Immunosuppressive agents in adult kidney transplantation in the National Health Service: a model-based economic evaluation.

BACKGROUND: Immunosuppression is required in kidney transplantation to prevent rejection and prolong graft survival. We conducted an economic evaluation to support England's National Institute for Health and Care Excellence in developing updated guidance on the use of immunosuppression, incorporating new immunosuppressive agents, and addressing changes in pricing and the evidence base. METHODS: A discrete-time state transition model was developed to simulate adult kidney transplant patients over their lifetime. A total of 16 different regimens were modelled to assess the cost-effectiveness of basiliximab and rabbit anti-thymocyte globulin (rabbit ATG) as induction agents (with no antibody induction as a comparator) and immediate-release tacrolimus, prolonged-release tacrolimus, mycophenolate mofetil, mycophenolate sodium, sirolimus, everolimus and belatacept as maintenance agents (with ciclosporin and azathioprine as comparators). Graft survival was extrapolated from acute rejection rates, graft function and post-transplant diabetes rates, all estimated at 12 months post-transplantation. National Health Service (NHS) and personal social services costs were included. Cost-effectiveness thresholds of £20 000 and £30 000 per quality-adjusted life year were used. RESULTS: Basiliximab was predicted to be more effective and less costly than rabbit ATG and induction without antibodies. Immediate-release tacrolimus and mycophenolate mofetil were cost-effective as maintenance therapies. Other therapies were either more expensive and less effective or would only be cost-effective if a threshold in excess of £100 000 per quality-adjusted life year were used. CONCLUSIONS: A regimen comprising induction with basiliximab, followed by maintenance therapy with immediate-release tacrolimus and mycophenolate mofetil, is likely to be effective for uncomplicated adult kidney transplant patients and a cost-effective use of NHS resources.

Antenatal anxiety disorder as a predictor of postnatal depression: a longitudinal study.

Previous research has implicated high levels of antenatal anxiety as a predictor of postnatal depression, but there is a paucity of evidence on the relationship between the various forms of anxiety and postnatal depression. A longitudinal study of 246 mothers (56 with antenatal generalised anxiety disorder (GAD), 68 with antenatal generalised social phobia, 28 with both disorders in the antenatal period, and 94 with no antenatal GAD or social phobia) allowed us to explore whether antenatal social phobia and GAD predict high Edinburgh Postnatal Depression Scale (EPDS) scores (probable depression >12) at 10-14 days, 10-12 weeks, 10 months, 14 months, and 24 months postnatally. We found that, after accounting for the presence of other antenatal anxiety disorders, antenatal depression, maternal age at child's birth, socio-economic status and ethnicity in the models, antenatal GAD independently predicted depression at all time points after delivery. A less robust relationship was found for antenatal social phobia, which predicted postnatal depression at only 10 months after birth. One possibility consistent with our findings is that there may be differences in the timing of postnatal depression with different forms of antenatal anxiety disorders.

Systematic review of topical capsaicin in the treatment of pruritus.

OBJECTIVE: To determine the efficacy of topical capsaicin in treating pruritus in any medical condition. DATA SOURCES: Cochrane library, Medline, Embase, Cinahl and Amed, up to April 2008. No language restrictions. STUDY SELECTION: Randomized, controlled trials comparing topically applied capsaicin with placebo or other standard treatment in patients with pruritus, independently selected by two reviewers. DATA EXTRACTION: Independently extracted by two reviewers. Quality assessed using the Jadad scale. DATA SYNTHESIS: Six randomized controlled trials were identified for inclusion. Three were for hemodialysis-related pruritus and provided insufficient data for the efficacy of topical capsaicin to be evaluated. A crossover study of capsaicin for treating idiopathic intractable pruritus ani reported a statistically significant difference in responder rates favoring capsaicin over placebo for itching scores but included insufficient data for the validity of this result to be assessed. A study on notalgia paresthetica reported a statistically significant difference in the first phase of a crossover study favoring capsaicin over placebo in a visual analogue scale for itch intensity but failed to report data for a second outcome measure. The final study on brachioradial pruritus used an inappropriate design and reported no significant reduction in itch between capsaicin and placebo. CONCLUSION: At present, there is no convincing evidence for the use of capsaicin to treat pruritus in any medical condition. Further research is needed, and should attempt to address methodological issues identified through this review including unblinding and the suitability of crossover designs.

Mindfulness-based cognitive therapy: evaluating current evidence and informing future research.

Mindfulness-based cognitive therapy (MBCT) is a recently developed class-based program designed to prevent relapse or recurrence of major depression (Z. V. Segal, J. M. G. Williams, & J. Teasdale, 2002). Although research in this area is in its infancy, MBCT is generally discussed as a promising therapy in terms of clinical effectiveness. The aim of this review was to outline the evidence that contributes to this current viewpoint and to evaluate the strengths and weaknesses of this evidence to inform future research. By systematically searching 6 electronic databases and the reference lists of retrieved articles, the authors identified 4 relevant studies: 2 randomized clinical trials, 1 study based on a subset of 1 of these trials, and 1 nonrandomized trial. The authors evaluated these trials and discussed methodological issues in the context of future research. The current evidence from the randomized trials suggests that, for patients with 3 or more previous depressive episodes, MBCT has an additive benefit to usual care. However, because of the nature of the control groups, these findings cannot be attributed to MBCT-specific effects. Further research is necessary to clarify whether MBCT does have any specific effects.

An investigation of the contents of complementary and alternative medicine journals.

CONTEXT: Previous research suggests that complementary and alternative medicine (CAM) journals publish few clinical trials, systematic reviews, and meta-analyses and a high proportion of positive articles. OBJECTIVE: This study describes the content of major CAM journals in 2005 and compares key findings with secondary data from previous years. DESIGN: PubMed-indexed CAM journals publishing in 2005 were identified using the search term "(alternative OR complementary) AND medicine." Review journals were excluded. All 2005 issues of the included journals were obtained and articles read. Articles were coded according to predefined criteria regarding the type of publication, area of CAM, and whether the outcome was positive, negative, or open. For comparison purposes, secondary data from 1995 and 2000 were obtained from previous research. RESULTS: Six journals publishing in 2005 (363 articles) were coded. Two datasets were produced, one excluding and one including recently established journals (2005a and 2005b, respectively). Proportionally fewer articles were clinical trials in 2005 (2005a=22.1%; 2005b=18.5%) than in 2000 (22.7%) and 1995 (27.7%). More than 50% of the 2005 articles were positive (2005a=51.1%; 2005b=50.7%), compared with 55.9% in 1995 and 43.5% in 2000. CONCLUSIONS: There is an apparent shift away from effectiveness research in CAM journals. This requires further investigation, and comparisons with other journals are needed. The large proportion of positive articles published in CAM journals appears to not adequately reflect the best available effectiveness evidence. This has implications for those using CAM journals as their main source of information in this area.

A family study of co-morbidity between generalized social phobia and generalized anxiety disorder in a non-clinic sample.

BACKGROUND: High rates of co-morbidity between Generalized Social Phobia (GSP) and Generalized Anxiety Disorder (GAD) have been documented. The reason for this is unclear. Family studies are one means of clarifying the nature of co-morbidity between two disorders. METHODS: Six models of co-morbidity between GSP and GAD were investigated in a family aggregation study of 403 first-degree relatives of non-clinical probands: 37 with GSP, 22 with GAD, 15 with co-morbid GSP/GAD, and 41 controls with no history of GSP or GAD. Psychiatric data were collected for probands and relatives. Mixed methods (direct and family history interviews) were utilised. RESULTS: Primary contrasts (against controls) found an increased rate of pure GSP in the relatives of both GSP probands and co-morbid GSP/GAD probands, and found relatives of co-morbid GSP/GAD probands to have an increased rate of both pure GAD and co-morbid GSP/GAD. Secondary contrasts found (i) increased GSP in the relatives of GSP only probands compared to the relatives of GAD only probands; and (ii) increased GAD in the relatives of co-morbid GSP/GAD probands compared to the relatives of GSP only probands. LIMITATIONS: The study did not directly interview all relatives, although the reliability of family history data was assessed. The study was based on an all-female proband sample. The implications of both these limitations are discussed. CONCLUSIONS: The results were most consistent with a co-morbidity model indicating independent familial transmission of GSP and GAD. This has clinical implications for the treatment of patients with both disorders.

Impact of psychiatric disturbance on identifying psychiatric disorder in relatives: study of mothers and daughters.

Previous studies have suggested that collecting psychiatric data on relatives in family studies by asking probands to provide information on them leads to a bias in estimates of morbidity risk, because probands'accounts are influenced by their own psychiatric histories. We investigated this in a UK sample and found that daughters'anxiety disorder histories did not influence their reports of anxiety disorder in mothers, but their history of mood disorder/alcohol dependence made them more sensitive in predicting mood disorder/alcohol dependence in mothers.