Patient-reported outcome assessment of inflammatory arthritis patient experience with intravenously administered biologic therapy

Objective: To evaluate patient perspectives regarding utilization of intravenous (IV) therapy for inflammatory arthritis (IA). Methods: This was a single-center, non-interventional, patient questionnaire-based study of adult IA patients currently receiving IV biologics. At a single visit, patients completed the questionnaire comprising 30 questions centered on their experience receiving an intravenously administered therapy to treat their IA. The questionnaire included questions on patient demographics, disease characteristics, and previous biologic treatment for IA (subcutaneous [SC] and IV). Patients rated their level of agreement with statements regarding satisfaction with current IV biologic therapy and potential advantages and disadvantages of IV biologic therapy using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results: One hundred patients were enrolled and completed the survey; 66% were female and the mean age was 58 years. Before IV treatment, 97% of patients received information regarding therapy options. Ninety patients ranked their satisfaction with current IV therapy as 4 or 5. The proportion of patients with an “extremely favorable” perception of IV therapy increased from 33% to 71% following initiation of their current medication. Thirty-one patients had previously received SC therapies to treat their IA. Conclusion: These results demonstrated an overall favorable perception of IV therapy among this patient population. Patients previously treated with SC therapy also had a positive shift in the perception of IV therapy after initiating IV therapy. Patients’ perception and preference for treatment options should be highly considered by the treating physician during or as part of a shared decision-making process. © 2017 Gaylis et al

The clinical effectiveness and cost-effectiveness of inhaled insulin in diabetes mellitus : a systematic review and economic evaluation

Background The two main types of diabetes are type 1 (formerly called insulin-dependent diabetes) and type 2 (formerly called non-insulin-dependent diabetes). In type 1, insulin is always required because the insulin-producing islet cells in the pancreas have been destroyed. In type 2, the pancreas can still produce insulin, and treatment is initially with diet and exercise, but the disease often progresses, with deteriorating control and rising blood glucose levels, and a need next for oral hypoglycaemic agents (OHAs), and later for insulin in about 30%. The aim of insulin therapy is to reduce blood glucose to normal levels, without going too low and causing hypoglycaemia. Insulin currently has to be given by injection. There are various types according to duration of action – short, intermediate and long. Short- and long-acting insulin both come in two forms: traditional and the newer analogues. The traditional form of short-acting insulin is known as soluble. It is given by injection using an insulin pen, or a syringe and needle. Insulin can also be given by continuous subcutaneous infusion by an insulin pump, usually only in selected patients with type 1 diabetes. Objective The aim was to review the clinical effectiveness and cost-effectiveness of a new technology, the inhaled insulin, Exubera® (Pfizer and Sanofi-Aventis in collaboration with Nektar Technologies), a short-acting insulin. Methods A systematic literature review was conducted and economic modelling carried out. Literature searches were done up to November 2005. The industry model, EAGLE, was used for modelling. Results Clinical effectiveness Nine trials of inhaled insulins were found, but only seven used the Exubera form of inhaled insulin. The other two used inhaled insulins that have not yet been licensed. There were five trials in type 1 and two in type 2 diabetes. Inhaled insulin is clinically effective, and is as good as short-acting soluble insulin in controlling blood glucose. The frequency of hypoglycaemia is similar. It works slightly more quickly than soluble insulin. None of the published trials compared it with short-acting analogues, which would have provided a better comparison since they also work slightly more rapidly than soluble. There is also a problem in most of the trials in that patients were on combinations of short-acting, and either long- or intermediate-acting insulin, and both were changed, making it more difficult to assess the effects of only the change from soluble to inhaled insulin. The only significant difference between inhaled and soluble insulin in the trials was in patient preference. Most patients preferred inhaled to injected short-acting insulin, and this has some effect on quality of life measures. However, there could be some bias operating in the trials. The control groups mostly used syringes and needles, rather than pens. As pens are more convenient, their use might have narrowed the patient satisfaction difference. The manufacturer, Pfizer, argues that this patient preference could lead to improved control in some type 1 patients, through improved compliance with treatment, and in some type 2 patients poorly controlled on oral agents, because a switch to insulin therapy would be more acceptable if people could use inhaled rather than injected insulin. These assertions are unproven. There were no trials of inhaled insulin against continuous subcutaneous insulin infusion (CSII). Safety Concern has been raised about the long-term effects of inhaled insulin in the lung. So far, no serious adverse effects have been seen, but until many thousands of people have used inhaled insulin for many years, one cannot rule out some uncommon or rare, but serious, adverse effects. Cost-effectiveness The manufacturer's model (EAGLE) appears to be a high-quality one. However, the results depend more on the assumptions fed into the model than on the model itself. The key assumptions are the size of the gain in quality of life utility from inhaling rather than injecting insulin, the effect of having an inhaled option on the willingness to start insulin among people with poor diabetic control on oral drugs, and the effect on glycaemic control. We consider that the assumptions used in the industry submission make the cost-effectiveness appear better than it really would be. The manufacturer's submission assumed utility gains of 0.036–0.075 in patients with type 1 diabetes, and 0.027–0.067 in those with type 2, based on an unpublished utility elicitation study sponsored by the manufacturer. We thought that these gains were optimistic and that gains of 0.02 or less were more likely, on average. However, patients with particular problems with injection sites might have more to gain, although they might also be a group with much to gain from CSII. A key factor is the cost of inhaled insulin. Much more insulin has to be given by inhaler than by injection, and so the cost of inhaled insulin is much higher than injected. The extra cost depends on dosage, but ranges from around £600 to over £1000 per patient per year. Conclusion The inhaled insulin, Exubera, appears to be effective and safe, but the cost is so much more that it is unlikely to be cost-effective

Promoting Behaviour Change in Long term Conditions using a Self-Management Platform

Physical rehabilitation of brain injuries and strokes is a time consuming and costly process. Over the past decade several studies have emerged looking at the use of highly sophisticated technologies, such as robotics and virtual reality to tap into the needs of clinicians and patients. While such technologies can be a valuable tool to facilitate intensive movement practice in a motivating and engaging environment, success of therapy also depends on self-administered therapy beyond hospital stay. With the emergence of low-cost gaming consoles such as the Nintendo Wii, new opportunities arise for home-therapy paradigms centred on social interactions and values, which could reduce the sense of isolation and other depression related complications. In this paper we examine the potential, user acceptance and usability of an unmodified Nintendo Wii gaming console as a low-cost treatment alternative to complement current rehabilitation programmes

Prediction models in the design of neural network based ECG classifiers: A neural network and genetic programming approach

BACKGROUND: Classification of the electrocardiogram using Neural Networks has become a widely used method in recent years. The efficiency of these classifiers depends upon a number of factors including network training. Unfortunately, there is a shortage of evidence available to enable specific design choices to be made and as a consequence, many designs are made on the basis of trial and error. In this study we develop prediction models to indicate the point at which training should stop for Neural Network based Electrocardiogram classifiers in order to ensure maximum generalisation. METHODS: Two prediction models have been presented; one based on Neural Networks and the other on Genetic Programming. The inputs to the models were 5 variable training parameters and the output indicated the point at which training should stop. Training and testing of the models was based on the results from 44 previously developed bi-group Neural Network classifiers, discriminating between Anterior Myocardial Infarction and normal patients. RESULTS: Our results show that both approaches provide close fits to the training data; p = 0.627 and p = 0.304 for the Neural Network and Genetic Programming methods respectively. For unseen data, the Neural Network exhibited no significant differences between actual and predicted outputs (p = 0.306) while the Genetic Programming method showed a marginally significant difference (p = 0.047). CONCLUSIONS: The approaches provide reverse engineering solutions to the development of Neural Network based Electrocardiogram classifiers. That is given the network design and architecture, an indication can be given as to when training should stop to obtain maximum network generalisation

The effectiveness and cost-effectiveness of computed tomography screening for coronary artery disease : systematic review

Coronary heart disease (CHD) is one of the main causes of mortality and morbidity in the UK and other Western countries. The disease can be asymptomatic until the first event, which may be a fatal myocardial infarction (heart attack). Half of all heart attacks occur in people who have had no prior warning of coronary disease, and almost half will die from the first attack. Risk scores based on well-known factors such as age, blood pressure, smoking, cholesterol and diabetes have been used to assess risk, but are imperfect: not all high-risk people develop heart disease, and many low-risk people do. Indeed, depending on which cut-off is used to define high risk, most heart attacks occur in low-risk people, because the number of people at low risk is much greater than the number at high risk. There is therefore a need for a better way of identifying those at risk so that they can treat themselves with lifestyle measures, or receive drug therapy such as statins and antihypertensive drugs as appropriate. Computed tomography (CT) is a form of radiological imaging that can detect calcium deposits in the coronary arteries. This calcification is a marker for CHD, and so CT imaging could be a way of detecting asymptomatic but serious CHD. CT is quick and non-invasive, but does involve a relatively large radiation dose