Life prolonging of disease management programs in patients with type 2 diabetes is cost-effective

AIM

Our objective was to examine the cost-effectiveness of disease management programs (DMPs) for type 2 diabetes mellitus (T2DM) taking into account their life prolonging effect.

METHODS

We compared real life costs in 19,888 propensity score matched pairs of T2DM DMP participants and T2DM patients in routine care (RC) according to sickness funds data. We estimated mean annual costs for survivors, last year of life costs for decedents, the influence of ageing on costs, incremental cost-effectiveness ratio and effects on hospitalization.

RESULTS

Annual costs for survivors were 3,318€ (DMP) and 3,570€ (RC). The mean costs in the last year of life were 16,911€ (DMP) and 15,763€ (RC). Ageing had a cost triggering effect for survivors (30€/36€ per year in DMP-/RC-group; p<0.001) and a cost decreasing effect in the last year of life (546€/483€ per year in DMP-/RC-group; p<0.001). The incremental cost-effectiveness ratio of the DMP vs. RC was -1396€ per life-year gained. Hospitalizations increased with age in case of survival and decreased with age in case of death but were always lower in the DMP-group.

CONCLUSION

Despite increase in costs due to longer life DMPs are cost-effective.

[Analysis of selection inventives for health insurances after introduction of the morbidity-oriented risk compensation scheme: an empirical analysis]

BACKGROUND

The risk compensation scheme (RCS) in the Statutory Health Insurance (SHI) was implemented in 1994 to discourage risk selection between sickness funds. However, several expertise papers have concluded since then that the sociodemographic risk adjusters in place could not adequately curb risk selection. To minimise incentives for risk selection in the Statutory Health Insurance (SHI) further, the RCS was refined in 2009 by adding 80 diseases as additional risk adjusters. In spite of the better compensation of differences in morbidity, however, incentives for risk selection may still persist. In this study, we investigated the association of indicators such as region (number of inhabitants in the city), income, level of education and family status (children in the household) with health care costs to determine if risk selection is still attractive for sickness funds under the refined RCS.

METHOD

The analysis is based on a 2002 cross-section survey comprising 75,122 individuals. Health expenditures were estimated using self-documented utilisation data and were standardised for age, sex and diagnoses covered by the risk adjustment scheme. We included costs for inpatient care, outpatient care, pharmaceuticals, rehabilitation, and medical devices. To assess the effects of the above-mentioned individual characteristics on health-care expenditure, regression analyses and analyses of variances were performed.

RESULTS

Full documentation was available for 52,484 individuals (69.86%). From these the variables "family status (children in the household)", "higher educational level", and "higher income" were associated with lower costs for individuals without chronic conditions. For individuals with chronic conditions, results were mixed. "Family status", "education" and "income" showed no clear association with lower or higher costs and were not statistically significant. The variable "region" was neither significantly associated with chronically ill nor for healthy individuals.

DISCUSSION

With respect to age, sex, and morbidity, individuals with high income and education and without chronic diseases apparently cause lower costs. Thus, health status, income and education remain as possible selection criteria for sickness funds in Germany. However, the refined RCS compensates for the largest proportion of cost differences between insured with and without chronic disease. Possible causes of the small but remaining differences and whether improving preventive programmes or providing awareness campaigns may be appropriate strategies to tackle this issue should be investigated in future research.

Triclabendazole for the treatment of fascioliasis and paragonimiasis

Fascioliasis and paragonimiasis, which are caused by liver flukes (Fasciola) and lung flukes (Paragonimus), are emerging public health problems. Several hundred millions of people are at risk of the two diseases that cause considerable morbidity and delay socio-economic development. Triclabendazole, a benzimidazole derivative, has been routinely used since 1983 in veterinary medicine to control infections with Fasciola spp. in domestic herbivorous animals. In 1986, a veterinary formulation of triclabendazole was first administered to two human patients with fascioliasis. Clinical data obtained thus far suggest that triclabendazole is the most efficacious and best tolerated drug for the treatment of fascioliasis. Moreover, the drug holds promise as a useful therapeutic alternative to praziquantel in the treatment of paragonimiasis. This review of triclabendazole includes an overview of the pharmacodynamics and pharmacokinetics, toxicology and efficacy against the major food-borne trematodes in laboratory animals. Data from case reports and clinical trials in humans infected with Fasciola spp. and Paragonimus spp. are summarised and the current state of triclabendazole regarding treatment of human fascioliasis and paragonimiasis is described. Efforts to facilitate broader registration of this drug should go hand-in-hand with research and development on novel drugs against food-borne trematodiasis, better access to improved sanitation, sound health education and the development of new technologies for assuring food safety.

Efficacy of a single milbemycin oxime administration in combination with praziquantel against experimentally induced heartworm (Dirofilaria immitis) infection in cats

The efficacy of a combination of milbemycin oxime and praziquantel in preventing the establishment of experimentally induced heartworm (Dirofilaria immitis) infection was investigated in a study involving 24 young domestic short-hair cats. The animals were inoculated with 50 infective larvae on day 0. Subsequently they were divided into two groups of 12 animals each. The animals in group 1 were treated once with medicated tablets containing 4 mg milbemycin (minimum dose 2 mg/kg body weight) and 10 mg praziquantel (MILBEMAX) on day 30 after infection. Cats in group 2 received placebo tablets on the same day. On day 183 post-infection a blood sample was taken from each animal before euthanasia and necropsy. The blood samples were tested for the presence of microfilariae and the necropsied animals were examined for the presence of adult worms. Microfilariae were not found in any of the investigated cats. No heartworms were found in the animals in group 1 (treated with medicated tablets). Out of the 12 placebo-treated cats 1 was heartworm-free, whereas all the others were found to be infected with 1-3 adult heartworms.

Efficacy of milbemycin oxime against fourth-stage larvae and adults of Ancylostoma tubaeforme in experimentally infected cats

The efficacy of milbemycin oxime against fourth-stage (L4) larvae and adults of Ancylostoma tubaeforme was investigated in a trial involving 24 young domestic shorthair cats. The animals were inoculated with approximately 300 infective stage three (L3) larvae and divided into three groups. After 12 days, eight cats (group 1) were treated with medicated tablets containing 4 mg milbemycin and 10 mg praziquantel to test the efficacy against L4 larvae; eight cats in group 2 were treated with the same tablets after 33 days to test the efficacy against adult worms; and eight cats in group 3 were treated with a placebo tablet. Faecal egg counts were determined periodically in each cat and after 40 or 41 days the number of worms in each animal was determined postmortem. The egg count reduction was determined by comparing the geometric mean numbers of eggs per gram of faeces in the placebo and medicated groups, and the worm reduction by comparing the geometric mean numbers of worms. The egg count reduction was more than 99 per cent in both treated groups, while the number of worms in groups 1 and 2 were reduced by 94.7 per cent and 99.2 per cent, respectively.

The efficacy of triclabendazole and other anthelmintics against Fasciola hepatica in controlled studies in cattle

In eight controlled tests 274 cattle were used to assess the efficacies of triclabendazole, albendazole, clorsulon, nitroxynil, oxyclozanide and rafoxanide against Fasciola hepatica. Against one-, two- and four-week-old early immature fluke the mean efficacies of triclabendazole given orally at 12 mg/kg were 88.1, 95.3 and 90.7 per cent, respectively. Clorsulon, nitroxynil and rafoxanide administered at recommended dose rates showed negligible activity against these stages of the parasite. Against six- and eight-week-old infections the mean efficacies of triclabendazole at 12 mg/kg were 87.5 per cent and 95.7 per cent, respectively. Against F hepatica aged six weeks, albendazole and oxyclozanide showed no activity and clorsulon, nitroxynil and rafoxanide had only slight to moderate activity. The efficacies of triclabendazole, clorsulon, nitroxynil and rafoxanide against 10- or 12-week-old parasites were 100, 99.0, 99.1 and 90.1 per cent, respectively. Albendazole and oxyclozanide showed poor efficacy against 12-week-old infections.

The effects of triclabendazole on the lung fluke, Paragonimus uterobilateralis in the experimental host Sigmodon hispidus

The new veterinary drug triclabendazole (Fasinex) was tested for its anthelmintic activity against adult Paragonimus uterobilateralis in experimentally infected cotton rats, Sigmodon hispidus. After a single dose of 50, 100 or 150 mg/kg b.w. triclabendazole or after two doses of 5 or 10 mg/kg b.w. given at an interval of 24 hours, 56-61% of the flukes were dead at three to five weeks after treatment. Two doses of 50 or 75 mg/kg b.w. triclabendazole killed all flukes. The flukes, which were still alive three to five weeks after treatment, were significantly smaller than the un-treated controls. Histological sections from these flukes showed severely damaged tissues. It is assumed that these flukes would have died later.

The infection of various tick species with Babesia bigemina, its transmission and identification

Strains of Boophilus decoloratus and B. microplus were easily infected with a single stock of Babesia bigemina; Boophilus annulatus could be infected less easily, and it was difficult to infect Rhipicephalus evertsi. Two strains of R. appendiculatus and one strain each of R. bursa and Hyalomma anatolicum excavatum were refractory. The same stock of B. bigemina was transmitted by nymphs and adults of B. decoloratus but only by nymphs of R. evertsi. Vertical infection was not observed in R. evertsi, whereas it persisted in B. decoloratus for at least two generations. The sporokinetes in the hemolymph of R. evertsi were significantly shorter than those in the three Boophilus species.

Quantitative description of the development of Babesia ovis in Rhipicephalus bursa (hemolymph, ovary, eggs)

The development and infection dynamics of Babesia ovis in the hemolymph, ovaries, and eggs of Rhipicephalus bursa are described quantitatively, based mainly on examination of Giemsa-stained smears. After alimentary infection of female ticks, their hemolymph became infected 5 days after repletion (p.repl.). The prevalence and mean intensity of infection increased during the course of infection studied, up to 17 days p.repl. After vertical infection of female ticks, their hemolymph was infected only during the first 3 days after the onset of infestation (p. infest.) and again after the onset of alimentary infection 5 days p.repl. There was a positive correlation between prevalence and mean intensity of infection in the hemolymph. The prevalence of infection decreased with aging of the unfed adult ticks. After alimentary infection, the ovaries became infected 6 days p.repl., and after vertical infection, 3 days p. infest; they remained infected until the death of the tick. Ticks selected for susceptibility during 18 and 19 vertically infected generations were more susceptible than ticks in their first to third vertically infected generations or alimentarily infected ticks. Eggs deposited on day 1 of oviposition were noninfected after alimentary infection of the female tick. After vertical infection of the tick, even such eggs became infected; the infection, then, was detectable in eggs produced throughout the oviposition period regardless of the infection mode. Intense hemolymph infections induced an increase of egg degeneration and a decrease of total as well as infected egg production. There was a positive correlation between the number of deposited and infected eggs as well as between prevalence and mean intensity of infection in eggs.(ABSTRACT TRUNCATED AT 250 WORDS)

Transmission of Trypanosoma theileri to cattle by Tabanidae

Tabanids were collected in an area in northern Germany, where pastured cattle were abundant. Trypanosomatidae were identified in 14% of tabanids examined. Twelve cattle became infected with Trypanosoma theileri after applying usually 2-5 infected tabanids, to the intact oral mucosa. Haematopota pluvialis, Haematopota italica, Hybomitra micans and Tabanus bromius were identified as vectors. Infective stages of Trypanosoma theileri were identified in the gut and in the faeces of tabanids by transmission experiments. The minimum prepatent period was less than 4 days. No apparent signs of disease were observed in the infected cattle.

Stercorarian trypanosomes from deer (Cervidae) in Germany

Twenty of 35 roe deer (Capreolus capreolus), eight of 12 red deer (Cervus elaphus), and nine of 21 fallow deer (Cervus dama) but none of four moose (Alces alces) examined from April to November 1983 were infected with trypanosomes. Morphometric data of the bloodstream trypomastigotes from the three deer species differed significantly. This appears to be the first report of stercorarian trypanosomes from Cervidae in the Old World and the first description of representatives of the subgenus Megatrypanum in the three deer species.

Titration in cattle of infectivity and immunogenicity of autologous cell lines infected with Theileria parva

Cell lines infected with Theileria parva were derived by infection of bovine peripheral blood lymphocytes with sporozoites in vitro. Cattle were inoculated with doses of autologous infected cells ranging from 1 X 10(1) to 1 X 10(8). Infection became established in animals which received 1 X 10(2) or more cells. While 1 X 10(2) cells resulted in sub-patent infection with development of immunity to challenge with sporozoites, larger doses of cells gave rise to patent infections of increasing severity. Thus, doses of 1 X 10(5) and 1 X 10(6) cells sometimes produced lethal infections and with 1 X 10(7) and 1 X 10(8) the outcome was invariably lethal. Based on the previous observation that induction of immunity by allogeneic cells requires transfer of infection into the recipient-host cells, a comparison of the infections produced by autologous and allogeneic cells indicated that the transfer of infection from allogeneic cells occurs at a frequency of maximally 1 X 10(-5). Two pairs of cattle were identified as being mutually non-reactive in the mixed leukocyte reaction (MLR). Doses of 1 X 10(6) and 1 X 10(7) cells of cell lines derived from 1 animal of each pair were inoculated into the autologous host, the non-reactive partner and an animal which was shown to be strongly reactive to the donor in the MLR. In each instance, the reaction in the MLR non-reactive recipient was not significantly different from that of the MLR reactive recipient, but was markedly different from that of the autologous recipient.

Trypanosomes in Cervidae in Germany

Trypanosoma cervi Kingston et Morton, 1975 was demonstrated in 2 fallow deer (Dama dama) in 1976, and in 10 roe deer (Capreolus capreolus) and one red deer (Cervus elaphus) in spring 1983. The infected deer originated from the vicinity of Hannover, Germany.

The morphology of ovine Trypanosoma melophagium (zoomastigophorea: kinetoplastida)

Morphologic and biometric data on bloodstream stages of Trypanosoma melophagium are presented. An increasing parasitemia with 111 trypomastigote stages of T. melophagium were found in Giemsa-stained thin blood smears taken from a splenectomized, cortisone-treated sheep recently infested with Melophagus ovinus infected with T. melophagium . The arithmetic mean and standard deviation in micron of the distances between posterior end and kinetoplast were 14.7 and 2.9, from the kinetoplastic to the center of the nucleus 5.1 and 1.1, and from there to the anterior end 19.5 and 1.9. The free flagellum measured 6.0 microns +/- 1.6 microns. The median and the range of the central 70% of values (median +/- 35%) of the nuclear index were 1.1 and 0.9-1.2 and of the kinetoplastic index 3.8 and 3.3-4.9. The same data in microns for the maximal width were 3.1 and 2.1-4.6, and for the width at the level of the nucleus 2.9 and 2.2-4.6. The larger and smaller diameters of the nucleus measured 2.6 (2.2-3.7) micron and 1.7 (1.3-1.7) micron, respectively. The corresponding kinetoplast diameters were 1.1 (0.9-1.3) microns and 0.9 (0.6-0.9) micron, respectively.

Salivary gland of the tick vector of East Coast fever. IV. Cell type selectivity and host cell responses to Theileria parva

Responses of cells in the tick salivary gland to parasitism by Theileria parva were studied by electron microscopy. The gland is composed of three distinct types of acini (I, II, III) which together include ten or more different cell types. Of some 30 infected cells observed in the present study, all were E-cells of acinus III. The parasite thus exhibits a high degree of selectivity for acinus and cell type. The glandular cell invaded undergoes massive hypertrophy and accumulates glycogen deposits in its cytoplasm which may serve as an energy source for the growing intracellular parasite. As synthesis of its secretory material declines the product is packaged in progressively smaller secretory granules. The extensive arrays of endoplasmic reticulum are dismantled and eliminated in autophagic vacuoles. Excess secretory granules are also broken down by crinophagy. After 4 days, sporogony is completed and the host cell contains 30,000-50,000 sporozoites in an electron-lucent cytoplasm largely devoid of cytomembranes and secretory granules. Mitochondria are still present and normal in appearance. The loss of basophilia and secretory granules observed heretofore by light microscopy have been attributed to ingestion and destruction of host organelles by the parasite. The pallid appearance of the cytoplasm has been interpreted as a sign of impending degeneration of the host cell. In electron micrographs no ingestion of organelles by the parasite or degenerative changes were found. The host cell clearly remains viable and metabolically active throughout sporogony. The striking changes in its ultrastructure result from active elimination of organelles and inclusions by the host cell itself in response to parasitism.

Salivary gland of the tick vector of East Coast fever. III. The ultrastructure of sporogony in Theileria parva

Sporogony of the sporozoan Theileria parva in the salivary gland of the tick vector of East Coast fever was studied in electron micrographs. The findings differ in several respects from previous interpretations based upon light microscopy. Cytokinesis of the primary sporoblast to form secondary and tertiary sporoblasts is not substantiated. Instead it is suggested that the parasite develops as a ramifying, multinucleate syncytium rapidly increasing in size and complexity until it gives rise to myriad sporozoites in a terminal episode of cytoplasmic fission. The proliferating nuclei initially occupy peripheral lobules that are continuous with a central labyrinth of branching and anastomosing processes which present a very large surface area for interchange of metabolites with the host cell cytoplasm. The membrane of the labyrinth is rich in cytostomes, but no evidence if found to bulk uptake of host cytoplasmic matrix or organelles into food vacuoles. Rhoptries are the first of the polar organelles of the parasite to develop and are associated with dense plaques irregularly distributed on the inner aspect of the parasite membrane. Micronemes form independently of the rhoptries at a later stage. After 3-4 days of tick feeding, sporogeny is complete and the infected salivary gland cell contains up to 50, 000 spherical or ovoid sporozoites about 1 micrometer in diameter. These are limited by a simple plasma membrane. The inner layer of the 'pellicle', the polar ring, and the conoid described for zoites of other Apicomplexa are lacking. Maturational changes are noted in sporozoites after sporogony is completed. Micronemes appear to increase in size, and possibly in number, from days 3-5 and the majority take up positions immediately subjacent to the plasmalemma.

Salivary gland of the tick vector (R. appendiculatus) of East Coast fever. II. Cellular basis for fluid secretion in the type III acinus

Fluid balance is a major physiological problem for hematophagous ticks. To maintain osmotic balance they must conserve water for prolonged periods while seeking a mammalian host, and they must eliminate a very large volume of excess fluid taken in during a relatively short period of feeding. This is accomplished in part by modification of the salivary gland during 7-10 days of feeding to secrete a copious saliva which is pumped into the bovine host. This function has previously been attributed to certain interstitial epithelial cells of the type III acinus which differentiate in the course of feeding into cells reminiscent of those of the avian salt gland. The ultrastructural changes in the type III acinus during the blood-meal were studied. In addition to the differentiation of the interstitial cells, this paper describes a remarkable sequence of changes in external form and internal organization of the e-cells. This results in their transformation from typical protein-secreting glandular cells to transport cells having myriad basolateral processes interdigitating with those of the ablumenal interstitial cells to form a basal labyrinth comparable to that of other fluid-transporting epithelia. The findings are discussed in relation to various postulated mechanisms for fluid and electrolyte transport.

Salivary gland of the tick vector (R. appendiculatus) of East Coast fever. I. Ultrastructure of the type III acinus

The brown ear tick Rhipicephalus appendiculatus is the vector for East Coast fever, a disease that seriously limits livestock production in East Africa. The sporozoites of the infectious agent Theileria parva develop in the tick salivary gland. This paper describes the organization of the type III acinus of the gland and establishes unambiguous ultrastructural criteria for identification of the three secretory cell types: the d-cell, e-cell and f-cell. These observations are basic to exploration of possible cell-type specificity of the invading theileria and other aspects of host-parasite relations.

[Light microscopic studies on the development of Theileria annulata (Dschunkowsky and Luhs, 1904) in Hyalomma anatolicum excavatum (Koch, 1844). I. The development in the gut of engorged nymphs (author's transl)]

A laboratory strain of H. a. excavatum was selected on high susceptibility for T. annulata through several generations. Giemsa-stained smears and wet smears of gut and gut content were studied. After engorgement of erythrocytic stages of T. annulata by the nymphs the following development was observed: 1. Erythrocytic merozoites developed to slender, spindleshaped "microgamonts" in the gut 24 to 96 hours after repletion (p. repl.). Spherical stages with a conspicuous spike developed at the same time and earlier. The "microgamonts" then form up to 4 nuclei and several flagella-like appendices. Filiform "microgametes" obviously develop from the "microgamonts". In addition, spherical stages, i.e. "macrogametes", occur. 2. Spherical "zygotes" with a vacuole-like center appear in the epithelial cells of the gut from day 5 p. repl. These "zygotes" increase steadily in size and then stain more intensely up to day 12 p. repl. 3. From day 12 p. repl. the spherical "Zygotes" change to elongate forms by a continuing process of folding. Finally, from day 13 p. repl., they extend to clubshaped kinetes. These kinetes move actively by gliding within the gut cells and from day 17 p. repl. in the haemolymph. It could not be decided yet whether these kinetes are oo- or sporokinetes.

[Electron microscope studies on development stages of Theileria annulata (Dschunkowsky, Luhs, 1904) in the intestine and haemolymph of Hyalomma anatolicum excavatum (Koch, 1844) (author's transl)]

For the first time developmental stages of Theileria within the intestine and haemolymph of ticks were studied by electron microscopy. On the 1st-6th day post repletionem the intestine of the ticks contained humerous tages, which were very similar to microgamonts and microgametes of haemosporidia. Later, on the 14th-19th day p.r. ookinete-like stages ere found in the haemolymph of ticks. From these results it seemed likely that gamogony of Theileria takes place in the intestine of ticks. In more detail: The microgamont-like stages were spindle-shaped; they measured about 8-12 mu in length with a diameter of about. 08 mu in their middle region...