Structure and photochemistry of di-tert-butyldiphosphatetrahedrane

Di-tert-butyldiphosphatetrahedrane (tBuCP)2 (1) is a mixed carbon- and phosphorus-based tetrahedral molecule, isolobal to white phosphorus (P4). However, despite the fundamental significance and well-explored reactivity of the latter molecule, the precise structure of the free (tBuCP)2 molecule (1) and a detailed analysis of its electronic properties have remained elusive. Here, single-crystal X-ray structure determination of 1 at low temperature confirms the tetrahedral structure. Furthermore, quantum chemical calculations confirm that 1 is isolobal to P4 and shows a strong largely isotropic diamagnetic response in the magnetic field and thus pronounced spherical aromaticity. A spectroscopic and computational study on the photochemical reactivity reveals that diphosphatetrahedrane 1 readily dimerises to the ladderane-type phosphaalkyne tetramer (tBuCP)4 (2) under irradiation with UV light. With sufficient thermal activation energy, the dimerisation proceeds also in the dark. In both cases, an isomerisation to a 1,2-diphosphacyclobutadiene 1' is the first step. This intermediate subsequently undergoes a [2 + 2] cycloaddition with a second 1,2-diphosphacyclobutadiene molecule to form 2. The 1,2-diphosphacyclobutadiene intermediate 1' can be trapped chemically by N-methylmaleimide as an alternative [2 + 2] cycloaddition partner.

Current-Density Calculations on Zn-Porphyrin40 Nanorings

Two porphyrinoid nanorings have been studied computationally. They were built by linking 40 Zn-porphyrin units with butadiyne bridges. The molecular structures belonging to the D40h point group were fully optimized with the Turbomole program at the density functional theory (DFT) level using the B3LYP functional and the def2-SVP basis sets. The aromatic character was studied at the DFT level by calculating the magnetically induced current-density (MICD) susceptibility using the GIMIC program. The neutral molecules are globally non-aromatic with aromatic Zn-porphyrin units. Charged nanorings could not be studied because almost degenerate frontier orbitals led to vanishing optical gaps for the cations. Since DFT calculations of the MICD are computationally expensive, we also calculated the MICD using three pseudo-π models. Appropriate pseudo-π models were constructed by removing the outer hydrogen atoms and replacing all carbon and nitrogen atoms with hydrogen atoms. The central Zn atom was either replaced with a beryllium atom or with two inner hydrogen atoms. Calculations with the computationally inexpensive pseudo-π models yielded qualitatively the same magnetic response as obtained in the all-electron calculations.

Recommendations for patient involvement in health technology assessment in Central and Eastern European countries

Introduction

Meaningful patient involvement in health technology assessment (HTA) is essential in ensuring that the interests of the affected patient population, their families, and the general public are accurately reflected in coverage and reimbursement decisions. Central and Eastern European (CEE) countries are generally at less advanced stages of implementing HTA, which is particularly true for patient involvement activities. As part of the Horizon2020 HTx project, this research aimed to form recommendations for critical barriers to patient involvement in HTA in CEE countries.

Methods

Built on previous research findings on potential barriers, a prioritisation survey was conducted online with CEE stakeholders. Recommendations for prioritised barriers were formed through a face-to-face workshop by CEE stakeholders and HTx experts.

Results

A total of 105 stakeholders from 13 CEE countries completed the prioritisation survey and identified 12 of the 22 potential barriers as highly important. The workshop had 36 participants representing 9 CEE countries, and 5 Western European countries coming together to discuss solutions in order to form recommendations based on best practices, real-life experience, and transferability aspects. Stakeholder groups involved in both phases included HTA organisation representatives, payers, patients, caregivers, patient organisation representatives, patient experts, health care providers, academic and non-academic researchers, health care consultants and health technology manufacturers/providers. As a result, 12 recommendations were formed specified to the CEE region's context, but potentially useful for a broader geographic audience.

Conclusion

In this paper, we present 12 recommendations for meaningful, systematic, and sustainable patient involvement in HTA in CEE countries. Our hope is that engaging more than a hundred CEE stakeholders in the study helped to spread awareness of the importance and potential of patient involvement and that the resulting recommendations provide tangible steps for the way forward. Future studies shall focus on country-specific case studies of the implemented recommendations.

Current-density pathways in figure-eight-shaped octaphyrins

We have calculated the current density induced by an external magnetic field in a set of figure-eight-shaped expanded porphyrinoids. The studied octaphyrins can be divided into three classes (N2, N4, and N6) based on the number of the inner hydrogen atoms of the pyrrole rings. Using the Runge-Kutta method, the current density is split into diatropic and paratropic contributions that are analyzed separately. The calculations show that one common ring current consists of two rather independent pathways. Each of them follows the outer side of the molecular frame of one half of the molecule and passes to the inner side of the frame on the other half. The ring-current pathways are similar to the ones for [12]infinitene. However, the current density of the octaphyrins is more complex having many branching points and pathways. Vertical through-space current-density pathways pass in the middle of the molecules through a plane that is parallel to the figure-eight-shaped view of the molecules when the magnetic field is perpendicular to the plane. The isolectronic N2 and the N4 dication sustain a weak paratropic ring current inside the molecule, which is also observed in the ¹H NMR magnetic shielding constant of the inner hydrogen atoms. The diatropic current-density contribution dominates in the studied molecules. For the N4 and N6 molecules, the global current-density pathways are only diatropic and N6 sustains the strongest global diatropic current-density flux of 13.2 nA T^-1.

Guidance on using real-world evidence from Western Europe in Central and Eastern European health policy decision making

Aim: Real-world data and real-world evidence (RWE) are becoming more important for healthcare decision making and health technology assessment. We aimed to propose solutions to overcome barriers preventing Central and Eastern European (CEE) countries from using RWE generated in Western Europe. Materials & methods: To achieve this, following a scoping review and a webinar, the most important barriers were selected through a survey. A workshop was held with CEE experts to discuss proposed solutions. Results: Based on survey results, we selected the nine most important barriers. Multiple solutions were proposed, for example, the need for a European consensus, and building trust in using RWE. Conclusion: Through collaboration with regional stakeholders, we proposed a list of solutions to overcome barriers on transferring RWE from Western Europe to CEE countries.

Treatment patterns, adherence to international guidelines, and financial mechanisms of the market access of advanced breast cancer therapy in Bulgaria

Introduction

Breast cancer is the most common type of cancer affecting women in Europe. Advanced breast cancer (ABC) poses a significant therapeutic challenge, and therefore, timely access to treatment is crucial. The aim of the present study was to evaluate the treatment patterns and patients' access to new therapies for ABC in Bulgaria.

Methods

We conducted a retrospective study in the period 2008-2021. Based on the European Medicines Agency (EMA) database, we analyzed a number of medicinal products with marketing authorization for ABC in the last 13 years. Time to market access was evaluated as the degree of availability, which is measured by the number of medicines that are available to patients (availability index, AI), and the average time elapsed between obtaining a marketing authorization and time to inclusion in the Positive Drug List. Data were analyzed through descriptive statistics via Microsoft Excel version 10.

Results

The average time to access was 564 days for targeted therapy. The availability and compliance index for chemotherapy and hormonal therapy in advanced breast cancer was 1, while the average AI for targeted therapy was 0.67. Patient access to targeted oncology therapy of ABC is above average for Europe and takes 1-2 years.

Conclusion

Faster access is more evident for biosimilars. National regulatory requirements for pricing and reimbursement have a major impact on market access.

Budget cap and pay-back model to control spending on medicines: A case study of Bulgaria

Central and Eastern European countries (CEEC) have among the highest rates of increase in healthcare expenditure. External reference pricing, generics and biologics price capping, regressive scale for price setting, health technology assessment (HTA), and positive drug lists for reimbursed medicines are among the variety of implemented cost-containment measures aimed at reducing and controlling the rising cost for pharmaceuticals. The aim of our study was to analyze the influence of a recently introduced measure in Bulgaria-budget capping in terms of overall budget expenditure. A secondary goal was to analyze current and extrapolate future trends in the healthcare and pharmaceutical budget based on data from 2016 to 2021. The study is a retrospective, observational and prognostic, macroeconomic analysis of the National Health Insurance Fund's (NHIF) budget before (2016-2018) and after (2019-2021) the introduction of the new budget cap model. Subgroups analysis for each of the three new budget groups of medicines (group A: medicines for outpatient treatment, prescribed after approval by a committee of 3 specialists; group B: all other medicines out of group A; and group C: oncology and life-saving medicines out of group A) was also performed, and the data were extrapolated for the next 3 years. The Kruskal-Wallis test was applied to establish statistically significant differences between the groups. During 2016-2021, healthcare services and pharmaceutical spending increased permanently, observing a growth of 82 and 80%, respectively. The overall healthcare budget increased from European €1.8 billion to 3.3 billion. The subgroup analysis showed a similar trend for all three groups, with similar growth between them. The highest spending was observed in group C, which outpaced the others mainly due to the particular antineoplastic (chemotherapy) medicines included in it. The rising overall healthcare cost in Bulgaria (from European €1.8 billion to 3.3 billion) reveals that implementation of a mechanism for budget predictability and sustainability is needed. The introduced budget cap is a relatively effective measure, but the high level of overspending and pay-back amount (from European €34 billion to 59 billion during 2019-2021) reveals that the market environmental risk factors are not well foreseen and practically implemented.

Magnetically Induced Current Densities in π-Conjugated Porphyrin Nanoballs

Magnetically induced current densities (MICDs) of Zn-porphyrinoid nanostructures have been studied at the density functional theory level using the B3LYP functional and the def2-SVP basis set. Six of the studied Zn-porphyrinoid nanostructures consist of two crossing porphyrinoid belts, and one is a porphyrinoid nanoball belonging to the octahedral (O) point group. The Zn-porphyrin units are connected to each other via butadiyne linkers as in a recently synthesized porphyrinoid structure resembling two crossed belts. The MICDs are calculated using the gauge-including magnetically induced current method. Current-density pathways and their strengths were determined by numerically integrating the MICD passing through selected planes that cross chemical bonds or molecular rings. The current-density calculations show that the studied neutral molecules are globally nonaromatic but locally aromatic sustaining ring currents only in the individual porphyrin rings or around two neighboring porphyrins. The ring-current strengths of the individual porphyrin rings are 20% weaker than in Zn-porphyrin, whereas oxidation leads to globally aromatic cations sustaining ring currents that are somewhat stronger than for Zn-porphyrin.

A natural scheme for the quantitative analysis of the magnetically induced molecular current density using an oriented flux-weighted stagnation graph. I. A minimal example for LiH

A new natural scheme is introduced to analyze quantitatively the magnetically induced molecular current density vector field, J. The set of zero points of J, which is called its stagnation graph (SG), has been previously used to study the topological features of the current density of various molecules. Here, the line integrals of the induced magnetic field along edges of the connected subset of the SG are calculated. The edges are oriented such that all weights, i.e., flux values become non-negative, thereby, an oriented flux-weighted (current density) stagnation graph (OFW-SG) is obtained. Since in the exact theoretical limit, J is divergence-free and due to the topological characteristics of such vector fields, the flux of all separate vortices (current density domains) and neighbouring connected vortices can be determined exactly by adding the weights of cyclic subsets of edges (i.e., closed loops) of the OFW-SG. The procedure is exemplified by the minimal example of LiH for a weak homogeneous external magnetic field, B, perpendicular to the chemical bond. The OFW-SG exhibits one closed loop (formally decomposed into two edges), and an open line extending to infinity on both of its ends. The method provides the means of accurately determining the strength of the current density even in molecules with a complicated set of distinct vortices.

Using real-world evidence in healthcare from Western to Central and Eastern Europe: a review of existing barriers

As part of the HTx (Next Generation Health Technology Assessment) project, this study was aimed at identifying the main barriers for application of real-world evidence (RWE) for the purposes of health technology assessment in the Central and Eastern European countries. A mixed methods approach was employed to identify the main barriers: a scoping review of the literature and a series of discussions with stakeholders. Based on the applied approaches, we attempted to summarize the main barriers and challenges related to transferability of RWE in five main groups: technical, regulatory, clinical, scientific and perceptional barriers. Further research should pursue the development of detailed, consensus-based guidelines to improve the harmonization and standardization of RWE.

Potential Barriers of Patient Involvement in Health Technology Assessment in Central and Eastern European Countries

Patients' perspectives are important to identify preferences, estimate values and appreciate unmet medical needs in the process of research and development and subsequent assessment of new health technologies. Patient and public involvement in health technology assessment (HTA) is essential in understanding and assessing wider implications of coverage and reimbursement decisions for patients, their relatives, caregivers, and the general population. There are two approaches to incorporating the patients' voice in HTA, preferably used in a mix. In the first one, patients, caregivers and/or their representatives directly participate at discussions in different stages of the HTA process, often at the same table with other stakeholders. Secondly, patient involvement activities can be supported by evidence on patient value and experience collected directly from patients, caregivers and/or their representatives often by patient groups Patient involvement practices, however, are limited in Central and Eastern European (CEE) countries without clear methodology or regulatory mechanisms to guide patient involvement in the HTA process. This poses the question of transferability of practices used in other countries, and might call for the development of new CEE-specific guidelines and methods. In this study we aim to map potential barriers of patient involvement in HTA in countries of the CEE region.

Barriers to Use Artificial Intelligence Methodologies in Health Technology Assessment in Central and East European Countries

The aim of this paper is to identify the barriers that are specifically relevant to the use of Artificial Intelligence (AI)-based evidence in Central and Eastern European (CEE) Health Technology Assessment (HTA) systems. The study relied on two main parallel sources to identify barriers to use AI methodologies in HTA in CEE, including a scoping literature review and iterative focus group meetings with HTx team members. Most of the other selected articles discussed AI from a clinical perspective (n = 25), and the rest are from regulatory perspective (n = 13), and transfer of knowledge point of view (n = 3). Clinical areas studied are quite diverse—from pediatric, diabetes, diagnostic radiology, gynecology, oncology, surgery, psychiatry, cardiology, infection diseases, and oncology. Out of all 38 articles, 25 (66%) describe the AI method and the rest are more focused on the utilization barriers of different health care services and programs. The potential barriers could be classified as data related, methodological, technological, regulatory and policy related, and human factor related. Some of the barriers are quite similar, especially concerning the technologies. Studies focusing on the AI usage for HTA decision making are scarce. AI and augmented decision making tools are a novel science, and we are in the process of adapting it to existing needs. HTA as a process requires multiple steps, multiple evaluations which rely on heterogenous data. Therefore, the observed range of barriers come as a no surprise, and experts in the field need to give their opinion on the most important barriers in order to develop recommendations to overcome them and to disseminate the practical application of these tools.

Diagnosing Ring Current(s) in Figure-Eight Skeletons: A 3D Through-Space Conjugation in the Two-Loops Crossing

The macrocyclic structures with local conjugation readily undergo a redox-triggered change in the diatropic character, leading to a global current–density pathway of the doubly charged systems. The figure-eight geometry of the neutral dimer does not significantly change upon oxidation according to the spectroscopic and computational data. The oxidation leads to 3D cross-conjugation at the intersection of the two ethylene bridges resulting in a global ring current.

Pharmacists‘ attitudes to dispensing food supplements to chronically ill patients: a pilot survey among community pharmacies in Bulgaria

Background: Within the last years, excessive utilization of food supplements for prevention and prophylaxis in different chronic diseases is observed. In order to extend the control on the arrangement of the market, utilization, and safety of food supplements, the European Commission took genuine regulatory steps to harmonize the criteria for FS and to guarantee that they are not giving deceiving information. However, excessive use, uncontrolled patients consumption, exposure to higher than recommended intakes, and even interaction with specific medicines can cause toxicity risks and pose serious health concerns. The aim of this study is to examine the tendency of pharmacists to correctly recommend food supplements to chronically ill patients in order to extend the pharmaceutical care and prevent side effects.

Materials and methods: The used method is an anonymous survey that was conducted by using the direct questionnaire method among master pharmacists and assistant pharmacists working in community pharmacies in Bulgaria.

Results: The results show that the majority of the pharmacists are willing to recommend food supplements and that they could participate in the monitoring of chronically ill patients with food supplements intake. On the other side, the survey shows that most of the patients are seeking for food supplements and do ask for advice.

Conclusion: In conclusion, pharmacists as the most accessible health care professionals can provide more detailed information concerning food supplements in order to avoid negative effects on the safety of chronically ill patients, especially with additional training in the field.

Magnetically Induced Current Densities in Zinc Porphyrin Nanoshells

The molecular structures of porphyrinoid cages were obtained by constructing small polyhedral graphs whose vertices have degree-4. The initial structures were then fully optimized at the density functional theory (DFT) level using the generalized gradient approximation. Some of polyhedral vertices were replaced with Zn–porphyrin units and their edges were replaced with ethyne or butadiyne bridges or connected by fusing two neighboring Zn–porphyrin units. Molecule 1 is an ethyne-bridge porphyrinoid nanotube, whose ends are sealed with a Zn–porphyrin. Molecule 2 is the corresponding open porphyrinoid nanotube. Molecule 3 is a clam-like porphyrinoid cage, whose shells consist of fused Zn–porphyrins, and the two halves are connected via butadiyne bridges. Molecule 4 is a cross-belt of fused Zn–porphyrins, and molecule 5 is a cross-belt of Zn–porphyrins connected with butadiyne bridges. The magnetically induced current density of the optimized porphyrinoid cages was calculated for determining the aromatic character, the degree of aromaticity and the current-density pathways. The current-density calculations were performed at the DFT level with the gauge—including magnetically induced currents (GIMIC) method using the B3LYP hybrid functional and def2-SVP basis sets. Calculations of the current densities show that molecule 2 sustains a paratropic ring current around the nanotube, whereas sealing the ends as in molecule 1 leads to an almost nonaromatic nanotube. Fusing porphyrinoids as in molecules 3 and 4 results in complicated current-density pathways that differ from the ones usually appearing in porphyrinoids. The aromatic character of molecules 4 and 5 changes upon oxidation. The neutral molecule 4 is antiaromatic, whereas the dication is nonaromatic. Molecule 5 is nonaromatic, and its dication is aromatic.

A rare case of aseptic herpes simplex virus-1 meningitis in a patient with recent COVID-19

The aim of presenting this case was to show the difficulties in making the differential diagnosis of viral meningitis during the COVID pandemic situation.

We report a case of a young man with clinical features of viral meningitis and with epidemiological history of COVID-19 in his family. The patient complained of fever, headache, photophobia, nausea, myalgia, and fatigue. He gave a history of diarrhea and vomiting two weeks before admission and close relatives with COVID-19. The neurological examination revealed a meningeal irritation syndrome. The diagnostic tests we performed were as follows: nasopharyngeal swab and PCR of cerebrospinal fluid (CSF) for SARS CoV-2, computed tomography scan of the head, general CSF examination, viral tests, and microbiology of CSF, enzyme-linked immunosorbent assay (ELISA) IgM and IgG.

The results were consistent with viral meningitis due to HSV-1 in simultaneously found high titres of plasma SARS CoV-2 specific IgA and SARS CoV-2 specific IgG and active viral serum infection for CMV and EBV.

Correlation between cognitive abilities and social functioning in patients with multiple sclerosis

Introduction: Cognitive impairment has been found in all stages and subtypes of multiple sclerosis (MS). It has a broad negative impact on the lives of people with MS independent of physical symptoms. Perhaps the most severe and far-reaching effect is unemployment, which results in extensive personal, social, and financial costs. Cognition has been linked to unemployment in many countries and shown to mediate the effects of disability on employment status.

Aim: The primary aim of this study was to assess social functioning in the context of activities of daily living and employment in patients with MS and to find a correlation between them and cognitive performance in these patients. The secondary aim was to find an association between employment and factors such as demography, emotional factors, and disease progression. 

Materials and methods: The research included a study group of 100 patients with MS meeting the defined exclusion and inclusion criteria, and a control group of 40 healthy subjects. Disability was assessed with the Expanded Disability Status Scale (EDSS). The employment status was appraised in interviews with the subjects. The patients were divided into two groups: employed (working on a full-time or part-time job) and unemployed (not-working). The study aimed to assess the cognitive performance of all subjects. We examined cognitive domains such as short-term memory, psychomotor speed, and executive functions with a battery of neuropsychological tests.

Results: We found a connection between performance on neuropsychological tests and employment and engagement in activities of daily living. Another main conclusion of our study is that unemployed are older patients with longer duration of disease. They have excessive fatigue and unsatisfied results and impairment of memory functions. As to the reasons we found in our study for losing a job, some identified factors are the presence of excessive fatigue (44%), movement disorders (41%), cognitive impairment (30%), pain (15%), dizziness (15%), dexterity (11%), emotional disorders, bowel and bladder disorders (7%), visual deficit (7%), and heat sensitivity (4%).

Conclusions: Unemployed patients have severe depressive symptoms.

Analysis of Healthcare Expenditures in Bulgaria

The growth of public expenditure worldwide has set the priority on assessment of trends and establishment of factors which generate the most significant public costs. The goal of the current study is to review the tendencies in public healthcare expenditures in Bulgaria and to analyze the influence of the demographic, economic, and healthcare system capacity indicators on expenditures dynamics. A retrospective, top-down, financial analysis of the healthcare system expenditures was performed. Datasets of the National Statistical Institute (NSI), National Health Insurance Fund (NHIF), and National Center of Public Health and Analysis (NCPHA) were retrospectively reviewed from2014–2019 to collect the information in absolute units of healthcare expenditures, healthcare system performance, demographics, and economic indicators. The research showed that increasing GDP led to higher healthcare costs, and it was the main factor affecting the cost growth in Bulgaria. The number of hospitalized patients and citizens in retirement age remained constant, confirming that their impact on healthcare costs was negligible. In conclusion, the population aging, average life expectancy, patient morbidity, and hospitalization rate altogether impacted healthcare costs mainly due to the multimorbidity of older people and the rising need for outpatient hospital services and medications.

Magnetically induced ring currents in metallocenothiaporphyrins

The magnetically induced current-density susceptibility tensor (CDT) of the lowest singlet and triplet states of the metallocenothiaporphyrins, where the metal is V, Cr, Mn, Fe, Co, Ni, Mo, Tc, Ru, or Rh, have been studied with the gauge-including magnetically induced currents (GIMIC) method. The compounds containing V, Mn, Co, Tc or Rh were studied as cations because the neutral molecules have an odd number of electrons. The calculations show that the aromatic nature of most of the studied molecules follows the Hückel and Baird rules of aromaticity. CDT calculations on the high-spin states of the neutral metallocenothiaporphyrins with V, Mn, Co, Tc or Rh also shows that these molecules follow a unified extended Hückel and Baird aromaticity orbital-count rule stating that molecules with an odd number of occupied conjugated valence orbitals are aromatic, whereas molecules with an even number of occupied conjugated orbitals are antiaromatic.

Integration of global ring currents using the Ampère-Maxwell law

Magnetically induced ring currents are calculated from the magnetic shielding tensor by employing the Ampère-Maxwell law. The feasibility of the method is demonstrated by integrating the zz component of the shielding tensor along the symmetry axis of highly symmetric ring-shaped aromatic, antiaromatic and nonaromatic molecules. The calculated ring-current strengths agree perfectly with the ones obtained by integrating the current-density flux passing through a plane cutting half the molecular ring. The method can be used in combination with all electronic structure codes capable of calculating nuclear magnetic resonance (NMR) shielding tensors in general points in space. We also show that nucleus independent chemical shifts (NICS) along the symmetry axis are related to the spatial derivative of the strength of the global ring-current along the z axis.

Current density and molecular magnetic properties

We give an overview of the molecular response to an external magnetic field perturbing quantum mechanical systems. We present state-of-the-art methods for calculating magnetically-induced current-density susceptibilities. We discuss the essence and properties of current-density susceptibilities and how molecular magnetic properties can be calculated from them. We also review the theory of spin-current densities, how relativity affects current densities and magnetic properties. An overview of the magnetic ring-current criterion for aromaticity is given, which has implications on theoretical and experimental research. The recently reported theory of antiaromaticity and how molecular symmetry affects the magnetic response are discussed and applied to closed-shell paramagnetic molecules. The topology of magnetically induced current densities and its consequences for molecular magnetic properties are also presented with twisted and toroidal molecules as examples.

Tripeptidyl peptidase I activity in porcine lumbar spinal ganglia - a histochemical study

Distribution of tripeptidyl peptidase I (TPPI) activity in the structures of porcine lumbar spinal ganglia (LSG) was studied by enzyme histochemistry on cryostat sections from all the ganglia using the substrate glycyl-L-prolyl-L-methionyl-5-chloro-1-anthraquinonyl hydrazide (GPM-CAH) and 4-nitrobenzaldehyde (NBA) as visualization factor. Light microscopic observations showed TPPI activity in almost all the LSG structures. The enzyme reaction in different cell types was compared semi-quantitatively. Strong reaction was observed in the small neurons, satellite ganglia cells and some nerve fibers. Weak reactivity was found in the large sensory somatic neurons, whereas moderate reaction for TPPI was determined in the middle sensory somatic neurons and some nerve fibers. Statistical analysis by one-way ANOVA showed no significance of difference (when p⟨0.05) for the number of TPPI positive neurons per mm2. The original data obtained by the enzyme histochemistry method give us a reason to presume that TPPI actively participates in the functions of all the neuronal structures in porcine LSG. According to our results, it could be suggested that TPPI activity is important for the functions of autonomic and somatic sensory neurons.

Pricing and Reimbursement of Patent-Protected Medicines: Challenges and Lessons from South-Eastern Europe

BACKGROUND

Efficiency and transparency of pricing and reimbursement (P&R) rules and procedures as well as their implementation in South-eastern Europe (SEE) lag substantially behind Western European practice. Nevertheless, P&R systems in SEE are rarely critically assessed, warranting a detailed and wider-encompassing exploration.

OBJECTIVE

Our study provides a comparative assessment of P&R processes for patent-protected medicines in ten SEE countries-EU member states: Croatia, Slovenia, Hungary, Romania and Bulgaria; and non-EU countries: Albania, Montenegro, Serbia, North Maceodina, Bosnia and Herzegovina. P&R systems are compared and evaluated through a research framework that focuses on: (1) public financing of patent-protected medicines, (2) definition of benefit packages, (3) requirements for the submission of reimbursement dossiers, (4) assessment and appraisal processes, (5) reimbursement decision making, (6) processes that occur post reimbursement, and (7) pricing. The study aims to contribute to the discussion on improving the efficiency and quality of P&R of patent-protected medicines in the region.

METHODS

We conducted a non-systematic literature review of published literature, as well as policy briefs and reports on healthcare systems in the SEE region along with legal documents framing the P&R procedures in local languages. The information gathered from these various sources was then discussed and clarified through structured telephone interviews with relevant national experts from each SEE country, mainly current and former senior officials and/or executives of the funding and assessment/ appraisal bodies (total of 20 interviews conducted in late 2019).

RESULTS

Capacity building through sharing knowledge and information on successful reforms across borders is an opportunity for SEE countries to further develop their P&R policies and increase (equitable) access to patent-protected medicines (especially expensive medicines), increasing affordability and containing costs. Simple yet robust and systematic decision-making frameworks that rely on international health technology assessment (HTA) procedures and are based on the pursuit of transparency seem to be the most cost-effective approach to strengthening P&R systems in SEE.

CONCLUSIONS

Further reforms aiming to develop transparent and robust national decision-making frameworks (including oversight) and build institutional HTA-related and decision-making capacity are awaited in most of SEE countries, especially the non-EU members. In non-EU SEE countries, these efforts could increase access to patent-protected medicines, which is-at the moment-very limited. The EU-member SEE countries operate more developed P&R systems but could further benefit from developing their procedures, oversight and value-for-money assessment toolbox and capacity, hence further improving the transparency and efficiency of procedures that regulate access to patent-protected medicines.

Basic versus biofeedback-mediated intensive pelvic floor muscle training for women with urinary incontinence: the OPAL RCT

BACKGROUND

Urinary incontinence affects one in three women worldwide. Pelvic floor muscle training is an effective treatment. Electromyography biofeedback (providing visual or auditory feedback of internal muscle movement) is an adjunct that may improve outcomes.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of biofeedback-mediated intensive pelvic floor muscle training (biofeedback pelvic floor muscle training) compared with basic pelvic floor muscle training for treating female stress urinary incontinence or mixed urinary incontinence.

DESIGN

A multicentre, parallel-group randomised controlled trial of the clinical effectiveness and cost-effectiveness of biofeedback pelvic floor muscle training compared with basic pelvic floor muscle training, with a mixed-methods process evaluation and a longitudinal qualitative case study. Group allocation was by web-based application, with minimisation by urinary incontinence type, centre, age and baseline urinary incontinence severity. Participants, therapy providers and researchers were not blinded to group allocation. Six-month pelvic floor muscle assessments were conducted by a blinded assessor.

SETTING

This trial was set in UK community and outpatient care settings.

PARTICIPANTS

Women aged ≥ 18 years, with new stress urinary incontinence or mixed urinary incontinence. The following women were excluded: those with urgency urinary incontinence alone, those who had received formal instruction in pelvic floor muscle training in the previous year, those unable to contract their pelvic floor muscles, those pregnant or < 6 months postnatal, those with prolapse greater than stage II, those currently having treatment for pelvic cancer, those with cognitive impairment affecting capacity to give informed consent, those with neurological disease, those with a known nickel allergy or sensitivity and those currently participating in other research relating to their urinary incontinence.

INTERVENTIONS

Both groups were offered six appointments over 16 weeks to receive biofeedback pelvic floor muscle training or basic pelvic floor muscle training. Home biofeedback units were provided to the biofeedback pelvic floor muscle training group. Behaviour change techniques were built in to both interventions.

MAIN OUTCOME MEASURES

The primary outcome was urinary incontinence severity at 24 months (measured using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score, range 0-21, with a higher score indicating greater severity). The secondary outcomes were urinary incontinence cure/improvement, other urinary and pelvic floor symptoms, urinary incontinence-specific quality of life, self-efficacy for pelvic floor muscle training, global impression of improvement in urinary incontinence, adherence to the exercise, uptake of other urinary incontinence treatment and pelvic floor muscle function. The primary health economic outcome was incremental cost per quality-adjusted-life-year gained at 24 months.

RESULTS

A total of 300 participants were randomised per group. The primary analysis included 225 and 235 participants (biofeedback and basic pelvic floor muscle training, respectively). The mean 24-month International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score was 8.2 (standard deviation 5.1) for biofeedback pelvic floor muscle training and 8.5 (standard deviation 4.9) for basic pelvic floor muscle training (adjusted mean difference -0.09, 95% confidence interval -0.92 to 0.75; p = 0.84). A total of 48 participants had a non-serious adverse event (34 in the biofeedback pelvic floor muscle training group and 14 in the basic pelvic floor muscle training group), of whom 23 (21 in the biofeedback pelvic floor muscle training group and 2 in the basic pelvic floor muscle training group) had an event related/possibly related to the interventions. In addition, there were eight serious adverse events (six in the biofeedback pelvic floor muscle training group and two in the basic pelvic floor muscle training group), all unrelated to the interventions. At 24 months, biofeedback pelvic floor muscle training was not significantly more expensive than basic pelvic floor muscle training, but neither was it associated with significantly more quality-adjusted life-years. The probability that biofeedback pelvic floor muscle training would be cost-effective was 48% at a £20,000 willingness to pay for a quality-adjusted life-year threshold. The process evaluation confirmed that the biofeedback pelvic floor muscle training group received an intensified intervention and both groups received basic pelvic floor muscle training core components. Women were positive about both interventions, adherence to both interventions was similar and both interventions were facilitated by desire to improve their urinary incontinence and hindered by lack of time.

LIMITATIONS

Women unable to contract their muscles were excluded, as biofeedback is recommended for these women.

CONCLUSIONS

There was no evidence of a difference between biofeedback pelvic floor muscle training and basic pelvic floor muscle training.

FUTURE WORK

Research should investigate other ways to intensify pelvic floor muscle training to improve continence outcomes.

TRIAL REGISTRATION

Current Controlled Trial ISRCTN57746448.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 70. See the NIHR Journals Library website for further project information.

Outpatient parenteral antimicrobial therapy (OPAT) versus inpatient care in the UK: a health economic assessment for six key diagnoses

OBJECTIVES

To compare costs associated with different models of outpatient parenteral antimicrobial therapy (OPAT) delivery with costs of inpatient (IP) care across key infection groups managed via OPAT in the UK.

DESIGN

A cost-minimisation design was used due to evidence of similarities in patient and treatment outcomes between OPAT and IP care. A bottom-up approach was undertaken for the evaluation of OPAT associated costs. The British Society of Antimicrobial Chemotherapy National Outcomes Registry System was used to determine key infection diagnoses, mean duration of treatment and most frequent antibiotics used.

SETTING

Several OPAT delivery settings were considered and compared with IP care.

INTERVENTIONS

OPAT models considered were OP clinic model, nurse home visits, self (or carer)-administration by a bolus intravenous, self-administration by a commercially prefilled elastomeric device, continuous intravenous infusion of piperacillin with tazobactam or flucloxacillin with elastomeric device as OP once daily and, specifically for bone and joint and diabetic foot infections, complex outpatient oral antibiotic therapies.

RESULTS

Base case and a range of scenario results showed all evaluated OPAT service delivery models to be less costly than IP stay of equivalent duration. The extent of savings varied by OPAT healthcare delivery models. Estimated OPAT costs as a proportion of IP costs were estimated at 0.23-0.53 (skin and soft-tissue infections), 0.34-0.46 (complex urinary tract infections), 0.23-0.51 (orthopaedic infections), 0.24-0.42 (diabetic foot infections) 0.40-0.56 (exacerbations of bronchiectasis) and 0.25-0.42 (intra-abdominal infections). Partial or full complex oral antibiotic therapies in orthopaedic or diabetic foot infections costs were estimated to be 0.13-0.26 of IP costs. Main OPAT costs were associated with staff time and antimicrobial medications.

CONCLUSIONS

OPAT is a cost-effective use of National Health Service resources for the treatment of a range of infections in the UK in patients who can be safely managed in a non-IP setting.

Analysis of patients' access to reimbursed biotechnological medicines for multiple sclerosis in Bulgaria and Greece

OBJECTIVE

The goal is to perform a comparative analysis of multiple sclerosis patients' access to medicines in Bulgaria and Greece.

MATERIALS AND METHODS

A comparative analysis of pharmaceutical legislation of Bulgaria and Greece focusing on medicines for multiple sclerosis (MS) was performed. Patients' access to therapy is assessed through the guideline compliance index (GCI) and availability index.

RESULTS

The procedures for marketing authorization, pricing and reimbursement, and inclusion of medicines in the positive drug list (PDL) are identical in both European Union member states. Almost all MS medicines authorized for sale in the European Union are included in the Bulgarian and Greek PDL. In both PDLs are included medicines from different groups: immunostimulants, other immunostimulants, immunosuppressors, selective immunosuppressors, and other immunosuppressors. All medicines are fully paid by the health insurance funds in both countries. The average time for inclusion of medicines for MS in the PDL of Bulgaria after their marketing authorization is 3 years. The analysis of pharmacotherapeutic guidelines showed high GCI as it is higher for Bulgaria: 0.846 vs. 0.769 out of 1.

CONCLUSION

The existing legislative measures at the national level of Bulgaria and Greece ensure adequate and timely access of patients with MS to treatment.

COVID-19 pandemic impact on the pharmaceutical sector in Bulgaria

In December, 2019 in Wuhan, Hubei Province, China, a new, unknown strain of coronavirus called SARS-CoV-2 was identified. The virus has spread rapidly to other countries around the world, among which the most affected were Italy, Spain and the United States. As a result, in March 2020 The WHO has declared the new coronavirus epidemic a global pandemic. Despite timely measures and efforts to reduce morbidity, up to date, confirmed cases are 119,452,269, while the number of deaths reached 2,647,662 people. The COVID-19 pandemic has affected all areas of human life – health, social, economic. In each of them, a number of restrictions and obligations were imposed, including wearing of masks, use of disinfectants, education in an online environment, limited work in restaurants and shops. The health sector was particularly affected, and all actors in the pharmaceutical system had to reorganize and adapt their activities in the name of a common goal – ending the COVID-19 pandemic.

Nuclear export of plant pararetrovirus mRNAs involves the TREX complex, two viral proteins and the highly structured 5' leader region

In eukaryotes, the major nuclear export pathway for mature mRNAs uses the dimeric receptor TAP/p15, which is recruited to mRNAs via the multisubunit TREX complex, comprising the THO core and different export adaptors. Viruses that replicate in the nucleus adopt different strategies to hijack cellular export factors and achieve cytoplasmic translation of their mRNAs. No export receptors are known in plants, but Arabidopsis TREX resembles the mammalian complex, with a conserved hexameric THO core associated with ALY and UIEF proteins, as well as UAP56 and MOS11. The latter protein is an orthologue of mammalian CIP29. The nuclear export mechanism for viral mRNAs has not been described in plants. To understand this process, we investigated the export of mRNAs of the pararetrovirus CaMV in Arabidopsis and demonstrated that it is inhibited in plants deficient in ALY, MOS11 and/or TEX1. Deficiency for these factors renders plants partially resistant to CaMV infection. Two CaMV proteins, the coat protein P4 and reverse transcriptase P5, are important for nuclear export. P4 and P5 interact and co-localise in the nucleus with the cellular export factor MOS11. The highly structured 5′ leader region of 35S RNAs was identified as an export enhancing element that interacts with ALY1, ALY3 and MOS11 in vitro.

Early detection of neovascular age-related macular degeneration: an economic evaluation based on data from the EDNA study

BACKGROUND/AIMS

To evaluate the cost-effectiveness of non-invasive monitoring tests to detect the onset of neovascular age-related macular degeneration (nAMD) in the unaffected second eye of patients receiving treatment for unilateral nAMD in a UK National Health Service (NHS) hospital outpatient setting.

METHODS

A patient-level state transition model was constructed to simulate the onset, detection, and treatment of nAMD in the second eye. Five index tests were compared: self-reported change in visual function, Amsler test, clinic measured change in visual acuity from baseline, fundus assessment by clinical examination or colour photography, and spectral domain optical coherence tomography (SD-OCT). Diagnosis of nAMD was confirmed by fundus fluorescein angiography (FFA) before prompt initiation of antivascular endothelial growth factor treatment. Quality-adjusted life-years (QALYs) and costs of health and social care were modelled over a 25-year time horizon.

RESULTS

SD-OCT generated more QALYs (SD-OCT, 5.830; fundus assessment, 5.787; Amsler grid, 5.736, patient's subjective assessment, 5.630; and visual acuity, 5.600) and lower health and social care costs (SD-OCT, £19 406; fundus assessment, £19 649; Amsler grid, £19 751; patient's subjective assessment, £20 198 and visual acuity, £20 444) per patient compared with other individual monitoring tests. Probabilistic sensitivity analysis indicated a high probability (97%-99%) of SD-OCT being the preferred test across a range of cost-effectiveness thresholds (£13 000-£30 000) applied in the UK NHS.

CONCLUSIONS

Early treatment of the second eye following FFA confirmation of SD-OCT positive findings is expected to maintain better visual acuity and health-related quality of life and may reduce costs of health and social care over the lifetime of patients.

Pharmacotherapeutic Patterns and Patients' Access to Pharmacotherapy for Some Rare Diseases in Bulgaria - A Pilot Comparative Study

Provision of the latest innovative and advanced therapies for rare diseases (RDs) patients, following the international therapeutic recommendations, is crucial and necessary for both practitioners and patients. The goal is to assess the access of Bulgarian patients with the most cost-consuming RDs to medicines and to compare the pharmacotherapeutic patterns in Bulgaria and the relevant European professional associations. Pharmaco-therapeutic guidelines for treating the most cost-consuming RDs in Bulgaria were analyzed to assess their compliance with the European ones. Market entrance was evaluated through analysis of the availability of medicines in the Positive Drug List (PDL) and their date of inclusion since marketing authorization. Guidelines’ compliance index was calculated and patient access was analyzed through evaluation of the National Health Insurance Fund (NHIF) standards, which provide additional criteria for treatment initiation. The analyzed guidelines follow the adopted recommendations by the relevant European professional associations. NHIF have exclusion and inclusion criteria for initiating treatment with medicines for rare diseases and for continuation. The average time-lag between centralized procedure approval and inclusion in the Bulgarian PDL for orphan medicinal products (MPs) is 6.75 years (SD = 4.96) with the longest time observed for eptacog alfa (20 years) and the shortest for rurioctocog alfa pegol, octocog alfa and simoctocog alfa (1 year). Bulgarian patients with cystic fibrosis with pulmonary manifestation had a wait time of only 1.6 years to get access to innovative, centrally authorized medicines, whereas the period for access to acromegaly treatment was 8.2 years. The main factors influencing market entrance and patient access are the time to inclusion in the PDL and the NHIF criteria.

Magnetically Induced Ring-Current Strengths of Planar and Nonplanar Molecules: New Insights from the Pseudo-π Model

The pseudo-π model yields current densities and induced magnetic fields that mimic the π-component, allowing investigations of large molecular structures, whether they are planar or not, at a low computational cost but with high accuracy. Herein the π-contribution to the magnetically induced current densities and induced magnetic fields of large planar molecules and nonplanar molecules (such as [10]cyclophenacene and chiral toroidal nanotubes C₂₀₁₆ and C₂₁₉₆) were computed using the pseudo-π model with the gauge-including magnetically induced currents method. Additionally, we provide a way to determine the π-component of the ring-current strengths, which can be used for assessing the aromatic character of large carbon molecules.

Role of the EMA specific marketing authorization procedures for early access on the time to patient access in Bulgaria

Despite the early access procedures for marketing authorization (MA) valid throughout the European Union still in the most of the Member states patient access to innovative medicines depends on cost-effectiveness, budget impact assessment and negotiations for price discount with the public payers.

Retrospective analysis on the availability and time to market access of medicines authorized under the European medicines agency’s specific procedures for early access shows that despite the shortening of the time to market access after 2013, for most medicines still exceeds 365 days. This is due to the fact that requirements for pricing and reimbursement across EU is fixed to some degree and medicines with MA for early access are subject to the same legal requirements as the medicines with standard centralized marketing authorization. Some specific national legal requirements for pricing and reimbursement decisions, population of interest and manufactures intentions to enter certain markets should also be considered.

Benchmarking Magnetizabilities with Recent Density Functionals

We have assessed the accuracy of the magnetic properties of a set of 51 density functional approximations, including both recently published and already established functionals. The accuracy assessment considers a series of 27 small molecules and is based on comparing the predicted magnetizabilities to literature reference values calculated using coupled-cluster theory with full singles and doubles and perturbative triples [CCSD(T)] employing large basis sets. The most accurate magnetizabilities, defined as the smallest mean absolute error, are obtained with the BHandHLYP functional. Three of the six studied Berkeley functionals and the three range-separated Florida functionals also yield accurate magnetizabilities. Also, some older functionals like CAM-B3LYP, KT1, BHLYP (BHandH), B3LYP, and PBE0 perform rather well. In contrast, unsatisfactory performance is generally obtained with Minnesota functionals, which are therefore not recommended for calculations of magnetically induced current density susceptibilities and related magnetic properties such as magnetizabilities and nuclear magnetic shieldings. We also demonstrate that magnetizabilities can be calculated by numerical integration of magnetizability density; we have implemented this approach as a new feature in the gauge-including magnetically induced current (GIMIC) method. Magnetizabilities can be calculated from magnetically induced current density susceptibilities within this approach even when analytical approaches for magnetizabilities as the second derivative of the energy have not been implemented. The magnetizability density can also be visualized, providing additional information that is not otherwise easily accessible on the spatial origin of magnetizabilities.

Spatial Contributions to Nuclear Magnetic Shieldings

We develop a methodology for calculating, analyzing, and visualizing nuclear magnetic shielding densities which are calculated from the current density via the Biot-Savart relation. Atomic contributions to nuclear magnetic shielding constants can be estimated within our framework with a Becke partitioning scheme. The new features have been implemented in the GIMIC program and are applied in this work to the study of the 1H and 13C nuclear magnetic shieldings in benzene (C6H6) and cyclobutadiene (C4H4). The new methodology allows a visual inspection of the spatial origins of the positive (shielding) and negative (deshielding) contributions to the nuclear magnetic shielding constant of a single nucleus, something which has not been hitherto easily accomplished. Analysis of the shielding densities shows that diatropic and paratropic current-density fluxes yield both shielding and deshielding contributions, as the shielding or deshielding is determined by the direction of the current-density flux with respect to the studied nucleus instead of the tropicity. Becke partitioning of the magnetic shieldings shows that the magnetic shielding contributions mainly originate from the studied atom and its nearest neighbors, confirming the localized character of nuclear magnetic shieldings.

The Expiry of Humira® Market Exclusivity and the Entry of Adalimumab Biosimilars in Europe: An Overview of Pricing and National Policy Measures

Background: From October 2018, adalimumab biosimilars could enter the European market. However, in some countries, such as Netherlands, high discounts reported for the originator product may have influenced biosimilar entry.

Objectives: The aim of this paper is to provide a European overview of (list) prices of originator adalimumab, before and after loss of exclusivity; to report changes in the reimbursement status of adalimumab products; and discuss relevant policy measures.

Methods: Experts in European countries received a survey consisting of three parts: 1) general financing/co-payment of medicines, 2) reimbursement status and prices of originator adalimumab, and availability of biosimilars, and 3) policy measures related to the use of adalimumab.

Results: In May 2019, adalimumab biosimilars were available in 24 of the 30 countries surveyed. Following introduction of adalimumab biosimilars, a number of countries have made changes in relation to the reimbursement status of adalimumab products. Originator adalimumab list prices varied between countries by a factor of 2.8 before and 4.1 after loss of exclusivity. Overall, list prices of originator adalimumab decreased after loss of exclusivity, although for 13 countries list prices were unchanged. When reported, discounts/rebates on originator adalimumab after loss of exclusivity ranged from 0% to approximately 26% (Romania), 60% (Poland), 80% (Denmark, Italy, Norway), and 80–90% (Netherlands), leading to actual prices per pen or syringe between €412 (Finland) and €50 – €99 (Netherlands). To leverage competition following entry of biosimilar adalimumab, only a few countries adopted measures specifically for adalimumab in addition to general policies regarding biosimilars. In some countries, a strategy was implemented even before loss of exclusivity (Denmark, Scotland), while others did not report specific measures.

Conclusion: Even though originator adalimumab is the highest selling product in the world, few countries have implemented specific policies and practices for (biosimilar) adalimumab. Countries with biosimilars on the market seem to have competition lowering list or actual prices. Reported discounts varied widely between countries.

A Systematic Review of Collective Evidences Investigating the Effect of Diabetes Monitoring Systems and Their Application in Health Care

INTRODUCTION

Diabetes monitoring systems (DMS) are a possible approach for regular control of glucose levels in patients with Type 1 or 2 diabetes in order to improve therapeutic outcomes or to identify and modify inappropriate patient behaviors in a timely manner. Despite the significant number of studies observing the DMS, no collective evidence is available about the effect of all devices.

GOAL

To review and consolidate evidences from multiple systematic reviews on the diabetes monitoring systems and the outcomes achieved.

MATERIALS AND METHODS

Internet-based search in PubMed, EMBASE, and Cochrane was performed to identify all studies relevant to the research question. The data regarding type of intervention, type of diabetes mellitus, type of study, change in clinical parameter(s), or another relevant outcome were extracted and summarized.

RESULTS

Thirty-three out of 1,495 initially identified studies, involving more than 44,100 patients with Type 1, Type 2, or gestational diabetes for real-time or retrospective Continuous Glucose Monitoring (CGMS), Sensor Augmented Pump Therapy (SAPT), Self-monitoring Blood Glucose (SMBG), Continuous subcutaneous insulin infusion (CSII), Flash Glucose Monitoring (FGM), Closed-loop systems and telemonitoring, were included. Most of the studies observed small nominal effectiveness of DMS. In total 11 systematic reviews and 15 meta-analyses, with most focusing on patients with Type 1 diabetes (10 and 6, respectively), reported a reduction in glycated hemoglobin (HbA1c) levels from 0.17 to 0.70% after use of DMS.

CONCLUSION

Current systematic review of already published systematic reviews and meta-analyses suggests that no statistically significant difference exists between the values of HbA1c as a result of application of any type of DMS. The changes in HbA1c values, number and frequency of hypoglycemic episodes, and time in glucose range are the most valuable for assessing the appropriateness and effectiveness of DMS. Future more comprehensive studies assessing the effectiveness, cost-effectiveness, and comparative effectiveness of DMS are needed to stratify them for the most suitable diabetes patients' subgroups.

Treatment of Corticosteroid Non-responsive Relapse of Neuromyelitis Optica with Intravenous Gamma Globulin &ndash; a Case Report

We report a case of a patient with a relapse of neuromyelitis optica. The relapse was initially treated with intravenous corticosteroids. A therapy with intravenous gamma globulin was started as there was no symptomatic improvement. The patient responded well to the treatment with no significant side effects. Worldwide experience with gamma globulin treatment of neuromyelitis optica is limited and randomised control trials are lacking, therefore accumulation of data from case reports is of paramount importance.

Assessment of Anxiety and Depressive Symptoms in the Early Post-stroke Period

INTRODUCTION

There is some evidence suggesting an association between cerebrovascular diseases and the development of depression on the one hand, and between depression and post-stroke recovery on the other. Post-stroke depression can occur in the early post-stroke period or in the later stages of recovery (over 9 months after the incident).

AIM

To find a connection between stroke and the development of anxiety and depression in the early period after the development of neurological deficit and to evaluate several scales for their potential usefulness in the screening of post-stroke patients for early signs of depression and anxiety.

MATERIALS AND METHODS

We conducted a study on the presence of depression in 117 patients, divided into 2 groups: 73 of these patients were admitted due to ischemic stroke, while the other 44 were controls matching the patients in age, sex and education status. The inclusion and exclusion criteria were defined clearly. We included patients that consented to undergo psychiatric evaluation be-tween 24 hours and 7 days after the onset of neurological symptoms. Both groups were assessed by the Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Rating Scale (HAM-A), Hospital Anxiety and Depression Scale - Depression Subscale and Combined Scale (HADS-D, HADS-T).

RESULTS

On evaluation with HADS-D we noted the largest difference between the two groups with a very high statistical significance and a medium effect size (7.92±4.44 points vs. 4.86±4.27 points for the control group, p<0.001, r= -0.417). Anxiety and depressive symp-toms were found also with MADRS and HAM-A.

CONCLUSIONS

Anxiety and depressive symptoms were found in the early post-stroke period. MADRS, HADS-D, and HAM-A are suf-ficiently specific and sensitive in the evaluation of post-stroke anxiety and depression.