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Long-term Benefits (long-term + benefit)
Selected AbstractsCarvedilol Produces Sustained Long-Term Benefits: Follow-Up at 12 YearsCONGESTIVE HEART FAILURE, Issue 1 2009John F. MacGregor MD The authors measured long-term outcomes of patients who initiated carvedilol between 1990 and 1992 to test the hypothesis that carvedilol produces sustained benefits in heart failure patients. The study population consisted of 57 patients who completed a carvedilol placebo-controlled phase II trial. Patients were given open-label carvedilol and were titrated to the maximum dose. Patients were assessed by serial multigated acquisition, echocardiography, and symptom scores. Survival was assessed for all patients and censored as of January 1, 2004. Survival for ischemic vs nonischemic patients was compared using the log-rank test and further compared using Cox regression, controlling for covariates. Etiology of heart failure was ischemic in 15 patients and nonischemic in 42 patients. Median follow-up was 12.9 years. Resting left ventricular ejection fraction (LVEF) and heart failure symptom scores improved at 4 months of treatment and were sustained at 24 months. Left ventricular internal diameter in systole (LVIDS) and left ventricular internal diameter in diastole decreased significantly at 4 and 8 months, respectively, and LVIDS continued to improve at 24 months. Overall mortality was 43% in nonischemic patients and 73% in ischemic patients. In a multivariate analysis, ischemic etiology and baseline LVEF were significant predictors of mortality. Carvedilol produces sustained improvements in left ventricular remodeling and symptoms. Long-term survival is good, particularly in nonischemic patients. [source] Long-Term Benefits of Delaying First Sex Appear to Be LimitedPERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH, Issue 2 2008D. Hollander No abstract is available for this article. [source] Long-term benefit to pallidal deep brain stimulation in a case of dystonia secondary to pantothenate kinase-associated neurodegenerationMOVEMENT DISORDERS, Issue 12 2006Martin Krause MD Abstract Pantothenate kinase-associated neurodegeneration (PKAN) is a rare autosomal recessive disorder with onset in childhood and rapid progression. There is no causative and insufficient symptomatic drug therapy. Deep brain stimulation (DBS) of the internal pallidum (GPi) has been reported to improve motor function. Most case reports, however, are limited to short observational periods. The impact of DBS on the progression and life expectancy in PKAN is unknown. We present a 5-year outcome and video documentation of bilateral GPi-DBS of an adolescent patient suffering from genetically defined PKAN. © 2006 Movement Disorder Society [source] Long-term benefits of rivastigmine in dementia associated with Parkinson's disease: An active treatment extension studyMOVEMENT DISORDERS, Issue 4 2006Werner Poewe MD Abstract In patients with dementia associated with Parkinson's disease (PD), the efficacy and safety of rivastigmine, an inhibitor of acetylcholinesterase and butyrylcholinesterase, were previously demonstrated in a 24-week double-blind placebo-controlled trial. Our objective was to determine whether benefits were sustained over the long term. Following the double-blind trial, all patients were permitted to enter an active treatment extension study, during which they received rivastigmine 3,12 mg/day. Standard safety assessments were performed. Efficacy assessments included the Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog) and other measures of cognition, daily function, neuropsychiatric symptoms, and executive function. Of 433 patients who completed the double-blind trial, 334 entered and 273 completed the active treatment extension. At 48 weeks, the mean ADAS-cog score for the whole group improved by 2 points above baseline. Placebo patients switching to rivastigmine for the active treatment extension experienced a mean cognitive improvement similar to that of the original rivastigmine group during the double-blind trial. The adverse event profile was comparable to that seen in the double-blind trial. Long-term rivastigmine treatment appeared well tolerated and may provide sustained benefits in dementia associated with PD patients who remain on treatment for up to 48 weeks. © 2005 Movement Disorder Society [source] Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysmsBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 6 2007H. A. Ashton Background: Long-term benefits of screening for abdominal aortic aneurysm (AAA) are uncertain. These are the final results of a randomized controlled screening trial for AAA in men, updating those reported previously. Benefit and compliance over a median 15-year interval were examined. Methods: One group of men were invited for ultrasonographic AAA screening, and another group, who received standard care, acted as controls. A total of 6040 men aged 65,80 years were randomized to one of the two groups. Outcome was monitored in terms of AAA-related events (surgery or death). Results: In the group invited for screening, AAA-related mortality was reduced by 11 per cent (from 1·8 to 1·6 per cent, hazard ratio 0·89) over the follow-up interval. Screening detected an AAA in 170 patients; 17 of these died from an AAA-related cause, seven of which might have been preventable. The incidence of AAA rupture after an initially normal scan increased after 10 years of follow-up, but was still low overall (0·56 per 1000 person-years). Conclusion: Screening with a single ultrasonography scan still conferred a benefit at 15 years, although the results were not significant for this population size. Fewer than half of the AAA-related deaths in those screened positive could be prevented. Registration number: ISRCTN 00079388 (http://www.controlled-trials.com). Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Regulated cross-border transmission investment in EuropeEUROPEAN TRANSACTIONS ON ELECTRICAL POWER, Issue 6 2006Leonardo Meeus Abstract In a liberalized market, generation and transmission investment decisions are decoupled, so that a more elaborated grid is necessary. The European transmission grid has to ensure security of supply, facilitate the market and integrate renewables. Transmission grid investments are clearly needed, especially to increase the scarcely available cross-border transfer capacities. The regulatory framework in which these investments have to take place is discussed in this paper. It is stated that this framework does not ensure that congestion revenues are used for transmission investments that are in the long-term benefit of the market, because regulators are biased towards a short-term tariff reduction. The authors conclude that more coordination is clearly necessary, either pushed by European regulation or driven by coordinated regulatory actions. Copyright © 2006 John Wiley & Sons, Ltd. [source] Long-term follow-up of interferon alfa treatment in chinese patients with chronic hepatitis B infection: The effect on hepatitis B e antigen seroconversion and the development of cirrhosis-related complicationsHEPATOLOGY, Issue 1 2001Man-Fung Yuen The long-term effect of interferon alfa (IFN-,) in Chinese patients with chronic hepatitis B infection is unknown. A total of 411 chronic hepatitis B patients (208 treated with IFN-, and 203 as control) were followed up for hepatitis B serology and the development of hepatoma and other cirrhosis-related complications. The hepatitis B e antigen (HBeAg) seroconversion rate in the IFN-,,treated group, though significantly greater at 6 and 24 months, was comparable with the control group on subsequent follow-up, irrespective of pretreatment alanine transaminase (ALT) levels. HBeAg seroreversion rate was higher in the IFN-, group compared with the control group (21.1% vs. 2.2%; P = .001). Loss of hepatitis B surface antigen (HBsAg) occurred in 2.4% of the IFN-,,treated patients and 0.49% of the control patients (P = NS). Around 90% of the anti-HBe,positive patients in both groups were still hepatitis B virus (HBV)-DNA,positive by polymerase chain reaction (PCR) assay. Two patients suffered from hepatic reactivation during the course of treatment. Nine (4.3%) patients in the IFN-, group and 2 (1.0%) in the control group developed complications of cirrhosis and hepatoma (P = .062). In Chinese HBsAg carriers, IFN-, was of no long-term benefit in inducing HBeAg seroconversion or in the prevention of hepatoma and other cirrhosis-related complications. [source] Productivity,quality,costs,safety: A sustained approach to competitive advantage,a systematic review of the national safety council's case studies in safety and productivityHUMAN FACTORS AND ERGONOMICS IN MANUFACTURING & SERVICE INDUSTRIES, Issue 2 2008Tushyati Maudgalya The marked improvement in workplace safety levels in the past few decades has resulted in companies experiencing fewer safety accidents than before, thus making it less effective to argue that money spent on workplace safety and on injury prevention will yield much bottom-line benefit. To make a compelling business case for workplace safety investment, one must link safety objectives to other business objectives. The objective of this study is to determine whether workplace safety as a business objective adds value to the business bottom line. This research reviews published case studies to determine if there is a relationship between safety initiatives and increased productivity, quality, and cost efficiencies. Eighteen case studies (17 published by the National Safety Council) were analyzed using the Workplace Safety Intervention Appraisal Instrument. The appraisal scores ranged from 0.55 to 1.27, with an average of 0.91. The case studies were relatively strong in the Evidence Reporting and Data Analysis categories, as compared to the Subject Selection, Observation Quality, and Generalization to Other Populations categories. Following workplace safety initiatives, the studies revealed an average increase of 66% (2%,104%) in productivity, 44% (4%,73%) in quality, 82% (52%,100%) in safety records, and 71% (38%,100%) in cost benefits. In a few reported cases, it took only 8 months to obtain a payback in terms of monetary investment in the safety initiative. Although the studies did display a correlation between safety, productivity, and quality, there is insufficient evidence to categorically state that the improvements in productivity, quality, and cost efficiency were brought about by the introduction of an organization-wide safety culture. Notwithstanding, there is demonstrable evidence to indicate that safety as a business objective can assist an organization in achieving the long-term benefit of operational sustainability, that is, achieve a long-term competitive advantage by balancing business costs against social costs. Further research is required to conclusively prove the exact (possibly quantifiable) impact of safety investment on increased productivity, quality, and cost efficiency. © 2008 Wiley Periodicals, Inc. [source] Assessment and Intervention to Teach Age Recognition Skills: a Suggested Programme Using the Example of a Case Study to IllustrateJOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES, Issue 3 2000Dorothy M. Bell A 43-year-old man with mild intellectual disabilities was referred after several contacts with the law when he had been seen in the street talking to children who were unknown to him. Some staff members feared that he had a sexual interest in children. Other colleagues considered that the behaviour was innocent, reflecting his friendly nature, but that it was a behaviour which was misinterpreted by others. The present paper charts the assessment of this man's difficulties and abilities over a wide range of relevant areas, and a reassessment following an intensive period of one-to-one training on age-recognition skills. Although the training was unsuccessful, the measures used assisted in making a detailed assessment and providing clear instructions to care staff, all of which was to the subject's long-term benefit. The present paper also illustrates the way in which difficulties of this nature can be assessed and uses allied assessment measures which may be helpful in looking at the whole picture of any person with such problems. It also considers how these areas may then be addressed. Although, in this case, the subject was unable to learn to discriminate specific age groups despite intensive training, he was consequently able to be advised in a manner which should keep him from getting into trouble in the future and the now detailed knowledge of his abilities in all these areas is valuable for his long-term support in the community. [source] Incidence of Atrial Fibrillation Post-Cavotricuspid Isthmus Ablation in Patients with Typical Atrial Flutter: Left-Atrial Size as an Independent Predictor of Atrial Fibrillation RecurrenceJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 8 2007KEITH ELLIS M.D. Introduction: Atrial fibrillation and atrial flutter often coexist. The long-term occurrence of atrial fibrillation in patients presenting with atrial flutter alone is unknown. We report the long-term follow-up in patients who underwent cavotricuspid isthmus ablation for treatment of lone atrial flutter. Methods and Results: Between January 1997 and June 2002, 632 patients underwent cavotricuspid isthmus ablation for the treatment of typical atrial flutter at the Cleveland Clinic Foundation. Three hundred sixty-three patients were included in this study and followed for a mean duration of 39 ± 11 months. The mean duration of atrial flutter symptoms was 12 ± 5 months. Mean left-atrial size and left-ventricular ejection fraction were 4.2 ± 0.8 cm and 47 ± 13%, respectively. After a mean follow-up time of 39 ± 11 months, 13% (48 of 363) of the patients remained in sinus rhythm. Five percent (18 of 363) of patients experienced recurrence of atrial flutter only. Sixty-eight percent (246 of 363) experienced the onset of atrial fibrillation and 14% (51 of 363) experienced recurrence of atrial flutter and the new onset of atrial fibrillation. Overall, 82% (297 of 363) of the patients experienced new onset of drug refractory atrial fibrillation. Left-atrial size was a predictor of atrial fibrillation recurrence post-atrial flutter ablation. Conclusion: At long-term follow-up, approximately 82% of patients post-cavotricuspid isthmus ablation for atrial flutter developed drug refractory atrial fibrillation. This finding suggests that elimination of atrial flutter might delay, but does not prevent, atrial fibrillation. Evidence suggests both arrhythmias may share common triggers and such patients may derive a better long-term benefit from anatomical ablative treatment of atrial fibrillation as well. [source] Diagnostic Coronary Angiography in Patients with Peripheral Arterial Disease: A Sub-study of the Coronary Artery Revascularization Prophylaxis TrialJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2008SANTIAGO GARCIA M.D. Background: Although patients in need of elective vascular surgery are often considered candidates for diagnostic coronary angiography, the safety of this invasive study has not been systematically studied in a large cohort of patients scheduled for an elective vascular operation. The goal of this sub-study of the Coronary Artery Revascularization Prophylaxis (CARP) trial was to assess the safety of coronary angiography in patients with peripheral vascular disease. Methods: The CARP trial tested the long-term benefit of coronary artery revascularization prior to elective vascular operations. Among those patients who underwent diagnostic coronary angiography during screening for the trial, the associated complications were determined at 24 hours following the diagnostic procedure. Results: Over 5,000 patients were screened during a 4-year recruitment period at 18 major VA medical centers and the present cohort consists of 1,298 patients who underwent preoperative coronary angiography. Surgical indications for vascular surgery included an expanding aortic aneurysm (AAA) (n = 446; 34.4%) or arterial occlusive disease with either claudication (n = 457; 35.2%) or rest pain (n = 395; 30.4%). A total of 39 patients had a confirmed complication with a major complication identified in 17 patients (1.3%). Complication rates were higher in patients with arterial occlusive symptoms compared with expanding aneurysms (1.8% vs. 0.5%; P = 0.07) and were not dissimilar with femoral (2.8%) versus nonfemoral (4.7%) access sites (P = 0.42). Conclusions: Coronary angiography is safe in patients with peripheral arterial disease undergoing preoperative coronary angiography. The complication rate is higher in patients with symptoms of arterial occlusive disease. [source] Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the Leicester Assessment PackageMEDICAL EDUCATION, Issue 7 2000Robert K McKinley Objective To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter-assessor reliability, acceptability, feasibility and educational impact. Design 180 third and fourth year Leicester medical students were directly observed consulting with six general practice patients and independently assessed by a pair of assessors. A total of 70 practice and 16 departmental assessors took part. Performance scores were subjected to generalizability analysis and students' views of the assessment were gathered by questionnaire. Results Four of the five categories of consultation performance (Interviewing and history taking, Patient management, Problem solving and Behaviour and relationship with patients) were assessed in over 99% of consultations and Physical examination was assessed in 94%. Seventy-six percent of assessors reported that the case mix was ,satisfactory' and 20% that it was ,borderline'; 85% of students believed it to have been satisfactory. Generalizability analysis indicates that two independent assessors assessing the performance of students across six consultations would achieve a reliability of 0·94 in making pass or fail decisions. Ninety-eight percent of students perceived that their particular strengths and weaknesses were correctly identified, 99% that they were given specific advice on how to improve their performance and 98% believed that the feedback they had received would have long-term benefit. Conclusions The modified version of the LAP is valid, reliable and feasible in formative assessment of the consultation performance of medical students. Furthermore, almost all students found the process fair and believed it was likely to lead to improvements in their consultation performance. This approach may also be applicable to regulatory assessment as it accurately identifies students at the pass/fail margin. [source] Interferon-alpha therapy in idiopathic thrombocytopenic purpuraPEDIATRICS INTERNATIONAL, Issue 6 2001Bunyamin Dikici AbstractBackground: Acute idiopathic thrombocytopenic purpura (ITP) represents the most frequent hemorrhagic diathesis in childhood. Up to 30% of patients with ITP are regarded as refractory to standard therapy. The rare mortality from acute ITP in childhood is almost exclusively due to intracranial hemorrhage. This complication occurs in less than 1% of ITP patients. This study was designed to evaluate the effect of ,-interferon (IFN-,) in eight patients whom did not respond to conventional therapy. Method: In spite of conventional therapies, the patient whose platelet count could not be increased to 50`109/L were accepted as refractory ITP. Eight of these patients whose platelet count lower than 20`109/L were included in the prospective cohort study. Interferon alpha 2b 5 MU/m2 was administered subcutaneously three times a week, totalling 12 times in a month. According to the platelet count on the 28th day of therapy, we grouped the patients into three categories. After 60 days, the survey was re-evaluated according to the platelet count. Results: The mean age of children was 3.5±2.5 (ranged between 3.5 and 9) years. Six of them were boys and two were girls. There was no response in one patient, partial response in one, and good response in six patients on the 28th day of therapy. The maximum rise in platelet count was observed from 7 to 14 days after the initiation of interferon. The median platelet count which was 15±5`109/L before therapy, raised to 60±12`109/L after therapy. However, on the 60th day of therapy, there were only two patients who had a platelet count over 100`109/L. Conclusion: In our study, we did not observe the long-term benefit of IFN-, therapy in refractor ITP in childhood. However, in good responding patients, platelet levels were increased in a short time. Alpha-interferon may be alternative therapy for patients whom had a platelet count below 20`109/L and not responding to standard therapy, or for patients whom immunosuppressive therapy is contraindicated. [source] Latest news and product developmentsPRESCRIBER, Issue 19 2008Article first published online: 16 OCT 200 ARBs less effective than ACE inhibitors? The efficacy of angiotensin-II receptor blockers (ARBs) in preventing cardiovascular events in high-risk patients has been challenged by the findings of a large randomised trial (Lancet 2008 published online; doi 10.1016/ S0140-6736(08)61242-8). In the TRANSCEND trial, 5926 patients with cardiovascular disease or diabetes with end-organ damage who could not tolerate ACE inhibitor therapy were randomised to placebo or telmisartan (Micardis) 80mg per day in addition to standard therapies. After 56 months, mean blood pressure was lower with telmisartan (by 4.0/2.2mmHg) but there were no significant differences between telmisartan and placebo in the risk of cardiovascular events , a composite of cardiovascular death, myocardial infarction, stroke, or hospitalisation for heart failure. Hospitalisation for cardiovascular reasons were slightly but significantly reduced by telmisartan (33 vs 30 per cent). MHRA: fentanyl patch errors potentially fatal Errors in dosing, accidental exposure and enhanced absorption from heat exposure have resulted in life-threatening and fatal incidents with transdermal fentanyl, warns the MHRA in its latest Drug Safety Update (September 2008). There is also evidence that fentanyl patches are being prescribed for nonlicensed indications, including treatment of opioid-naive patients. Other topics in this issue include managing adverse reactions to HPV vaccine and an update on new cases of progressive multifocal leucoencephalopathy associated with natalizumab (Tysabri). Call for DURG research The Drug Utilisation Research Group is inviting abstracts for oral and poster presentations at its 20th annual meeting on 5 February 2009. The theme of the morning session is ,Whose prescribing budget is it anyway?'. Abstracts will be accepted on any drug utilisation research studies and will be published in the Journal of Pharmacoepidemiology and Drug Safety. Information is available at www.durg.org.uk the deadline for submissions is 1 December. Early bromocriptine no benefit in Parkinson's Initiating treatment of Parkinson's disease with the dopamine agonist bromocriptine offers no long-term benefit compared with levodopa, the UK Parkinson's Disease Research Group trial has shown (Neurology 2008;71:474-80). After 14 years' follow-up of 166 patients, there were no differences in the prevalence of motor complications, dementia or mortality, but levodopa was associated with superior scores of disability and physical functioning. The authors say the belief that early dopamine agonist treatment is neuroprotective in Parkinson's disease should be abandoned. Ezetimibe with statin cancer risk ,not credible' Analysis of data pooled from two large trials provides ,no credible evidence' that ezetimibe (Ezetrol) is associated with an increased risk of cancer when added to statin therapy (N Engl J Med 2008 published online; doi 10.1056/NEJMsa0806603). A possible link with increased risk of cancer with ezetimibe plus simvastatin was suggested by the SEAS trial (N Engl J Med 2008 published online; doi 10.1056/NEJMoa 0804602). This hypothesis was tested in two trials involving more than 20 500 patients over 1.0-2.7 years. There was no excess of cancer overall or at particular sites; cancer deaths were more numerically but not significantly higher with ezetimibe and there was no evidence of increased risk with duration of treatment. Telmisartan provides no advantage after stroke Adding telmisartan (Micardis) to standard treatment after ischaemic stroke does not reduce morbidity, US investigators report (N Engl J Med 2008 published online; doi 10.1056/NEJMoa 0804593). A total of 20 332 patients with recent ischaemic stroke were randomised to placebo or telmisartan 80mg per day in addition to antiplatelet therapy and antihypertensive agents. After 2.5 years, blood pressure was 3.8/2.0mmHg lower in patients taking telmisartan but there were no significant differences from placebo in the risks of recurrent stroke, cardiovascular events or new-onset diabetes. Copyright © 2008 Wiley Interface Ltd [source] Antiangiogenesis agents in the treatment of soft tissue sarcomasCANCER, Issue 5 2010Kristen Ganjoo MD Abstract Soft tissue sarcomas (STSs) are a heterogeneous group of malignancies that includes >50 different subtypes, each with unique clinical and pathologic qualities. In general, there is a 50% cure rate, and most cures are achieved with complete surgical resection with or without radiation therapy. The results from chemotherapeutic agents for unresectable or metastatic disease have been disappointing with minimal long-term benefit. New targeted and novel agents are needed to improve response and survival. Tumor angiogenesis has been an intense focus in cancer therapy over the past decade. Several of numerous antiangiogenesis agents have been developed, and many already have been approved for the treatment of both solid and liquid tumors. Certain STSs are highly vascular tumors that often demonstrate angiogenesis markers. The objective of this review was to evaluate these angiogenesis markers in defining the role of angiogenesis in the treatment of patients with STS. In addition, the authors conducted an in-depth review of the results from using key antiangiogenesis agents in the treatment of STS. Cancer 2010. © 2010 American Cancer Society. [source] Biogeographic Crossroads as Priority Areas for Biodiversity ConservationCONSERVATION BIOLOGY, Issue 6 2002Sacha Spector I suggest that targeting the regions where biogeographic assemblages intersect,"biogeographic crossroads",is a strategy that may achieve significant conservation economy by focusing on areas that satisfy many conservation criteria. I used a combination of data on Scarabaeine beetles in Bolivia and on other taxa and locations from the literature to consider the short- and long-term benefits of conserving these biogeographic crossroads. Biogeographic crossroads are areas of high species richness and beta diversity, often across many taxonomic groups. They are also regions where representativeness can be achieved with relative efficiency. Recent evidence that ecotones may be loci of evolution suggests that evolutionary processes such as speciation and coevolution may be conserved at biogeographic crossroads. Biogeographic crossroads appear to be areas of high conservation priority and opportunity in both the short and long term and require increased attention in the process of setting conservation priorities. Resumen: Las amenazas a la biodiversidad rebasan los recursos de la comunidad conservacionista y requieren de una cuidadosa priorización de las acciones de conservación. Sugiero que enfocar en las regiones donde intersectan ensambles biogeográficos,"intersecciones biogeográficas", es una estrategia que puede lograr una economía significativa de los esfuerzos de conservación al atender áreas que satisfacen muchos criterios de conservación. Utilicé una combinación de datos de escarabajos Scarabaeine de Bolivia y de otros taxones y localidades de la literatura para considerar los beneficios a corto y largo plazo de conservar estas intersecciones biogeográficas. Las intersecciones biogeográficas son áreas de alta riqueza de especies y de diversidad beta, y probablemente éste sea el caso de muchos grupos taxonómicos. También son regiones en las que se puede alcanzar representatividad con relativa eficiencia. Evidencia reciente de que los ecotonos pueden ser sitios de evolución sugiere que los procesos evolutivos tales como la especiación y coevolución pueden ser conservados en intersecciones biogeográficas. Las intersecciones biogeográficas parecen ser áreas de alta prioridad y oportunidad de conservación tanto a corto como a largo plazo y requieren mayor atención en el proceso de definición de prioridades de conservación. [source] Customer Learning Processes, Strategy Selection, and Performance in Business-to-Business Service Firms,DECISION SCIENCES, Issue 2 2004Debra Zahay ABSTRACT Learning about customers takes place through relevant dialogues with those customers, also known as customer relationship management (CRM). As relationships develop, information about the customer is gathered in the firm's customer information systems (CIS): the content, processes, and assets associated with gathering and moving customer information throughout the firm. This research develops a measure of CIS management capabilities based on learning organization theory and measured by the ability to get, store, move, and use information throughout the business unit. This measure is then used to analyze customer learning processes and associated performance in the context of marketing strategic decision making. This study of 209 business services firms finds that generic marketing strategy positioning (low-cost and differentiation) and the marketing tactics of personalization and customization are related to CIS development. Customer information systems development in turn is associated with higher levels of customer-based performance, which in turn is associated with increased business growth. Since the strongest association with customer-based performance is strategy selection, the long-term benefits of the knowledge gained from the CIS may be in the ability to assist in measuring customer-based performance, rather than in the ability to immediately contribute to performance. Finally, for these firms, customization and personalization are not directly associated with performance and thus may not be necessary to support every firm's marketing strategy. [source] The costs and benefits of fast livingECOLOGY LETTERS, Issue 12 2009Karen E. Rose Abstract Growth rates play a fundamental role in many areas of biology (Q. Rev. Biol., 67, 1992, 283; Life History Invariants. Some Explorations of Symmetry in Evolutionary Biology, 1993; Philos. Trans. R. Soc. Lond. B Biol. Sci., 351, 1996, 1341; Plant Strategies, Vegetation Processes, and Ecosystem Properties, 2002; Trends Ecol. Evol., 18, 2003, 471; Q. Rev. Biol., 78, 2003, 23; J. Ecol., 95, 2007, 926.) but the cost and benefits of different growth rates are notoriously difficult to quantify (Q. Rev. Biol., 72, 1997, 149; Funct. Ecol., 17, 2003, 328). This is because (1) growth rate typically declines with size and yet the most widely used growth measure , relative growth rate or RGR (conventionally measured as the log of the ratio of successive sizes divided by the time interval) , is not size-corrected and so confounds growth and size, (2) organisms have access to different amounts of resource and (3) it is essential to allow for the long-term benefits of larger size. Here we experimentally demonstrate delayed costs and benefits of rapid growth in seven plant species using a novel method to calculate size-corrected RGR. In control treatments, fast-growing plants benefited from increased reproduction the following year; however, fast-growing plants subjected to an experimental stress treatment (defoliation) showed strongly reduced survival and reproduction the following year. Importantly, when growth was estimated using the classical RGR measure, no costs or benefits were found. These results support the idea that life-history trade-offs have a dominant role in life-history and ecological theory and that the widespread failure to detect them is partly due to methodological shortcomings. Ecology Letters (2009) 12: 1379,1384 [source] Long-term Prognosis and Psychosocial Outcomes after Surgery for MTLEEPILEPSIA, Issue 12 2006Sophie Dupont Summary:,Purpose: To assess the seizure-freedom rates and self-perceived psychosocial changes associated with the long-term outcome of epilepsy surgery in patients with refractory medial temporal lobe epilepsy associated with hippocampal sclerosis. Methods: A standard questionnaire was given to 183 patients who underwent surgery between 1988 and 2004, and 110 were completed. Results: The mean duration of follow-up after surgery was 7 years, with a maximum of 17 years. The probability that patients were seizure-free after surgery was dependent on the definition of the seizure freedom. For the patients who were seizure-free since surgery (Engel's class Ia), the probability was 97.6% at 1 year after surgery, 85.2% at 2 years after surgery, 59.5% at 5 years after surgery, and 42.6% at 10 years after surgery. For the patients who still experienced rare disabling seizures after surgery but were seizure-free at least 1 year before the time of assessment, the probability was of 97.6% at 1 year after surgery, 95% at 2 years after surgery, 82.8% at 5 years after surgery, and 71.1% at 10 years after surgery. The psychosocial long-term outcome, as measured by indices of driving, employment, familial and social relationships, and marital status, was similar to the psychosocial short-term outcome. It did not depend on seizure freedom or on follow-up time interval and was not influenced statistically by seizure frequency in cases of persisting seizures. Most but not all patients noticed a substantial overall improvement in their psychosocial condition; 48% drove (increased by 7%), 47% improved (14% worsened) in their employment status, and 68% improved (5% worsened) in their familial and social relationships. Overall, 91% of patients were satisfied with the surgery, and 92% did not regret their decision. Conclusions: The results of this study suggest that temporal lobe surgery has real long-term benefits. Two specific conclusions emerge: (a) the long-term rates of freedom from seizure depend on how seizure freedom is defined, and (b) the psychosocial long-term outcome does not change dramatically over years and does not depend on seizure freedom. [source] How a major multinational is working to overcome the barriers to improved expatriate ROIGLOBAL BUSINESS AND ORGANIZATIONAL EXCELLENCE, Issue 3 2008Yvonne McNulty Despite the growing use of international assignments and the high cost of expatriates, few global firms have found the key to gauging the success of their mobility program, especially their expatriate return on investment (ROI). The author reports on one global firm that has made great strides towards a practical ROI tool by targeting the fundamental systems and processes needed to manage international assignments. The author also makes the case that an assignment's purpose, relative to business and/or organizational strategies, determines the types of inputs and outcomes to measure; and that ROI determinations for expatriates must include intangible and long-term benefits and costs. © 2008 Wiley Periodicals, Inc. [source] TPM,Total Productive Maintenance: Impact on competitiveness and a framework for successful implementationHUMAN FACTORS AND ERGONOMICS IN MANUFACTURING & SERVICE INDUSTRIES, Issue 4 2001K.S. Park Total Productive Maintenance (TPM) describes a synergistic relationship among all organizational functions, but particularly between production and maintenance, for continuous improvement of product quality, operational efficiency, capacity assurance, and safety. This article provides the key factors that are critical to the successful implementation of TPM. It is thus crucial to provide and discuss those factors for more effective TPM implementation. Also, this study explores the impact of TPM on the competitiveness of the company. This research concludes that long-term benefits of TPM are the result of considerable investment in human resource development and management. For TPM practitioners, we advise to build a supportive culture and environment with a strong emphasis on human and organizational aspects to promote effective TPM implementation. © 2001 John Wiley & Sons, Inc. [source] Relay Cropping of Sorghum and Legume Shrubs for Crop Yield Improvement and Striga Control in the Subsistence Agriculture Region of Tigray (Northern Ethiopia)JOURNAL OF AGRONOMY AND CROP SCIENCE, Issue 1 2005F. Reda Abstract Striga hermonthica is a major constraint in the subsistence agriculture regions of northern Ethiopia. Low soil fertility and overall environmental degradation has contributed to the build up of the parasitic weed infestation. Improved cropping systems have to be introduced to address the interrelated problems of Striga and soil fertility decline. Thus, relay cropping of sorghum with legume shrubs was investigated at two locations representing different environments. Results showed that the output of the improved cropping system was dependent on ecological endowments. Relay cropping led to significant improvement in yield at Sheraro, at the site with relatively better weather and soil conditions. The legume shrubs resulted in significantly lower sorghum yield in a dryland location (Adibakel). Overall Striga infestation declined over the 3-year period; however, treatment differences were not apparent. Among the two legume shrubs, Sesbania sesban was better adapted to the dryland areas. Relay cropping could provide a viable option for farmers in both types of environments that are characterized by accelerated decline in natural resource base. However, it could mean compromising the yield of non-fertilized sorghum in the interest of long-term benefits of low incidence of Striga and more rewarding crop enterprise in dry areas. [source] What Matters When Deciding Whether to Participate in Colorectal Cancer Screening?JOURNAL OF APPLIED BIOBEHAVIORAL RESEARCH, Issue 1 2010The Moderating Role of Time Perspective According to construal level theory (CLT), the more distant an event, the more likely it is to be represented in terms of abstract (e.g., desirability) versus concrete features (e.g., feasibility). This online study tested temporal distance effects in the context of colorectal cancer screening, which is desirable in terms of detecting cancer but relatively unpleasant. Consistent with CLT, participants in the distant future condition acquired more knowledge relating to the desirability of performing the test, attached greater weight to information emphasizing the long-term benefits, and exhibited stronger intentions to use the test. These findings suggest that the temporal distance between decision-making and behavioral execution plays an important role in the construal and application of central features of health actions. [source] Ecotourism and biodiversity conservation in Jozani,Chwaka Bay National Park, ZanzibarAFRICAN JOURNAL OF ECOLOGY, Issue 2009Layla A. Salum Abstract This study is based on a study undertaken to assess how ecotourism has influenced biodiversity conservation in Jozani,Chwaka Bay National Park (JCBNP). It involved two communities surrounding the park, namely Pete and Kitogani. Field data were collected using structured questionnaires, key informant interviews and field observations. Questionnaires were administered to 76 households, whereas key informant interviews were conducted with foresters and JCBNP officials. Data analysis was undertaken using standard statistical methods. Findings from the study show that biodiversity management in the JCBNP has improved considerably after the introduction of ecotourism. The number of endemic colobus monkeys (Piliocolobus kirkii) and other rare species has increased. However, this achievement has been attained by restricting surrounding communities from using forest resources without providing alternative sources of livelihood. Findings also show that the benefits from ecotourism do not reach individual households, but the community as whole, in form of various social services. This has caused some resentment among the local people leading to their reluctance to reduce their direct use of ecosystem services available in the JCBNP, claiming that they cannot sustain their livelihood without such services. This has become a major source of conflict between the JCBNP and surrounding communities. Increased awareness and knowledge on biodiversity conservation would be needed for the communities surrounding the park to realize the potential and long-term benefits of ecotourism, and hence the need for their increased involvement in biodiversity management. [source] Short- and long-term benefits and detriments to recombination under antagonistic coevolutionJOURNAL OF EVOLUTIONARY BIOLOGY, Issue 3 2007A. D. PETERS Abstract We explored the evolution of recombination under antagonistic coevolution, concentrating on the equilibrium frequencies of modifier alleles causing recombination in initially nonrecombining populations. We found that the equilibrium level of recombination in the host depended not only on parasite virulence, but also on the strength of the modifier allele, and on whether or not the modifier was physically linked to the parasite interaction loci. Nonetheless, the maximum level of recombination for linked loci at equilibrium was about 0.3 (60% of free recombination) for interactions with highly virulent parasites; the level decreased for unlinked modifiers, and for lower levels of parasite virulence. We conclude that recombination spreads because it provides a combination of an immediate (next-generation) fitness benefit and a delayed (two or more generations) increase in the rate of response to directional selection. The relative impact of these two mechanisms depends on the virulence of parasites early in the spread of the modifier, but a trade-off between the two dictates the equilibrium modifier frequency for all nonzero virulences that we examined. In addition, population mean fitness was higher in populations at intermediate equilibria than populations fixed for free recombination or no recombination. The difference, however, was not enough on its own to overcome the two-fold cost of producing males. [source] Postnatal corticosteroids and sensorineural outcome at 5 years of ageJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 3 2000The Victorian Infant Collaborative Study Group Background: Postnatal corticosteroids reduce ventilator dependence in preterm infants, but possible long-term benefits for either survival or sensorineural morbidity are not proved. Aim: The aim of this study was to determine the association between corticosteroid therapy given postnatally and sensorineural outcome in childhood. Subjects: The subjects comprised 346 consecutive livebirths either of birthweight < 1000 g or with gestational age < 28 weeks born in the state of Victoria during 1991 and 1992, and who survived the first week after birth; 120 (34.7%) were given corticosteroids postnatally. Results: Of the 120 children who received corticosteroids, 98 (81.7%) survived to 5 years of age, compared with 200 (88.5%) of the 226 children who did not receive corticosteroids. At 5 years of age, survivors treated with corticosteroids postnatally had significantly higher rates of cerebral palsy (corticosteroids 23%, no corticosteroids 4%), blindness (corticosteroids 4%, no corticosteroids 1%) or an intelligence quotient more than one standard deviation below the mean (corticosteroids 54%, no corticosteroids 32%) compared with children not treated with corticosteroids. The rate of sensorineural disabilities imposed by these impairments was significantly higher in children treated with postnatal corticosteroids, and the association between adverse sensorineural outcome and postnatal corticosteroids remained after adjustments for potentially confounding variables. In a separate case-control analysis of 60 children in each group, the rate of cerebral palsy remained significantly elevated (corticosteroids 22%, no corticosteroids 5%). Conclusion: Postnatal corticosteroid therapy is associated with substantial adverse sensorineural outcomes at 5 years of age. [source] Interferon-, treatment in children and young adults with chronic hepatitis B: a long-term follow-up study in TaiwanLIVER INTERNATIONAL, Issue 9 2008Hong-Yuan Hsu Abstract Background/Aims: The short- and long-term benefits of interferon (IFN)-, therapy in young patients with chronic hepatitis B (CHB) acquiring infection perinatally or during early childhood have been questioned. Methods: Twenty-one Taiwanese hepatitis B envelope antigen (HBeAg)-positive CHB patients aged 1.8,21.8 years (median 14.0 years) with alanine aminotransferase (ALT)>80 IU/L at entry were enrolled for IFN-, therapy. They received IFN-, therapy with a dose of 3 MU/m2/day three times a week for 24 weeks. A control group included untreated 21 CHB patients closely matched for gender, age, duration of ALT >80 IU/L and HBeAg status. All 42 patients were prospectively followed for 6.5,12.5 years after the end of therapy. Results: The cumulative rate of virological response [anti-HBe seroconversion and serum hepatitis B virus (HBV)-DNA <105 copies/ml] was not different between the IFN-treated patients and control patients at 1 year (41 vs 44%) and at 6 years (88 vs 89%) after stopping treatment. Serum hepatitis B surface antigen loss occurred in two (9.5%) treated patients and in one (4.8%) control patient. Patients with a successful treatment response (anti-HBe seroconversion, HBV-DNA <102 copies/ml and ALT normalization at 1 year after stopping treatment) were younger than those without a successful response (P=0.03). A lower pretreatment serum HBV-DNA level (<2 × 108 copies/ml) is not only a significant factor to predict successful treatment response (P=0.008) but also has a beneficial effect on the long-term cumulative rate of virological response in IFN-treated patients (P=0.021), but not in control patients. Genotype difference or emergence of a precore stop codon mutant before treatment was not predictive for HBeAg clearance. Conclusion: For young CHB patients in Taiwan with infection occurring perinatally or in early childhood, the real advantage of IFN-, therapy was not observed. IFN-, therapy showed a beneficial effect on short- and long-term virological outcomes only in those with a lower pretreatment serum HBV-DNA level. [source] The Psychological Impact of Implantable Cardioverter-Defibrillator Recalls and the Durable Positive Effects of CounselingPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2009JOHN D. FISHER M.D. Background: It is known that patients with lifesaving devices such as implantable cardioverter-defibrillators (ICDs) may be alarmed and worried by recalls or alerts related to their ICDs. Objectives: This study aimed to determine whether counseling has any short- or long-term benefits, and to look for characteristics that identify those most worried and those most in need of counseling. Methods: Among 100 patients with recall or alert ICDs, 14 were pacer dependent; 50 had ICDs for 1° prevention and 22 were women. Patients completed a survey indicating how worried they were on learning of the recall or alert (0,10 scale). After counseling and advice in accordance with manufacturer guidelines, patients were asked to indicate their level of worry, and were again asked after 6 months. Results: For all patients, the "worry level" at the initial interview was 5.0±3.7, falling to 2.2±3.0 after counseling (P < 0.001) and 1.4±2.3 after 6 months (P < 0.001 vs both earlier levels). There were no significant differences between those implanted for 1° versus 2° prevention or for pacer dependency. Women were initially more worried than men, but not for the long term. The 49 patients whose ICDs could be managed by reprogramming or software fix had significant reduction in worry after counseling and at 6 months compared to others. The 18 patients recommended for operative intervention remained more concerned after counseling (3.5±3.3 vs 1.9±2.9, P = 0.043). Conclusions: Patients' concerns resulting from ICD recalls or alerts can be reduced by appropriate counseling. Those patients whose ICDs could be reprogrammed to safer parameters had the most reduction in worry levels. [source] Long-Term Outcomes of a Telephone Intervention After an ICDPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 11 2005CYNTHIA M. DOUGHERTY Background: The purpose of this study was to determine the long-term benefits of participating in a structured, 8-week educational telephone intervention delivered by expert cardiovascular nurses post-ICD. The intervention was aimed to (1) increase physical functioning, (2) increase psychological adjustment, (3) improve self-efficacy in managing the challenges of ICD recovery, and (4) lower levels of health care utilization over usual care in the first 12 months post-ICD. This article reports on the 6- and 12-month outcomes of the nursing intervention trial. Methods and Results: A two-group (N = 168) randomized control group design was used to evaluate intervention efficacy with persons receiving an ICD for the secondary prevention of sudden cardiac arrest. Measures were obtained at baseline, 6 and 12 months post hospitalization. Outcomes included (1) physical functioning (Patient Concerns Assessment [PCA], Short Form Health Survey [SF-12], ICD shocks), (2) psychological adjustment (State-Trait Anxiety Inventory [STAI], Centers for Epidemiologic Studies,Depression [CES-D], fear of dying), (3) self-efficacy (Sudden Cardiac Arrest,Self-Efficacy [SCA-SE], Sudden Cardiac Arrest,Behavior [SCA-B], Sudden Cardiac Arrest,Knowledge [SCA-K]), and (4) health care utilization (emergency room [ER] visits, outpatient visits, hospitalizations). Using repeated measures ANOVA, the 6- and 12-month benefits of the intervention over usual care were in reductions in physical concerns (P = 0.006), anxiety (P = 0.04), and fear of dying (P = 0.01), with enhanced self-confidence (P = 0.04) and knowledge (P = 0.001) to manage ICD recovery. There were no statistically significant differences between the groups on total outpatient visits, hospitalizations, or ER visits over 12 months. Conclusion: A structured 8-week post-hospital telephone nursing intervention after an ICD had sustained 12-month improvements on patient concerns, anxiety, fear of dying, self-efficacy, and knowledge. Results may not apply to individuals with congestive heart failure who receive an ICD for primary prevention of sudden cardiac arrest. [source] Latest news and product developmentsPRESCRIBER, Issue 22 2007Article first published online: 28 DEC 200 Glitazones: benefits outweigh the risks Following a review of the safety of rosiglitazone and pioglitazone, the European Medicines Agency (EMEA) has concluded that their benefits outweigh their risks in the approved indications. The review was prompted by reports of an increased risk of fractures in women and, in patients taking rosiglitazone, ischaemic heart disease. The EMEA concluded that prescribing information for rosiglitazone should now include a warning that, in patients with ischaemic heart disease, it should only be used after careful evaluation of each patient's individual risk, and the combination of rosiglitazone and insulin should only be used in exceptional cases and under close supervision. No change was considered necessary to the prescribing information for pioglitazone. Modern dressings no better? A systematic review has found only weak evidence that modern dressings are better than saline gauze or paraffin gauze for healing acute and chronic wounds (Arch Dermatol 2007;143: 1297-304). The analysis, which included 99 studies, found that only hydrocolloids were demonstrably better than older dressings for healing chronic wounds, and alginates were superior to other modern dressings for debriding necrotic wounds. There was no evidence that modern dressings offered superior overall performance to the older alternatives. Hospital inflation twice primary care level The cost of drugs prescribed in secondary care but dispensed in the community increased by 6.4 per cent in 2006 - twice the rate of inflation in primary care - according to the latest statistics on hospital prescribing in England. The increase follows a reduction in costs in 2005 after the introduction of the new PPRS scheme. Data from The Information Centre (www.ic.nhs.uk) show that hospital medicines make up about 24 per cent of the NHS drugs budget. Secondary care has a consistently better record than primary care in prescribing lower-cost alternatives within therapeutic categories, eg simvastatin and pravastatin among the statins, omeprazole and lansoprazole among PPIs, and ACE inhibitors among drugs acting on the renin angiotensin system. The most expensive drug prescribed by hospital specialists and dispensed in the community is interferon beta. MHRA limits the use of fibrates The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that fibrates should now be reserved for the treatment of isolated severe hypertriglyceridaemia. They should be considered for hypercholesterolaemia only when a statin or other treatment is contraindicated or not tolerated. In the latest Drug Safety Update, the MHRA says there is insufficient evidence of long-term benefits from fibrates, and first-line use is no longer justified because the evidence for the benefits of statins is robust. The MHRA also warns that some breastfeeding infants have increased susceptibility to the adverse effects of codeine taken by their mother, and that St John's wort may affect the hepatic metabolism of any anticonvulsant. Annual zoledronic acid infusion cuts mortality after hip fracture Once-yearly infusion of zoledronic acid (Aclasta) after hip fracture reduces deaths over a two-year period by 28 per cent compared with placebo, US investigators say (N Engl J Med 2007;357:1799-809). The HORIZON Recurrent Fracture Trial randomised 2127 men and women (mean age 75) within 90 days of surgery for hip fracture to zoledronic acid 5mg yearly or placebo. Mortality over 1.9 years of follow-up was 9.6 per cent with zoledronic acid and 13.3 per cent with placebo. Zoledronic acid also significantly reduced the rate of any new clinical fractures (by 35 per cent) and new clinical vertebral fractures(by 45 per cent),but the lower rate of hip fracture (2.0 vs 3.5 per cent with placebo) was not statistically significant. Rivastigmine patch for mild to moderate AD Rivastigmine (Exelon) is now available as a transdermal patch for the treatment of mild to moderate Alzheimer's disease. Applied once daily, the patch delivers 9.5mg per 24 hours and, says manufacturer Novartis, is associated with a lower incidence of nausea and vomiting than a comparable oral dose. The patch is available in two strengths: 4.6mg per 24hr is equivalent to oral doses of 3 or 6mg per day, and the 9.5mg per 24hr patch is equivalent to 9 or 12mg per day orally. The recommended dose of the patch is 9.5mg per day; both strengths cost £83.84 for 30 patches. Women more aspirin resistant than men? The cardioprotective effect of low-dose aspirin may be lower in women than men, say Canadian investigators (BMC Medicine 2007;5:29 doi: 10.1186/1741-70155-29). Their meta-analysis of 23 randomised trials involving a total of 113 494 participants found that aspirin significantly reduced the risk of nonfatal but not fatal myocardial infarction (MI). About one-quarter of the variation in its effects on nonfatal MI was accounted for by the sex mix of the trial population. Separating the results by sex showed the reduction in risk with aspirin use was statistically significant in men (relative risk, RR, 0.62) but not in women (RR 0.87). Look after physical health of mentally ill GPs and other primary care workers should take more responsibility for the physical health of their mentally ill patients, say advocacy groups. Mind and Body: Preventing and Improving Physical Health Problems in Patients With Schizophrenia points out that the mental health needs of patients with schizophrenia are met in secondary care, but their physical health needs should be met in primary care. In particular, the metabolic effects of antipsychotics may lead to obesity, diabetes and cardiovascular disease, and weight gain in particular is a frequent reason for nonadherence to treatment. The Mind and Body Manifesto was developed by SANE, The Mental Health Nurses Association, The National Obesity Forum and The Disability Rights Commission and sponsored by Bristol-Myers Squibb Pharmaceuticals Limited and Otsuka Pharmaceuticals (UK) Ltd. Copies are available from elizabeth.green@ ogilvyhealthworld.com. Health eCard costs Some costs quoted in our article on the Health eCard (The Health eCard: the way ahead for medical records?,5 October issue, pages 28-9) have been revised: the card and initial download will cost patients £39.50, and GPs will be entitled to charge patients £10 per annum for subsequent downloads. NICE appraisals of cytokine inhibitors in RA NICE has endorsed the use of the anti-TNF agents adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade), normally in conjunction with methotrexate, for the treatment of active RA when methotrexate and another DMARD have failed (also see New from NICE below). NICE has provisionally concluded, subject to consultation, that abatacept (Orencia) should not be recommended for the treatment of RA. Boots and BMJ launch health advice site www.askbootshealth.com is a new website providing information about health and medicines for the public produced by Boots using information provided by the BMJ Publishing Group. The website covers many of the topics already available from NHSDirect, with perhaps more information about available treatments. Diabetes care shows small improvement The third National Diabetes Audit in England and Wales has found that more people with diabetes were achieving the targets set by NICE for cholesterol levels, glycaemic control and blood pressure in 2005/06 - but younger patients were doing less well. Overall, the HbA1C target of ,7.5 per cent was achieved in 60 per cent of people with diabetes compared with 58 per cent in 2004/05. However, HbA1C was >9.5 per cent in 30 per cent of children and young people, of whom 9 per cent experienced at least one episode of ketoacidosis. More topics for NICE New topics referred to NICE include clinical guidelines on ovarian cancer, coeliac disease and stable angina, public health guidance on preventing cardiovascular disease, and technology appraisals on insulin detemir (Levemir) for type 1 diabetes, several treatments for cancer and hepatic and haematological disorders, and biological therapies for juvenile arthritis. New from NICE NICE appraisal on anti-TNFs for RA Since NICE published its first appraisal of agents acting against tumour necrosis factor-alpha (anti-TNFs) for the treatment of RA in 2002, the product licences for etanercept (Enbrel) and infliximab (Remicade) have changed and a new agent, adalimumab (Humira), has been introduced. The anti-TNFs act in different ways. Infliximab is a chimeric monoclonal antibody that binds to TNF-alpha, neutralising its activity. Etanercept, a recombinant human TNF-alpha receptor fusion protein, and adalimumab, a human-sequence antibody, both bind to TNF-alpha and block its interaction with cell surface receptors. Adalimumab also modulates some biological responses induced or regulated by TNF-alpha. These agents are recommended for adults with severe active RA (defined as a disease activity score - DAS28 - greater than 5.1) who have already tried two disease-modifying drugs, including methotrexate (if not contraindicated). Prior treatment should have been of at least six months' duration, including two months at the standard dose (unless limited by toxicity). Anti-TNFs should normally be prescribed with methotrexate; when this is not appropriate, etanercept and adalimumab may be prescribed as monotherapy. Treatment with an anti-TNF should be continued beyond six months only if there is an adequate response (defined as an improvement in DAS28 of at least 1.2). Data from the British Rheumatology Society Biologics register show that, after six months, 67 per cent of patients met NICE criteria for an adequate response; this declined to 55 per cent at 18 months. The basic annual cost of treatment is £9295 for adalimumab 40mg on alternate weeks or etanercept 25mg twice weekly; infliximab costs £3777 for a loading dose, then £7553-£8812 depending on dose. Assuming no progression of disability, the incremental costs per QALY (compared with sequential DMARDs) were £30 200 for adalimumab, £24 600 for etanercept and £39 400 for infliximab. There are no direct comparative trials of the anti-TNFs, and their clinical trial findings are not directly comparable. Unless other factors determine treatment choice, NICE therefore recommends the least expensive. If the first anti-TNF is withdrawn within six months due to an adverse event, a second may be tried. [source] | ||||||||||||||||||||||||||||||||||||||||