Evaluating thinking styles in adults with an eating disorder: Associations with life satisfaction, psychological symptoms, and treatment engagement.

Cognitive weaknesses have been implicated as a vulnerability factor in the development and maintenance of eating disorders. Despite this, cognitive styles are not routinely assessed in adult outpatient eating disorder programs and little is known about how they may impact patients' functional outcomes, psychological symptoms, or treatment engagement. The aim of this study was to evaluate thinking styles (i.e., cognitive rigidity and attention to detail) among adults attending specialized outpatient treatment for an eating disorder and assess whether such styles were associated with participants' satisfaction with life, psychological symptoms, and engagement in the outpatient group therapy program. Demographic and physical health information was collected from 95 adults who were eligible for an outpatient program. Participants completed the Detail and Flexibility Questionnaire, Satisfaction with Life Scale, Beck Depression Inventory second edition, and Beck Anxiety Inventory. Elevated scores for cognitive rigidity and attention to detail were transdiagnostic rather than specific to eating disorder diagnoses. Cognitive rigidity and attention to detail were associated with lower satisfaction with life, and increased anxiety and depression. Cognitive styles of cognitive rigidity and attention to detail were not associated with engagement in treatment or treatment completion. Cognitive patterns may be important for clinicians to evaluate as part of routine outpatient care given that they occur transdiagnostically and are linked with psychological symptoms and functional outcomes for adults struggling with an eating disorder.

To Reoffend or Not to Reoffend? An Investigation of Recidivism Among Individuals With Sexual Offense Histories and Psychopathy.

Although psychopathy is a well-established risk factor for recidivism among those who have committed sexual offenses, there are nonetheless some individuals with sexual offense histories who are high in psychopathy but do not recidivate. This population-nonrecidivating psychopathic sex offenders (NRP-SOs)-was the focus of the current investigation. Data from 111 individuals with sexual offense histories who received a Hare Psychopathy Checklist-Revised (PCL-R) rating of at least 25 (suggesting the presence of psychopathy) were analyzed. With recidivism operationalized as the accrual of any new serious-that is, violent or sexual-charges, 39 recidivated (RP-SOs), whereas 72 did not (NRP-SOs). A logistic regression was conducted to assess whether NRP-SOs could be differentiated from RP-SOs. Being older at the time of release, a lesser criminal history, and being married predicted nonrecidivism. PCL-R factor scores and sexual deviance were not predictive. These findings highlight the heterogeneity that exists, even among those high in psychopathy.

Motivation and engagement during cognitive training for schizophrenia spectrum disorders.

BACKGROUND: Motivation and engagement are important factors associated with therapeutic outcomes in cognitive training for schizophrenia. The goals of the present report were to examine relations between objective treatment engagement (number of sessions attended, amount of homework completed) and self-reported motivation (intrinsic motivation and perceived competence to complete cognitive training) with neurocognitive and functional outcomes from cognitive training. METHODS: Data from a clinical trial comparing two cognitive training approaches in schizophrenia-spectrum disorders were utilized in the current report (n = 38). Relations were examined between baseline intrinsic motivation, perceived competence, homework completion, and session attendance with improvements in neurocognition, functional competence, and community functioning. RESULTS: Number of sessions attended (r = 0.38) and time doing homework (r = 0.51) were significantly associated with improvements in neurocognition. Homework completion was associated with change in community functioning at a trend-level (r = 0.30). Older age was associated with greater treatment engagement (ß = 0.37) and male biological sex was associated with greater self-reported motivation (ß = 0.43). Homework completion significantly mediated the relationship between session attendance and neurocognitive treatment outcomes. CONCLUSIONS: Objective measures of treatment engagement were better predictors of treatment outcomes than subjective measures of motivation. Homework completion was most strongly related to treatment outcomes and mediated the relationship between session attendance and treatment outcomes, suggesting continued engagement with cognitive stimulation may be an especially important component of cognitive remediation programs. Future research should examine methods to improve homework completion and session attendance to maximize therapeutic outcomes.

It's raining men: descriptive results for engaging men with eating disorders in a specialized male assessment and treatment track (MATT).

PURPOSE: Men with eating disorders are not well understood and there is a need for innovative methods for engaging men in specialized outpatient assessment and treatment. We examined data collected over a 4-year period to explore whether the addition of a designated track for men at a hospital-based adult eating disorders program influenced the number of referrals or treatment engagement. METHODS: During assessment and treatment as usual (ATAU; September 2013-August 2015), 283 referrals were received (275 women, 8 men), with 3 men engaging in assessment and treatment (Mage = 36 years, SD = 14.18). After instatement of a male assessment and treatment track (MATT; September 2015-August 2017), 320 referrals were received (300 women, 20 men), with 14 men engaging in the specialized assessment and treatment (Mage = 28.21 years, SD = 8.04). Both groups of men completed measures of demographic characteristics, life satisfaction, depressive and anxiety symptoms, and eating disorder symptoms. RESULTS: Significantly more referrals for men, but not women, were received after the instatement of the MATT (i.e., a 250% increase). More men also engaged in specialized assessment and treatment after the instatement of the MATT (i.e., a 467% increase in engagement). CONCLUSIONS: The current study describes the number of referrals and the number of men who engaged in treatment before and after the instatement of a specialized treatment track for men. The results suggest that the addition of the MATT helped to increase the number of men referred and promoted their engagement in recommended care. LEVEL OF EVIDENCE: V retrospective descriptive study.

Exposure with response prevention (ERP) for body dissatisfaction in a group therapy format: an exploratory study.

PURPOSE: The aim of this exploratory study was to examine patient satisfaction and outcomes from exposure with response prevention (ERP) delivered in a group therapy format. The group was aimed at addressing eating disorder symptoms associated with body dissatisfaction in the later stages of outpatient treatment. METHODS: 33 adults with a DSM-5 diagnosis of an eating disorder participated in the ERP group. Participants completed pre- and post-ERP group measures of depression, anxiety, self-evaluation based on body image, restraint, eating concern, weight concern, shape concern, upward and downward appearance comparisons, and patient satisfaction. RESULTS: Involvement in the ERP group was associated with significant decreases in self-evaluation based on body image, restraint, eating concern, weight concern, shape concern, and upward physical appearance comparisons post-group treatment. This adjunct treatment group was well received and viewed as being helpful by participants. CONCLUSIONS: ERP in a group therapy format for addressing body dissatisfaction may represent a complimentary approach to current evidence-based treatments for an eating disorder, and warrant further investigation.

A pilot evaluation of group-based programming offered at a Canadian outpatient adult eating disorders clinic.

Eating disorder clinics across Canada place heavy reliance on group-based programming. However, little work has examined whether this modality of treatment is well-received by patients and results in clinical improvements. The purpose of this pilot study was to evaluate patient satisfaction and outcomes for group-based programming offered through an adult eating disorders clinic. Participants were 81 adults who met DSM-5 criteria for an eating disorder and participated in the study as part of the clinic's program evaluation. Participants received medical monitoring, psychiatric follow-up, adjunct nutrition and pre-psychological treatment, and participated in the clinic's core cognitive behavioural therapy (CBT) group. Demographic information and weight were collected at intake. Participants also completed pre- and post-group programming measures of life satisfaction, depressive and anxiety symptoms, psychological symptoms of the eating disorder, and satisfaction with the programming. Participants' experienced a significant increase in satisfaction with life, and decreases in depressive symptoms and psychological symptoms of the eating disorder post-group. Adults endorsed feeling fairly satisfied with the group-based services provided. Results draw attention to the importance of program evaluation as an integral component of an adult outpatient eating disorder clinic by providing a voice for patients' views of the services received and program outcomes.

The potential clinical relevance of serum vascular endothelial growth factor (VEGF) and VEGF-C in recurrent papillary thyroid carcinoma.

BACKGROUND: Vascular endothelial growth factor (VEGF) promotes tumor angioinvasion while VEGF-C is a potent lymphangiogenic factor. This study aims at evaluating serum VEGF (sVEGF) and sVEGF-C levels in recurrent papillary thyroid carcinoma (PTC) patients. METHODS: Serum samples were collected preoperatively from 85 patients with primary PTC, 44 with benign thyroid diseases, and 19 with recurrent PTC. sVEGF and sVEGF-C levels were measured by enzyme-linked immunosorbent assay. RESULTS: Twelve patients had locoregional recurrence only while 7 patients had distant metastases, including 6 with concomitant or history of locoregional recurrence. Patients with recurrent PTC had significantly higher sVEGF (432 vs 263 pg/mL, P = .004) and sVEGF-C (6,433 vs 5,289 pg/mL, P = .006) levels than benign controls. sVEGF level was significantly elevated in patients with distant metastases compared with those of local recurrences only (580 vs 345 pg/mL, P = .037) while there was no significant difference of sVEGF-C level in both subgroup of patients. sVEGF, but not VEGF-C, showed a linear correlation with thyroglobulin levels in recurrent PTC patients. CONCLUSION: Both sVEGF and sVEGF-C levels are elevated in patients with recurrent PTC, and sVEGF distinguishes the presence of distant metastasis. Angiogenic markers should be further evaluated for their clinical relevance in monitoring and predicting the type of recurrence.

Serum vascular endothelial growth factor C correlates with lymph node metastases and high-risk tumor profiles in papillary thyroid carcinoma.

OBJECTIVE: To evaluate the clinical relevance of serum vascular endothelial growth factor (VEGF) and VEGF-C in papillary thyroid carcinoma (PTC). SUMMARY BACKGROUND DATA: VEGF is a potent angiogenic factor promoting tumor angioinvasion and distant metastases, whereas VEGF-C enhances nodal metastases because of its lymphangiogenic effect. Although both tissues VEGF and VEGF-C have been shown to contribute to tumor metastases in PTC, the clinical relevance of serum VEGF (sVEGF) and sVEGF-C remains unknown. METHODS: Preoperative serum samples collected from 85 primary PTC patients and 44 control subjects with benign thyroid diseases were measured for sVEGF and sVEGF-C levels. Potential correlations between their serum levels and clinicopathologic features as well as the commonly adopted risk group stratification profiles of the tumors were analyzed. RESULTS: Preoperative sVEGF and sVEGF-C levels of PTC patients were significantly higher compared with those of control subjects (P = 0.001 and P < 0.001, respectively). sVEGF-C level was significantly elevated in older patients, those with extrathyroidal invasion and with lymph node metastases whereas sVEGF level was significantly increased in multifocal tumors. sVEGF-C, but not sVEGF, correlated significantly with high risk tumors in all commonly adopted risk group stratification profiles. An elevated preoperative sVEGF-C level of >7200 pg/mL was shown to be the only independent risk factor for nodal metastases. sVEGF-C levels declined significantly at 3 months after thyroidectomy in PTC but not control patients. CONCLUSIONS: sVEGF-C levels in PTC patients correlated significantly with the presence of nodal metastases and advanced tumor stages. Its clinical relevance needs further evaluation.

Hepatic stellate cell-targeted delivery of M6P-HSA-glycyrrhetinic acid attenuates hepatic fibrogenesis in a bile duct ligation rat model.

BACKGROUND/AIMS: Hepatic stellate cells (HSCs) play a key role in fibrogenesis. Here, we used mannose-6-phosphate-modified human serum albumin (M6P(26)-HSA) as a selective carrier to deliver antifibrotic drug 18beta-glycyrrhetinic acid (18beta-GA) in experimental fibrosis animals, and tested its effect in injured liver tissues. METHODS: Bile duct ligation (BDL) was performed to induce liver damage in rats. Masson's stain and immunocytochemistry were used to assess hepatic collagen deposits and uptakes of M6P(26)-HSA-GA in HSCs in rat livers. Gene expression profiles of procollagen type I alpha2, smooth muscle actin (SMA), and transforming growth factor-beta1 (TGF-beta1) were analysed by TaqMan and quantitative polymerase chain reaction assays. The depositions of M6P(26)-HSA-GA in the HSC-T6 cell line and primary HSCs were assessed by immunofluorescent staining. RESULTS: Treatment with M6P(26)-HSA-GA at 10 mg/kg (three times/week for 2 weeks), but not the equivalent doses of free 18beta-GA and M6P(26)-HSA carrier alone, could significantly attenuate collagen deposits in BDL rat liver. Masson's stain and TaqMan assay revealed significant modulation of procollagen type I alpha2 in the BDL-injured liver. The depositions of M6P(26)-HSA-GA in HSCs were revealed by immunostaining with HSA and SMA markers. M6P(26)-HSA bound activated HSCs in vitro and the immunoreactivity of M6P(26)-HSA-GA was detected in the cytoplasm and cell surface of HSCs and HSC-T6 cells. The gene transcript levels of SMA and TGF-beta1 were modulated in HSC-T6 cells treated with M6P(26)-HSA-GA. CONCLUSIONS: The M6P(26)-HSA holds promise as a targeting carrier for the liver or HSCs, which may be used to deliver 18beta-GA as a therapeutic agent to treat liver fibrosis.

Clinicopathological roles of alterations of tumor suppressor gene p16 in papillary thyroid carcinoma.

BACKGROUND: Alterations of the p16 gene are common in human cancers, but their roles in thyroid cancers have not been clearly defined. The aim of the present study was to investigate the clinicopathological roles of the p16 gene in papillary thyroid carcinoma (PTC). METHODS: p16 gene alterations were investigated in 44 patients with PTC (9 men, 35 women) by immunohistochemistry, reverse transcriptase-polymerase chain reaction and methylation-specific polymerase chain reaction. The findings were correlated with their clinicopathological features. RESULTS: p16 protein expression, mRNA alterations, and promoter methylation were detected in 89% (n = 39), 77% (n = 33), and 41% (n = 18) of patients with PTC, respectively. There was no marked relationship between p16 protein expression, mRNA alteration, and promoter methylation. In follicular variant of PTC (FVPTC), there was a frequent lack of p16 protein expression and promoter methylation. PTCs showing p16 promoter methylation were often associated with a high AMES (age, metastasis to distant sites, extrathyroidal invasion, size) risk group and advanced pTNM (tumor-lymph node-metastasis) stages. CONCLUSIONS: p16 gene alterations are common and correlate with histological features and biological aggressiveness in PTC, suggesting that they might play an important role in its pathogenesis.

Liver intestine-cadherin (CDH17) haplotype is associated with increased risk of hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC), the most common form of liver cancer, is a leading cause of cancer death worldwide. We previously showed that aberrant mRNA splicing of the liver intestine-cadherin gene CDH17 in liver tissues was triggered by the specific constellation of two CDH17 single nucleotide polymorphisms (651T and IVS6+35G). CDH17 aberrant splicing was highly associated with tumor dissemination and shorter survival of HCC patients. Consequently, it is highly relevant to assess whether the presence of these single nucleotide polymorphisms in the general population represents a risk to the development of HCC. EXPERIMENTAL DESIGN: We conducted a case-control study including 164 HCC and 99 cirrhosis patients and 293 healthy controls. Genotyping was done by PCR and direct sequencing. Odds ratio (OR) and chi2 analysis were used to analyze genotypes and haplotypes. RESULTS: Genotypes 651TT [OR, 2.62; 95% confidence interval (95% CI), 1.34-5.03] and IVS6+35 GG (OR, 1.95; 95% CI, 1.04-3.62) were highly associated with HCC disease. The 651T (C>T) and IVS6+35G (A>G) alleles were also overrepresented in HCC patients and, in particular, the T-G haplotype was the most prevalent in HCC patients when compared with healthy controls (OR, 1.57; 95% CI, 1.167-2.109; P=0.004), which was in agreement with the aberrant splicing observed in tumor tissues. There was no significant difference in genotype and allele frequencies between cirrhosis patients and controls. CONCLUSION: The functional T-G haplotype of CDH17 (651 C>T and IVS6+35A>G) is a genetic susceptibility factor for the development of HCC in a Chinese population.

The gene expression of adrenomedullin, calcitonin-receptor-like receptor and receptor activity modifying proteins (RAMPs) in CCl4-induced rat liver cirrhosis.

This study was undertaken to determine AM expression in carbon tetrachloride (CCl4)-induced liver cirrhosis developed with peritoneal ascites. Sprague-Dawley rats received subcutaneous injections of CCl4 twice weekly in olive oil (1:1, 0.3 ml per kg body weight) for 6 or 12 weeks until ascites developed, or saline in olive oil as control. At 6 weeks, fibrosis developed and at 12 weeks cirrhosis developed with ascites formation. At both 6 and 12 weeks, increases in plasma renin and AM were evident, as was the gene expression of AM. At 12 weeks after CCl4 injection, the gene expression of calcitonin-like-receptor (CRLR) and receptor activity modifying proteins (RAMP1, RAMP2 and RAMP3) were all elevated when compared to the control. The results suggest that liver cirrhosis increases mRNA expressions of AM, CRLR and RAMP1, RAMP2 and RAMP3 and that the increase in AM gene expression precedes the development of cirrhosis. The increase in AM synthesis as reflected by an increase in AM gene expression, together with a lack of increase in AM peptide at both 6 and 12 weeks may suggest an elevation of AM release. Given the potent vasodilatory action of AM, the increase in the synthesis and release of AM in the cirrhotic liver may also contribute to peripheral vasodilatation in liver cirrhosis.

Kidney claudin-19: localization in distal tubules and collecting ducts and dysregulation in polycystic renal disease.

Tight junction (TJ) constitutes the barrier by controlling the passage of ions and molecules via paracellular pathway and the movement of proteins and lipids between apical and basolateral domains of the plasma membrane. Claudins, occludin, and junctional adhesion molecules are the major three transmembrane proteins at TJ. This study focuses a newly identified mammalian TJ gene, claudin-19, in kidneys. Mouse claudin-19 composes of 224 amino acids and shares 98.2% and 95% amino acid homology with rat and human, respectively; the most evolutionary-related claudins are claudin-1 and -7, which share approximately 75% DNA sequence homology with claudin-19. Claudin-19 is abundantly expressed in the mouse and rat kidneys among the organs examined by Northern blots, and to a much less extent, also found in brain by RT-PCR. Claudin-19 and zonula occludens-1 (ZO-1) are localized at junctional regions of Madin-Darby canine kidney (MDCK) cells by immunofluorescent microscopy. In addition, ZO-1 is found in the claudin-19-associated protein complexes in MDCK cells by co-immunoprecipitation. Using aquaporin-1 and aquaporin-2 antibodies as markers for different renal segment, strong expression of claudin-19 was observed in distal tubules of the cortex as well as in the collecting ducts of the medulla. To less extent, claudin-19 is also present in the proximal tubules (cortex) and in the loop of Henle (medulla). Furthermore, intense claudin-19 immunoreactivity is found co-localized with the ZO-1 in kidneys from postnatal day 15, day 45, and adult rats and mice. Similar localizations of claudin-19 and ZO-1 are also observed in human kidneys. Since these renal segments are mainly for controlling the paracellular cation transport, it is suggested that claudin-19 may participate in these processes. In human polycystic kidneys, decreased expression and dyslocalization of claudin-19 are noticed, suggesting a possible correlation between claudin-19 and renal disorders. Taken together, claudin-19 is a claudin isoform that is highly and specifically expressed in renal tubules with a putative role in TJ homeostasis in renal physiology.

Increased expression of vascular endothelial growth factor C in papillary thyroid carcinoma correlates with cervical lymph node metastases.

PURPOSE: Despite recent studies showing that vascular endothelial growth factor C (VEGF-C) mRNA is up-regulated in papillary thyroid carcinoma (PTC), the role of VEGF-C in lymph node metastasis is still unclear. The aim of this study is to investigate the expression pattern of VEGF-C immunoreactive protein in PTC and its relationship with cervical lymph node metastasis. EXPERIMENTAL DESIGN: Tissue samples were obtained from 39 specimens of PTC (20 with and 19 without lymph node metastasis) as well as 20 benign thyroid nodules. Overexpression of the VEGF-C protein was evaluated by immunoblotting with specific anti-VEGF-C antibody in paired tumor and nontumor tissues from PTC. The data were compared with patients' clinicopathologic features and lymph node metastasis. Immunohistochemical staining was done on selected paraffin sections to determine cellular localization of VEGF-C and to assess flt-4 (or VEGFR-3)-positive vessel density in PTC lesions. RESULTS: Overexpression of VEGF-C was detected in 69% of the PTC and in 5% of the benign thyroid specimens. When comparing between the metastatic and nonmetastatic groups of PTC, a higher expression level of VEGF-C was detected in both the tumor (P = 0.004) and adjacent nontumor tissues (P = 0.011). Positive immunostaining for VEGF-C was confirmed in PTC tumor tissues and metastatic lymph nodes, which correlated with flt-4-positive vessel density in tumor and peritumor tissues. The increased expression of VEGF-C protein in PTC is associated with lymph node metastasis (P = 0.004) and lymphovascular permeation (P = 0.001) but is independent of other clinicopatholgic variables. CONCLUSIONS: The VEGF-C immunoreactive protein is overexpressed in PTC lesions, which correlates with lymph node metastases. VEGF-C expression may play a role in lymphangiogenesis of PTC and further study is necessary to evaluate the clinical application of VEGF-C as a molecular marker for tumor metastases to cervical lymph nodes.

High prevalence of cyclooxygenase 2 expression in papillary thyroid carcinoma.

BACKGROUND: Cyclooxygenase-2 (COX-2) seems to play a role in the development and carcinogenesis of papillary thyroid carcinoma. Its incidence of expression and potential application as a tumor marker remain to be elucidated. MATERIALS AND METHODS: Immunohistochemical staining for COX-2 expression was performed for 30 papillary thyroid carcinoma (PTC) and 40 benign thyroid specimens. COX-2 mRNA expression was analyzed using a reverse transcriptase-polymerase chain reaction (RT-PCR) for paired fresh frozen tissues removed from surgically resected PTC specimens. RESULTS: COX-2 expression was detected by immunohistochemistry in 27 of 30 (90%) PTC but was absent in 40 benign thyroid specimens, including 27 nodular hyperplasia, 7 follicular adenoma and 6 lymphocytic thyroiditis. Two of the three COX-2 negative carcinomas were follicular variant of PTC. RT-PCR analysis confirmed COX-2 mRNA over-expression in 14 of 20 (70%) paired specimens of PTC. Real-time quantitative RT-PCR showed that the level of COX-2 mRNA expression was significantly higher in PTC than in both the adjacent non-cancerous tissues and the benign thyroid specimens. CONCLUSION: COX-2 is frequently expressed in PTC but not in benign thyroid specimens. COX-2 expression may serve as a useful molecular marker for PTC in cases of diagnostic difficulty.

Alternative mRNA splicing of liver intestine-cadherin in hepatocellular carcinoma.

PURPOSE: To identify alternative splicing of the liver intestine-cadherin (LI-cadherin) gene in hepatocellular carcinoma (HCC) and correlate its aberrant expression with clinical outcomes. EXPERIMENTAL DESIGN: Reverse transcription-PCR (RT-PCR) and quantitative real-time RT-PCR were used to examine alternative mRNA splicing and mRNA level of LI-cadherin in 50 paired tumor-peritumor tissues of 50 HCC and 8 normal liver specimens. The minigene exon-trapping strategy was employed to investigate the splicing mechanism introduced by nucleotide polymorphisms. Association of LI-cadherin splicing with tumor venous infiltration, first-year tumor recurrence, and overall survival after partial hepatectomy were determined. RESULTS: Alternative mRNA splicing of LI-cadherin was identified in half of the HCC specimens. Sequencing analysis indicated the loss of exon 7 in the spliced LI-cadherin gene. LI-cadherin mRNA was up-regulated from 2.58-fold to 800-fold in over 80% of HCC samples when compared with normal liver by quantitative PCR. Furthermore, nucleotide polymorphisms were identified in putative branch point at IVS6 + 35 (intron 6) as well as in coding sequence 651 (exon 6) in HCC tissues, which may affect alternative mRNA splicing. Clinically, those patients who harbored the alternative splicing of LI-cadherin were strongly associated with shorter overall survival time (P < 0.01) as well as higher incidences of tumor recurrences and venous infiltration (both P < 0.05) after hepatectomy. CONCLUSIONS: Over-expression of LI-cadherin was frequently detected in liver cancer patients. Aberrant alternative splicing of LI-cadherin was detected in 50% of HCC specimens and its clinical significance hinted at early tumor recurrence and poor overall survival of HCC patients.

Applicability of tissue aspirate for quick parathyroid hormone assay to confirm parathyroid tissue identity during parathyroidectomy for primary hyperparathyroidism.

HYPOTHESIS: Intraoperative quick parathyroid hormone (PTH) assay for tissue aspirate facilitates the confirmation of parathyroid tissue identity and allows a more selective use of frozen section examination during parathyroidectomy for primary hyperparathyroidism. DESIGN: A retrospective review of a prospective protocol of the applicability and accuracy of quick PTH assay for tissue aspirate as a biochemical frozen section tool. SETTING: A university hospital department of surgery. PATIENTS: Quick PTH assay for aspirate obtained from suspected parathyroid gland excised during parathyroidectomy for primary hyperparathyroidism. MAIN OUTCOME MEASURES: The accuracy of this biochemical identification of parathyroid tissue identity was correlated with histological examination and outcome. RESULTS: Quick PTH assay was performed for aspirate from at least 1 excised parathyroid gland in 122 (98%) of 125 patients while 13 patients (10%) had PTH aspirate for nonparathyroid tissues including thyroid (n = 10), thymic (n = 2) and lymphatic (n = 1) tissues. Frozen section examination was performed for 15 patients (12%), including the 3 patients who did not undergo tissue aspirate for quick PTH assay. All except 3 patients had an aspirate assay value of greater than 1500 pg/mL (range, 625 to >1500 pg/mL) for parathyroid tissue while the value of PTH aspirate for nonparathyroid tissue ranged from 27 to 229 pg/mL (median, 72 pg/mL) in 13 patients. The median size of abnormal parathyroid gland was 70 to 15,000 mg (median, 775 mg). CONCLUSIONS: With the availability of quick PTH assay, tissue aspirate for PTH assay can be adopted as an alternative to traditional frozen section examination to confirm parathyroid gland identity. Frozen section examination can be employed more selectively.

Using decision modeling to determine pricing of new pharmaceuticals: the case of neurokinin-1 receptor antagonist antiemetics for cancer chemotherapy.

OBJECTIVES: Decision analysis is commonly used to perform economic evaluations of new pharmaceuticals. The outcomes of such studies are often reported as an incremental cost per quality-adjusted life year (QALY) gained with the new agent. Decision analysis can also be used in the context of estimating drug cost before market entry. The current study used neurokinin-1 (NK-1) receptor antagonists, a new class of antiemetics for cancer patients, as an example to illustrate the process using an incremental cost of dollars Can20,000 per QALY gained as the target threshold. METHODS: A decision model was developed to simulate the control of acute and delayed emesis after cisplatin-based chemotherapy. The model compared standard therapy with granisetron and dexamethasone to the same protocol with the addition of an NK-1 before chemotherapy and continued twice daily for five days. The rates of complete emesis control were abstracted from a double-blind randomized trial. Costs of standard antiemetics and therapy for breakthrough vomiting were obtained from hospital sources. Utility estimates characterized as quality-adjusted emesis-free days were determined by interviewing twenty-five oncology nurses and pharmacists by using the Time Trade-Off technique. These data were then used to estimate the unit cost of the new antiemetic using a target threshold of dollars Can20,000 per QALY gained. RESULTS: A cost of dollars Can6.60 per NK-1 dose would generate an incremental cost of dollars Can20,000 per QALY. The sensitivity analysis on the unit cost identified a range from dollars Can4.80 to dollars Can10.00 per dose. For the recommended five days of therapy, the total cost should be dollars Can66.00 (dollars Can48.00-dollars Can100.00) for optimal economic efficiency relative to Canada's publicly funded health-care system. CONCLUSIONS: The use of decision modeling for estimating drug cost before product launch is a powerful technique to ensure value for money. Such information can be of value to both drug manufacturers and formulary committees, because it would facilitate negotiations for optimal pricing in a given jurisdiction.