Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN. METHOD: The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses. RESULTS: Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends. CONCLUSIONS: Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Fetal weight estimation by ultrasound: comparison of 11 different formulae and examiners with differing skill levels.

PURPOSE: Fetal weight is an important predictive parameter of neonatal morbidity and mortality. Precise estimation of fetal weight is therefore a valuable item of information for further prenatal and obstetric management. Many regression formulae for sonographic fetal weight estimation have been published during the last 30 years, which, unfortunately, generally show poor rates of accuracy. The aim of this study was to compare commonly used formulae in different birth weight groups in order to assess whether any of the formulae are more or less favourable. The second purpose was to estimate the role of examiners on the accuracy of fetal weight estimation. MATERIALS AND METHODS: 11 different formulae were evaluated in a group of 1941 pregnancies. Each fetus underwent ultrasound examination with complete biometric parameters within seven days before delivery. The assessment was carried out by either experienced or inexperienced sonographers. RESULTS: Over the whole weight range and in the subgroup of newborns with a birth weight less than 2500 g (n = 160), two Hadlock regression formulae (including abdominal circumference, femur length, head circumference, biparietal diameter, and abdominal circumference, femur length, biparietal diameter, respectively) showed the best levels of accuracy. Infants with a birth weight between 2500 and 3999 g (n = 1570) were best estimated using the gender-specific Schild formula. Macrosomic newborns (n = 211) were best evaluated using Merz's regression formula. The more skilled sonographers were able to achieve much higher intraclass correlation coefficients for all formulae. CONCLUSION: Some regression formulae appear to be favourable within defined weight ranges. Accuracy of the formulae, however, is still unsatisfactory, and new formulae focusing on specific weight ranges (e. g., macrosomic fetuses) are needed. In addition, experience in obstetric ultrasound improves accuracy of fetal weight estimation.

Effects of 5-aminolaevulinic acid on human ovarian cancer cells and human vascular endothelial cells in vitro.

Results are reported on the cellular effects and the sensitivity of cultured tumor epithelial cells (TEC) derived from human ovarian cystadenocarcinoma and human umbilical vein-derived endothelial cells (HUVEC) to exogenous 5-aminolaevulinic acid (ALA) and ALA-induced photodynamic therapy (PDT). Cellular alterations and PDT efficiency were evaluated using colorimetric thiazolyl blue (MTT) assay, trypan blue exclusion assay, electron microscopy, and gel electrophoresis. ALA-induced protoporphyrin IX (PpIX) accumulation in TEC was associated with a concentration and time-dependent significant decrease in mitochondrial activity, increase in cell membrane permeability, and dark toxicity. Maximum PpIX loaded TEC demonstrated a high sensitivity to PDT. Neither cellular alterations nor PDT effects were observed in HUVEC under identical experimental conditions. These results indicate a potential clinical value for the use of ALA-mediated PDT to treat minimal residual disease in mucinous ovarian carcinoma. In addition, the ALA-induced PpIX cytotoxicity may be exported to a new chemotherapeutic regimen via a conventionally viewed photochemotherapeutic agent.

A study of aminolevulinic acid-induced protoporphyrin IX fluorescence kinetics in the canine oral cavity.

BACKGROUND AND OBJECTIVE: 5-Aminolevulinic acid-induced protoporphyrin IX is a promising photosensitizer that could enhance the spectroscopic contrast between normal and diseased oral tissues. Knowledge of the pharmacokinetics and effects on tissue type are important for diagnostic and therapeutic procedures. STUDY DESIGN/MATERIALS AND METHODS: Dogs randomly were administered five doses of 5-aminolevulinic acid: 5, 25, 50, 75, and 100 mg/kg. The fluorescence was recorded from buccal mucosa, gums, tongue, and facial skin using a fiberoptic probe connected to an optical multichannel analyzer. Blood samples were collected for hematologic and serum biochemical analysis. Pharmacokinetic parameters of interest were estimated using a compartmental model. RESULTS: Protoporphyrin fluorescence at all sites reached a peak in 2-6 hours, and returned to baseline in 24-31 hours, depending on the dose. Plasma protoporphyrin peaked earlier than oral tissues. CONCLUSION: The rate of synthesis of protoporphyrin, and its conversion to heme products are dose dependent. Different tissues have different pharmacokinetic response.

Polyatomics in zinc isotope ratio analysis of plasma samples by inductively coupled plasma-mass spectrometry and applicability of nonextracted samples for zinc kinetics.

Inductively coupled plasma-mass spectrometry (ICP-MS) is a powerful tool for both quantitative multielement analyses of inorganic elements and measurement of isotope ratios (IRs). The main disadvantage of this technique is the existence of polyatomic isobaric interferences at some key masses. Zinc has been investigated for such potential interferences in serum or plasma. The Zn isotopes, 66Zn and 68Zn, have no apparent interferences, but 32S1602 and 32S2 are isobaric with 64Zn. The possible effects of S and other major components of blood plasma-Na, K, Cl, P, Ca-on Zn IRs were investigated using a series of mineral solutions which simulated human plasma with respect to these elements. The mixture of all mineral elements interfered only with 64Zn (6.66 ng/mL) and 70Zn (8.51 ng/mL). Interferences to 66Zn, 67Zn, and 68Zn were minimal containing 0.90, 0.94, and 0.39 ng/mL, respectively. The copresence of Na or S shifted 35Cl16O2 (atomic mass 67 coming from Cl solution) to 35Cl2 which reduced the contribution to 67Zn. The hypothesis that Zn IRs obtained from plasma at various intervals after the intravenous administration of enriched 67Zn to humans would reflect those obtained after extraction of Zn was therefore tested. To compare the two pretreatment methods, "extraction" versus "nonextraction," specimens were collected from 10 human subjects at intervals of 5 min to 24 h postinjection, and in 4 subjects from 5 min to 9 d postinjection. Two separate aliquots of plasma from each time-point were dried and digested with hydrogen peroxide, and the residue dissolved in nitric acid. One specimen was subjected to zinc extraction using ammonium diethyldithiocarbamate chelate followed by back extraction into nitric acid. The matching aliquot received no further pretreatment. The normalized IRs obtained from 67Zn/66Zn and 67Zn/68Zn in both the "extracted" and "nonextracted" samples agreed well (r2 = 0.976 and r2 = 0.985, respectively) compared to those from other ratios (r2 = 0.838 for 67Zn/64Zn and r2 = 0.747 for 67Zn/70Zn). Considering the minimum possibility of isobaric interferences in plasma samples, 67Zn/68Zn obtained from "nonextracted" samples is sufficient for routine Zn kinetic analysis by ICP-MS.

Nutritional status and assessment of patients on home parenteral nutrition: anthropometry, bioelectrical impedance, or clinical judgment?

The optimal method of assessing protein energy nutritional status in patients receiving home parenteral nutrition (HPN) is unknown. We evaluated protein energy nutritional status in 47 outpatients (23 male; 24 female) on HPN by measuring anthropometry, plasma proteins, and lymphocyte counts and compared these with the results of subjective clinical assessment and bioelectrical impedance measurements. Sixteen of the 47 patients (34%) were underweight (body mass index < 5th percentile of the reference) and 21 (45%) were below the 5th percentile of the reference for both triceps skinfold thickness and midarm muscle circumference. Plasma proteins were subnormal in 1-5 patients (2-11%). Lymphocyte counts were subnormal in 19 patients (40%). Clinical assessment classified 23 patients (49%) as well nourished and 24 (51%) as moderately malnourished. Moderately malnourished patients had a significantly lower body mass index than well-nourished patients (P = 0.02). Clinical assessment did not correlate with bioelectrical impedance analysis. Fat-free mass determined by bioelectrical impedance analysis resulted in values up to 9.4 kg lower and 8 kg higher than fat-free mass obtained by anthropometry. Weighing combined with a subjective clinical assessment is sufficient for evaluation of protein calorie nutritional status in patients on HPN.

Delta-aminolevulinic acid-mediated photosensitization of prostate cell lines: implication for photodynamic therapy of prostate cancer.

BACKGROUND: Delta-aminolevulinic acid (ALA)-mediated photodynamic therapy (PDT) is currently being investigated for the treatment of prostate diseases. In this study, we evaluate 1) the in vitro production of protoporphyrin IX (PPIX) (the active photosensitizing agent of ALA-mediated PDT) by two different prostate cancer cell lines (LNCaP and PC-3) and a benign, modified, prostatic cell line (TP-2), and 2) the extent of PDT-induced cell injury, as determined by electron microscopy (EM) and cell survival. METHODS: The cell lines were assigned into four treatment groups: group 1, control, no ALA and no light irradiation; group 2, dark control, ALA only; group 3, light control, radiation only; and group 4, PDT, ALA followed by irradiation (630 nm, 3 joules/cm2). The experiments were performed in triplicate. ALA concentration was 50 microg/ml of media in all instances. RESULTS: Following incubation with ALA, PPIX production was significantly increased in the three cell lines studied, and more notably in the PC-3 cell line. Compared to controls, EM and cell survival studies demonstrated significant mitochondrial damage and decreased survival, respectively, in the cells treated with PDT. This was also more evident in the PC-3 cell line. CONCLUSIONS: Our results demonstrate that prostate cells differ in their response to ALA-mediated PDT. This response appears to depend on the intracellular production of PPIX and the cell type, i.e., on the functional and structural characteristics of the cell mitochondria. In addition, our results suggest that PDT might be effective at killing prostate cancer cells.

Photosensitization of experimental hepatocellular carcinoma with protoporphyrin synthesized from administered delta-aminolevulinic acid: studies with cultured cells and implanted tumors.

BACKGROUND/AIMS: Photodynamic therapy using porphyrins or related compounds and laser light is an investigational treatment for neoplasms. The aim of this study was to establish whether this might be applicable for hepatocellular carcinoma using protoporphyrin synthesized in the tissue from administered delta-aminolevulinic acid. METHODS: We measured porphyrin accumulation in normal rat hepatocytes and Morris hepatoma cells in culture, and in subcutaneously implanted hepatomas and other tissues of the rat after administration of delta-aminolevulinic acid, and assessed cell and tissue damage after application of laser light. RESULTS: Porphyrin accumulation after delta-aminolevulinic acid was added to the medium was greater and continued to increase for a longer period of time in hepatoma cells than in hepatocytes (1337+/-42 vs 513+/-31 fluorescence units/cell at 8 h, means+/-SE, p<0.001). After intraperitoneal injection of delta-aminolevulinic acid to rats with subcutaneously growing hepatomas, porphyrin content in tumor and liver was similar at 4 h but was higher in tumor at 6 h. Laser light caused necrosis of normal and malignant liver cells in culture and subcutaneous hepatomas in vivo. CONCLUSIONS: We conclude from these in vitro and in vivo studies that porphyrin accumulation after administration of delta-aminolevulinic acid in this hepatoma is substantial and time dependent, and delivery of laser light locally can cause tumor photosensitization and necrosis.

Effects of chloroquine in hematoporphyrin-treated animals.

Porphyrins and related compounds are useful in photodynamic therapy but can cause cutaneous photosensitivity. We determined whether chloroquine, which is effective in treating porphyria cutanea tarda, would mobilize an administered porphyrin from tissues and enhance its excretion. Hematoporphyrin with and without chloroquine was administered to chick embryos, mice, and rats. Tissue and plasma porphyrin levels were markedly increased after hematoporphyrin dosing. Porphyrin concentrations in liver, spleen, and kidney were not significantly affected by chloroquine. Total urinary and fecal porphyrin excretion in rats treated with hematoporphyrin (50 mg/kg, i.p.) was not influenced by chloroquine treatment (100 mg/kg, s.c.). Excretion of heptacarboxylporphyrin, normally a minor fraction of urinary porphyrins, was significantly increased in chloroquine-treated rats. These results suggest that chloroquine is unlikely to be useful after photodynamic therapy for mobilizing exogenous porphyrins from tissues such as liver, spleen, and kidney. Increased urinary excretion of heptacarboxylporphyrin may contribute to the beneficial effect of chloroquine in porphyria cutanea tarda.

Accumulation of porphyrins in plasma and tissues of dogs after delta-aminolevulinic acid administration: implications for photodynamic therapy.

Protoporphyrin accumulates in tissues after administration of delta-aminolevulinic acid, and can be used as a photosensitizer for photodynamic therapy. To determine the distribution of porphyrins in a large animal model after administration of this porphyrin precursor, delta-aminolevulinic acid was administered to anesthetized dogs (100 mg/kg body weight intravenously) and porphyrin concentrations were measured in tissues (liver, pancreas, prostate, bladder, muscle and skin), plasma and urine for 6-10 h. Porphyrins increased markedly (up to 50-fold) in plasma within 1 h, were still markedly increased at 8 h, and consisted mostly of coproporphyrin III and protoporphyrin. Tissue porphyrin concentrations increased more slowly, were highest in liver, pancreas and prostate 7-10 h after delta-aminolevulinic acid administration, and were predominantly protoporphyrin. Maximum porphyrin concentrations in liver were 3- and 4-fold higher than in pancreas and prostate, respectively. Urinary delta-aminolevulinic acid excretion increased and was greatest 2-4 h after dosing; urinary porphobilinogen and porphyrins increased more gradually and remained increased up to at least 8 h. Coproporphyrin III was the predominant porphyrin in urine at all times, but hepta-, hexa- and pentacarboxyl porphyrins increased proportionally after administration of delta-aminolevulinic acid. These results indicate that porphyrins accumulate in plasma as well as tissues and urine after administration of delta-aminolevulinic acid, and may contribute to tumor necrosis during photodynamic therapy.