Modeling payback from research into the efficacy of left-ventricular assist devices as destination therapy

Objectives: Ongoing developments in design have improved the outlook for left-ventricular assist device (LVAD) implantation as a therapy in end-stage heart failure. Nevertheless, early cost-effectiveness assessments, based on first-generation devices, have not been encouraging. Against this background, we set out (i) to examine the survival benefit that LVADs would need to generate before they could be deemed cost-effective; (ii) to provide insight into the likelihood that this benefit will be achieved; and (iii) from the perspective of a healthcare provider, to assess the value of discovering the actual size of this benefit by means of a Bayesian value of information analysis. Methods: Cost-effectiveness assessments are made from the perspective of the healthcare provider, using current UK norms for the value of a quality-adjusted life-year (QALY). The treatment model is grounded in published analyses of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial of first-generation LVADs, translated into a UK cost setting. The prospects for patient survival with second-generation devices is assessed using Bayesian prior distributions, elicited from a group of leading clinicians in the field. Results: Using established thresholds, cost-effectiveness probabilities under these priors are found to be low (.2 percent) for devices costing as much as £60,000. Sensitivity of the conclusions to both device cost and QALY valuation is examined. Conclusions: In the event that the price of the device in use would reduce to £40,000, the value of the survival information can readily justify investment in further trials

Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial

BACKGROUND: Beta blockers reduce mortality in patients who have chronic heart failure, systolic dysfunction, and are on background treatment with diuretics and angiotensin-converting enzyme inhibitors. We aimed to compare the effects of carvedilol and metoprolol on clinical outcome. METHODS: In a multicentre, double-blind, and randomised parallel group trial, we assigned 1511 patients with chronic heart failure to treatment with carvedilol (target dose 25 mg twice daily) and 1518 to metoprolol (metoprolol tartrate, target dose 50 mg twice daily). Patients were required to have chronic heart failure (NYHA II-IV), previous admission for a cardiovascular reason, an ejection fraction of less than 0.35, and to have been treated optimally with diuretics and angiotensin-converting enzyme inhibitors unless not tolerated. The primary endpoints were all-cause mortality and the composite endpoint of all-cause mortality or all-cause admission. Analysis was done by intention to treat. FINDINGS: The mean study duration was 58 months (SD 6). The mean ejection fraction was 0.26 (0.07) and the mean age 62 years (11). The all-cause mortality was 34% (512 of 1511) for carvedilol and 40% (600 of 1518) for metoprolol (hazard ratio 0.83 [95% CI 0.74-0.93], p=0.0017). The reduction of all-cause mortality was consistent across predefined subgroups. The composite endpoint of mortality or all-cause admission occurred in 1116 (74%) of 1511 on carvedilol and in 1160 (76%) of 1518 on metoprolol (0.94 [0.86-1.02], p=0.122). Incidence of side-effects and drug withdrawals did not differ by much between the two study groups. INTERPRETATION: Our results suggest that carvedilol extends survival compared with metoprolo

Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET.

BACKGROUND: It is unclear whether beta-blocker therapy should be reduced or withdrawn in patients who develop acute decompensated heart failure (HF). We studied the relationship between changes in beta-blocker dose and outcome in patients surviving a HF hospitalisation in COMET. METHODS: Patients hospitalised for HF were subdivided on the basis of the beta-blocker dose administered at the visit following hospitalisation, compared to that administered before. RESULTS: In COMET, 752/3029 patients (25%, 361 carvedilol and 391 metoprolol) had a non-fatal HF hospitalisation while on study treatment. Of these, 61 patients (8%) had beta-blocker treatment withdrawn, 162 (22%) had a dose reduction and 529 (70%) were maintained on the same dose. One-and two-year cumulative mortality rates were 28.7% and 44.6% for patients withdrawn from study medication, 37.4% and 51.4% for those with a reduced dosage (n.s.) and 19.1% and 32.5% for those maintained on the same dose (HR,1.59; 95%CI, 1.28-1.98; p<0.001, compared to the others). The result remained significant in a multivariable model: (HR, 1.30; 95%CI, 1.02-1.66; p=0.0318). No interaction with the beneficial effects of carvedilol, compared to metoprolol, on outcome was observed (p=0.8436). CONCLUSIONS: HF hospitalisations are associated with a high subsequent mortality. The risk of death is higher in patients who discontinue beta-blocker therapy or have their dose reduced. The increase in mortality is only partially explained by the worse prognostic profile of these patients

Black hole candidate XTE J1752-223: Swift observations of canonical states during outburst

We present Swift broadband observations of the recently discovered black hole candidate, X-ray transient, XTE J1752-223, obtained over the period of outburst from October 2009 to June 2010. From Swift-UVOT data we confirm the presence of an optical counterpart which displays variability correlated, in the soft state, to the X-ray emission observed by Swift-XRT. The optical counterpart also displays hysteretical behaviour between the states not normally observed in the optical bands, suggesting a possible contribution from a synchrotron emitting jet to the optical emission in the rising hard state. We offer a purely phenomenological treatment of the spectra as an indication of the canonical spectral state of the source during different periods of the outburst. We find that the high energy hardness-intensity diagrams over two separate bands follows the canonical behavior, confirming the spectral states. Our XRT timing analysis shows that in the hard state there is significant variability below 10Hz which is more pronounced at low energies, while during the soft state the level of variability is consistent with being minimal. These properties of XTE J1752-223 support its candidacy as a black hole in the Galactic centre region.Comment: 8 pages, 8 figures; MNRAS in pres

Composition of the pericellular matrix modulates the deformation behaviour of chondrocytes in articular cartilage under static loading

The aim was to assess the role of the composition changes in the pericellular matrix (PCM) for the chondrocyte deformation. For that, a three-dimensional finite element model with depth-dependent collagen density, fluid fraction, fixed charge density and collagen architecture, including parallel planes representing the split-lines, was created to model the extracellular matrix (ECM). The PCM was constructed similarly as the ECM, but the collagen fibrils were oriented parallel to the chondrocyte surfaces. The chondrocytes were modelled as poroelastic with swelling properties. Deformation behaviour of the cells was studied under 15% static compression. Due to the depth-dependent structure and composition of cartilage, axial cell strains were highly depth-dependent. An increase in the collagen content and fluid fraction in the PCMs increased the lateral cell strains, while an increase in the fixed charge density induced an inverse behaviour. Axial cell strains were only slightly affected by the changes in PCM composition. We conclude that the PCM composition plays a significant role in the deformation behaviour of chondrocytes, possibly modulating cartilage development, adaptation and degeneration. The development of cartilage repair materials could benefit from this information

Static and Dynamic Properties of a Viscous Silica Melt Molecular Dynamics Computer Simulations

We present the results of a large scale molecular dynamics computer simulation in which we investigated the static and dynamic properties of a silica melt in the temperature range in which the viscosity of the system changes from O(10^-2) Poise to O(10^2) Poise. We show that even at temperatures as high as 4000 K the structure of this system is very similar to the random tetrahedral network found in silica at lower temperatures. The temperature dependence of the concentration of the defects in this network shows an Arrhenius law. From the partial structure factors we calculate the neutron scattering function and find that it agrees very well with experimental neutron scattering data. At low temperatures the temperature dependence of the diffusion constants $D$ shows an Arrhenius law with activation energies which are in very good agreement with the experimental values. With increasing temperature we find that this dependence shows a cross-over to one which can be described well by a power-law, D\propto (T-T_c)^gamma. The critical temperature T_c is 3330 K and the exponent gamma is close to 2.1. Since we find a similar cross-over in the viscosity we have evidence that the relaxation dynamics of the system changes from a flow-like motion of the particles, as described by the ideal version of mode-coupling theory, to a hopping like motion. We show that such a change of the transport mechanism is also observed in the product of the diffusion constant and the life time of a Si-O bond, or the space and time dependence of the van Hove correlation functions.Comment: 30 pages of Latex, 14 figure

Microstructural magnetic phases in superconducting FeTe0.65Se0.35

In this paper, we address a number of outstanding issues concerning the nature and the role of magnetic inhomogenities in the iron chalcogenide system FeTe1-xSex and their correlation with superconductivity in this system. We report morphology of superconducting single crystals of FeTe0.65Se0.35 studied with transmission electron microscopy, high angle annular dark field scanning transmission electron microscopy and their magnetic and superconducting properties characterized with magnetization, specific heat and magnetic resonance spectroscopy. Our data demonstrate a presence of nanometre scale hexagonal regions coexisting with tetragonal host lattice, a chemical disorder demonstrating non homogeneous distribution of host atoms in the crystal lattice, as well as hundreds-of-nanometres-long iron-deficient bands. From magnetic data and ferromagnetic resonance temperature dependence, we attribute magnetic phases in Fe-Te-Se to Fe3O4 inclusions and to hexagonal symmetry nanometre scale regions with structure of Fe7Se8 type. Our results suggest that nonhomogeneous distribution of host atoms might be an intrinsic feature of superconducting Fe-Te-Se chalcogenides and we find a surprising correlation indicating that faster grown crystal of inferior crystallographic properties is a better superconductor.Comment: 16 pages, 8 figures, 2 table

The effect of sevelamer carbonate and lanthanum carbonate on the pharmacokinetics of oral calcitriol

Background. Lanthanum carbonate and sevelamer carbonate are non-calcium-based phosphate binders used to manage hyperphosphataemia in patients with chronic kidney disease (CKD). Patients with CKD may require intravenous or oral active vitamin D. We investigated the effects of lanthanum carbonate and sevelamer carbonate on the bioavailability of oral calcitriol