Real-world Treatment Patterns and Clinical Outcomes for Metastatic Renal Cell Carcinoma in the Current Treatment Era

Background

Immuno-oncology (IO) agents and tyrosine kinase inhibitors (TKIs) have revolutionized the treatment paradigm for metastatic renal cell carcinoma (mRCC). Data on real-world usage and outcomes are limited.

Objective

To examine real-world treatment patterns and clinical outcomes for mRCC.

Design setting and participants

This retrospective cohort study included 1538 patients with mRCC who received first-line treatment with pembrolizumab + axitinib (P + A; n = 279, 18%), ipilimumab + nivolumab (I + N; n = 618, 40%), or TKI monotherapy (TKIm; cabozantinib, sunitinib, pazopanib, or axitinib; n = 641, 42%) between January 1, 2018 and September 30, 2020 in US Oncology Network/non-network practices.

Outcome measurements and statistical analysis

The relationship with outcomes, time on treatment (ToT), time to next treatment (TTNT), and overall survival (OS) was analyzed using multivariable Cox proportional-hazards models.

Results and limitations

The median age of the cohort was 67 yr (interquartile range 59.5-74.4), 70% were male, 79% had clear cell RCC, and 87% had an intermediate or poor International mRCC Database Consortium risk score. The median ToT was 13.6 for P + A versus 5.8 for I + N versus 3.4 mo for TKIm (p < 0.001) and the median TTNT was 16.4 for P + A versus 8.3 for I + N versus 8.4 mo for TKIm (p < 0.001) . Median OS was not reached for P + A, 27.6 mo for I + N, and 26.9 mo for TKIm (p = 0.237). On adjusted multivariable analysis, treatment with P + A was associated with better ToT (adjusted hazard ratio [aHR] 0.59, 95% confidence interval [CI] 0.47-0.72 vs I + N; 0.37, 95% CI, 0.30-0.45 vs TKIm; p < 0.0001) and better TTNT (aHR 0.61, 95% CI 0.49-0.77 vs I + N; 0.53, 95% CI 0.42-0.67 vs TKIm; p < 0.0001). Limitations include the retrospective design and the limited follow-up for characterization of survival.

Conclusions

We noted substantial uptake of IO-based therapies in the first-line community oncology setting since their approval. In addition, the study provides insights into clinical effectiveness, tolerability, and/or compliance of IO-based therapies.

Patient summary

We examined the use of immunotherapy for patients with metastatic kidney cancer. The findings suggest rapid implementation of these new treatments by oncologists working in the community setting, which is reassuring for patients with this disease.

A Real-World Evidence Study of CDK4/6 Inhibitor Treatment Patterns and Outcomes in Metastatic Breast Cancer by Germline BRCA Mutation Status

Introduction

Limited data exist on real-world treatment patterns and the effectiveness of cyclin-dependent kinase (CDK) 4/6 inhibitors in germline BRCA (gBRCA)-mutated breast cancer.

Methods

Adults with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2−) metastatic breast cancer (mBC) treated with CDK4/6 inhibitor therapy between 2013 and 2018 were retrospectively selected from the Flatiron Health database. Patients with known gBRCA status were classified as mutated (gBRCAm) or wild type (gBRCAwt). Time-to-first subsequent therapy or death (TFST) and overall survival (OS) were calculated from the earliest line of therapy with a CDK4/6 inhibitor.

Results

Of 2968 patients with HR+/HER2− mBC receiving a CDK4/6 inhibitor, 859 (28.9%) had known gBRCA status, of whom 9.9% were gBRCAm and 90.1% gBRCAwt. Median (95% confidence interval [CI]) TFST was 10 (7–11) months in the gBRCAm group, 10 (9–11) months in the gBRCAwt group, and 11 (10–12) months in the combined gBRCAwt and unknown gBRCA group; median (95% CI) OS was 26 (21–not estimated), 37 (31–51), and 33 (31–35) months, respectively. Cox models indicated the gBRCAm group had shorter TFST (stratified hazard ratio [sHR] 1.24; 95% CI 0.96–1.59) and OS (sHR 1.50; 95% CI 1.06–2.14) than the gBRCAwt group. The gBRCAm group had shorter TFST (sHR 1.38; 95% CI 1.08–1.75) and OS (sHR 1.22; 95% CI 0.88–1.71) than the combined group.

Conclusion

The results of this real-world study suggest that treatment outcomes with CDK4/6 inhibitors may be worse in patients with gBRCAm mBC than in their counterparts with gBRCAwt and unknown gBRCA status, suggesting potential differences in tumor biology. This result highlights the unmet need in patients with gBRCAm requiring optimized treatment selection and sequencing. Future exploration in larger samples of patients who have had biomarker testing is warranted.

A real-world evidence study of CDK4/6 inhibitor treatment patterns and outcomes in metastatic breast cancer by gBRCA mutation status

1563

Background: Limited data exist on the real-world treatment patterns and effectiveness of cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors in the germline BRCA (g BRCA) mutated breast cancer population. Methods: Adults with human epidermal growth factor receptor 2 negative (HER2-), hormone receptor positive (HR+) metastatic breast cancer (mBC) treated with a CDK4/6 inhibitor from 01Jan2013–31Jan2018 were retrospectively selected from the Flatiron Health Oncology electronic medical record database. Patients with known g BRCA status were classified as having g BRCA mutated (g BRCAm) or wild type (g BRCAwt) disease. Time to first subsequent therapy or death (TFST) and overall survival (OS) were calculated from start of the earliest line of therapy with a CDK4/6 inhibitor. Kaplan-Meier (KM) medians were estimated, and TFST and OS compared between g BRCA groups with Cox models stratified by line of therapy and adjusting for demographic and clinical characteristics that modified hazard ratios (HRs) for g BRCA status by > 10%. Results: Of 2968 HER2- HR+ patients with mBC receiving a CDK4/6 inhibitor, g BRCA status was known for 859 (28.9%). Patients with g BRCAm and g BRCAwt received letrozole plus palbociclib (42.4 and 39.8%, respectively), fulvestrant plus palbociclib (32.9 and 30.7%), or other CDK4/6 regimens (24.7 and 29.5%) across all lines. The g BRCAm group had a non-significant, shorter TFST than g BRCAwt (stratified HR 1.24; 95% CI 0.96–1.59). OS was significantly shorter in g BRCAm than g BRCAwt patients (stratified HR 1.50; 95% CI 1.06–2.14). Conclusions: The results of this real-world study suggest that treatment outcomes with CDK4/6 inhibitors may be poorer in patients with g BRCAm compared with g BRCAwt disease. These findings indicate a higher unmet need among patients with g BRCAm, potentially requiring alternative treatment options. [Table: see text]

Cross-sectional study estimating the psychosocial impact of genital warts and other anogenital diseases in South Korea

OBJECTIVES

To estimate self-reported human papillomavirus (HPV) disease-related psychosocial impact among male and female patients in South Korea.

DESIGN

In this multicentre cross-sectional study, psychosocial impacts were estimated using a one-time survey capturing HPV Impact Profile (HIP) results, CuestionarioEspecifico en Condilomas Acuminados (CECA; in Spanish)-'Specific questionnaire for Condylomata Acuminata' and the EuroQol-5 Dimension (EQ-5D) surveys. Student's t-tests or Mann-Whitney U tests were used for continuous comparisons; χ² or Fisher's exact tests were applied for categorical comparisons.

SETTING

5098 clinics throughout Seoul, Busan, Daegu, Kwangju and Daejeon (South Korea).

PARTICIPANTS

Patients with and without genital warts (GW) (males) and selected HPV diseases (females) visiting primary care physicians, obstetricians/gynaecologists, urologists and dermatologists with 2-30 years experience.

RESULTS

Of 150 male and 250 female patients, HIP scores showed 85.3% of male patients with GW and 32.0% without reported moderate psychological impact (p<0.0001). In categorised total scores, 88.5% of female patients with and 66.0% without selected HPV-related diseases reported moderate or high psychological impacts (p=0.0004). In the CECA questionnaire, male patients had mean (SD) scores of 10.51 (3.79) in 'emotional health' and 15.90 (6.13) in 'sexual activity'. Female patients with GW reported lower scores in both dimensions with mean scores of 7.18 (4.17) in 'emotional health' and 10.97 (5.80) in 'sexual activity' (p<0.0001), indicating worse health-related quality of life (HRQoL). For the EQ-5D, male patients with GW reported lower mean Visual Analogue Scale (VAS) scores than those without (75.1 vs 81.13, p<0.0135). Mean VAS score and utility values were lower for females with HPV-related diseases than those without (72.18 vs 76.86 and 0.90 vs 0.94, respectively).

CONCLUSION

In South Korea, GW in men and HPV-related diseases in women negatively impact patient well-being and HRQoL scores. Among women, those with GW suffered a greater psychosocial impact than those with other selected HPV-related diseases.

Prevalence and Burden Related to Genital Warts in India

The prevalence of genital warts (GW) and self-reported human papillomavirus (HPV) as well as disease-related psychosocial impact among male and female patients aged 18-60 years in India were assessed. GW prevalence was estimated using a 2-week daily log of patients examined from June 7-September 22, 2011 by 200 participating physicians in 6 regions of India. Psychosocial impact was estimated using one-time, self-administered surveys, including HPV Impact Profile (HIP), Cuestionario Específico para Condiloma Acuminado ([Spanish] CECA; "Specific questionnaire for Condylomata Acuminata") and EuroQol-5 Dimension survey. T-tests or Mann-Whitney U-tests were used for continuous comparisons and Chi-square or Fisher exact tests were applied for categorical comparisons. Overall GW prevalence in India was estimated at 1.07% (95% confidence interval = 0.97-1.17) and was higher among men than women. Regional prevalence ranged from high in Delhi (2.17%) to low in Bangalore (0.40%). Patients aged 25-29 years had the highest GW prevalence (1.42%). GW patients were most often newly diagnosed (74.07%). Among those with existing GW, 56.24% were recurrent, and 43.76% were resistant. According to total HIP scores, 55.4% of male GW patients and 20.0% of those without GW reported moderate psychological impact (p < 0.0001). HIP scores among women revealed that patients with abnormal Papanicolaou (Pap) test results (34.3%), precancerous lesions (46.2%), external GW (48.0%), and those without HPV-related disease (18.5%) reported moderate psychological impact (p = 0.0089) (Psychosocial impact results are reported in the Supplementary Data ). Estimated national GW prevalence, diagnosis, and treatment costs in India were higher for men than for women. GW in men and HPV infection in women had a negative psychosocial impact on well-being and health-related quality of life (HRQoL) scores, especially among women diagnosed with GW and precancerous lesions compared to those with other selected HPV-related diseases. Despite its limitations, this study provides an estimation of GW data in India not previously available.

A cross-sectional study estimating the burden of illness related to genital warts in South Korea

OBJECTIVES

Estimate the prevalence of genital warts (GW) and GW-related healthcare resource use and costs among male and female patients seeking treatment in South Korea.

DESIGN

To estimate GW prevalence, physicians in five major South Korean regions recorded daily logs of patients (n=71 655) seeking care between July 26 and September 27, 2011. Overall prevalence estimates (and 95% CIs) were weighted by the estimated number of physicians in each specialty and the estimated proportion of total patients visiting each specialist type. Healthcare resource use was compared among different specialties. Corresponding p values were calculated using Mann-Whitney U tests.

SETTING

The database covers 5098 clinics and hospitals for five major regions in South Korea: Seoul, Busan, Daegu, Gwangju and Daejeon.

PARTICIPANTS

Primary care physicians (general practice/family medicine), obstetricians/gynaecologists, urologists and dermatologists with 2-30 years' experience.

RESULTS

The estimated overall GW prevalence was 0.7% (95% CI 0.7% to 0.8%). Among women, GW prevalence was 0.6% (95% CI 0.6% to 0.7%); among men prevalence was 1.0% (95% CI 0.9% to 1.0%), peaking among patients aged 18-24 years. Median costs for GW diagnosis and treatment for male patients were US$58.2 (South Korean Won (KRW) ₩66 857) and US$66.3 (KRW₩76 113) for female patients.

CONCLUSIONS

The estimated overall GW prevalence in South Korea was 0.7% and was higher for male patients. The overall median costs associated with a GW episode were higher for female patients than for male patients.

Geographic variation and risk factors for systemic and limb ischemic events in patients with symptomatic peripheral artery disease: Insights from the REACH Registry

Background

Patients with symptomatic peripheral artery disease (PAD) are at high risk of ischemic events. However, data about predictors of this risk are limited.

Hypothesis

We analyzed baseline characteristics and 4‐year follow‐up of patients enrolled in the international REduction of Atherothrombosis for Continued Health (REACH) Registry with symptomatic PAD and no history of stroke/transient ischemic attack to describe annual rates of recurrent ischemic events globally and geographically.

Methods

The primary outcome was systemic ischemic events (composite of cardiovascular death, myocardial infarction, or stroke) at 4 years. The secondary outcome was limb ischemic events (composite of lower limb amputation, peripheral bypass graft, and percutaneous intervention for PAD) at 2 years. Multivariate analysis identified risk factors associated with recurrent ischemic events.

Results

The primary endpoint rate reached 4.7% during the first year and increased continuously (by 4%–5% each year) to 17.6% by year 4, driven mainly by cardiovascular mortality (11.1% at year 4). Japan experienced lower adjusted ischemic rates (P < 0.01) vs North America. Renal impairment (P < 0.01), congestive heart failure (P < 0.01), history of diabetes (P < 0.01), history of myocardial infarction (P = 0.01), vascular disease (single or poly, P < 0.01), and older age (P < 0.01) were associated with increased risk of systemic ischemic events, whereas statin use was associated with lower risk (P = 0.03). The limb ischemic event rate was 5.7% at 2 years.

Conclusions

Four‐year systemic ischemic risk in patients with PAD and no history of stroke or transient ischemic attack remains high, and was mainly driven by cardiovascular mortality.

Residual Ischemic Risk and Its Determinants in Patients With Previous Myocardial Infarction and Without Prior Stroke or TIA: Insights From the REACH Registry

BACKGROUND

Although the rate of in-hospital ischemic events after myocardial infarction (MI) has dramatically decreased, long-term residual risk may remain substantial. However, most of the information on current residual risk is derived from highly selected randomized trials.

HYPOTHESIS

In patients with previous MI and no prior ischemic stroke/transient ischemic attack (TIA), residual ischemic risk increases over time.

METHODS

Using the international Reduction of Atherothrombosis for Continued Health (REACH) registry, we analyzed baseline characteristics and 4-year follow-up of patients with previous MI and no history of stroke/TIA to describe annual rates of recurrent ischemic events globally and by geography. The primary outcome was the composite of cardiovascular death, MI, or stroke. Multivariate analysis identified risk factors associated with recurrent ischemic events.

RESULTS

Data from 16 770 patients enrolled at 5587 sites in 44 countries were analyzed. The rate of the primary outcome increased annually from 4.7% during year 1 to reach a 4-year rate of 15.1%. Compared with North America, Japan experienced lower ischemic event rates (P < 0.01), whereas Eastern Europe (P < 0.01) and the Middle East (P = 0.01) experienced higher ischemic event rates. The presence of congestive heart failure, polyvascular disease, diabetes, atrial fibrillation or flutter, and older age were associated with increased residual risk (all P < 0.01). Statin use was associated with lower ischemic risk (P < 0.01).

CONCLUSIONS

In this study, residual ischemic risk after MI accrued progressively up to 4 years of follow-up, emphasizing the value of intensive secondary prevention strategies to minimize residual risk.

In Vitro Activity of Oral Antimicrobial Agents against Pathogens Associated with Community-Acquired Upper Respiratory Tract and Urinary Tract Infections: A Five Country Surveillance Study

Introduction

Bacterial infections that cause community-acquired urinary tract infections (CA-UTI) and upper respiratory tract infections (CA-URTI) are most frequently treated empirically. However, an increase in antimicrobial resistance has become a problem when treating outpatients.

Methods

This study determined the in vitro activities of oral antibiotics among 1501 pathogens from outpatients with CA-UTI and CA-URTI in medical centers during 2012 and 2013 from Argentina, Mexico, Venezuela, Russia, and the Philippines. Minimal inhibitory concentrations (MICs) were determined using broth microdilution and susceptibility defined by Clinical Laboratory Standards Institute (CLSI) and European Committee for Antimicrobial Susceptibility Testing (EUCAST) criteria.

Results

Ceftibuten (MIC₅₀, ≤0.25 mg/L) was more potent in vitro compared to other β-lactams against Enterobacteriaceae from CA-UTI. Susceptibility to fluoroquinolones using CLSI criteria varied: Argentina and Mexico (50%), the Philippines (60%), Venezuela (70%), and Russia (80%). Fosfomycin susceptibility was >90% against Enterobacteriaceae in each country. Susceptibility among Enterobacteriaceae to trimethoprim-sulfamethoxazole was 30.6–75.6% and nitrofurantoin susceptibility also varied among the countries and was higher when EUCAST breakpoints were applied (65–>90%) compared to CLSI (52–84%). All Haemophilus influenzae isolates from CA-URTI were susceptible to ceftibuten, cefixime, cefpodoxime, and cefuroxime using CLSI breakpoint criteria. EUCAST criteria produced intermediate and resistant MIC values for these oral cephalosporins. Country-specific susceptibility variation for fluoroquinolones, macrolides, and trimethoprim-sulfamethoxazole was observed among Streptococcus pneumoniae and Streptococcus pyogenes from CA-URTI.

Conclusion

This study demonstrated that antimicrobial susceptibility patterns varied in the five countries investigated among pathogens from CA-UTI and CA-URTI.

Funding

Merck & Co. Inc., Kenilworth, New Jersey, USA.

Abstract 372: Health Outcomes Associated With Triple Antiplatelet Therapy for the Secondary Prevention of Atherothrombotic Events

Vorapaxar is a protease-activated receptor-1 (PAR-1) antagonist indicated for the reduction of atherothrombotic cardiovascular (CV) events in patients with a history of myocardial infarction (MI) or with peripheral arterial disease (PAD), based on the findings of the TRA 2°P-TIMI 50 trial for patients without a history of stroke or transient ischemic attack. This analysis evaluated the health outcomes of triple antiplatelet therapy with vorapaxar when added to a standard care regimen of clopidogrel plus aspirin (ASA) in comparison with standard care alone, for patients without a history of transient ischemic attack or stroke who survived hospitalization for a qualifying MI.

A cohort-level state-transition model was developed in Microsoft Excel to estimate membership in health states over a lifetime time horizon: event-free, post-MI, post-stroke, dead due to bleeding, dead due to CV causes, and dead due to other causes. Predictive equations were developed from patient-level data from TRA 2°P, in order to estimate CV event-related transition probabilities, based on patient characteristics. These improve upon Framingham risk equations as they consider the time since the most recent myocardial infarction, and they are based on a greater number of CV events from a larger and more diverse population. Meta-analyses, national statistics, and other publications were used to estimate case fatality and bleeding rates, the risk of non-CV mortality, as well as utilities for estimation of quality-adjusted life years (QALYs). For validation, the risk equation and model results were compared with the observed event rates in TRA 2°P, risk estimates from Framingham Heart Study publications, as well as QALY and life-year outcomes from other published models.

Over a lifetime time horizon, the model predicted 8.3 fewer recurrent MIs, 3.8 fewer strokes, and 18.2 fewer CV deaths in the vorapaxar plus standard care arm in comparison with standard care alone, per 1,000 patients treated, with an increase of 26.4 transfusions, 3.6 intracranial hemorrhage, and 0.9 fatal bleeding events. Discounted life-years and QALYs increased by 0.4 and 0.3 respectively with vorapaxar treatment. In validation, modeled CV event counts were within 0.1% of the observed rates in TRA 2°P. The model’s prediction of 8.94 QALYs in the standard care arm is comparable to the prediction of 9.55 to 9.78 QALYs in a recent UK model of antiplatelet monotherapy after MI.

Based on model results, triple antiplatelet therapy with vorapaxar provides additional clinical benefit versus standard care after MI, for a patient population that is at high risk for recurrent and potentially fatal events. In validation, the model yielded projections of CV morbidity and mortality comparable to the observed outcomes from the TRA 2°P clinical trial, Framingham equations, and other models.

Costs of adult vaccination in medical settings and pharmacies: an observational study

BACKGROUND

Community pharmacies are a convenient setting for vaccinating adults against infectious diseases in the United States. Whether the costs paid for vaccination in pharmacies differ from those in medical settings is unclear.

OBJECTIVE

To examine whether the direct medical costs paid for adult vaccination differ by vaccination setting.

METHODS

This was an observational retrospective study using 2010 MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. Adults receiving herpes zoster or shingles vaccine, pneumococcal vaccine 23-valent, or influenza vaccines were identified using Current Procedural Terminology codes and National Drug Code numbers from medical and pharmacy claims files, respectively, between January 1 and December 31, 2010, in 1 of the following 3 settings: physician offices; other medical settings (e.g., inpatient/outpatient hospitals, emergency rooms); and pharmacies. Patients were adults aged ≥60 years on the date of zoster vaccination and aged ≥19 years on the date of pneumococcal or influenza vaccinations. The final study samples meeting inclusion/exclusion criteria were 54,042 for zoster vaccine, 154,994 for pneumococcal vaccine, and 1,657,264 for influenza vaccine. The vaccination costs included the health plan and enrollee paid amounts for the product; vaccine administration; dispensing fee; and, where applicable, the visit. The mean (SD) vaccination costs paid per vaccine administration were estimated by vaccine and type of setting, overall, and by geographic region and type of health plan. The costs paid for the same vaccine across vaccination settings were compared using analysis of variance with post hoc tests (Tukey).

RESULTS

Of those receiving zoster, pneumococcal, and influenza vaccines, 25%, 1%, and 7%, respectively, received the vaccines at a pharmacy. Compared with other U.S. regions, pharmacy-based vaccination for these 3 vaccines was generally more frequent in the West and the South. Overall, the mean (SD) costs paid per enrollee per vaccine administration at physician offices, other medical settings, and pharmacies were as follows: for zoster vaccine, $208.72 (42.10), $209.51 (50.83), and $168.50 (15.66), respectively (P <0.05); for pneumococcal vaccine, $65.69 (27.54), $72.11 (49.95), and $54.98 (9.72), respectively (P <0.05); and for influenza vaccine, $29.29 (15.29), $24.20 (13.12), and $21.57 (6.63), respectively (P <0.05). The mean amounts paid also differed by geographic region and type of health plan, with costs usually lower for the vaccinations given at pharmacies.

CONCLUSIONS

The average direct costs paid per adult vaccination were lower in pharmacies compared with physician offices and other medical settings by 16%-26% and 11%-20%, respectively. These results were mostly consistent across geographic regions and types of health plans. These data may help payers and policymakers understand the economic value of adult vaccination in different settings, especially in pharmacies.

The Cost-Effectiveness Analysis of a Quadrivalent Human Papillomavirus Vaccine (6/11/16/18) for Females in Japan

OBJECTIVE

We assessed the epidemiological and economic impact of a quadrivalent human papillomavirus (HPV) (6/11/16/18) vaccine for females in preventing cervical cancer, cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3), cervical intraepithelial neoplasia grade 1 (CIN 1), and genital warts in Japan by using a transmission dynamic model.

METHODS

A published mathematical model of the transmission dynamics of HPV infection and disease was adapted for Japan. Model inputs were used from Japan or the Asia/Pacific region when available; otherwise, the default values in the original model were used. The transmission dynamic model was used to assess the epidemiological and economic impact of a quadrivalent HPV (6/11/16/18) vaccine for females in preventing cervical cancer, CIN 2/3, CIN 1, and genital warts in Japan.Maintaining current cervical cancer screening practices, we evaluated two strategies: routine vaccination of females by age 12 years (S1), and S1 combined with a temporary (5 years) female catch-up program for age 12 to 24 years (S2). The vaccine coverage rate was 80% for the routine and 50% for the catch-up vaccination programs.

RESULTS

Compared with no vaccination, both vaccination strategies significantly reduced the incidence of HPV 6/11/16/18-related disease. The most effective strategy was S2. By using this strategy over 100 years in the Japanese population, the estimated cumulative percentage reduction in incident HPV 6/11/16/18-related genital warts-female, genital warts-male, cervical CIN 1, CIN 2/3, and cervical cancer cases was 90% (2,113,723 cases), 86% (2,082,637 cases), 72% (263,406 cases), 71% (1,328,366 cases), and 58% (323,145 cases), respectively. The cost-effectiveness ratios were JPY 1,244,000, and JPY 1,205,800 per quality-adjusted life-year gained for S1 and S2 compared with no vaccination, respectively, over a time horizon of 100 years.

CONCLUSION

We conclude that a quadrivalent HPV vaccination program for females can reduce the incidence of cervical cancer, CIN, and genital warts in Japan at a cost-per-quality-adjusted life-year ratio within the range defined as cost-effective.

Estimated health and economic impact of quadrivalent HPV (types 6/11/16/18) vaccination in Brazil using a transmission dynamic model

BACKGROUND

Cervical cancer is the second most common cancer among women in Brazil. We examined the health and economic impacts of quadrivalent HPV vaccination in Brazil.

METHODS

We adapted a previously developed transmission dynamic model to estimate the effectiveness of HPV vaccination on cervical cancer, cervical intraepithelial neoplasia grades 2 and 3 (CIN2/3), CIN1, and genital warts. We evaluated following vaccination strategies: routine vaccination of 12-year-old girls and routine vaccination in combination with a catch-up vaccination of 12 to 26-year-old women.

RESULTS

The model projected that the vaccination would reduce the incidence rates of HPV 6/11/16/18-related cervical cancer, CIN2/3, CIN1, and female genital warts by 94% to 98% at year 100. Routine vaccination in combination with a catch-up vaccination could prevent approximately 163,000 cases of cervical cancer, 48,000 deaths from cervical cancer, 2.3 million cases of CIN2/3, and 11.4 million genital warts in the next 50 years. The incremental cost-effectiveness ratios for female vaccination strategies ranged from R$350 to R$720 (US$219 to US$450) per quality-adjusted life year (QALY) gained.

CONCLUSIONS

Our study demonstrates that quadrivalent HPV female vaccination can be a cost-effective public health intervention that can substantially reduce the burden of cervical diseases and genital warts in Brazil.

Work and productivity loss related to herpes zoster

OBJECTIVE

To estimate absenteeism and presenteeism-related work loss due to herpes zoster (HZ) among working individuals of 50-64 years of age.

METHODS

This telephone survey included individuals with ≥1 insurance claim for HZ in the past year in administrative claims data from five US commercial health plans. Demographic information, characteristics of the HZ episode; impact of HZ on activities of daily living (ADL), and work days loss and productivity were surveyed.

RESULTS

Responses were obtained from 153 of 1654 individuals who were contacted and were eligible for the survey (9.3%). Most had moderate or severe HZ (72.6%). Close to two-thirds reported some impact of HZ on ADL such as shopping, housework/chores, and social engagement. About half (51%) reported missing work due to HZ, and about an equal percentage reported little or much worse productivity than usual due to HZ while at work. On average, age-adjusted absenteeism- and presenteeism-related work loss was estimated at 31.6 hours, and 84.4 hours, respectively, with a combined work loss of 116.0 hours per HZ episode in a working person of 50-64 years of age. Work loss tended to increase with age and the duration and severity of the HZ episode.

CONCLUSIONS

The study documents a substantial societal burden of HZ-related work and productivity loss. This is important information to take into consideration, in addition to the direct medical burden, when making policy decisions around vaccine prevention of HZ.

LIMITATIONS

The study may potentially be subject to selection bias due to low survey response rate and since only those cases who sought care for a HZ episode were captured. The study may also be subject to respondent recall bias. Finally, since some respondents could still be having the HZ episode at the time of survey, the study may potentially have under-estimated the work and productivity loss.

Biotechnological advancement in isolation of anti-neoplastic compounds from natural origin: a novel source of L-asparaginase

L-asparaginase catalyzes the hydrolysis of L-asparagine into aspartate and ammonia, which is used as an anti-neoplastic agent. Isolation of asparaginase from microorganisms may be cardinal for producing this anticancer agent at industrial level. A total of three hundred fungal isolates were screened for L-asparaginase production. These fungal isolates were growing on various fruits and vegetables. Among these, the Fusariumn sp. isolate that was growing on green chilly showed highest enzyme production. This study may give an outstanding contribution for finding organisms with high yielding L-asparaginase. Fungal L-asparaginase is superior in terms of its eukaryotic origin that may be responsible for its lesser toxicity.

Assessing incidence and economic burden of genital warts with data from a US commercially insured population

OBJECTIVE

This study examined the incidence of and healthcare costs attributable to genital warts within a large US commercially insured, geographically dispersed population.

RESEARCH DESIGN AND METHODS

Using a retrospective cohort study design, this longitudinal analysis assessed administrative claims of integrated medical and pharmacy encounters from five Blue Cross Blue Shield health plans. Genital warts cases were identified using a methodology previously described by Insinga et al.

MAIN OUTCOME MEASURES

Age- and gender-specific incidence of genital warts per 1000 person-years in 2004, and duration-of-episode attributable direct medical costs (2004 US dollars) and healthcare resource utilization of cases diagnosed in 2002. Overall outcome measures were age- and gender-adjusted to the 2004 US civilian population.

RESULTS

Genital warts incidence in 2004 was 1.2/1000 females and 1.1/1000 males. Incidence was highest among females aged 20-24 (4.6/1000) and males aged 25-29 (2.7/1000). Projected overall incidence was over 340,000 cases in 2004. Mean duration-of-episode per incident case in 2002 was 95.4 days (males 116.3 days; females 69.7 days). Mean ambulatory visits per episode were 1.5 for females and 1.9 for males, with <1 drug prescription/episode. Mean costs were $647/episode ($745 males; $528 females). The 2004 estimated economic burden was $760 per 1000 individuals in the general population with the total exceeding $220 million.

LIMITATIONS

Only those genital warts cases that sought evaluation or for which the treating provider was covered by the health plan were captured in the study.

CONCLUSIONS

Genital warts represent a significant health and cost burden in the US. Adoption of novel healthcare technologies such as vaccines along with traditional interventions such as physician education of signs and symptoms, condom use and abstinence or limiting number of sexual partners may significantly help reduce the burden of genital warts.

Incremental 1-year medical resource utilization and costs for patients with herpes zoster from a set of US health plans

BACKGROUND

Nearly 1 million new episodes of herpes zoster (HZ) occur annually in the US, yet little is known about the medical resource utilization (RU) and costs associated with HZ and its complications.

OBJECTIVES

To describe the medical RU and cost burden of HZ in the first 90 days and the first year after diagnosis from the health insurer perspective and to stratify this burden for patients diagnosed with post-herpetic neuralgia (PHN) and those who are immunocompromised. In addition, this study explores costs from the societal perspective as a result of work loss in the first year after diagnosis.

METHODS

The medical RU and cost data were obtained from the MarketScan Research Database for the years 1998-2003. This database contains inpatient, outpatient and prescription drug data for approximately 14 million individuals of all ages, covered under a variety of fee-for-service and capitated provider reimbursement arrangements, including those with Medicare and private insurance. The work loss estimates were based on the MarketScan Health and Productivity Management Database. Claims for services incurred between 1 January 1998 and 31 December 2003 were screened to identify a cohort of HZ patients based on the presence of at least one International Classification of Diseases, 9th Revision (ICD-9) diagnosis code 053.xx. Each patient was assigned an index date based on the earliest observed occurrence of an HZ diagnosis. A cohort of PHN patients was identified as a subset of the HZ cohort with ICD-9 codes 053.12, 053.13, 053.19 or 729.2x in the period of 90 days to 12 months after the index date. Multivariable regression was used to compare HZ cases with matched controls after adjusting for demographic characteristics, insurance status, co-morbidities and medical expenditure in the 6 months prior to diagnosis for each of the endpoints. Separate regression models were developed, in which age and immune status were stratified. All costs were adjusted to March 2008 values using the medical care component of the Consumer Price Index. The average per patient cost of all HZ cases was $US605 in the first 90 days after diagnosis and $US1052 at 1 year. For the subset with PHN, the average per patient cost of HZ at 1 year was $US3815. For the subset with an immunocompromising condition, the average HZ cost at 1 year was $US1745. The majority of the costs were the result of outpatient visits and prescription drugs. The subset of HZ cases that had both absence hour and short-term disability (STD) records available had 26.5 absence hours and 2.9 STD days. Healthcare utilization, medical care costs and work loss all increased with age for all HZ cases. Based on the results from the present study, the direct medical cost burden of HZ in the US is high, exceeding $US1000 per HZ patient. This direct medical cost may be nearly twice as high in immunocompromised patients and four times as high in the subset of HZ cases with PHN. The direct medical cost burden of HZ may exceed $US1 billion annually in the US. The majority of medical RU and cost burden is incurred by the elderly. Although many people with HZ may no longer be in the workforce, HZ does contribute to lost work time.

Five-year routine cervical cancer screening rates and intervals in a US health plan

OBJECTIVE

Cervical cancer screening with liquid-based cytology or concurrent HPV screening may decrease positive predictive value and specificity of screening results. Following changes to leading guidelines for cervical cancer screening, policy-makers may benefit from more detailed statistics to improve management of routine screening intervals. This paper reports annual cervical cancer screening rates, intervals between routine screenings, population cost burden of routine screening, and concurrent HPV screening rates in the medical claims database of a large US health plan between 2000 and 2004.

RESEARCH DESIGN AND METHODS

Annual cervical cancer screening rates were reported for each calendar year between 2000 and 2004, plus intervals between routine screenings in a cohort enrolled for 5 years after a first routine screening. Interval estimates accounted for women not screened in the first year of the study period. Overall screening rates and intervals were adjusted to the US civilian female population, and costs were adjusted to 2004 dollars. This database research was exempt from IRB review.

RESULTS

Annual routine screening rates during the 5-year period ranged from 33.7 to 37.2 tests per 100 enrollees. Among females with routine screenings, 68.8% were re-screened within 3 years, and 26.8% were not re-screened within 5 years. Concurrent HPV screening was 1.9 tests per 1000 routine screenings in 2000, and 27.9 per 1000 in 2004. The cost of routine screening per 1000 females was $31,282.00 in 2000 and $38,515.07 in 2004.

CONCLUSION

More than a quarter of women with evidence of a routine cervical cancer screening were not re-screened within 5 years, while 43.4% were re-screened within a year. Triennial screening rates reported here are not comparable to traditional 3-year screening rates, and screening intervals were not reported separately by conventional and liquid-based cytology. Reducing rates of women receiving annual routine screening may offset the cost burden of newer screening technologies, but must be managed carefully to avoid decreasing 3-year screening rates. Clinicians should reinforce with their patients the need for routine screening at least triennially.

Healthcare resource use and costs associated with cervical, vaginal and vulvar cancers in a large U.S. health plan

OBJECTIVES

To estimate healthcare resource utilization and costs of cervical, vulvar and vaginal cancers in a large U.S. health plan.

METHODS

We estimated incremental ambulatory visits, hospitalizations, prescription fills and healthcare costs for cancer cases relative to population controls. Data for cervical (n=2788), vulvar (n=621) and vaginal cancer (n=254) cases and an identical number of controls were obtained from a large U.S. health plan. Cases were identified via diagnostic codes on a healthcare claim and matched to controls. Incremental resource use was assessed using a two-stage regression method developed by Carides, with costs analyzed using Lin's regression method.

RESULTS

Through 4 years of follow-up, cervical cancer patients had incremental resource use of 12.0 ambulatory visits, 0.6 hospital admissions and 7.0 prescription fills per case. Cumulative 4-year incremental healthcare costs per case ranged from $8236 for vulvar cancers to $18,799 for cervical cancers. When adjusted to cervical, vulvar and vaginal cancer excess mortality rates observed within the U.S. Surveillance Epidemiology and End Results program, estimated incremental costs were $29,649 for cervical, $11,356 for vulvar and $21,963 for vaginal cancers. There was a significant upward trend in costs with increasing age for cervical cancer, however trends were less consistent for vulvar and vaginal cancers.

CONCLUSIONS

Direct medical costs associated with cervical, vulvar and vaginal cancers were observed to be substantial. These data can help inform evaluations of the economic burden and cost-effectiveness of prevention of these cancers, particularly for vulvar and vaginal disease, where such data have not been previously reported.

Quality of drug treatment of childhood persistent asthma in Maryland medicaid recipients in transition from managed fee for service to managed capitation

BACKGROUND

From December 1991 to June 1997, approximately 80% of Maryland's Medicaid recipients were served through a fee-for-service (FFS) managed care delivery system in which assigned primary care providers served as gatekeepers for hospital and specialty services. The remaining 20% of recipients were voluntarily enrolled in 1 of 5 available health maintenance organizations (HMOs). Beginning in June 1997, Maryland required most Medicaid recipients to enroll in capitated managed care organizations (MCOs), also referred to as managed Medicaid plans. Although research has been conducted on the quality of asthma care among MCOs and in MCOs for Medicaid versus non-Medicaid members, the quality of asthma care has been less well studied for MCO patients than for FFS patients.

OBJECTIVE

To determine whether quality of drug use among Medicaid children with persistent asthma was different after the transition from the managed care FFS system to a capitated managed Medicaid system.

METHODS

This 4-year retrospective cohort study (from June 1, 1996, to December 31, 2000) followed children aged 5 to 18 years with persistent asthma (defined by the existence of at least 1 medical claim with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 493.x and receipt of 2 or more pharmacy claims for beta2-agonists in a 6-month period) enrolled in Maryland Medicaid as they transitioned from the managed FFS system to 1 of 4 large capitated MCOs. Children were selected from a review of Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1, 1996, and December 31, 1997. Children with a diagnosis of cystic fibrosis were excluded. The asthma quality indicator was defined as the proportion of children with persistent asthma (who had 2 or more claims for any short-acting beta2-agonists [SABAs], including metered-dose inhalers, nebulizers, or oral forms, which we defined as rescue medication, within a 6-month period), who also had at least 1 claim for a controller medication (inhaled corticosteroid, mastcell stabilizer, or leukotriene-receptor modifier) in the same 6-month period. Subjects were followed from June 1, 1996 (or, if later, the first Medicaid eligibility date), through December 31, 2000 (or, if earlier, the last Medicaid eligibility date). Mean quality indicator rates were calculated for the 2 managed FFS periods (FFS1 and FFS2) and the 6 managed Medicaid 6-month periods. We used generalized estimating equations to test for significant trends over time and to compare changes in the quality indicator in the managed Medicaid plans.

RESULTS

There were 3,721 children who met the inclusion and exclusion criteria for the study. The quality indicator (proportion of patients who received a controller medication among those receiving SABAs for asthma) was 62% in managed FFS1 and 57% in managed FFS2. In the first 6 months of managed Medicaid plans, the quality indicator rose from 56% to 57%, 59%, 61%, 66%, and 59% in the ensuing five 6-month observation periods. The results from the generalized estimating equations suggested slight improvement in the quality indicator in the managed Medicaid plans, but the difference was not significant (relative risk 1.01, 95% confidence interval, 0.95-1.08). There was no significant trend in the asthma quality indicator over time in the managed Medicaid plans.

CONCLUSION

There was no distinct improvement or worsening in asthma care as measured by the quality indicator (proportion of patients who received a controller medication among those receiving SABAs for asthma) as children moved from managed FFS to managed Medicaid. Larger sample sizes with no data loss may have produced a different result.

National Estimates of Exposure to Prescription Drugs with Addiction Potential in Community-Dwelling Elders

The use of prescription drugs with addiction potential is an overlooked and growing problem among today's elderly. This paper provides national prevalence estimates of exposure to prescription drugs with addiction potential among community-dwelling elders and explores risk factors for such exposure. Using the Medicare Current Beneficiary Survey, a nationally-representative database of Medicare eligibles, we calculated the prevalence of abusable prescription drug use, overall, by therapeutic class, and by drug. Nearly 22% (7.22 million) of all community-dwelling Medicare elders used at least one prescription medication with addiction potential. Opioid analgesics were used most frequently (14.9%; 95% CI 14.0, 15.8%); central nervous system (CNS) depressants were used by 10.4% of the nation's elders (95% CI 9.5, 10.8%). Using logistic regression analysis, we examined the association of explanatory variables with three outcome variables: any controlled substances use, any opioid analgesic use, and any CNS depressant use. We found that females, whites, those aged 65-79, and those with non-spousal others, were significantly more likely to use one or more prescription drugs with addiction potential, controlling for health status and severity-of-illness. The significance and magnitude of several explanatory variables, including age, race, ethnicity, living arrangement, and health status, varied by therapeutic category. This paper provides an important first step in acknowledging the widespread use of abusable prescription drugs in elders, and provides a foundation for future research and practical solutions to preventing subsequent problem use of prescription drugs.

Medicare cost differences between nursing home patients admitted with and without dementia

PURPOSE

Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings.

DESIGN AND METHODS

An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups.

RESULTS

Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS.

IMPLICATIONS

Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.

Comparative efficacy and safety evaluation of cefaclor vs amoxycillin + clavulanate in children with Acute Otitis Media (AOM)

Acute Otitis Media (AOM) is the most frequent respiratory tract infection of infancy and childhood that is treated with antimicrobial agents. The most common causative pathogens include Streptococcus pneumoniae, Hemophilus influenzae and Moxarella catarrhalis, and therefore antibacterial management should target against these isolates. Cefaclor, a congener of cephalexin monohydrate, is a semisynthetic cephalosporin antibiotic. It is an orally active cephalosporin which has demonstrated activity against a wide range of organisms in vitro. Present study is designed as a multicentric prospective trial to study and compare the efficacy and safety of cefaclor versus amoxicillin + clav in children with acute otitis media. One hundred and sixty seven patients were evaluated for efficacy endpoints in the cefaclor arm comprised of 104 males and 63 females with a mean age of 5.74+/-2.80 years and 185 patients in the amoxy-clav group comprised of 118 males and 67 females with a mean age of 4.93+/-2.92 years. Both cefaclor and amoxy-clav caused a significant improvement in all the signs and symptoms after a 10-day treatment period. However, between-the-group comparisons showed that the reduction in most of the symptoms was significantly more in cefaclor arm as compared to amoxicillin-clav arm. The clinical success (clinical cure + improvement) at the end of therapy was significantly more in cefaclor arm: 98% with cefaclor versus 85% with amoxicillin + clav, p<0.05 Table 3. Failure cases were prescribed other antibiotics according to the culture sensitivity reports, as rescue medication. Bacterial eradication rates were largely consistent with clinical responses. Bacteriological eradication was seen in 95% of patients in cefaclor group and 78% of patients in amoxicillin + clav group. In conclusion, cefaclor is a well tolerated and effective antibacterial option for acute otitis media in children and it is superior to the combination of amoxicillin + clav in efficacy and tolerability in acute AOM. Moreover, its expanded spectrum of activity, ability to achieve adequate concentrations in tissues, suitability for twice-daily dosing, and proven tolerability suggest that it is a good alternative to agents traditionally used in acute otitis media.

Comparative efficacy and safety evaluation of cefaclor VS amoxycillin + calvulanate in children with Acute Otitis Media (AOM)

Acute Otitis Media (AOM) is the most frequent respiratory tract infection of infancy and childhood that is treated with antimicrobial agents. The most common causative pathogens includeStreptococcus pneumoniae, Hemophilus influenzae andMoxarella catarrhalis, and therefore antibacterial management should target against these isolates. Cefactor, a congener of cephalexin monohydrate, is a semisynthetic cephalosporin antibiotic. It is an orally active cephalosporin which has demonstrated activity against a wide range of organismsin vitro. Present study is designed as a multicentric prospective trial to study and compare the efficacy and safety of cefaclor versus amoxicillin+clav in children with acute otitis media. One hundred and sixty seven patients were evaluated for efficacy endpoints in the cefaclor arm comprised of 104 males and 63 females with a mean age of 5.74±2.80 years and 185 patients in the amoxy-clav group comprised of 118 males and 67 females with a mean age of 4.93±2.92 years. Both cefaclor and amoxy-clav caused a significant improvement in all the signs and symptoms after a 10-day treatment period. However, between-the-group comparisons showed that the reduction i nmost of the symptoms was significantly more in cefaclor arm as compared to amoxicillin-clav arm. The clinical success (clinical cure + improvement) at the end of therapy was significantly more in cefaclor arm: 98% with cefaclor versus 85% with amoxicillin+clav, p<0.05 (Table 3). Failure cases were prescribed other antibiotics according to the culture sensitivity reports, as rescue medication. Bacterial eradication rates were largely consistent with clinical responses. Bacteriological eradication was seen in 95% of patients in cefaclor group and 78% of patients in amoxicillin+clav group. In conclusion, cefaclor is a well tolerated and effective antibacterial option for acute otitis media in children and it is superior to the combination of amoxicillin+clav in efficacy and tolerability in acute AOM. Moreover, its expanded spectrum of activity, ability to achieve adequate concentrations in tissues, suitability for twicedaily dosing, and proven tolerability suggest that it is a good alternative to agents traditionally used in acute otitis media.

How robust are health plan quality indicators to data loss? A Monte Carlo simulation study of pediatric asthma treatment

OBJECTIVES

(1) To test the robustness of a health plan quality indicator (QI) for persistent asthma to various forms of data loss and (2) to assess the implications of the findings for other health plan quality measures.

DATA SOURCES/STUDY SETTINGS

Maryland Medicaid fee-for-service (FFS) claims. Children with asthma (n = 5,804) were selected from Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1996 and December 1997.

STUDY DESIGN

A variant of a HEDIS measure for treatment of persistent asthma (the percent of asthma patients filling two or more rescue medications who also filled a controller medication) was selected to test the robustness of proportion-based QIs to loss of data. Data loss was simulated through a series of Monte Carlo experiments.

DATA COLLECTION/EXTRACTION METHODS

Merged FFS medical and prescription claims.

PRINCIPAL FINDINGS

The asthma QI measure was highly robust to systematic and random data loss. The measure declined by less than 2 percent in the presence of up to a 35 percent data loss. Redundancy in the numerator of the QI significantly increased the robustness of the measure to data loss.

CONCLUSIONS

A HEDIS-related QI measure for persistent asthma is robust to data loss. The findings suggest that other proportion-based quality indicators, particularly those in which plan members have multiple opportunities to meet the numerator criterion, are likely to reflect true levels of health plan quality in the face of incomplete data capture.

Employer-Sponsored Health Insurance And Prescription Drug Coverage For New Retirees: Dramatic Declines In Five Years

Employer-sponsored health insurance is often described as the most reliable private source of Medicare supplementation, particularly for prescription drug benefits. This study's findings show that employer coverage is becoming an increasingly less dependable source of coverage for new retirees, and the problem is likely to get worse. We found that the proportion of Medicare beneficiaries ages 65-69 with employer coverage declined from 46 percent in 1996 to 39 percent in 2000. The proportion with drug coverage from an employer declined from 40 percent in 1996 to 35 percent in 2000. Losses among males, the group most affected, would have been even greater had it not been for a slight increase in benefits from spouses' policies.

Impact of pharmacists' directive guidance behaviors on patient satisfaction

OBJECTIVE

To determine the impact of directive guidance (DG) behaviors by pharmacists on patient satisfaction with pharmaceutical care services. DG behaviors are social support behaviors and include such activities as supplying information about medications and providing encouragement and feedback regarding drug therapy.

DESIGN

Cross-sectional observational study using a self-administered survey.

SETTING

Two university-affiliated ambulatory care clinics, two chain pharmacies, and one independent pharmacy.

PATIENTS

One hundred sixty patients with a chronic disease (e.g., asthma, hypertension, diabetes).

MAIN OUTCOME MEASURE

Patient satisfaction with pharmaceutical care services.

RESULTS

A total of 160 completed questionnaires were collected from patients at 5 sites. Overall, patients patronizing ambulatory care clinics perceived higher rates of DG behaviors and were more satisfied with pharmaceutical care services, compared with patients in community pharmacies (P < .05). The hierarchical regression model was significant (F(13,112) = 4.9091, P < .001). DG behaviors explained 32.4% (P < .001) of the variance in patient satisfaction with pharmaceutical care services.

CONCLUSION

Higher rates of DG behaviors by pharmacists are associated with greater patient satisfaction with pharmaceutical care services.

Developing a community-specific health-related quality of life (HRQOL) questionnaire for asthma: the Asthma-Specific Quality of Life Questionnaire for Native American Adults (AQLQ-NAA)

The Asthma Quality of Life Questionnaire for Native American Adults (AQLQ-NAA) was developed by modifying the Asthma Quality of Life Questionnaire-Marks (AQLQ-M) using the focus group technique. The 19-item AQLQ-NAA has emphasis on restrictions in social, community, and cultural activities. Higher scores indicate a better quality of life. The modified questionnaire was administered to a sample of 51 Native American adults with asthma at the Albuquerque USPHS Indian Hospital and its affiliated field clinics. Principal components analysis identified three domains with eigenvalues greater than 1.00: Community and Social Restrictions (CSR), Psychological Impact (PIM), and Symptoms (SYM). Cronbach's coefficient alpha for the AQLQ-NAA was 0.95 and ranged from 0.82 to 0.93 for the individual domains, indicating good internal consistency. The AQLQ-NAA score correlated negatively and significantly to urgent care visits, physician visits, and total number of medications taken for asthma in the past 6 and 12 months (p < 0.05). Additionally, the AQLQ-NAA score was correlated positively and significantly to medication adherence in the past 6 and 12 months (p < 0.05). Similar patterns of correlations were found with all three domain scores. These results indicated that there is evidence for the construct validity of the AQLQ-NAA and its domains. The AQLQ-NAA should provide a useful measure of HRQOL in asthma-specific medical interventions for the population in which it was developed.

The lateral island trapezius myocutaneous flap for circumferential reconstruction of hypopharynx and cervical esophagus

The lateral island trapezius was utilized for reconstruction of hypopharyngeal and cervical esophagus defects in high-risk patients, avoiding entry into the celomic cavities as an approach to decrease morbidity and mortality. Seven male patients were treated at the State University of New York between 1988 and 1991 and underwent reconstruction with the lateral island trapezius flap. There was no mortality, 2 patients developed pharyngocutaneous fistulas; 1 patient operated after radiation treatment failure remained with positive margins at resection but his fistula never healed, and another patient underwent a minor revision with successful closure of the fistula. All patients regained swallowing and none required dilatations. The preferred methods of reconstruction for the reasonable risk patient are gastric pull-up and free jejunal transfer; both of which require entry into cavities. The lateral island is a reliable alternate method of reconstruction for high-risk patients in whom intracavitary surgery may lead to unacceptably high morbidity and mortality. When the vascular anatomy is not favorable, rerouting of the vessels may be required utilizing microvascular reconstruction. The donor site defect is closed primarily or skin grafted, and subsequent functional limitations are minimal and well tolerated.

The impact of pharmaceutical services in community and ambulatory care settings: evidence and recommendations for future research

OBJECTIVE

To review and evaluate research on pharmaceutical services in community and ambulatory care pharmacy settings, specifically study designs and patient outcome measures, and to provide recommendations to improve future research on pharmaceutical services in community and ambulatory care pharmacy settings.

DATA SOURCE

English-language articles were identified by searching MEDLINE (1966-December 1998) and International Pharmaceutical Abstracts (1970-December 1998), using a combination of search terms: pharmacist services, pharmacist interventions, community pharmacy, ambulatory care, primary care, and patient outcomes. Relevant studies were selected based on article abstracts.

DATA EXTRACTION

From each relevant study, we extracted the study objectives, sample size, study period, study design, major tasks performed by pharmacists, and economic, clinical, and humanistic outcomes (ECHO). Results were tabulated separately for research on community pharmacy and ambulatory care pharmacy settings.

RESULTS

We identified 95 relevant studies. Of these, 21 studies were conducted in community pharmacy settings and 74 in ambulatory care settings. Ten community pharmacy studies used prospective, single group, pretest/posttest, or posttest only designs; seven used prospective two or more group comparison designs; and four used randomized, controlled designs. Nine studies on community pharmacies measured clinical outcomes, two measured humanistic outcomes, and five measured economic outcomes. Four studies measured both clinical and humanistic outcomes and one measured humanistic and economic outcomes. No study measured all three ECHO variables. Twenty-three studies in ambulatory care settings used prospective or retrospective, single group, pretest/posttest or posttest only designs; 21 used prospective or retrospective two-or-more group comparison designs; and 30 used randomized, controlled designs. Thirty-six measured clinical outcomes, five measured humanistic outcomes, and 15 measured economic outcomes. Fifteen studies measured clinical and economic outcomes and three measured clinical and humanistic outcomes.

CONCLUSIONS

Only 21 of 95 selected studies were conducted in community pharmacy settings and measured the impact of pharmaceutical services on patient outcomes. Few studies employed adequate research designs to control threats to internal and external validity. In order to obtain a comprehensive and accurate picture of the impact of pharmaceutical services on patient outcomes, an attempt must be made to measure all three ECHO variables while employing adequate research design.

Convulsions in tuberculous meningitis

One-hundred-and-thirty-six children below 12 years of age hospitalized with a diagnosis of tuberculous meningitis (TBM) have been investigated to identify the underlying cause of convulsions. One-hundred-and-one children (74 per cent) presented with seizures before and/or during hospitalization. Generalized tonic and clonic seizures (GTCS) were the commonest (58 per cent) type of seizures followed by focal seizures (FS) (38 per cent) and tonic spasms (TS) (4 per cent). EEG changes were more frequently observed in cases with FS and in those children with GTCS who presented after first week of hospitalization. EEG findings included generalized dysrythmia with paroxysmal slow activity (38 per cent), interhemispheric asymmetry (23 per cent), multiple spike and wave pattern (10 per cent), and focal spike and wave pattern (15 per cent). CT scan findings were more common in those children with GTCS and TS who presented with recurrent seizures and/or seizures manifesting after first week of hospitalization. FS presenting at any stage of the disease were associated with CT scan abnormalities. Abnormalities detected in CT scan of brain included meningeal enhancement (55 per cent), hydrocephalus (32 per cent), tuberculomas (27 per cent), and cerebral infarctions (13 per cent). Clinical presentation and investigations indicate that the probable cause of convulsions could be attributed to cerebral edema (57 per cent), syndrome of inappropriate secretion of antidiuretic hormone (35 per cent), hydrocephalus (32 per cent), tuberculoma (27 per cent), abnormal electric focus (25 per cent), and cerebral infarction (13 per cent).

Long-term anticonvulsant therapy in tuberculous meningitis--a four-year follow-up

A treatment protocol for long-term anticonvulsant therapy (ACT) in children with tuberculous meningitis (TBM) has been followed depending upon clinical characteristics and EEG/CT scan findings suggestive of the underlying cause of convulsions. Sixty-three children which included all patients with focal seizures (FS), and those with generalized tonic and clonic seizures (GTCS), and tonic spasms (TS) manifesting more than once during hospitalization and/or associated with abnormal CT/EEG findings were given long-term ACT (Group A). Thirty-eight cases with GTCS before hospitalization, and/or not more than one seizure during first week of hospitalization and without any specific CT/EEG abnormalities (Group B) and 35 cases without any seizures (Group C) did not receive any ACT. Forty-four patients who were finally discharged on long-term ACT, were given phenobarbitone (57 per cent), phenytoin (23 per cent), and a combination of phenobarbitone+phenytoin (14 per cent), and phenobarbitone+sodium valproate (7 per cent). Follow-up was continued for 4 years with 93, 84 and 81 per cent attendance, respectively, in groups A, B and C. Some of the side-effects observed with anti-convulsant drugs included gingival hypertrophy in 11 out of 16 cases (69 per cent) on phenytoin, hyperkinetic behaviour in 3 out of 34 (9 per cent) cases on phenobarbitone, hypocalcaemia in 3 out of 44 cases (7 per cent), hypophosphataemia in 10 out of 44 cases (23 per cent) and increase in alkaline phosphatase in 14 out of 44 cases (32 per cent). CT scan of brain repeated in six cases with multiple tuberculomas showed marked improvement. While 4 out of 41 (10 per cent) cases in group A had recurrence of seizures in the follow-up, only 2 out of 28 cases (7 per cent) in group B presented with GTCS during first 3 months after discharge which was successfully controlled by long-term ACT in later part of the follow-up. Two out of 21 cases (10 per cent) in group C also presented with myoclonic seizures 3 and 5 months after discharge. There was no statistically significant difference in the recurrence/appearance of seizures in the three groups (P = > 0.05). Our results suggest that long-term ACT is not indicated in all cases of TBM with seizures. In view of the known side-effects of anticonvulsant drugs and danger of interaction with antitubercular drugs, it is mandatory to clinically evaluate the patients, identify the cause and restrict long-term ACT only to those cases who are likely to have some abnormal focus resulting in secondary epilepsy. All the cases with FS and some of the patients with GTCS and TS may need to be started on ACT. However, a close follow-up is necessary in all particularly in those for whom ACT has been withheld.

Childhood tuberculosis in a referral centre: clinical profile and risk factors

One hundred and ninety six children (age group 6 months to 12 years) attending the Pediatric Tuberculosis Clinic at AIIMS, New Delhi, over a period from January 1988 to December 1989 were analysed. Nearly 61% of children were malnourished (Grades III and IV). A positive family history was noted in nearly one third (33.7%) of cases while 41.3% of children had received BCG. A positive Mantoux test was noted in 77% of cases. The most prominent lesion on radiology was parenchymal (51.4%). In nearly two third of cases, both Mantoux test and X-ray chest was positive. A family history of tuberculosis and BCG vaccination was significantly associated with positive Mantoux test (p < 0.01). Fever and cough in older children (> 6 years) while weight loss in younger children (< 3 years) were the predominant symptoms. Most of the cases (82.1%) had pulmonary primary complex, the proportion being higher in older age group. The severe form of tuberculosis, i.e., progressive primary disease, military tuberculosis, etc., were significantly more in younger children. The various risk factors significantly associated with severe form of tuberculosis were very young children (< 3 years), no BCG vaccination, a negative family history and a negative Mantoux test.

Prevention of hypoglycemia: a controlled evaluation of sugar fortified milk feeding in small-for-gestational age infants

The study population included 110 term healthy small-for-gestational age (SGA) infants having a blood sugar of > 30 mg/dl at the age of < 30 minutes. They were randomized into two groups; (a) Group I (study group) received sugar-fortified milk formula and (b) Group II (control group) received standard milk formula. A minimum of 80 ml/kg/24 hour of milk was given. The first feeding was given within 45 minutes of birth and subsequently at 2 hours of age and then every 2 hourly till the age of 24 hours. The blood sugar (initial within 30 minutes of birth) was monitored at the age of 2, 4, 12 and 24 hours by dextrostix. The babies on fortified feeds received significantly (p < 0.001) higher amount of carbohydrate (8.1 mg/kg/min) as compared to those on standard milk (5.1 mg/kg/min). The incidence of hypoglycemia was reduced significantly (p < 0.01) by the sugar-fortified feeds. The mean blood sugar level in babies receiving fortified feeds was significantly higher at all the ages as compared to those receiving standard feeds. Nearly all the babies who subsequently developed hypoglycemia had a preceding blood sugar value of less than 60 mg/dl. The study highlights that sugar-fortified milk feeds are useful in preventing hypoglycemia in SGA infants and should be routinely recommended along with breast feeding in developing countries especially when facilities for monitoring of blood sugar are unsatisfactory or not available.

Spectrum of neonatal hyperbilirubinemia: an analysis of 454 cases

A prospective study of 454 newborn babies with pathological hyperbilirubinemia revealed that in about one-third of cases (34.6%), no cause could be identified despite detailed investigations. Nearly three-fifth of infants (62.5%) had hyperbilirubinemia due to hemolytic causes. On the basis of four variables, i.e., peak serum bilirubin level, age of attaining the peak level, age of starting phototherapy and total duration of phototherapy, the cases of hyperbilirubinemia can be categorized into three groups: (a) Group I (mild) included non-hemolytic hyperbilirubinemia, i.e., idiopathic, bacterial infections, intrauterine infections and others, (b) Group II (moderate) comprised of hemolytic as well as non-hemolytic hyperbilirubinemia due to prematurity, administration of oxytocin, bruising/cephalhematoma, and (c) Group III (severe) comprised of hyperbilirubinemia due to hemolysis as a result of blood group incompatibility between the mother and the neonate and G-6-PD deficiency. Sixty six babies required exchange blood transfusion (EBT) and a total of 100 EBTs were performed. Most of the babies (80.3%) requiring exchange blood transfusion belonged to Group III. The most common cause of hemolytic hyperbilirubinemia needing exchange blood transfusion was Rh isoimmunization followed by G-6-PD deficiency and ABO isoimmunization. There was no death attributable to the procedure of exchange blood transfusion.

Neonatal hypoglycemia--clinical profile and glucose requirements

A total of 2248 infants born at All India Institute of Medical Sciences Hospital, New Delhi were selectively screened for hypoglycemia over a period of 15 months. Hypoglycemia (blood glucose less than 30 mg/dl) was diagnosed in 107 cases (4.8%). Preterm babies had three times increased risk (12.8%) as compared to term babies (3.6%). Small-for-dates (SFDs) and large-for-dates (LFDs) infants were at increased risk of manifesting hypoglycemia (7 and 10 times, respectively) as compared to the appropriate-for-dates (AFDs) babies (2.7%). Approximately two-thirds of the hypoglycemic babies (67.3%) had one or more risk factors including birth asphyxia (24.2%), diabetic mothers (23.8%), respiratory distress (13.9%) and septicemia (11.6%). A total of 59.8% cases were asmyptomatic while the rest had one or more symptoms. The most common symptom observed was lethargy (81.4%), followed by jitteriness (67.4%), respiratory abnormalities (41.9%), hypotonia (39.5%) and seizures (30.2%). The amount of glucose (mg/kg/min) needed to maintain a stable blood sugar in various categories of hypoglycemic babies was observed to be in the following decreasing order of amount; symptomatic babies with seizures (Gp IV), IGDM's/IDM's and symptomatic babies with other features (Gp III), SFDs and LFDs (Gp II) and AFDs (Gp I). Such a categorization of hypoglycemic babies will help to treat them more precisely.

A controlled study of sugar-fortified milk feeding for prevention of neonatal hypoglycaemia

Healthy term, large for gestational age (LGA) infants (130) with blood sugar greater than 30 mg/dl at the age of less than 30 min were randomized into two groups. Group I (study group) babies received sugar-fortified milk formula while group II (control group) received standard milk formula. Milk was fed at a minimum of 80 ml/kg/24 h. The first feed was given within 45 min of birth and subsequently at 2 h of age and then 2 hourly till the age of 24 h. The blood sugar (initial within 30 min of birth) was monitored by dextrostix at the age of 2, 4, 12 and 24 h. The babies on fortified feeds received significantly (P less than 0.001) higher amount of carbohydrate (8.2 mg/kg/min) as compared to those on standard milk (5.2 mg/kg/min). The incidence of hypoglycaemia was reduced significantly (P less than 0.05) by the sugar fortified feeds. The mean blood sugar level in babies receiving fortified feeds was significantly (P less than 0.001) higher at all ages as compared to those receiving standard feeds. Nearly all the babies who subsequently developed hypoglycaemia had an earlier blood sugar level of less than 60 mg/dl. The study shows that sugar-fortified milk feeds are useful in preventing hypoglycaemia in LGA infants and should be routinely recommended in the special care neonatal units of developing countries especially when facilities for monitoring blood sugar are unsatisfactory or unavailable.

Clinical profile of trichotillomania

Twenty-four cases of trichotillomania attending psychiatry outpatient department and child guidance clinic at Kalawati Saran Children's and Smt Sucheta Kriplani Hospitals over a period of 2 years from July, 1985 to November 1987 were studied. Females (66.7%) outnumbered the males (33.3%). Majority of cases belonged to age group 6-10 years (54.2%) and nuclear family (68.5%). Nail-biting (25.0%) was the commonest associated neurotic trait, followed by enuresis (20.9%), temper-tantrum (12.5%), etc. A past history of hysterical fits and neurotic depression was found in 3 cases (12.5%) and 2 cases (8.3%) respectively. Family history of neurosis was seen in mothers and fathers of 20.9% and 12.5% cases respectively. Trichobezoars and trichophytobezoars were found in 6 cases (25.0%) and 3 cases (12.5%) respectively. Majority of patients of trichobezoars presented with vague complaints like heaviness in the stomach (55.6%), inability to gain weight (44.4%), etc, while 22.2% cases were asymptomatic and detected only on screening.

Maternal participation in the care of the high risk infant: follow-up evaluation

Fifty mothers of high risk infants admitted to the Neonatal Special Care Unit were followed up to the postnatal age of 2.5 mo +/- 15 days. Twenty five mothers (Group I) had stayed in the nursery with the infant for a period of 4.8 +/- 4.6 days until the discharge of the infant, providing expressed milk and participating in the non-specialised care of the infant. The other 25 mothers (Group II) remained separate from their babies for the duration of the latter's stay in the hospital although some of the mothers did come off and on to give expressed human milk and at times handle their infants. Family features such as parental age, educational and occupational status, and presence of residential elder women, were similar in the two groups. Infant characteristics too, such as sex, birth weight, and early neonatal morbidity were also comparable. Operative deliveries and maternal problems were as expected more in the separated group. The duration of the infants' hospital stay was also more in the latter (9.5 +/- 3.5 vs 6.3 +/- 3.9 days; p greater than 0.05). Subsequent to their discharge, mothers who had stayed with the infant identified the following benefits of their stay--acquiring of knowledge relevant to infant care especially hygiene (19) and their personal involvement in the care of their infant (12), both of which they said increased their self confidence in looking after the babies after discharge, and provision of breast milk round the clock (17).(ABSTRACT TRUNCATED AT 250 WORDS)

Neurodevelopmental outcome of asymptomatic & symptomatic babies with neonatal hypoglycaemia

A total of 107 babies with hypoglycaemia were studied over a period of 15 months. Symptomatic hypoglycaemia was found in 43 while it was asymptomatic in the others. Asymptomatic hypoglycaemia occurred at a relatively earlier post-natal age (4.5 +/- 2.2 h), as compared to symptomatic hypoglycemia (18.5 +/- 5.4 h, P less than 0.001). The mean blood glucose in hypoglycaemic babies with seizures was found to be significantly lower (P less than 0.001) when compared to those with other features as well as asymptomatic ones. Hypoglycaemia lasted for a significantly longer duration in symptomatic babies as compared to those without symptoms (P less than 0.001). On neurodevelopment follow up the mental developmental index (MDI) and the psychomotor developmental index (PDI) of symptomatic babies with seizures were significantly lower (P less than 0.001) as compared to those with other features of hypoglycaemia as well as asymptomatic babies. The neurodevelopmental status of babies with symptoms other than seizures was also significantly poorer (P less than 0.001), when compared to asymptomatic hypoglycaemic babies. The duration of hypoglycaemia was directly related to the MDI (r = -0.74, y = 102.5 - 0.69x) and PDI (r = -0.81, y = 105.6 - 0.86x). This study indicates that there is a need to identify babies vulnerable to symptomatic hypoglycaemia more precisely.

Breath holding spells: an analysis of 50 cases

Of 50 preschool children having breath holding spells (M:F::3:1) (BHS), 80.0% were less than 18 months of age (mean age 16 +/- 5 mo). More children came from a lower social class (70.0%) and a nuclear family (64.0%). Seventy four per cent cases had onset of BHS within 12 months of age (mean 9.6 mo) and the commonest frequency was 1 to 3 spells per week (56.0%). Cyanosis and tonic-clonic spasms were seen in 96.0 and 84.0% cases, respectively. Anger and frustration were the common triggering factors in 90.0% cases. No ante-, peri- and postnatal factors were significantly associated with the study group as compared to the control cases. The mean scores on Behaviour Screening Questionnaire measuring child's habits related to feeding, toilet and sleep were not significantly different in the study and control groups but the difference was significant (p less than 0.05) for behaviour measuring child's social habits. Parental attitudes, measured on Attitude Screening Questionnaires, were also not significantly different in the study and control groups. Mean hemoglobin and percentage transferrin saturation were significantly lower in the study group as compared to the controls (p less than 0.001). There was a significant decrease in severity and frequency of spells with oral iron therapy.

Temper tantrums. Prevalence and etiology in a non-referral outpatient setting

Of a total of 800 children (aged 3-12 years) attending a pediatric outpatient department, 182 (22.8%) were found to be having temper tantrums (mean age, 4.7 years). Temper tantrums were found to be most common at 3-5 years (75.3%), less common at 6-8 years (20.8%), and least common at 9-12 years (3.9%). Children aged 3-5 years were more likely to be of a lower social class (p less than 0.01), whereas in other age groups (6-8 years and 9-12 years) children were more likely to be of an upper social class. Boys dominated the study significantly: the ratio of boys to girls was 3.1:1. Boys having temper tantrums were more likely to be of an upper social class (p less than 0.001) compared with girls, who tended to be of a lower social class (p less than .01). Children showed a higher incidence of history of postnatal trauma and seizure disorder compared with the control group (p less than 0.05). Parental overprotection and marital discord were found to be stress factors in a significantly higher number of boys than girls (p less than 0.01); parental negligence was a significant stress factor for girls (p less than 0.01). Associated behavioral problems, such as thumb sucking, enuresis, tics, head banging, sleep disturbances, and hyperkinesis were found to be significantly higher among children with tantrums.