annual face-to-face survey in South Australia, collects health-related data from a representative sample of 4400 households. Piloted questions included in the 2001-2005 Health Omnibus surveys addressed death of a loved one, caregiving provided, impact of caregiving and caregiver characteristics. Of 18,224 respondents, 5302 reported a loved one's death due to terminal illness in the previous 5 years. In all, 502 (10%) provided daily care [5-7 days/week], 619 (12%) provided intermittent care [2-4 days/week] and 425 (8%) provided rare care. Active (daily plus intermittent) caregivers, compared with non-active (rare) caregivers, were more often women (63% vs 50%; P < 0.0001). Daily caregivers were distinguishable from intermittent; daily caregivers were more often widowed (95% vs 7%; P < 0.0001) and >or=60 years (80% vs 64%; P < 0.0001); intermittent caregivers were more commonly children/parents (35%), other relatives (33%), or friends (26%; P < 0.0001) and were better educated, more active in paid work and wealthier. Financial burden, experience at time of death, ability to move on after the death and need for grief support also differed by intensity of caregiving. Caregiver subpopulations can be defined according to intensity of caregiving with distinct demographic features helping to distinguish them.

The study of infectious intestinal disease in England: socio-economic impact.

To assess the socio-economic impact of infectious intestinal disease (IID) on the health care sector, cases and their families, cases of IID ascertained from a population cohort component and those presenting to general practices were sent a socio-economic questionnaire 3 weeks after the acute episode. The impact of the illness was measured and the resources used were identified and costed. The duration, severity and costs of illness linked to viruses were less than those linked to bacteria. The average cost per case of IID presenting to the GP was Pound Sterling253 and the costs of those not seeing a GP were Pound Sterling34. The average cost per case was Pound Sterling606 for a case with salmonella, Pound Sterling315 for campylobacter, Pound Sterling164 for rotavirus and Pound Sterling176 for SRSV. The estimated cost of IID in England was Pound Sterling743m expressed in 1994/5 prices. The costs of IID are considerable and the duration of the illness was found to be longer than previous reports have suggested.

Parental emotional and time costs predict compliance with respiratory syncytial virus prophylaxis.

BACKGROUND: Two agents are effective in preventing respiratory syncytial virus (RSV) hospitalization in premature infants: RSV immune globulin (RSV-IG) and palivizumab. RSV-IG is associated with greater parental emotional and time costs, which may account for the more limited adherence to recommended monthly treatment with this agent. OBJECTIVES: To compare the emotional distress and time costs associated with RSV-IG and palivizumab treatments and to determine the influence of these costs on treatment adherence. METHODS: We surveyed parents of 82 infants who received RSV-IG (90% of eligible) and parents of 61 infants who received palivizumab (87% of eligible) at Arkansas Children's Hospital by telephone. We measured infant distress during treatment, parental distress, parental time costs, and adherence with recommended monthly prophylaxis. RESULTS: Half of parents of RSV-IG recipients witnessed their infant in distress during infusion, over half (61%) were upset by observing the needle stick, and 22% observed infusion in the scalp. Fewer than 5% of parents of palivizumab recipients observed their infant in distress or were themselves distressed during treatment. A quarter of parents took time off from work for RSV-IG or palivizumab treatment. RSV-IG recipients completed 62% of recommended monthly treatments compared with 86% completed by palivizumab recipients. Increased parental distress and time costs largely accounted for the reduction in adherence to monthly treatment among RSV-IG recipients. CONCLUSIONS: The emotional and time costs of RSV-IG treatment far exceed those of palivizumab and predict substantial differences in treatment adherence between the 2 agents. The impact of hidden costs on treatment adherence should be included in economic evaluations of medical procedures.

The comparison of rapid bioassays for the assessment of urban groundwater quality.

Groundwater is a complex mixture of chemicals that is naturally variable. Current legislation in the UK requires that groundwater quality and the degree of contamination are assessed using chemical methods. Such methods do not consider the synergistic or antagonistic interactions that may affect the bioavailability and toxicity of pollutants in the environment. Bioassays are a method for assessing the toxic impact of whole groundwater samples on the environment. Three rapid bioassays, Eclox, Microtox and ToxAlert, and a Daphnia magna 48-h immobilisation test were used to assess groundwater quality from sites with a wide range of historical uses. Eclox responses indicated that the test was very sensitive to changes in groundwater chemistry; 77% of the results had a percentage inhibition greater than 90%. ToxAlert, although suitable for monitoring changes in water quality under laboratory conditions, produced highly variable results due to fluctuations in temperature and the chemical composition of the samples. Microtox produced replicable results that correlated with those from D. magna tests.