Evaluation of a general practice based Hepatitis C virus screening intervention

In 2003 an estimated 37,500 of Scotland's population was chronically infected with HCV; 44% were undiagnosed former injecting drug users (IDU) - a priority group for arrival therapy. Aims to evaluate a hepatitis C virus (HCV) screening intervention. Outcomes measures among two similar general practice populations in an area of high HCV and drug use prevalence, one of which was exposed to an HCV screening intervention, were compared. Thirty to fifty four year old attendees of the intervention practice were opportunistically offered testing and counselling, where clinically appropriate, (November 2003 - April 2004). Outcomes: HCV test uptake, case detection, referral and treatment administration rates. Of 584 eligible attendees, 421 (72%) were offered and 117 (28%) accepted testing in the intervention practice; no testing was undertaken in the comparison practice. Prevalences of HCV antibody were 13% (15/117), 75% (3/4) and 91% (10/11) among all tested persons, current IDUs and former IDUs respectively. For 4/15 (27%) evidence of binge drinking following the receipt of their positive result, was available. Of the 11 referred to specialist care because they were HCV RNA positive, nine attended at least one appointment. Two received treatment: one had achieved a sustained viral response as of February 2008. While non targeted HCV screening in the general practice setting can detect infected former IDU, the low diagnostic yield among non IDUs limited the effectiveness of the intervention. A more targeted approach for identifying former IDUs is recommended. Additionally, the low uptake of treatment among chronically infected persons four years after diagnosis demonstrates the difficulties in clinically managing such individuals. Strategies, including support for those with a history of problem alcohol use, to improve treatment uptake are required

Comment letters to the National Commission on Commission on Fraudulent Financial Reporting, 1987 (Treadway Commission) Vol. 2

https://egrove.olemiss.edu/aicpa_sop/1662/thumbnail.jp

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for the treatment of rheumatoid arthritis not previously treated with disease-modifying antirheumatic drugs and after the failure of conventional disease-modifying antirheumatic drugs only: systematic review and economic evaluation.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increasing disability, reduced quality of life and substantial costs (as a result of both intervention acquisition and hospitalisation). The objective was to assess the clinical effectiveness and cost-effectiveness of seven biologic disease-modifying antirheumatic drugs (bDMARDs) compared with each other and conventional disease-modifying antirheumatic drugs (cDMARDs). The decision problem was divided into those patients who were cDMARD naive and those who were cDMARD experienced; whether a patient had severe or moderate to severe disease; and whether or not an individual could tolerate methotrexate (MTX). DATA SOURCES: The following databases were searched: MEDLINE from 1948 to July 2013; EMBASE from 1980 to July 2013; Cochrane Database of Systematic Reviews from 1996 to May 2013; Cochrane Central Register of Controlled Trials from 1898 to May 2013; Health Technology Assessment Database from 1995 to May 2013; Database of Abstracts of Reviews of Effects from 1995 to May 2013; Cumulative Index to Nursing and Allied Health Literature from 1982 to April 2013; and TOXLINE from 1840 to July 2013. Studies were eligible for inclusion if they evaluated the impact of a bDMARD used within licensed indications on an outcome of interest compared against an appropriate comparator in one of the stated population subgroups within a randomised controlled trial (RCT). Outcomes of interest included American College of Rheumatology (ACR) scores and European League Against Rheumatism (EULAR) response. Interrogation of Early Rheumatoid Arthritis Study (ERAS) data was undertaken to assess the Health Assessment Questionnaire (HAQ) progression while on cDMARDs. METHODS: Network meta-analyses (NMAs) were undertaken for patients who were cDMARD naive and for those who were cDMARD experienced. These were undertaken separately for EULAR and ACR data. Sensitivity analyses were undertaken to explore the impact of including RCTs with a small proportion of bDMARD experienced patients and where MTX exposure was deemed insufficient. A mathematical model was constructed to simulate the experiences of hypothetical patients. The model was based on EULAR response as this is commonly used in clinical practice in England. Observational databases, published literature and NMA results were used to populate the model. The outcome measure was cost per quality-adjusted life-year (QALY) gained. RESULTS: Sixty RCTs met the review inclusion criteria for clinical effectiveness, 38 of these trials provided ACR and/or EULAR response data for the NMA. Fourteen additional trials contributed data to sensitivity analyses. There was uncertainty in the relative effectiveness of the interventions. It was not clear whether or not formal ranking of interventions would result in clinically meaningful differences. Results from the analysis of ERAS data indicated that historical assumptions regarding HAQ progression had been pessimistic. The typical incremental cost per QALY of bDMARDs compared with cDMARDs alone for those with severe RA is > £40,000. This increases for those who cannot tolerate MTX (£50,000) and is > £60,000 per QALY when bDMARDs were used prior to cDMARDs. Values for individuals with moderate to severe RA were higher than those with severe RA. Results produced using EULAR and ACR data were similar. The key parameter that affected the results is the assumed HAQ progression while on cDMARDs. When historic assumptions were used typical incremental cost per QALY values fell to £38,000 for those with severe disease who could tolerate MTX. CONCLUSIONS: bDMARDs appear to have cost per QALY values greater than the thresholds stated by the National Institute for Health and Care Excellence for interventions to be cost-effective. Future research priorities include: the evaluation of the long-term HAQ trajectory while on cDMARDs; the relationship between HAQ direct medical costs; and whether or not bDMARDs could be stopped once a patient has achieved a stated target (e.g. remission). STUDY REGISTRATION: This study is registered as PROSPERO CRD42012003386. FUNDING: The National Institute for Health Research Health Technology Assessment programme

Les grains et les vins : la nouvelle PAC, symphonie inachevée

La négociation du GATT a finalement débouché sur un accord, avec quelques accommodements de nature à réduire les risques d'incompatibilité avec la réforme de la PAC. La réforme elle-même est rentrée, avec la campagne 1994/1995, dans sa deuxième année de transition sans trop d'effets négatifs sur les revenus moyens et même avec quelques bonnes surprises. Mais cette réforme est-elle achevée ? Rien n'est moins sûr ! Entre le catastrophisme d'hier, que les incertitudes et les craintes à l'égard de la réforme avaient pu engendrer, et l'optimisme béat, il y a un moyen terme plus réaliste que l'auteur examine. On traite successivement : des développements récents sur la scène économique européenne et internationale ainsi que l'accord final du GATT ; des aménagements de la réforme ; des projets d'adaptation de certaines organisations communes des marchés (OCM), particulièrement celle de la viticulture, et des questions laissées en suspens par la réforme de la PAC qui portent en germe des problèmes futurs et donc de nouveaux aménagements

Evaluation of a disposable device for the measurement of haemoglobin A1c in dogs

A disposable device designed for measuring glycated haemoglobin (HbA1c) in human blood was evaluated for use in dogs. EDTA blood samples were collected from 50 normoglycaemic dogs, 10 dogs suffering from anaemia and 112 diabetic dogs. HbA1c was measured in all the dogs except for five of the diabetic animals, in which the concentrations were above the range of the device, that is, more than 13 per cent, and two of the anaemic dogs, in which they were below its limit of detection, that is less than 3 per cent. The diabetic dogs had higher HbA1c values (range 4.9 to >13 per cent, median 9.3 per cent) than the normoglycaemic dogs (range 3.7 to 5.6 per cent, median 4.7 per cent). in the anaemic dogs the values were significantly lower (range <3.0 per cent to 5.2 per cent, median 3.5 per cent) than in the normoglycaemic dogs. There was a good correlation (R-2=0.48) between the measurements obtained with the device and the measurements obtained with a system already validated for use in dogs