Concomitant health benefits package design and research prioritisation: development of a new approach and an application to Malawi

Health benefits packages (HBPs) are increasingly used in many countries to guide spending priorities on the path towards universal health coverage. Their design is, however, informed by an uncertain evidence base but research funds available to address this are limited. This gives rise to the question of which piece of research relating to the cost-effectiveness of interventions would most contribute to improving resource allocation. We propose to incorporate research prioritisation as an integral part of HBP design. We have, therefore, developed a framework and a freely available companion stand-alone tool, to quantify in terms of net disability-adjusted life-years (DALYs) averted, the value of research for the interventions considered for inclusion in a package. Using the tool, the framework can be implemented using sensitivity analysis results typically reported in cost-effectiveness studies. To illustrate the framework, we applied the tool to the evidence base that informed the Malawi Health Sector Strategic Plan 2017–2022. Out of 21 interventions considered, 8 investment decisions were found to be uncertain and three showed strong potential for research to generate large health gains: ‘male circumcision’, ‘community-management of acute malnutrition in children’ and ‘isoniazid preventive therapy in HIV +individuals’, with a potential to avert up to 65 762, 36 438 and 20 132 net DALYs, respectively. Our work can help set research priorities in resource-constrained settings so that research funds are invested where they have the largest potential to impact on the population health generated via HBPs.

Personalization of pulse arrival time based blood pressure surrogates through single spot check measurements

OBJECTIVE

We investigate the effect of selective single parameter personalization on the performance of multi-parameter models for pulse arrival time (PAT) based blood pressure (BP) surrogates.

METHODS

Our data set stems from 15 surgery patients, and we selected from each patient 5 segments of 30 min length each. We evaluate the root mean squared BP tracking error of the two models with and without single parameter personalization. We further compare the BP tracking performance to a surrogate-free sample-and-hold approach, e.g., as afforded by conventional non-invasive blood pressure (NIBP) oscillometry.

RESULTS

Parameter personalization is key to realizing a tracking performance benefit of PAT-based BP surrogates. The highest tracking error reduction of about 3.7 mmHg with respect to a sample-and-hold approach was reached with a personalized model which is linear in the pulse wave velocity domain. It achieves an estimation error of 7.8 mmHg with respect to a continuously measured invasive reference.Clinical Relevance-We give a performance analysis of PAT-based BP surrogates which are personalized to a patient with a single NIBP spot measurement. We show for surgery patients that patient-specific personalization enables continuous beat-to-beat BP monitoring over 30 min intervals with a average root mean squared error of less than 8 mmHg.

Non-invasive imaging software to assess the functional significance of coronary stenoses: a systematic review and economic evaluation

BACKGROUND

QAngio^® XA 3D/QFR^® (three-dimensional/quantitative flow ratio) imaging software (Medis Medical Imaging Systems BV, Leiden, the Netherlands) and CAAS^® vFFR^® (vessel fractional flow reserve) imaging software (Pie Medical Imaging BV, Maastricht, the Netherlands) are non-invasive technologies to assess the functional significance of coronary stenoses, which can be alternatives to invasive fractional flow reserve assessment.

OBJECTIVES

The objectives were to determine the clinical effectiveness and cost-effectiveness of QAngio XA 3D/QFR and CAAS vFFR.

METHODS

We performed a systematic review of all evidence on QAngio XA 3D/QFR and CAAS vFFR, including diagnostic accuracy, clinical effectiveness, implementation and economic analyses. We searched MEDLINE and other databases to January 2020 for studies where either technology was used and compared with fractional flow reserve in patients with intermediate stenosis. The risk of bias was assessed with quality assessment of diagnostic accuracy studies. Meta-analyses of diagnostic accuracy were performed. Clinical and implementation outcomes were synthesised narratively. A simulation study investigated the clinical impact of using QAngio XA 3D/QFR. We developed a de novo decision-analytic model to estimate the cost-effectiveness of QAngio XA 3D/QFR and CAAS vFFR relative to invasive fractional flow reserve or invasive coronary angiography alone. Scenario analyses were undertaken to explore the robustness of the results to variation in the sources of data used to populate the model and alternative assumptions.

RESULTS

Thirty-nine studies (5440 patients) of QAngio XA 3D/QFR and three studies (500 patients) of CAAS vFFR were included. QAngio XA 3D/QFR had good diagnostic accuracy to predict functionally significant fractional flow reserve (≤ 0.80 cut-off point); contrast-flow quantitative flow ratio had a sensitivity of 85% (95% confidence interval 78% to 90%) and a specificity of 91% (95% confidence interval 85% to 95%). A total of 95% of quantitative flow ratio measurements were within 0.14 of the fractional flow reserve. Data on the diagnostic accuracy of CAAS vFFR were limited and a full meta-analysis was not feasible. There were very few data on clinical and implementation outcomes. The simulation found that quantitative flow ratio slightly increased the revascularisation rate when compared with fractional flow reserve, from 40.2% to 42.0%. Quantitative flow ratio and fractional flow reserve resulted in similar numbers of subsequent coronary events. The base-case cost-effectiveness results showed that the test strategy with the highest net benefit was invasive coronary angiography with confirmatory fractional flow reserve. The next best strategies were QAngio XA 3D/QFR and CAAS vFFR (without fractional flow reserve). However, the difference in net benefit between this best strategy and the next best was small, ranging from 0.007 to 0.012 quality-adjusted life-years (or equivalently £140-240) per patient diagnosed at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year.

LIMITATIONS

Diagnostic accuracy evidence on CAAS vFFR, and evidence on the clinical impact of QAngio XA 3D/QFR, were limited.

CONCLUSIONS

Quantitative flow ratio as measured by QAngio XA 3D/QFR has good agreement and diagnostic accuracy compared with fractional flow reserve and is preferable to standard invasive coronary angiography alone. It appears to have very similar cost-effectiveness to fractional flow reserve and, therefore, pending further evidence on general clinical benefits and specific subgroups, could be a reasonable alternative. The clinical effectiveness and cost-effectiveness of CAAS vFFR are uncertain. Randomised controlled trial evidence evaluating the effect of quantitative flow ratio on clinical and patient-centred outcomes is needed.

FUTURE WORK

Studies are required to assess the diagnostic accuracy and clinical feasibility of CAAS vFFR. Large ongoing randomised trials will hopefully inform the clinical value of QAngio XA 3D/QFR.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019154575.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 56. See the NIHR Journals Library website for further project information.

Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT

Background

It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified.

Objectives

The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations).

Design

Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales.

Setting

The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales.

Participants

Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services.

Data sources

Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified.

Intervention

Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks.

Results

A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains.

Conclusions

We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation.

Future work

Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation.

Trial registration

Current Controlled Trials ISRCTN38920246.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Practical metrics for establishing the health benefits of research to support research prioritisation

INTRODUCTION

We present practical metrics for estimating the expected health benefits of specific research proposals. These can be used by research funders, researchers and healthcare decision-makers within low-income and middle-income countries to support evidence-based research prioritisation.

METHODS

The methods require three key assessments: (1) the current level of uncertainty around the endpoints the proposed study will measure; (2) how uncertainty impacts on the health benefits and costs of healthcare programmes and (3) the health opportunity costs imposed by programme costs. Research is valuable because it can improve health by informing the choice of which programmes should be implemented. We provide a Microsoft Excel tool to allow readers to generate estimates of the health benefits of research studies based on these three assessments. The tool can be populated using existing studies, existing cost-effectiveness models and expert opinion. Where such evidence is not available, the tool can quantify the value of research under different assumptions. Estimates of the health benefits of research can be considered alongside research costs, and the consequences of delaying implementation until research reports, to determine whether research is worthwhile. We illustrate the method using a case study of research on HIV self-testing programmes in Malawi. This analysis combines data from the literature with outputs from the HIV synthesis model.

RESULTS

For this case study, we found a costing study that could be completed and inform decision making within 1 year offered the highest health benefits (67 000 disability-adjusted life years (DALYs) averted). Research on outcomes improved population health to a lesser extent (12 000 DALYs averted) and only if carried out alongside programme implementation.

CONCLUSION

Our work provides a method for estimating the health benefits of research in a practical and timely fashion. This can be used to support accountable use of research funds.

SIPE - Psychotropes et créativités : rencontres ou distances ?

Depuis l’apparition des psychotropes, praticiens, chercheurs et artistes n’ont de cesse de louer, de dénigrer voire de dénoncer leurs impacts sur les potentialités créatives, l’expression esthétique, voire artistique des personnes en proie à des difficultés psychopathologiques. L’usage des produits illicites, que cela soit dans le courant psychédélique ou encore du New Age a simplement ajouté davantage de confusions aux débats. D’un autre côté, les praticiens de l’art-thérapie constatent la facilitation de l’accès aux ateliers et à l’utilisation de médiation par l’entremise des traitements psychotropes, même si le style, la forme et le contenu des productions se sont modifiés au cours des décennies. Entre charybde et scylla, la question de la temporalité et des objectifs diffèrent radicalement entre l’artiste, le psychopathologue de l’expression et l’art-thérapeute/praticien des thérapies médiatisées. Croiser ces trois regards constitue notre ambition dans cette session.

Developing and evaluating packages to support implementation of quality indicators in general practice: the ASPIRE research programme, including two cluster RCTs

Background

Dissemination of clinical guidelines is necessary but seldom sufficient by itself to ensure the reliable uptake of evidence-based practice. There are further challenges in implementing multiple clinical guidelines and clinical practice recommendations in the pressurised environment of general practice.

Objectives

We aimed to develop and evaluate an implementation package that could be adapted to support the uptake of a range of clinical guideline recommendations and be sustainably integrated within general practice systems and resources. Over five linked work packages, we developed ‘high-impact’ quality indicators to show where a measurable change in clinical practice can improve patient outcomes (work package 1), analysed adherence to selected indicators (work package 2), developed an adaptable implementation package (work package 3), evaluated the effects and cost-effectiveness of adapted implementation packages targeting four indicators (work package 4) and examined intervention fidelity and mechanisms of action (work package 5).

Setting and participants

Health-care professionals and patients from general practices in West Yorkshire, UK.

Design

We reviewed recommendations from existing National Institute for Health and Care Excellence clinical guidance and used a multistage consensus process, including 11 professionals and patients, to derive a set of ‘high-impact’ evidence-based indicators that could be measured using routinely collected data (work package 1). In 89 general practices that shared data, we found marked variations and scope for improvement in adherence to several indicators (work package 2). Interviews with 60 general practitioners, practice nurses and practice managers explored perceived determinants of adherence to selected indicators and suggested the feasibility of adapting an implementation package to target different indicators (work package 3). We worked with professional and patient panels to develop four adapted implementation packages. These targeted risky prescribing involving non-steroidal anti-inflammatory and antiplatelet drugs, type 2 diabetes control, blood pressure control and anticoagulation for atrial fibrillation. The implementation packages embedded behaviour change techniques within audit and feedback, educational outreach and (for risky prescribing) computerised prompts. We randomised 178 practices to implementation packages targeting either diabetes control or risky prescribing (trial 1), or blood pressure control or anticoagulation (trial 2), or to a further control (non-intervention) group, and undertook economic modelling (work package 4). In trials 1 and 2, practices randomised to the implementation package for one indicator acted as control practices for the other package, and vice versa. A parallel process evaluation included a further eight practices (work package 5).

Main outcome measures

Trial primary end points at 11 months comprised achievement of all recommended levels of glycated haemoglobin, blood pressure and cholesterol; risky prescribing levels; achievement of recommended blood pressure; and anticoagulation prescribing.

Results

We recruited 178 (73%) out of 243 eligible general practices. We randomised 80 practices to trial 1 (40 per arm) and 64 to trial 2 (32 per arm), with 34 non-intervention controls. The risky prescribing implementation package reduced risky prescribing (odds ratio 0.82, 97.5% confidence interval 0.67 to 0.99; p = 0.017) with an incremental cost-effectiveness ratio of £2337 per quality-adjusted life-year. The other three packages had no effect on primary end points. The process evaluation suggested that trial outcomes were influenced by losses in fidelity throughout intervention delivery and enactment, and by the nature of the targeted clinical and patient behaviours.

Limitations

Our programme was conducted in one geographical area; however, practice and patient population characteristics are otherwise likely to be sufficiently diverse and typical to enhance generalisability to the UK. We used an ‘opt-out’ approach to recruit general practices to the randomised trials. Subsequently, our trial practices may have engaged with the implementation package less than if they had actively volunteered. However, this approach increases confidence in the wider applicability of trial findings as it replicates guideline implementation activities under standard conditions.

Conclusions

This pragmatic, rigorous evaluation indicates the value of an implementation package targeting risky prescribing. In broad terms, an adapted ‘one-size-fits-all’ approach did not consistently work, with no improvement for other targeted indicators.

Future work

There are challenges in designing ‘one-size-fits-all’ implementation strategies that are sufficiently robust to bring about change in the face of difficult clinical contexts and fidelity losses. We recommend maximising feasibility and ‘stress testing’ prior to rolling out interventions within a definitive evaluation. Our programme has led on to other work, adapting audit and feedback for other priorities and evaluating different ways of delivering feedback to improve patient care.

Trial registration

Current Controlled Trials ISRCTN91989345.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode

BACKGROUND

ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations.

METHODS

This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests.

RESULTS

Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001).

LIMITATIONS

This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results.

CONCLUSION

Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.

Patterns and predictors of e-cigarette, cigarette and dual use uptake in UK adolescents: evidence from a 24-month prospective study

BACKGROUND AND AIMS

To assess prevalence and predictors of e-cigarettes/cigarettes patterns of use in adolescents in England.

DESIGN

Prospective study with 24-month follow-up of e-cigarette/cigarette ever/regular use with data from an intervention evaluation.

SETTING

Forty-five schools in England (Staffordshire and Yorkshire).

PARTICIPANTS

A total of 3210 adolescents who, at baseline, were aged 13-14 years and had never used e-cigarettes/cigarettes.

MEASUREMENTS

Based on e-cigarette/cigarette ever use at follow-up, six groups were created: (a) never user, (b) e-cigarette only, (c) cigarette only, (d) dual use-order of use unclear, (e) dual use-e-cigarettes used first and (f) dual use-cigarettes used first. Baseline measures were: gender, ethnicity, socio-economic status, impulsivity, family plus friend smoking and smoking-related beliefs (attitude and perceived behavioural control).

FINDINGS

In groups (a) to (f), there were 71.5, 13.3, 3.3, 5.7, 2.9 and 3.4% adolescents, respectively. Among groups using cigarettes, regular smoking was more prevalent in group (f) (dual use-cigarettes used first) [17.6%, 95% confidence interval (CI) = 10.4, 24.8] than in groups (c), (d) and (e) combined (7.3%, 95% CI = 4.7, 9.9). Among groups using e-cigarettes, regular use was less prevalent in group (b) (e-cigarette only) (1.9%, 95% CI = 0.6, 3.2) than in groups (d), (e) and (f) combined (12.2%, 95% CI = 8.9, 15.5). Higher impulsivity plus friends and family smoking were predictive of being in groups (b) to (f) compared with group (a) (never users). Males were more likely to be in group (b) compared to group (a); females were more likely to be in groups (c) to (f) compared to group (a).

CONCLUSIONS

Regular use of e-cigarettes/cigarettes varies across groups defined by ever use of e-cigarettes/cigarettes. Interventions targeted at tackling impulsivity or adolescents whose friends and family members smoke may represent fruitful avenues for future research.

Evidence that an intervention weakens the relationship between adolescent electronic cigarette use and tobacco smoking: a 24-month prospective study

BACKGROUND

The electronic cigarette (e-cigarette) use to subsequent smoking relationship in adolescents has received much attention. Whether an intervention to reduce smoking initiation attenuated this relationship was assessed.

METHOD

Data were from 3994 adolescent never smokers (aged 13-14 years at baseline) as part of a cluster randomised controlled trial. Self-report measures of smoking, e-cigarette use and covariates were assessed and used to predict ever smoked cigarettes, any recent tobacco smoking and regularly smoked cigarettes at 24-month follow-up.

RESULTS

Baseline ever use of e-cigarettes was associated with ever smoked cigarettes (OR=4.03, 95% CI 3.33 to 4.88; controlling for covariates, OR=2.78, 95% CI 2.20 to 3.51), any recent tobacco smoking (OR=3.38, 95% CI 2.72 to 4.21; controlling for covariates, OR=2.17, 95% CI 1.76 to 2.69) and regularly smoked cigarettes (OR=3.60, 95% CI 2.35 to 5.51; controlling for covariates, OR=1.27, 95% CI 1.17 to 1.39) at follow-up. For ever smoked cigarettes only, the impact of e-cigarette use was attenuated in the intervention (OR=1.83) compared with control (OR=4.53) condition. For ever smoked cigarettes and any recent tobacco smoking, the impact of e-cigarette use was attenuated among those with friends who smoked (OR=2.05 (ever smoked); 1·53 (any tobacco use)) compared with those without friends who smoked (OR=3.32 (ever smoked); 2·17 (any tobacco use)).

CONCLUSIONS

This is one of the first studies to show that e-cigarette use was robustly associated with measures of smoking over 24 months and the first to show an intervention to attenuate the relationship. Further research with a broader age range of adolescents is required.

Effectiveness and cost-effectiveness of repeated implementation intention formation on adolescent smoking initiation: A cluster randomized controlled trial

OBJECTIVE

Forming implementation intentions (if-then plans) about how to refuse cigarette offers plus antismoking messages was tested for reducing adolescent smoking.

METHOD

Cluster randomized controlled trial with schools randomized (1:1) to receive implementation intention intervention and messages targeting not smoking (intervention) or completing homework (control). Adolescents (11-12 years at baseline) formed implementation intentions and read messages on 8 occasions over 4 years meaning masking treatment allocation was not possible. Outcomes were: follow-up (48 months) ever smoking, any smoking in last 30 days, regular smoking, and breath carbon monoxide levels. Analyses excluded baseline ever smokers, controlled for clustering by schools and examined effects of controlling for demographic variables. Economic evaluation (incremental cost effectiveness ratio; ICER) was conducted. Trial is registered (ISRCTN27596806).

RESULTS

Schools were randomly allocated (September-October 2012) to intervention (n = 25) or control (n = 23). At follow-up, among 6,155 baseline never smokers from 45 retained schools, ever smoking was significantly lower (RR = 0.83, 95% CI [0.71, 0.97], p = .016) in intervention (29.3%) compared with control (35.8%) and remained so controlling for demographics. Similar patterns observed for any smoking in last 30 days. Less consistent effects were observed for regular smoking and breath carbon monoxide levels. Economic analysis yielded an ICER of $134 per ever smoker avoided at age 15-16 years.

CONCLUSIONS

This pragmatic trial supports the use of repeated implementation intentions about how to refuse the offer of a cigarette plus antismoking messages as an effective and cost-effective intervention to reduce smoking initiation in adolescents. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Brodalumab for the Treatment of Moderate-to-Severe Plaque Psoriasis: An Evidence Review Group Evaluation of a NICE Single Technology Appraisal

As part of the National Institute for Health and Care Excellence single technology appraisal process, brodalumab was assessed to determine the clinical and cost effectiveness of its use in the treatment of moderate-to-severe plaque psoriasis. The Centre for Reviews and Dissemination and the Centre for Health Economics Technology Assessment Group at the University of York were commissioned to act as the independent Evidence Review Group. This article provides a summary of the Evidence Review Group's review of the company's submission, the Evidence Review Group report and the National Institute for Health and Care Excellence Appraisal Committee's subsequent guidance issued in March 2018. The main clinical effectiveness data were derived from three well-conducted, multicentre, double-blind randomised controlled trials. The trials demonstrated that brodalumab statistically significantly reduced the severity of psoriasis and its impact on health-related quality of life, compared with placebo, at 12 weeks. In comparison with ustekinumab, statistically significantly more patients taking brodalumab had reduced psoriasis severity at 12 weeks. Psoriasis severity and quality of life also appeared improved at 52 weeks, although statistical significance was not assessed. Withdrawal rates were comparable to drug survival rates of other biological therapies and rates of adverse events were similar between brodalumab and ustekinumab. A network meta-analysis was presented, comparing brodalumab with other therapies available at the same point in the treatment pathway (i.e. in patients for whom standard systemic therapy or phototherapy is inadequately effective, not tolerated or contraindicated). The network meta-analysis ranked treatments in order of effectiveness, in terms of achieving different levels of Psoriasis Area and Severity Index response. The results indicated that brodalumab had a similar probability of response to ixekizumab, secukinumab and infliximab and a higher probability of response than ustekinumab, adalimumab, etanercept, apremilast, dimethyl fumarate and placebo. The company's economic model compared nine treatment sequences that included three lines of active therapy, consisting of brodalumab and other comparators recommended by the National Institute for Health and Care Excellence, followed by best supportive care. The sequence with brodalumab in the first-line position dominated sequences that started with adalimumab, infliximab, secukinumab and ustekinumab. The incremental cost-effectiveness ratio of the brodalumab sequence compared to less effective and non-dominated sequences ranged from £7145 (vs. the etanercept sequence) to £13,353 (vs. the dimethyl fumarate sequence) per quality-adjusted life-year gained. The incremental cost-effectiveness ratio for the more costly and effective ixekizumab sequence was £894,010 per quality-adjusted life-year gained compared to the brodalumab sequence. At a threshold of £20,000 per quality-adjusted life-year gained, the brodalumab sequence had the highest probability of being cost effective (96%). The main limitation of the company's economic model was the restrictive nature of the sequences compared. Twelve separate scenarios based on key uncertainties were explored by the Evidence Review Group. The only scenarios where brodalumab was ranked lower than first were not considered to be more appropriate or plausible than the assumptions or scenarios included in the company's base case. The treatment rankings identified in the Evidence Review Group's alternative base case were identical to those derived from the company's base case model. At the first National Institute for Health and Care Excellence Appraisal Committee meeting, the Committee concluded that brodalumab appears to be as effective as other anti-interleukin-17 agents and is cost effective, based on the discount agreed in the patient access scheme. Brodalumab is recommended as an option for treating adults with severe plaque psoriasis (defined by a total Psoriasis Area and Severity Index score of 10 or more and a Dermatology Life Quality Index score of more than 10) who have not responded to other systemic non-biological therapies. Brodalumab should be stopped at 12 weeks if the psoriasis has not responded adequately.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BACKGROUND

Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.

METHOD

The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.

RESULTS

The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.

CONCLUSION

These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

Red Blood Cell Omega-3 Fatty Acid Composition and Psychotropic Drug Use in Older Adults: Results from the MAPT Study

Low docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) concentration has been associated with the development of some psychiatric disorders.

OBJECTIVES

to assess the association between red blood cell (RBC) DHA-EPA concentration and psychotropic drug use in older adults and between the 1-year change in RBC DHA-EPA and psychotropic drug use at 12 months.

DESIGN

secondary analysis of multicenter, randomized controlled trial testing multidomain intervention and/or n-3 PUFA supplement on cognitive function (MAPT study).

SETTING

France, 2008-2014.

PARTICIPANTS

1680 participants ≥70 years, community-dwelling were included.

MEASUREMENTS

Psychotropic drug use was self-reported during medical interviews and assessments. RBC n-3 PUFA concentration was defined by % of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) among total fatty acids. Logistic regressions models controlling for age, sex, education, depression risk and intervention group were used.

RESULTS

1594 participants had baseline DHA-EPA concentration available (mean age=75.5±4.5 years, 65% females). At baseline, participants with DHA-EPA ≤4.82% (lowest quartile) reported higher prevalence of use of overall psychotropic drugs (34.0% vs 24.4%; aOR=1.33, 95%CI=[1.03-1.72]), anxiolytic/hypnotic drugs (25.0% vs 18.2%; aOR=1.42, 95%CI=[1.07-1.89]), and antidepressants (18.3% vs 13.5%; aOR=1.25, 95%CI=[0.93-1.72]) than participants with higher DHA-EPA. Participants who experienced an increase in DHA-EPA from baseline were less likely to use a psychotropic drug at 12 months than participants with no change or a decrease (aOR=0.72, 95%CI=[0.55-0.96]).

CONCLUSION

Low RBC DHA-EPA concentration was independently associated with psychotropic drug use. Future studies are needed to assess whether low RBC DHA-EPA is a risk marker for psychotropic drug use in older adults and to better understand underlying pathophysiological mechanisms. Registration number: ClinicalTrials.gov database (NCT00672685).

An intervention to support stroke survivors and their carers in the longer term (LoTS2Care): study protocol for a cluster randomised controlled feasibility trial

BACKGROUND

Despite the evidence that many stroke survivors report longer term unmet needs, the provision of longer term care is limited. To address this, we are conducting a programme of research to develop an evidence-based and replicable longer term care strategy. The developed complex intervention (named New Start), which includes needs identification, exploration of social networks and components of problem solving and self-management, was designed to improve quality of life by addressing unmet needs and increasing participation.

METHODS/DESIGN

A multicentre, cluster randomised controlled feasibility trial designed to inform the design of a possible future definitive cluster randomised controlled trial (cRCT) and explore the potential clinical and cost-effectiveness of New Start. Ten stroke services across the UK will be randomised on a 1:1 basis either to implement New Start or continue with usual care only. New Start will be delivered by trained facilitators and will be offered to all stroke survivors within the services allocated to the intervention arm. Stroke survivors will be eligible for the trial if they are 4-6 months post-stroke and residing in the community. Carers (if available) will also be invited to take part. Invitation to participate will be initiated by post and outcome measures will be collected via postal questionnaires at 3, 6 and 9 months after recruitment. Outcome data relating to perceived health and disability, wellbeing and quality of life as well as unmet needs will be collected. A 'study within a trial' (SWAT) is planned to determine the most acceptable format in which to provide the postal questionnaires. Details of health and social care service usage will also be collected to inform the economic evaluation. The feasibility of recruiting services and stroke survivors to the trial and of collecting postal outcomes will be assessed and the potential for effectiveness will be investigated. An embedded process evaluation (reported separately) will assess implementation fidelity and explore and clarify causal assumptions regarding implementation.

DISCUSSION

This feasibility trial with embedded process evaluation will allow us to gather important and detailed data regarding methodological and implementation issues to inform the design of a possible future definitive cRCT of this complex intervention.

TRIAL REGISTRATION

ISRCTN38920246 . Registered 22 June 2016.

[French Society for Biological Psychiatry and Neuropsychopharmacology and Fondation FondaMental task force: Formal Consensus for the management of treatment-resistant depression]

Major depression represents among the most frequent psychiatric disorders in the general population with an estimated lifetime prevalence of 16-17%. It is characterized by high levels of comorbidities with other psychiatric conditions or somatic diseases as well as a recurrent or chronic course in 50 to 80% of the cases leading to negative repercussions on the daily functioning, with an impaired quality of life, and to severe direct/indirect costs. Large cohort studies have supported that failure of a first-line antidepressant treatment is observed in more than 60% of patients. In this case, several treatment strategies have been proposed by classical evidence-based guidelines from internationally recognized scientific societies, referring primarily on: I) the switch to another antidepressant of the same or different class; II) the combination with another antidepressant of complementary pharmacological profile; III) the addition of a wide range of pharmacological agents intending to potentiate the therapeutic effects of the ongoing antidepressant medication; IV) the association with appropriate psychological therapies; and, V) the use of non-invasive brain stimulation techniques. However, although based on the most recently available data and rigorous methodology, standard guidelines have the significant disadvantage of not covering a large variety of clinical conditions, while currently observed in everyday clinical practice. From these considerations, formalized recommendations by a large panel of French experts in the management of depressed patients have been developed under the shared sponsorship of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and the Fondation FondaMental. These French recommendations are presented in this special issue in order to provide relevant information about the treatment choices to make, depending particularly on the clinical response to previous treatment lines or the complexity of clinical situations (clinical features, specific populations, psychiatric comorbidities, etc.). Thus, the present approach will be especially helpful for the clinicians enabling to substantially facilitate and guide their clinical decision when confronted to difficult-to-treat forms of major depression in the daily clinical practice. This will be expected to significantly improve the poor prognosis of the treatment-resistant depression thereby lowering the clinical, functional and costly impact owing directly to the disease.

Detection rate of fetal distress using contraction-dependent fetal heart rate variability analysis

OBJECTIVE

Monitoring of the fetal condition during labor is currently performed by cardiotocograpy (CTG). Despite the use of CTG in clinical practice, CTG interpretation suffers from a high inter- and intra-observer variability and a low specificity. In addition to CTG, analysis of fetal heart rate variability (HRV) has been shown to provide information on fetal distress. However, fetal HRV can be strongly influenced by uterine contractions, particularly during the second stage of labor. Therefore, the aim of this study is to examine if distinguishing contractions from rest periods can improve the detection rate of HRV features for fetal distress during the second stage of labor.

APPROACH

We used a dataset of 100 recordings, containing 20 cases of fetuses with adverse outcome. The most informative HRV features were selected by a genetic algorithm and classification performance was evaluated using support vector machines.

MAIN RESULTS

Classification performance of fetal heart rate segments closest to birth improved from a geometric mean of 70% to 79%. If the classifier was used to indicate fetal distress over time, the geometric mean at 15 minutes before birth improved from 60% to 72%.

SIGNIFICANCE

Our results show that combining contraction-dependent HRV features with HRV features calculated over the entire fetal heart rate signal improves the detection rate of fetal distress.

Patient emergency assessment following deliberate self-poisoning with benzodiazepines: Can cognitive markers predict recall of the psychiatric interview? A pilot study

STUDY HYPOTHESIS

In cases of deliberate self-poisoning (DSP), patients often ingest benzodiazepines (BZDs), known to alter memory. Experts recommend recovery of the patient's cognitive capacity before psychiatric assessment. Unfortunately, there is no validated tool in common practice to assess whether sufficient cognitive recovery has occurred after DSP with BZDs to ensure patient memory of the assessment.

OBJECTIVE

The aim of the study was to identify cognitive functions and markers which predict preserved memory of the mental health care plan proposed at the emergency department after DSP.

METHODS

We recruited patients admitted for DSP with BZDs and control patients. At the time of the psychiatric assessment, we performed cognitive tests and we studied the relationship between these tests and the scores of a memory test performed 24 h after.

RESULTS

In comparison with the control group, we found memory impairment in the BZD group. We found significant impairment on the Trail Making Test A (TMT A) in the BZD group in comparison with the control group, while TMT A and Wechsler Adult Intelligence Scale (WAIS) Coding test scores were significantly correlated with memory scores.

CONCLUSIONS

Attentional functions tested by WAIS Coding test and TMT A were correlated with memory score. It could be profitable to assess it in clinical practice prior to a psychiatric interview.

Selective heart rate variability analysis to account for uterine activity during labor and improve classification of fetal distress

Cardiotocography (CTG) is currently the most often used technique for detection of fetal distress. Unfortunately, CTG has a poor specificity. Recent studies suggest that, in addition to CTG, information on fetal distress can be obtained from analysis of fetal heart rate variability (HRV). However, uterine contractions can strongly influence fetal HRV. The aim of this study is therefore to investigate whether HRV analysis for detection of fetal distress can be improved by distinguishing contractions from rest periods. Our results from feature selection indicate that HRV features calculated separately during contractions or during rest periods are more informative on fetal distress than HRV features that are calculated over the entire fetal heart rate. Furthermore, classification performance improved from a geometric mean of 69.0% to 79.6% when including the contraction-dependent HRV features, in addition to HRV features calculated over the entire fetal heart rate.

A pharmacoeconomic approach to assessing the costs and benefits of air quality interventions that improve health: a case study

OBJECTIVE

This paper explores the use of pharmacoeconomic methods of valuation to health impacts resulting from exposure to poor air quality. In using such methods, interventions that reduce exposure to poor air quality can be directly compared, in terms of value for money (or cost-effectiveness), with competing demands for finite resources, including other public health interventions.

DESIGN

Using results estimated as part of a health impact assessment regarding a West Yorkshire Low Emission Zone strategy, this paper quantifies cost-saving and health-improving implications of transport policy through its impact on air quality.

DATA SOURCE

Estimates of health-related quality of life and the National Health Service (NHS)/Personal Social Services (PSS) costs for identified health events were based on data from Leeds and Bradford using peer-reviewed publications or Office for National Statistics releases.

POPULATION

Inhabitants of the area within the outer ring roads of Leeds and Bradford.

MAIN OUTCOMES MEASURES

NHS and PSS costs and quality-adjusted life years (QALYs).

RESULTS

Averting an all-cause mortality death generates 8.4 QALYs. Each coronary event avoided saves £28 000 in NHS/PSS costs and generates 1.1 QALYs. For every fewer case of childhood asthma, there will be NHS/PSS cost saving of £3000 and a health benefit of 0.9 QALYs. A single term, low birthweight birth avoided saves £2000 in NHS/PSS costs. Preventing a preterm birth saves £24 000 in NHS/PSS costs and generates 1.3 QALYs. A scenario modelled in the West Yorkshire Low Emission Zone Feasibility Study, where pre-EURO 4 buses and HGVs are upgraded to EURO 6 by 2016 generates an annual benefit of £2.08 million and a one-off benefit of £3.3 million compared with a net present value cost of implementation of £6.3 million.

CONCLUSIONS

Interventions to improve air quality and health should be evaluated and where improvement of population health is the primary objective, cost-effectiveness analysis using a NHS/PSS costs and QALYs framework is an appropriate methodology.

Patient assessment following substance overdose: Can we predict memory of the psychiatric interview?

Suicide is a major public health issue, and a critical step in its prevention is a psychiatric assessment of individuals following suicide attempts (NICE 2008). In cases where patients attempt suicide through substance overdose, the central nervous system and consciousness are altered in significant ways. This is problematic, given that patients must have recovered sufficient cognitive capacity if a psychiatric assessment is to yield a meaningful and suitable care plan that the patient will recall and follow (Lukens 2006). Currently, there is no validated tool to assess whether sufficient cognitive recovery has occurred in such patients to ensure their memory of the assessment. Therefore, our goal was to identify indicators that predict preserved memory of undergoing a psychiatric assessment. We carried out a prospective study with 41 patients recruited from an emergency department. We collected data on cognitive tests (including WAIS coding test), memory self-assessment, plasma benzodiazepine levels, age, gender, and educational level at the time of psychiatric assessment. We then assessed patients’ memory for undergoing a psychiatric interview 24 hours post-assessment, using an episodic memory score. Whereas memory self-assessment did not predict the episodic memory score, age, plasma benzodiazepine level, and cognitive test scores significantly influenced it, predicting 70% of memory score variation. Among these factors, the WAIS coding test predicted 57% of the memory score variation. To improve clinical practice, it may be useful to assess visual scanning, processing speed, and attentional function prior to psychiatric interview to ensure later patient recall.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Using uterine activity to improve fetal heart rate variability analysis for detection of asphyxia during labor

During labor, uterine contractions can cause temporary oxygen deficiency for the fetus. In case of severe and prolonged oxygen deficiency this can lead to asphyxia. The currently used technique for detection of asphyxia, cardiotocography (CTG), suffers from a low specificity. Recent studies suggest that analysis of fetal heart rate variability (HRV) in addition to CTG can provide information on fetal distress. However, interpretation of fetal HRV during labor is difficult due to the influence of uterine contractions on fetal HRV. The aim of this study is therefore to investigate whether HRV features differ during contraction and rest periods, and whether these differences can improve the detection of asphyxia. To this end, a case-control study was performed, using 14 cases with asphyxia that were matched with 14 healthy fetuses. We did not find significant differences for individual HRV features when calculated over the fetal heart rate without separating contractions and rest periods (p  >  0.30 for all HRV features). Separating contractions from rest periods did result in a significant difference. In particular the ratio between HRV features calculated during and outside contractions can improve discrimination between fetuses with and without asphyxia (p  <  0.04 for three out of four ratio HRV features that were studied in this paper).

Quelle stratégie psychothérapeutique pour les déprimés résistants aux antidépresseurs ?

On sait depuis longtemps que les traitements combinés d’antidépresseurs et de psychothérapies donnent les meilleurs résultats pour soigner les dépressions. L’étude STAR-D avec ses 4 étapes aboutit à 67 % de rémissions, une des dernières étapes associe la psychothérapie. Donc un tiers des patients reste sans amélioration. D’où l’idée d’associer ou de privilégier un traitement psychothérapeutique. Mais lequel, sachant qu’aucune forme de psychothérapie cognitive, interpersonnelle, dynamique ou de soutien n’a montré une réelle supériorité. Deux grandes stratégies psychothérapeutiques sont utilisées dans les dépressions résistantes :

– l’évaluation systématique d’un trouble de la personnalité, dont la personnalité état limite, d’un facteur de stress ou d’un événement traumatique, d’une addiction ou d’un trouble anxieux comorbide définit l’étape initiale. Elle se complète de l’évaluation des mécanismes de défense prévalant de la personnalité (cf. code additionnel du DSM-V) ;

– des techniques de soin récentes proviennent des thérapies dialectiques pour certaines, des thérapies psychodynamiques pour d’autres.

Ces approches prennent en compte l’importance des ruminations, du perfectionnisme, de l’attachement, de la détresse comme facteurs d’aggravation des dépressions. Elles tentent d’améliorer la difficulté qu’ont les patients pour exprimer des émotions, l’analyse d’une hyper-vigilance, les pensées rigides, la peur de s’engager dans des relations mutuelles, des pensées de jalousie et des idées de revanche. Dans la Tavistock Adult Depression Study, on s’intéresse aux enjeux de passivité, de barrière au traitement et de résilience qui jouent un rôle dans la chronicité d’un état dépressif. Parmi les facteurs d’efficacité des stratégies psychothérapeutiques il faut citer l’observance des patients vis-à-vis du dispositif de soins, une séance hebdomadaire avec des durées supérieures à 16 semaines de traitement.

Leçons du passé pour une art-thérapie institutionnelle actuelle

L’art-thérapie porte en terre hexagonale, un lourd bagage de fausses notes conceptuelles, d’hégémonies et de clivages cheminant parfois avec une certaine note d’obscurantisme consensuel. Toujours d’actualité, la répétition de cette dynamique souffre d’un manque d’autocritique et d’auto-analyse constructive. Pourtant les dinosaures de l’art-thérapie d’hier empruntent, lorsqu’ils n’ont pas tiré leur révérence, la voie de la sagesse. Ceux d’aujourd’hui s’échinent à tenir des vestiges, voire des temples vides, même lorsqu’ils empruntent la toge de la transmission. Si jusqu’à l’aube des années 1980, l’art-thérapie était encore l’apanage de la psychiatrie et des psychiatres, elle concerne aujourd’hui des praticiens d’origine multiple et s’étend du développement personnel aux champs du somatique, sans pour autant se cristalliser dans une réelle identité professionnelle. À l’instar d’autres spécialités d’antan, elle erre dans une sorte de flou-doux-mou peu et/ou mal étayée sur une recherche clinique à même de fournir des recommandations pour de bonnes pratiques et un corpus de savoir. Pourtant les approches symptomatologiques, psychopathologiques, phénoménologiques, structurales, pictographiques, psychobiographiques et autres, souvent référencées aux arts et/ou à la psychanalyse, produisent légitimement, sous couvert du piège de la séduction esthétique, une jouissance relativement éloignée du terrain. Quant aux organismes, plus ou moins fédératifs, leur prétention en matière « d’accréditation » des professionnels de l’art-thérapie, se révèle là-aussi bien éloignée du réel de la clinique et des expériences d’autres pays européens (Suisse, par exemple). Enfin, les intitulés des formations, initiales comme continues, jouent sur des ambiguïtés de vocabulaires et d’expressions, difficiles à décrypter par les novices. Nous développerons chacun de ces points en proposant quelques médications génériques pour traiter des pathologies endémiques « de la dame art-thérapie ».

Childhood maltreatment and personality disorders in patients with a major depressive disorder: A comparative study between France and Togo

Few studies have examined the association between childhood maltreatment (CM) and personality disorders (PDs) in adulthood in two different cultural contexts, including sub-Saharan Africa. The aims of this study were to compare the frequency of CM between patients in treatment in France and Togo for a major depressive disorder (MDD), to explore the link between CM and PDs, and to examine the mediating effect of personality dimensions in the pathway from CM to PDs in 150 participants (75 in each country). The 28-item Childhood Trauma Questionnaire, the International Personality Item Pool, and the Personality Diagnostic Questionnaire (PDQ-4+) were used to assess CM, personality dimensions, and PDs respectively. Togolese participants reported sexual and physical abuse (PA) and emotional and physical neglect significantly more frequently than French participants. In Togo, severe PA was associated with schizoid, antisocial, narcissistic, obsessive-compulsive, depressive, and negativist PDs whereas in France, PA was only linked to paranoid PD. In Togo, emotional instability partly mediated the relationship between CM and PDs while in France, no personality dimension appeared to mediate this link. Our results support the hypothesis that CM is more common in low-income countries and suggest that the links between CM and PDs are influenced by social environment.

Typology of "Fatigue" by Heart Rate Variability Analysis in Elite Nordic-skiers

This study investigated changes in heart rate variability (HRV) in elite Nordic-skiers to characterize different types of "fatigue" in 27 men and 30 women surveyed from 2004 to 2008. R-R intervals were recorded at rest during 8 min supine (SU) followed by 7 min standing (ST). HRV parameters analysed were powers of low (LF), high (HF) frequencies, (LF+HF) (ms(2)) and heart rate (HR, bpm). In the 1 063 HRV tests performed, 172 corresponded to a "fatigue" state and the first were considered for analysis. 4 types of "fatigue" (F) were identified: 1. F(HF(-)LF(-))SU_ST for 42 tests: decrease in LFSU (- 46%), HFSU (- 70%), LFST (- 43%), HFST (- 53%) and increase in HRSU (+ 15%), HRST (+ 14%). 2. F(LF(+) SULF(-) ST) for 8 tests: increase in LFSU (+ 190%) decrease in LFST (- 84%) and increase in HRST (+ 21%). 3. F(HF(-) SUHF(+) ST) for 6 tests: decrease in HFSU (- 72%) and increase in HFST (+ 501%). 4. F(HF(+) SU) for only 1 test with an increase in HFSU (+ 2161%) and decrease in HRSU (- 15%). Supine and standing HRV patterns were independently modified by "fatigue". 4 "fatigue"-shifted HRV patterns were statistically sorted according to differently paired changes in the 2 postures. This characterization might be useful for further understanding autonomic rearrangements in different "fatigue" conditions.

[Economic impact of consultation-liaison psychiatry in a French University Hospital Centre]

BACKGROUND

In times of fiscal restraint for health structures, apart from the clinical input, it seems important to discuss the economic impact of liaison psychiatry. There are only a few studies on the economic added value provided by a liaison psychiatry team. In addition to this, only a few psychiatric pathologies are coded as they should be, hence we make the assumption of an additional development provided by a specialised team.

METHODS

Over a short period of 4months, in three departments of the Toulouse University Hospital Centre, the added value to the general pricing system of liaison psychiatry was studied. The population was represented by all the consecutive requests for consultations from patients over 18years old, men and women, hospitalised at that time. These three departments frequently request consultations with the psychiatry liaison team. They set a diagnostic, and if this is associated with a higher Homogeneous Group of Patients (HGP), it provides added value.

RESULTS

Fifty-two patients benefited from a psychiatric consultation over 4months. The results highlight a development of € 8630.43 for the traumatology department, € 3325.03 for the internal medicine department, and € 513.61 for the haematology department over the study period. The overall development over this period was € 12,469.07.

CONCLUSION

To our knowledge, this approach is one of the first in France to highlight an economic impact of the intervention of liaison psychiatry in the claiming departments.

Nitrogen patterns in subsurface waters of the Yzeron stream: effect of combined sewer overflows and subsurface-surface water mixing

Urbanization subjects streams to increased nitrogen loads. Therefore studying nitrogen forms at the interface between urban stream and groundwater is important for water resource management. In this study we report results on water δ(18)O and nitrogen forms in subsurface waters of a stream (Yzeron, France). The sites studied were located upstream and downstream of combined sewer overflows (CSO) in a rural area and a periurban area, respectively. Water δ(18)O allowed us to follow the mixing of subsurface water with surface water. Dissolved organic nitrogen and organic carbon of fine sediment increased by 20-30% between rural and periurban subsurface waters in the cold season, under high flow. The highest nitrate levels were observed in rural subsurface waters in the cold season. The lowest nitrate levels were found in periurban subsurface waters in the warm season, under low flow. They corresponded to slow exchange of subsurface waters with channel water. Thus reduced exchange between surface and subsurface waters and organic-matter-rich input seemed to favor nitrate reduction in the downstream, periurban, subsurface waters impacted by CSO.

Rare inherited A2BP1 deletion in a proband with autism and developmental hemiparesis

Ataxin 2 binding protein 1 (A2BP1 aka FOX1, RBFOX1) is an RNA binding protein responsible for regulation of pre-mRNA splicing events in a number of critical developmental genes expressed in muscle, heart and neuronal cells [Shibata et al. (2000); Mamm Genome 12:595-601; Jin et al. (2003); EMBO J 22:905-912; Underwood et al. (2005); Mol Cell Biol 25:10005-10016]. Rare copy number abnormalities of A2BP1 have been previously associated with cognitive impairment, attention deficit disorder and autism [Martin et al. (2007); Am J Med Gen Part B 144B:869-876; Elia et al. (2010); Mol Psychiatry 15:637-646.]. Using a 1M Illumina SNP microarray, we identified a 1.3 kb deletion in A2BP1, which was subsequently validated by quantitative PCR. Here we present an in depth case study of an individual with autism and mild developmental hemiparesis in whom the deletion was detected. This study provides further support for the possible role of rare copy number variants in A2BP1 in the development of autism and associated motor asymmetries.

First measurement of chiral dynamics in π- γ → π- π- π+

The COMPASS Collaboration at CERN has investigated the π- γ → π- π- π+ reaction at center-of-momentum energy below five pion masses, sqrt[s]<5m(π), embedded in the Primakoff reaction of 190 GeV pions impinging on a lead target. Exchange of quasireal photons is selected by isolating the sharp Coulomb peak observed at smallest momentum transfers, t'<0.001  GeV2/c2. Using partial-wave analysis techniques, the scattering intensity of Coulomb production described in terms of chiral dynamics and its dependence on the 3π-invariant mass m(3π)=sqrt[s] were extracted. The absolute cross section was determined in seven bins of sqrt[s] with an overall precision of 20%. At leading order, the result is found to be in good agreement with the prediction of chiral perturbation theory over the whole energy range investigated.

Teaching neuroscience to science teachers: facilitating the translation of inquiry-based teaching instruction to the classroom

In science education, inquiry-based approaches to teaching and learning provide a framework for students to building critical-thinking and problem-solving skills. Teacher professional development has been an ongoing focus for promoting such educational reforms. However, despite a strong consensus regarding best practices for professional development, relatively little systematic research has documented classroom changes consequent to these experiences. This paper reports on the impact of sustained, multiyear professional development in a program that combined neuroscience content and knowledge of the neurobiology of learning with inquiry-based pedagogy on teachers' inquiry-based practices. Classroom observations demonstrated the value of multiyear professional development in solidifying adoption of inquiry-based practices and cultivating progressive yearly growth in the cognitive environment of impacted classrooms.

Incidence and predictive factors of depressive symptoms in Alzheimer's disease: the REAL.FR study

BACKGROUND

Many patients develop psychiatric and behavioral disturbances in the course of Alzheimer's disease (AD). Among these disturbances, depressive symptoms are frequent and affect nearly 40% of patients. The natural history and course of such symptoms in AD, and in particular the predictive factors, are little known. We studied the incidence and risk factors for the development of the first depressive symptoms in AD.

DESIGN

Multicenter prospective study.

PARTICIPANTS

Three hundred twelve AD patients from the French Network on AD (REAL.FR) without depression and without antidepressant treatment at baseline were followed up and assessed every 6 months for 4 years. During follow-up, all events occurring between two visits were carefully recorded.

MEASUREMENTS

We used the Neuropsychiatric Inventory (NPI) for comprehensive evaluation of behavioral and psychological symptoms and depressive symptoms in particular. A multivariate analysis was performed using a backward stepwise Cox proportional hazards model.

RESULTS

The incidence of depressive symptoms was 17.45% person/years, 95%CI (13.88-21.02). Among non-time dependent variables, duration of disease (RR=0.51; 95%CI: 0.30-0.85, p=0.0102) and the number of comorbid conditions (RR=0.45; 95%CI: 0.24-0.83, p=0.0115) were protective factors against the development of depressive symptoms. Agitation/aggression (RR=1.96; 95%CI: 1.19-3.23, p=0.0078) and sleep disturbances (RR=2.65; 95%CI: 1.40-5.00, p=0.0026) were time-dependent variables predictive of depressive symptoms.

CONCLUSION

Better knowledge of predictive factors of mood disturbances in AD will enable clinicians to set up appropriate management of their patients. As published longitudinal studies are few, further works should be carried out to improve knowledge of the pattern and course of depression and depressive symptoms in AD.

[Differential indications for psychotherapies in borderline personality disorder]

BACKGROUND

Borderline personality disorder (BPD) accounts for 10% of outpatient psychiatric practice. The risk of suicide attempts is high and the psychosocial impairment significant. Different theoretical streams have suggested psychotherapeutical approaches for BPD.

OBJECTIVE

to examine the efficacy of psychotherapy for BPD patients on affective symptoms, behavioural outcomes, interpersonal and social functioning, as well as BPD criteria.

METHODS

We reviewed the medical literature from 1990 to 2008 on Medline by combining the following keywords "borderline personality disorder" and "psychotherapy" (inclusion criteria). We restricted the analysis to "randomised control trial" or "meta analysis".

RESULTS

Of the 39 abstracts that came out from the search, we selected 17 (44%) after applying the exclusion criteria. According to our review, different types of psychotherapies have shown some efficacy on reducing affective symptoms and BPD criteria, as well as improving behavioural outcomes and psychosocial functioning. Dialectical behavioural therapy presents the best-documented efficacy, notably on reducing self-mutilating and suicidal behaviours (five randomized controlled trials [RCT]). Mentalization based treatment seems to be efficient on the four types of outcomes, but has been the object of only one RCT. Finally, some evidence suggests that Manual Assisted Cognitive Treatment and Systems Training for Emotional Predictability and Problem Solving are the most cost-effective and easiest to be implemented.

CONCLUSION

According to our review, some evidence supports an efficiency of psychotherapies in the management of several features of BPD. It is likely that, depending on the target symptoms, one type of therapy might be more efficient than another. The acceptability of these long-term treatments is however unknown.