The syndromic triad of COVID-19, type 2 diabetes, and malnutrition.

The coronavirus disease 2019 (COVID-19) pandemic challenges our collective understanding of transmission, prevention, complications, and clinical management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Risk factors for severe infection, morbidity, and mortality are associated with age, environment, socioeconomic status, comorbidities, and interventional timing. Clinical investigations report an intriguing association of COVID-19 with diabetes mellitus and malnutrition but incompletely describe the triphasic relationship, its mechanistic pathways, and potential therapeutic approaches to address each malady and their underlying metabolic disorders. This narrative review highlights common chronic disease states that interact epidemiologically and mechanistically with the COVID-19 to create a syndromic phenotype-the COVID-Related Cardiometabolic Syndrome-linking cardiometabolic-based chronic disease drivers with pre-, acute, and chronic/post-COVID-19 disease stages. Since the association of nutritional disorders with COVID-19 and cardiometabolic risk factors is well established, a syndromic triad of COVID-19, type 2 diabetes, and malnutrition is hypothesized that can direct, inform, and optimize care. In this review, each of the three edges of this network is uniquely summarized, nutritional therapies discussed, and a structure for early preventive care proposed. Concerted efforts to identify malnutrition in patients with COVID-19 and elevated metabolic risks are needed and can be followed by improved dietary management while simultaneously addressing dysglycemia-based chronic disease and malnutrition-based chronic disease.

Diabetes-Specific Nutrition Formulas in the Management of Patients with Diabetes and Cardiometabolic Risk.

Food-based dietary management, enhanced with evidence-based commercial products, such as diabetes-specific nutrition formulas (DSNFs), can help control the development, progression, and severity of certain chronic diseases. In this review, evidence is detailed on the use of DSNFs in patients with or at risk for diabetes and cardiometabolic-based chronic disease. Many DSNF strategies target glycemic excursions and cardiovascular physiology, taking into account various elements of healthy eating patterns. Nevertheless, significant research, knowledge, and practice gaps remain. These gaps are actionable in terms of formulating and testing relevant and pragmatic research questions, developing an educational program for the uniform distribution of information, and collaboratively writing clinical practice guidelines that incorporate the evidence base for DSNF. In sum, the benefits of DNSF as part of validated clinical practice algorithms include mitigation of chronic disease progression, cost-savings for the healthcare system, and applicability on a global scale.

Therapies for Psoriasis: Clinical and Economic Comparisons.

BACKGROUND: Clinical and economic comparisons of therapies for plaque psoriasis are regularly updated following each new devel- opment in the field. With the recent availability of a novel accessory (Multi Micro DoseTM [MMD®] tip) for the 308nm excimer laser (XTRAC®, Strata Skin Sciences, Horsham, PA), which can determine and deliver an optimal therapeutic dose (OTDTM) of ultraviolet-B light in an improved protocol, the need for comparative health-economic assessment recurs. To this end, a comprehensive evaluation of treatment-related costs was undertaken from the payer perspective. Results show that outcomes are influenced by many factors; most importantly, the severity and extent of disease, treatment selection, and patient preference, as well as compliance, adherence, and persistence with care. Among study comparators, the 308nm excimer laser – XTRAC – with its latest MMD enhancement, is safe and delivers incremental clinical benefits with the potential for significant cost savings. These benefits are particularly relevant today in the context of SARS-CoV-2 virus and the COVid-19 pandemic. J Drugs Dermatol. 2020;19(11):1101-1108. doi:10.36849/JDD.2020.5510.

Development and validation of a continuously age-adjusted measure of patient condition for hospitalized children using the electronic medical record.

Awareness of a patient's clinical status during hospitalization is a primary responsibility for hospital providers. One tool to assess status is the Rothman Index (RI), a validated measure of patient condition for adults, based on empirically derived relationships between 1-year post-discharge mortality and each of 26 clinical measurements available in the electronic medical record. However, such an approach cannot be used for pediatrics, where the relationships between risk and clinical variables are distinct functions of patient age, and sufficient 1-year mortality data for each age group simply do not exist. We report the development and validation of a new methodology to use adult mortality data to generate continuously age-adjusted acuity scores for pediatrics. Clinical data were extracted from EMRs at three pediatric hospitals covering 105,470 inpatient visits over a 3-year period. The RI input variable set was used as a starting point for the development of the pediatric Rothman Index (pRI). Age-dependence of continuous variables was determined by plotting mean values versus age. For variables determined to be age-dependent, polynomial functions of mean value and mean standard deviation versus age were constructed. Mean values and standard deviations for adult RI excess risk curves were separately estimated. Based on the "find the center of the channel" hypothesis, univariate pediatric risk was then computed by applying a z-score transform to adult mean and standard deviation values based on polynomial pediatric mean and standard deviation functions. Multivariate pediatric risk is estimated as the sum of univariate risk. Other age adjustments for categorical variables were also employed. Age-specific pediatric excess risk functions were compared to age-specific expert-derived functions and to in-hospital mortality. AUC for 24-h mortality and pRI scores prior to unplanned ICU transfers were computed. Age-adjusted risk functions correlated well with similar functions in Bedside PEWS and PAWS. Pediatric nursing data correlated well with risk as measured by mortality odds ratios. AUC for pRI for 24-h mortality was 0.93 (0.92, 0.94), 0.93 (0.93, 0.93) and 0.95 (0.95, 0.95) at the three pediatric hospitals. Unplanned ICU transfers correlated with lower pRI scores. Moreover, pRI scores declined prior to such events. A new methodology to continuously age-adjust patient acuity provides a tool to facilitate timely identification of physiologic deterioration in hospitalized children.

Sepsis as 2 problems: Identifying sepsis at admission and predicting onset in the hospital using an electronic medical record-based acuity score.

PURPOSE: Early identification and treatment improve outcomes for patients with sepsis. Current screening tools are limited. We present a new approach, recognizing that sepsis patients comprise 2 distinct and unequal populations: patients with sepsis present on admission (85%) and patients who develop sepsis in the hospital (15%) with mortality rates of 12% and 35%, respectively. METHODS: Models are developed and tested based on 258 836 adult inpatient records from 4 hospitals. A "present on admission" model identifies patients admitted to a hospital with sepsis, and a "not present on admission" model predicts postadmission onset. Inputs include common clinical measurements and the Rothman Index. Sepsis was determined using International Classification of Diseases, Ninth Revision, codes. RESULTS: For sepsis present on admission, area under the curves ranged from 0.87 to 0.91. Operating points chosen to yield 75% and 50% sensitivity achieve positive predictive values of 17% to 25% and 29% to 40%, respectively. For sepsis not present on admission, at 65% sensitivity, positive predictive values ranged from 10% to 20% across hospitals. CONCLUSIONS: This approach yields good to excellent discriminatory performance among adult inpatients for predicting sepsis present on admission or developed within the hospital and may aid in the timely delivery of care.

Transcultural Diabetes Nutrition Algorithm: Brazilian Application.

The prevalence of obesity, pre-diabetes, and type 2 diabetes (T2D) is increasing worldwide, especially in the developing nations of South America. Brazil has experienced an exponential increase in the prevalence of these chronic non-communicable diseases. The rising prevalence is probably due to changing eating patterns, sedentary living, and a progressive aging of the population. These trends and their underlying causes carry untoward consequences for all Brazilians and the future of Brazilian public health and the healthcare system. Lifestyle changes that include healthy eating (nutrition therapy) and regular physical activity (structured exercise) represent efficient inexpensive measures to prevent and/or treat the aforementioned disorders and are recommended for all afflicted patients. Regrettably, the implementation of lifestyle changes is fraught with clinical and personal challenges in real life. The transcultural Diabetes Nutrition Algorithm (tDNA) is a therapeutic tool intended to foster implementation of lifestyle recommendations and to improve disease-related outcomes in common clinical settings. It is evidence-based and amenable to cultural adaptation. The Brazilian Diabetes Association, Society of Cardiology and Ministry of Health guidelines for nutrition therapy and physical exercise were considered for the Brazilian adaptation. The resultant tDNA-Brazil and its underlying recommendations are presented and explained.

Transcultural diabetes nutrition algorithm (tDNA): Venezuelan application.

Medical nutrition therapy (MNT) is a necessary component of comprehensive type 2 diabetes (T2D) management, but optimal outcomes require culturally-sensitive implementation. Accordingly, international experts created an evidence-based transcultural diabetes nutrition algorithm (tDNA) to improve understanding of MNT and to foster portability of current guidelines to various dysglycemic populations worldwide. This report details the development of tDNA-Venezuelan via analysis of region-specific cardiovascular disease (CVD) risk factors, lifestyles, anthropometrics, and resultant tDNA algorithmic modifications. Specific recommendations include: screening for prediabetes (for biochemical monitoring and lifestyle counseling); detecting obesity using Latin American cutoffs for waist circumference and Venezuelan cutoffs for BMI; prescribing MNT to people with prediabetes, T2D, or high CVD risk; specifying control goals in prediabetes and T2D; and describing regional differences in prevalence of CVD risk and lifestyle. Venezuelan deliberations involved evaluating typical food-based eating patterns, correcting improper dietary habits through adaptation of the Mediterranean diet with local foods, developing local recommendations for physical activity, avoiding stigmatizing obesity as a cosmetic problem, avoiding misuse of insulin and metformin, circumscribing bariatric surgery to appropriate indications, and using integrated health service networks to implement tDNA. Finally, further research, national surveys, and validation protocols focusing on CVD risk reduction in Venezuelan populations are necessary.

The transcultural diabetes nutrition algorithm: a canadian perspective.

The Transcultural Diabetes Nutrition Algorithm (tDNA) is a clinical tool designed to facilitate implementation of therapeutic lifestyle recommendations for people with or at risk for type 2 diabetes. Cultural adaptation of evidence-based clinical practice guidelines (CPG) recommendations is essential to address varied patient populations within and among diverse regions worldwide. The Canadian version of tDNA supports and targets behavioural changes to improve nutritional quality and to promote regular daily physical activity consistent with Canadian Diabetes Association CPG, as well as channelling the concomitant management of obesity, hypertension, dyslipidemia, and dysglycaemia in primary care. Assessing glycaemic index (GI) (the ranking of foods by effects on postprandial blood glucose levels) and glycaemic load (GL) (the product of mean GI and the total carbohydrate content of a meal) will be a central part of the Canadian tDNA and complement nutrition therapy by facilitating glycaemic control using specific food selections. This component can also enhance other metabolic interventions, such as reducing the need for antihyperglycaemic medication and improving the effectiveness of weight loss programs. This tDNA strategy will be adapted to the cultural specificities of the Canadian population and incorporated into the tDNA validation methodology.

The transcultural diabetes nutrition algorithm toolkit: survey and content validation in the United States, Mexico, and Taiwan.

BACKGROUND: Evidence demonstrates that medical nutrition therapy (MNT) in prediabetes and type 2 diabetes (T2D) improves glycemic control and reduces diabetes risks and complications. Consequently, MNT is included in current clinical practice guidelines. Guideline recommendations, however, are frequently limited by their complexity, contradictions, personal and cultural rigidity, and compromised portability. The transcultural Diabetes Nutrition Algorithm (tDNA) was developed to overcome these limitations. To facilitate tDNA uptake and usage, an instructional Patient Algorithm Therapy (PATh) toolkit was created. Content validation of tDNA-PATh is needed before widespread implementation. SUBJECTS AND METHODS: Healthcare providers (n=837) in Mexico (n=261), Taiwan (n=250), and the United States (n=326) were questioned about challenges implementing MNT in clinical practice and the projected utilization and impact of tDNA-PATh. To assess the international portability and applicability of tDNA-PATh, the survey was conducted in countries with distinct ethnic and cultural attributes. Potential respondents were screened for professional and practice demographics related to diabetes. The questionnaire was administered electronically after respondents were exposed to core tDNA-PATh components. RESULTS: Overall, 61% of respondents thought that tDNA-PATh could help overcome MNT implementation challenges, 91% indicated positive impressions, 83% believed they would adopt tDNA-PATh, and 80% thought tDNA-PATh would be fairly easy to implement. CONCLUSIONS: tDNA-PATh appears to be an effective culturally sensitive tool to foster MNT in clinical practice. By providing simple culturally specific instructions, tDNA-PATh may help to overcome current impediments to implementing recommended lifestyle modifications. Specific guidance provided by tDNA-PATh, together with included patient education materials, may increase healthcare provider efficiency.

Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective.

BACKGROUND: Assessing the costs of healthcare-associated infection (HAI) is challenging. Methodological issues abound. Previous estimates have been derived in diverse ways from varied perspectives in different settings with dissimilar data. RESULTS can be confusing. Full societal costs, which are more inclusive than commonly reported direct hospital costs, have never been fully measured or reported. OBJECTIVE: To update, combine, and expand previous cost estimates to determine the annual societal burden of illness (direct medical, non-medical, and indirect costs) arising from HAIs in US acute-care hospitals. METHODS: The research approach encompassed literature and internet searches; reference identification, selection, and review; then data abstraction, compilation, and analyses to estimate full societal costs. Previously published systemic reviews, surveillance reports, and individual clinical studies, along with newly computed component costs, all contributed to final estimates. RESULTS: HAIs in US acute-care hospitals lead to direct and indirect costs totaling $96-$147 billion annually. These results are subject to the same limitations as previous studies from which contributing data were derived. CONCLUSION: The enormous clinical and economic burden of infection places HAIs high on the list of devastating and costly illnesses, such as cancer, heart attack, stroke, and diabetes, thereby mandating further research and greater efforts to contain a pressing healthcare problem.

Transcultural diabetes nutrition algorithm: a malaysian application.

Glycemic control among patients with prediabetes and type 2 diabetes mellitus (T2D) in Malaysia is suboptimal, especially after the continuous worsening over the past decade. Improved glycemic control may be achieved through a comprehensive management strategy that includes medical nutrition therapy (MNT). Evidence-based recommendations for diabetes-specific therapeutic diets are available internationally. However, Asian patients with T2D, including Malaysians, have unique disease characteristics and risk factors, as well as cultural and lifestyle dissimilarities, which may render international guidelines and recommendations less applicable and/or difficult to implement. With these thoughts in mind, a transcultural Diabetes Nutrition Algorithm (tDNA) was developed by an international task force of diabetes and nutrition experts through the restructuring of international guidelines for the nutritional management of prediabetes and T2D to account for cultural differences in lifestyle, diet, and genetic factors. The initial evidence-based global tDNA template was designed for simplicity, flexibility, and cultural modification. This paper reports the Malaysian adaptation of the tDNA, which takes into account the epidemiologic, physiologic, cultural, and lifestyle factors unique to Malaysia, as well as the local guidelines recommendations.

Transculturalization of a diabetes-specific nutrition algorithm: Asian application.

The prevalence of type 2 diabetes (T2D) in Asia is growing at an alarming rate, posing significant clinical and economic risk to health care stakeholders. Commonly, Asian patients with T2D manifest a distinctive combination of characteristics that include earlier disease onset, distinct pathophysiology, syndrome of complications, and shorter life expectancy. Optimizing treatment outcomes for such patients requires a coordinated inclusive care plan and knowledgeable practitioners. Comprehensive management starts with medical nutrition therapy (MNT) in a broader lifestyle modification program. Implementing diabetes-specific MNT in Asia requires high-quality and transparent clinical practice guidelines (CPGs) that are regionally adapted for cultural, ethnic, and socioeconomic factors. Respected CPGs for nutrition and diabetes therapy are available from prestigious medical societies. For cost efficiency and effectiveness, health care authorities can select these CPGs for Asian implementation following abridgement and cultural adaptation that includes: defining nutrition therapy in meaningful ways, selecting lower cutoff values for healthy body mass indices and waist circumferences (WCs), identifying the dietary composition of MNT based on regional availability and preference, and expanding nutrition therapy for concomitant hypertension, dyslipidemia, overweight/obesity, and chronic kidney disease. An international task force of respected health care professionals has contributed to this process. To date, task force members have selected appropriate evidence-based CPGs and simplified them into an algorithm for diabetes-specific nutrition therapy. Following cultural adaptation, Asian and Asian-Indian versions of this algorithmic tool have emerged. The Asian version is presented in this report.

Diabetes-specific nutrition algorithm: a transcultural program to optimize diabetes and prediabetes care.

Type 2 diabetes (T2D) and prediabetes have a major global impact through high disease prevalence, significant downstream pathophysiologic effects, and enormous financial liabilities. To mitigate this disease burden, interventions of proven effectiveness must be used. Evidence shows that nutrition therapy improves glycemic control and reduces the risks of diabetes and its complications. Accordingly, diabetes-specific nutrition therapy should be incorporated into comprehensive patient management programs. Evidence-based recommendations for healthy lifestyles that include healthy eating can be found in clinical practice guidelines (CPGs) from professional medical organizations. To enable broad implementation of these guidelines, recommendations must be reconstructed to account for cultural differences in lifestyle, food availability, and genetic factors. To begin, published CPGs and relevant medical literature were reviewed and evidence ratings applied according to established protocols for guidelines. From this information, an algorithm for the nutritional management of people with T2D and prediabetes was created. Subsequently, algorithm nodes were populated with transcultural attributes to guide decisions. The resultant transcultural diabetes-specific nutrition algorithm (tDNA) was simplified and optimized for global implementation and validation according to current standards for CPG development and cultural adaptation. Thus, the tDNA is a tool to facilitate the delivery of nutrition therapy to patients with T2D and prediabetes in a variety of cultures and geographic locations. It is anticipated that this novel approach can reduce the burden of diabetes, improve quality of life, and save lives. The specific Southeast Asian and Asian Indian tDNA versions can be found in companion articles in this issue of Current Diabetes Reports.

Transcultural diabetes nutrition therapy algorithm: the Asian Indian application.

India and other countries in Asia are experiencing rapidly escalating epidemics of type 2 diabetes (T2D) and cardiovascular disease. The dramatic rise in the prevalence of these illnesses has been attributed to rapid changes in demographic, socioeconomic, and nutritional factors. The rapid transition in dietary patterns in India-coupled with a sedentary lifestyle and specific socioeconomic pressures-has led to an increase in obesity and other diet-related noncommunicable diseases. Studies have shown that nutritional interventions significantly enhance metabolic control and weight loss. Current clinical practice guidelines (CPGs) are not portable to diverse cultures, constraining the applicability of this type of practical educational instrument. Therefore, a transcultural Diabetes Nutrition Algorithm (tDNA) was developed and then customized per regional variations in India. The resultant India-specific tDNA reflects differences in epidemiologic, physiologic, and nutritional aspects of disease, anthropometric cutoff points, and lifestyle interventions unique to this region of the world. Specific features of this transculturalization process for India include characteristics of a transitional economy with a persistently high poverty rate in a majority of people; higher percentage of body fat and lower muscle mass for a given body mass index; higher rate of sedentary lifestyle; elements of the thrifty phenotype; impact of festivals and holidays on adherence with clinic appointments; and the role of a systems or holistic approach to the problem that must involve politics, policy, and government. This Asian Indian tDNA promises to help guide physicians in the management of prediabetes and T2D in India in a more structured, systematic, and effective way compared with previous methods and currently available CPGs.

Managing acute acetaminophen poisoning with oral versus intravenous N-acetylcysteine: a provider-perspective cost analysis.

BACKGROUND: Acetaminophen (APAP) overdose, which can lead to hepatotoxicity, is the most commonly reported poisoning in the United States and has the highest rate of mortality, with more than 100,000 exposures and 300 deaths reported annually (1) . The treatment of choice, N-acetylcysteine (NAC), is effective in both oral (PO) and intravenous (IV) formulations. The main difference in therapies, other than administration route, is time to complete delivery--72 hours for PO NAC versus 21 hours for IV NAC, according to full prescribing information. This distinction is the primary basis for variation in management costs for hospitalized patients receiving these products. OBJECTIVES: To quantify and compare full treatment costs from the provider perspective to manage acute APAP poisoning with either PO or IV NAC in a standard treatment regimen. METHODS: A cost model was developed and populated with published data comprising probabilities of potential clinical outcomes and the costs of resources consumed during patient care. RESULTS: For patients who present <10 hours post-ingestion, the estimated total cost of care with PO NAC in the treatment regimen is $5,817 (ICU patients) or $3,850, (ward patients) compared with $3,765 and $2,768 for similar care with IV NAC. Potential cost savings equal - $2,052 (-35%) or -$1,083 (-28%), respectively, in favor of IV NAC. Similar potential savings were estimated for patients presenting 10-24 hours post-ingestion. CONCLUSION: IV NAC is the less costly therapeutic option for APAP poisonings, based on simulation modeling and retrospective data. The current economic evaluation is restricted by the absence of comparative data from head-to-head, matched-cohort studies and the limitations common to retrospective APAP toxicology datasets. Additional research could refine these results.

Loss of confidence in diabetes management.

UNLABELLED: Using current treatment approaches, many patients with type 2 diabetes do not achieve glycemic goals--and do experience macrovascular complications that contribute to morbidity and mortality. It's time to consider other options. IMPLICATIONS: Aggressive therapeutic interventions aimed at insulin resistance and cell dysfunction may alter outcomes. Managed care organizations may need to modify the way they look at diabetes and should consider changing their focus from drug costs to wellness. Value-based insurance design may provide opportunities to optimize diabetes management, resulting in improved outcomes for patients and economic benefits for managed care organizations.

Costs and benefits of an early-alert surveillance system for hospital inpatients.

BACKGROUND: The economic implications of inpatient adverse events and rising healthcare costs have intensified interest in patient safety and the efficient delivery of products and services with cost-saving potential. New technologies may help in this regard but must be evaluated economically as well as clinically and should demonstrate cost-benefit for consideration by payers and providers. One such technology--an automated early-alert system for patient distress--has been developed. Performance data suggest clinical worthiness and warrant economic evaluation of the system. SCOPE: A hospital-perspective analysis was conducted with cost modeling and retrospective data to estimate the economic consequences of deleterious clinical events and the impact of the early-alert system when deployed during routine medical-surgical admissions. The principal outcome was expected per-patient direct costs associated with inpatients falls and cardiopulmonary arrests. Reduction of these clinical events through intelligent surveillance with the early-alert system suggested economic benefits that may offset the cost of the technology. FINDINGS: The expected per-patient direct cost for inpatient falls and cardiopulmonary arrests was 191.73 dollars per hospitalization. Estimated economic benefits associated with early-alert surveillance supported a break-even cost of 14.59 dollars per day for the system. CONCLUSION: This study estimated the impact of the early-alert system on the deleterious clinical and economic consequences of inpatient falls and cardiopulmonary arrests on the medical-surgical ward as well as a break-even cost for the system. Results are limited by retrospective data and cost modeling. Ongoing clinical evaluation is required to quantify and compare more precisely the cost of care with and without the system in real-life clinical settings. In the interim, this study may provide some insight into the components and magnitude of the cost for the cited events and the potential benefits and detriments that offset or contribute to the cost of the early-alert system. Study results can be more accurately specified per hospital using institutional data as inputs in the model.

Longitudinal assessment of the dose consistency of botulinum toxin type A (BOTOX) for cervical dystonia.

Botulinum toxin type A (BoNT/A) is the principal therapy for patients with cervical dystonia. Repeated treatments over many years are required in most cases. This retrospective review evaluates the dose of BoNT/A used to treat cervical dystonia and the interval between treatments during a 2-year observation period. Outcomes data were abstracted from the medical records of 172 patients at 3 different sites who had received BoNT/A between January and December 1998. A total of 1059 treatments were assessed. Mean per-treatment doses throughout the 2-year study ranged from 241.80 to 254.07 units. The mean interval between treatments was 108.48 days during the first year of observation and 114.14 days during the second year. These findings indicate that doses of and intervals between BoNT/A treatments for cervical dystonia were consistent throughout 2 years of observation.

Retrospective evaluation of the dose of Dysport and BOTOX in the management of cervical dystonia and blepharospasm: the REAL DOSE study.

The purpose of this study is to evaluate the real-world dose utilization of Dysport and BOTOX for cervical dystonia and blepharospasm. Six investigational sites (five countries) were identified. Investigators abstracted utilization data for patients who received Dysport before switching to BOTOX or BOTOX before switching to Dysport. Patients were identified during scheduled clinic visits and selected if they met study criteria, which included treatment for at least 2 consecutive years (at least 1 year with Dysport or BOTOX, then switched and maintained on BOTOX or Dysport for at least another year). A total of 114 patients were included in the assessment. Ratios of mean dose for Dysport to BOTOX ranged from a low of 2:1 to a high of 11:1. Thirty-one percent of patients fell into the Dysport-to-BOTOX ratio grouping of 5:1 to less than 6:1; 30% of patients had a mean ratio of Dysport to BOTOX of 4:1 to less than 5:1; and only 21% of all patients evaluated fell into the Dysport-to-BOTOX ratio grouping of 3:1 to less than 4:1. Results are consistent with United Kingdom labeling for botulinum toxins stating that units of different serotype A toxins are not interchangeable and simple dose-conversion factors are not applicable.

Treatments for mild-to-moderate recalcitrant plaque psoriasis: expected clinical and economic outcomes for first-line and second-line care.

The cost effectiveness of treatments for psoriasis has been evaluated previously by several different investigators. Such evaluations should be updated as new products or data become available. To this end, a comparison of expected treatment-related clinical and economic outcomes is undertaken from the payer perspective using a disease-intervention model, decision analyses, and newly emergent information. The model is based on academy guidelines and recommended clinical practice. Model inputs (clinical and cost data) are culled from the medical literature and advisory clinical assessment surveys. Comparable therapies are various topical pharmacotherapies and phototherapies, including the 308-nm excimer laser (XTRAC, PhotoMedex, Montgomeryville, PA). Analytic results indicate that clinical and economic outcomes are influenced by treatment selections but are muted by the rotational nature of treatment regimens. Multiple analyses are required to reveal individual product performance. On the basis of these analyses, the addition of the 308-nm excimer laser to the rotational mix of treatments commonly utilized as second-line therapies for mild-to-moderate plaque psoriasis is expected to add incremental clinical benefit for patients without incremental cost for payers, because the laser can replace both more costly and less costly alternatives for appropriately selected patients who require a different therapeutic modality to maintain or improve their responsiveness.