Ivacaftor for cystic fibrosis: An evaluation of real world utilisation and expenditure in the Irish Healthcare Setting.

In Ireland, Ivacaftor is reimbursed, on the High-Tech Drug Scheme, for the treatment of cystic fibrosis in patients age 6 years and older who have the G551D mutation. The aim of this study was to analyse the utilisation and expenditure of Ivacaftor on this scheme in the 12 month period post-reimbursement. All patients who had received Ivacaftor (regardless of General Medical Services Scheme eligibility/ineligibility) were included. A total of 140 individuals (male=74; 53%) received Ivacaftor over the defined 12 month study period (from January 2015 to December 2015 inclusive). The cohort ranged in age from 6 years to 61 years. The mean age was 22 years; a positive skew in age distribution indicated that a greater number of the cohort were in the younger age groups. No statistically significant difference was detected in the mean ages of the male and female subgroups. Drug acquisition expenditure by the Health Services Executive on Ivacaftor over the 12 month study period was €29.81 million.

Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy.

BACKGROUND: Several colorectal cancer-screening tests are available, but it is uncertain which provides the best balance of risks and benefits within a screening programme. We evaluated cost-effectiveness of a population-based screening programme in Ireland based on (i) biennial guaiac-based faecal occult blood testing (gFOBT) at ages 55-74, with reflex faecal immunochemical testing (FIT); (ii) biennial FIT at ages 55-74; and (iii) once-only flexible sigmoidoscopy (FSIG) at age 60. METHODS: A state-transition model was used to estimate costs and outcomes for each screening scenario vs no screening. A third party payer perspective was adopted. Probabilistic sensitivity analyses were undertaken. RESULTS: All scenarios would be considered highly cost-effective compared with no screening. The lowest incremental cost-effectiveness ratio (ICER vs no screening euro 589 per quality-adjusted life-year (QALY) gained) was found for FSIG, followed by FIT euro 1696) and gFOBT (euro 4428); gFOBT was dominated. Compared with FSIG, FIT was associated with greater gains in QALYs and reductions in lifetime cancer incidence and mortality, but was more costly, required considerably more colonoscopies and resulted in more complications. Results were robust to variations in parameter estimates. CONCLUSION: Population-based screening based on FIT is expected to result in greater health gains than a policy of gFOBT (with reflex FIT) or once-only FSIG, but would require significantly more colonoscopy resources and result in more individuals experiencing adverse effects. Weighing these advantages and disadvantages presents a considerable challenge to policy makers.

Impact of an alternate feeding program on broiler breeder pullet behavior, performance, and plasma corticosterone.

Broiler breeders are commonly feed restricted using some variation of skip-a-day feeding to prevent excessive body weight (BW) gain and poor flock uniformity that results in lower production levels. However, the level of feed restriction has increased leading to negative effects on broiler breeder welfare. Research needs to be conducted to evaluate alternative feeding programs to diminish the negative impact of restricted feeding on bird welfare. This research examined pullets that were fed soybean hulls (alternate day feeding, ATD) on the off day of a traditional skip-a-day feeding program in comparison to the standard skip-a-day program (SAD). The 2 dietary feeding treatments each had 3 replicate pens of 210 pullets each and were fed from wk 5 to 21 of age. Nitrogen-corrected true metabolizable energy and digestible amino acid coefficients of soybean hulls were determined. Body weight in the ATD feed program was significantly higher (P < 0.001) than the birds on the SAD feed program until 16 wk of age. Feed allocations for the SAD feeding program was increased at 11 wk of age to achieve similar BW prior to photo stimulation. The ATD feed program significantly improved BW uniformity of the birds for weeks 8, 12, 16, and 20. Hens fed on the SAD feed program had a lower mean egg production than the hens fed on the ATD program. There were significant differences on plasma corticosterone concentrations between the feeding days (24 or 48 h after feeding) in both feed programs. There was a shift in the behavior of the birds with significant differences in the feeding, foraging, and comfort behaviors between the feeding programs on the same feed day. Overall, feeding the ATD females soybean hulls on the off feed day improved the BW uniformity and egg production, but further research will be needed to determine potential differences in nutrient utilization or behavior of the pullets that positively impacted this flock performance.

Drug expenditure in Ireland 1997-2007.

Community prescribing accounts for approximately 85% of total drug expenditure. In 2007 spending on medicines under the Community Drugs Schemes exceeded Euro 1.74 billion, a five-fold increase over the decade 1997-2007. The year on year increase in spending on medicines is amongst the highest in Europe. The desire of the HSE to reduce or at least contain drug expenditure is appreciated and is consistent with approaches across other EU member states. Recent developments in drug pricing and reimbursement as outlined here may help to contain the drugs bill. However, the emergence of promising but expensive biologic agents for cancer therapy and other chronic conditions threaten any cost containment measures.

Prescribing for patients with diabetes in the community drug schemes.

The aim of the study was to examine the management of diabetes patients particularly in relation to secondary preventative therapies within the community drug schemes across the health board regions in Ireland. The study population was identified using two national primary care prescribing databases from the Long Term Illness (LTI) and General Medical Services (GMS) scheme for 2003. 65,593 patients were identified as having 'treated' diabetes. Logistic regression was used to predict the likelihood of receiving secondary preventative therapies by region and drug scheme using adjusted odds ratios (ORs) and 95% confidence intervals (CI). The proportion of diabetes patients in each drug scheme with Ischaemic Heart Disease (IHD) was also calculated. Prevalence of 'treated' diabetes was calculated for each health board also. Regional and scheme-based variations within each region exist in the prescribing of secondary preventative therapies after adjustment for IHD rates. Prevalence of treated diabetes varied between regions from 1.5% in the Eastern region to 2.2% in the Southern region. While the location of specialised diabetes clinics may be a contributing factor, inequalities in prescribing across regions within the drug schemes are apparent.

Generic medicines and generic substitution: contrasting perspectives of stakeholders in Ireland.

BACKGROUND: The Health (Pricing and Supply of Medical Goods) Act 2013 passed into law in July 2013 and legislated for generic substitution in Ireland. The aim of the study was to ascertain the knowledge and perceptions of stakeholders i.e. patients, pharmacists and prescribers, of generic medicines and to generic substitution with the passing of legislation. METHODS: Three stakeholder specific questionnaires were developed to assess knowledge of and perceptions to generic medicines and generic substitution. Purposive samples of patients, prescribers and pharmacists were analysed. Descriptive quantitative and qualitative analyses were undertaken. RESULTS AND DISCUSSION: A total of 762 healthcare professionals and 353 patients were recruited. The study highlighted that over 84% of patients were familiar with generic medicines and are supportive of the concept of generic substitution. Approximately 74% of prescribers and 84% of pharmacists were supportive of generic substitution in most cases. The main areas of concern highlighted by the healthcare professionals that might impact on the successful implementation of the policy, were the issue of bioequivalence with generic medicines, the computer software systems used at present in general practitioner (GP) surgeries and the availability of branded generics. The findings from this study identify a high baseline rate of acceptance to generic medicines and generic substitution among patients, prescribers and pharmacists in the Irish setting. The concerns of the main stakeholders provide a valuable insight into the potential difficulties that may arise in its implementation, and the need for on-going reassurance and proactive dissemination of the impact of the generic substitution policy. CONCLUSION: The existing positive attitude to generic medicines and generic substitution among key stakeholders in Ireland to generic substitution, combined with appropriate support and collaboration should result in the desired increase in rates of prescribing, dispensing and use of generic medicines.

A comparison of conventional, conformal and intensity-modulated coplanar radiotherapy plans for posterior fossa treatment.

Radiotherapy of the posterior fossa for medulloblastoma treatment can induce ototoxicity, especially when combined with cisplatin chemotherapy. Sensorineural hearing loss can be severe enough to cause permanent disability, which may compromise cognitive development in paediatric patients. This study evaluates the sparing of the cochlea in conventional radiotherapy, three-dimensional conformal radiotherapy (3D-CRT), and intensity-modulated radiotherapy (IMRT). CT scans of three patients were used to plan posterior fossa radiotherapy using coplanar beam arrangements. The posterior fossa and the cochlea were contoured as well as other organs-at-risk (non-posterior fossa brain, lenses, optic nerves, pituitary and cervical spinal cord). Three treatment plans were compared: conventional two-dimensional treatment (parallel-opposed lateral pair); 3D-CRT (two wedged posterior oblique fields); and a four-field coplanar IMRT plan. 3D-CRT and IMRT reduced cochlear doses to less than 70% of the mean target dose. These plans also reduced dose to the non-posterior fossa brain and cervical spinal cord. IMRT showed no advantage over 3D-CRT in sparing the optic nerves and lenses, compared with 3D-CRT. Normal tissue doses were higher in both conformal techniques than in the IMRT plans. Conformal techniques reduced the dose to the cochlea, non-posterior fossa brain and cervical spinal cord. The small size and proximity to the planning target volume (PTV) of the cochlea limited the effectiveness of the IMRT plan. Coplanar 3D-CRT was judged superior to coplanar IMRT, particularly in children, because it achieved adequate sparing of the cochlea and anterior cranial structures, such as the lenses and optic nerves, without compromising the dose to the posterior fossa.

Efficacy of ivermectin against Dermatobia hominis in cattle.

Dermatobia hominis, the tropical warble fly, is one of the most important ectoparasites of cattle in Latin America. The results of five trials conducted in Paraguay, Brazil and Colombia showed that ivermectin administered subcutaneously at a dose level of 200 mcg/kg body weight was highly effective against the three larval stages of D. hominis in cattle.

Prophylactic use of ivermectin against cattle myiasis caused by Cochliomyia hominivorax (Coquerel, 1858).

The prophylactic efficacy of ivermectin against navel or scrotal myiasis in calves was evaluated in eight trials in Argentina and Brazil. In two trials, calves were injected subcutaneously with ivermectin at a dosage of at least 200 microg kg(-1) within 24 h of birth. In the other six trials, two with two-month-old calves and four with four-month-old or older calves, all calves were treated with ivermectin at a dosage of at least 200 microg kg(-1) immediately after castration. In all trials, calves were maintained together on pasture and naturally exposed to Cochliomyia hominivorax. Navel and scrotal wounds were examined for myiasis daily for at least 14 days. Incidence of navel and scrotal myiasis was significantly lower (P < 0.01) in treated calves than in control calves.

Managing care across systems to improve outcomes for families and communities.

Behavioral health administrators deserve much credit for their efforts to integrate services for children with serious emotional disturbances and to instill a concern for efficiency through the concept of managed care. Recent changes in federal policy signal the next stage of development in systems of care. Issues of accountability now are shifting toward comprehensive systems of care and improving outcomes for families and communities, not just individuals. As they help build such systems in their states and communities, behavioral health administrators can help their colleagues in other systems understand the potential usefulness of concepts and practices associated with managed care and the broader notion of a system of care. In turn, they will be asked to expand their conception of the accountability of the mental health agency for the outcomes being experienced by families, neighborhoods, and the community as a whole.

A prediction model for bovine ostertagiasis.

A mathematical model based on development and mortality rates, and incorporating data on the infectivity, fecundity and migratory behaviour of Ostertagia ostertagi, was used to predict the level of pasture contamination and the occurrence of clinical ostertagiasis in grazing calves during 1975 and 1976. A comparison of the predicted and observed events showed a good correlation.

Prescription patterns in the elderly population--"new" versus "old" medical card holders.

INTRODUCTION: In July 2001, the GMS Scheme was extended to the whole elderly population aged 70 and over, permitting access to medical care services free of charge. We undertook a study to compare prescribing patterns between those relatively affluent people referred to as "new" over 70s with those relatively deprived people referred to as "old" over 70's, over the 18 months since the introduction of the scheme. Patients who had received a prescription for antibacterials, diuretics, psycholeptics, psychoanaleptics, statins, b-blockers, antithrombolytics, antianaemic drugs and drugs for obstructive airway diseases, were identified over the 18 month period using the GMS database. We also compared the average defined daily dose (DDD) received per month for each of the therapies above. RESULTS: All therapies directed at treatment were significantly more likely to be prescribed to the old over 70's, such as the vasodilators (OR=1.59, 1.51-1.67), peptic ulcer drugs (OR=1.37, 1.33-1.43) and the antibacterials (OR=1.37, 1.33-1.41) with the exception of those associated with cardiovascular prevention; statins (OR=0.88, 0.85-0.92), beta-blockers (OR=0.95, 0.92-0.98) and antithrombolytics (OR=0.96, 0.93-0.99). The old over 70's received more prescriptions with a higher than the average DDD per month for vasodilators, diuretics, and drugs for obstructive airway disease. This study highlights a potential inequality in prescribing in primary care, evident following a change in the health policy in Ireland. These results suggest that differences in socio-economic status (such as income) and morbidity may be associated with differences in prescribing by GPs.

Measuring performance in child welfare: secondary effects of success.

The Adoption and Safe Families Act of 1997 mandates the development of a system to rate the performance of state child welfare programs. The resulting system, built on broader efforts to measure outcomes for children and families who receive support and services from the child welfare system, will inform perspectives on family foster care in the next century. Drawing on findings from evaluations of recent reform initiatives in Alabama, North Carolina, and Ohio, this article suggests that performance measurement systems must be adaptable to changing circumstances, particularly when improvements in one area can affect standards and expectations in others.

Head injury at the southeastern Georgia Regional Trauma Center: a three-year review.

The impact of head injury on our trauma center is significant because of the large number of cases with their heavy utilization of trauma center resources. Head injury also exerts a major influence on the Trauma Center in a rural area since it serves as a major provider of care for the head injured over a wide geographical area. Mortality rates seen in this population compare favorably with contemporary data from other studies using GCS and Head AIS as indicators of level of injury.

Cost of care for colorectal cancer in Ireland: a health care payer perspective.

OBJECTIVE: Management options for colorectal cancer have expanded in recent years. We estimated average lifetime cost of care for colorectal cancer in Ireland in 2008, from the health care payer perspective. METHOD: A decision tree model was developed in Microsoft EXCEL. Site and stage-specific treatment pathways were constructed from guidelines and validated by expert clinical opinion. Health care resource use associated with diagnosis, treatment and follow-up were obtained from the National Cancer Registry Ireland (n=1,498 cancers diagnosed during 2004-2005) and three local hospital databases (n=155, 142 and 46 cases diagnosed in 2007). Unit costs for hospitalisation, procedures, laboratory tests and radiotherapy were derived from DRG costs, hospital finance departments, clinical opinion and literature review. Chemotherapy costs were estimated from local hospital protocols, pharmacy departments and clinical opinion. Uncertainty was explored using one-way and probabilistic sensitivity analysis. RESULTS: In 2008, the average (stage weighted) lifetime cost of managing a case of colorectal cancer was €39,607. Average costs were 16% higher for rectal (€43,502) than colon cancer (€37,417). Stage I disease was the least costly (€23,688) and stage III most costly (€48,835). Diagnostic work-up and follow-up investigations accounted for 4 and 5% of total costs, respectively. Cost estimates were most sensitive to recurrence rates and prescribing of biological agents. CONCLUSION: This study demonstrates the value of using existing data from national and local databases in contributing to estimating the cost of managing cancer. The findings illustrate the impact of biological agents on costs of cancer care and the potential of strategies promoting earlier diagnosis to reduce health care resource utilisation and care costs.

A dosimetric comparison between two intensity-modulated radiotherapy techniques: tomotherapy vs dynamic linear accelerator.

This manuscript describes a direct comparison between radiation treatment plans in terms of dosimetric outcomes created by two different IMRT systems: TomoTherapy HiArt and dynamic linac intensity-modulated radiotherapy (dIMRT). Three patient cases were selected (with disease in different anatomical areas): vertebral metastasis re-treatment, radical prostate therapy and an ethmoid sarcoma re-treatment. Each case presents significant and varying dosimetric difficulties with respect to avoidance of adjacent organs. The patients were each planned and treated at the Cromwell Hospital (London, UK) using the TomoTherapy HiArt system, with planning replicated at St Bartholomew's Hospital (London, UK) using Eclipse Treatment Planning System and a 6EX linac with a 120-leaf multileaf collimator (Varian Medical Systems). For both modalities, all treatment plans conformed to the stringent clinical dose constraints set. For the vertebral body re-treatment, both techniques demonstrated adequate and similar planning target volume (PTV) coverage and sparing of the spinal cord. The critical structure sparing and PTV coverage for the prostate treatment was again similar for both modalities. For re-treatment of the paediatric ethmoid sarcoma, tomotherapy was able to produce slightly better organ sparing whilst producing PTV coverage similar to linac dIMRT. The data presented in this manuscript demonstrate subtle dosimetric differences between the two techniques but no marked advantage with either system. Therefore, other factors may need to be considered when making a decision between tomotherapy and linac dIMRT.

The ticks (Acari: Ixodida: Argasidae, Ixodidae) of Paraguay.

The ticks reported in Paraguay, which are here reviewed, can be categorized as 'endemic or established' (Argas persicus or a sibling species, Ornithodoros hasei, O. rostratus, O. rudis, O. talaje/O. puertoricensis, Amblyomma aureolatum, Am. auricularium, Am. brasiliense, Am. cajennense, Am. calcaratum, Am. coelebs, Am. dissimile, Am. dubitatum, Am. incisum, Am. longirostre, Am. nodosum, Am. ovale, Am. pacae, Am. parvum, Am. pseudoconcolor, Am. rotundatum, Am. scutatum, Am. tigrinum, Am. triste, Dermacentor nitens, Haemaphysalis juxtakochi, H. leporispalustris, Ixodes loricatus, Rhipicephalus microplus, and Rh. sanguineus), 'probably endemic or established' (Ar. miniatus, Ar. monachus, Am. argentinae, Am. humerale, Am. naponense, Am. oblongoguttatum, Am. pseudoparvum, I. aragaoi/I. pararicinus, I. auritulus, I. luciae), or 'erroneously reported from Paraguay' (O. coriaceus, Am. americanum and Am. maculatum). Most Paraguayan tick collections have been made in the Chaco phyto-geographical domain, in the central part of the country. Argas persicus or a related species, Am. cajennense, D. nitens, Rh. microplus and Rh. sanguineus are important parasites of domestic animals. Ornithodoros rudis, Am. aureolatum, Am. brasiliense, Am. cajennense, Am. coelebs, Am. incisum, Am. ovale and Am. tigrinum have all been collected from humans. In terms of public health, the collections of Am. cajennense and Am. triste from humans may be particularly significant, as these species are potential vectors of Rickettsia rickettsii and Ri. parkeri, respectively.