The cost of treatment failure: resource use and costs incurred by hepatitis C virus genotype 1-infected patients who do or do not achieve sustained virological response to therapy.

Chronic hepatitis C virus (HCV) infection places a considerable economic burden on health services. Cost-effectiveness analyses of antiviral treatment for patients with chronic HCV infection are dependent on assumptions about cost reductions following sustained virological response (SVR) to therapy. This study quantified the medium-term difference in health resource usage and costs depending on treatment outcome. Retrospective chart review of patients with HCV genotype 1 infection who had received at least 2 months pegylated interferon and ribavirin therapy, with known treatment outcome was conducted. Disease status was categorized as chronic hepatitis, cirrhosis or decompensated liver disease. Health resource use was documented for each patient in each disease state. Unit costs were from the NHS 'Payment by Results' database and the British National Formulary. One hundred and ninety three patients (108 SVR, 85 non-SVR) with mean follow-up of 3.5 (SVR) and 4.9 (non-SVR) years were enrolled. No SVR patient progressed to a more severe liver disease state. Annual transition rates for non-SVR patients were 7.4% (chronic hepatitis to cirrhosis) and 4.9% (cirrhosis to decompensated liver disease). By extrapolation of modelled data over a 5-year post-treatment period, failure of patients with chronic hepatitis to achieve SVR was associated with a 13-fold increase (roughly £2300) in costs, whilst for patients who were retreated, the increase was 56-fold, equating to more than £10 000. Achievement of an SVR has significant effects on health service usage and costs. This work provides real-life data for future cost-effectiveness analyses related to the treatment for chronic HCV infection.

The relationship between contractile force and intracellular [Ca2+] in intact rat cardiac trabeculae.

The control of force by [Ca2+] was investigated in rat cardiac trabeculae loaded with fura-2 salt. At sarcomere lengths of 2.1-2.3 microns, the steady state force-[Ca2+]i relationship during tetanization in the presence of ryanodine was half maximally activated at a [Ca2+]i of 0.65 +/- 0.19 microM with a Hill coefficient of 5.2 +/- 1.2 (mean +/- SD, n = 9), and the maximal stress produced at saturating [Ca2+]i equalled 121 +/- 35 mN/mm2 (n = 9). The dependence of steady state force on [Ca2+]i was identical in muscles tetanized in the presence of the Ca(2+)-ATPase inhibitor cyclopiazonic acid (CPA). The force-[Ca2+]i relationship during the relaxation of twitches in the presence of CPA coincided exactly to that measured at steady state during tetani, suggesting that CPA slows the decay rate of [Ca2+]i sufficiently to allow the force to come into a steady state with the [Ca2+]i. In contrast, the relationship of force to [Ca2+]i during the relaxation phase of control twitches was shifted leftward relative to the steady state relationship, establishing that relaxation is limited by the contractile system itself, not by Ca2+ removal from the cytosol. Under control conditions the force-[Ca2+]i relationship, quantified at the time of peak twitch force (i.e., dF/dt = 0), coincided fairly well with steady state measurements in some trabeculae (i.e., three of seven). However, the force-[Ca2+]i relationship at peak force did not correspond to the steady state measurements after the application of 5 mM 2,3-butanedione monoxime (BDM) (to accelerate cross-bridge kinetics) or 100 microM CPA (to slow the relaxation of the [Ca2+]i transient). Therefore, we conclude that the relationship of force to [Ca2+]i during physiological twitch contractions cannot be used to predict the steady state relationship.

Mechanism of force inhibition by 2,3-butanedione monoxime in rat cardiac muscle: roles of [Ca2+]i and cross-bridge kinetics.

1. We investigated the mechanism of force inhibition by 2,3-butanedione monoxime (BDM) on rat cardiac trabeculae. [Ca2+]i was measured by iontophoretic injection of fura-2 salt. Isometric force was recorded at an end-systolic sarcomere length of 2.1-2.2 microns. 2. With an external [Ca2+] of 1 mM, peak twitch force was monotonically reduced with increasing [BMD]; at 5 and 20 mM [BDM], force was 35 and 1% of the control force. In contrast, the mean peak [Ca2+]i during transients was only reduced at [BDM] > or = 10 mM. 3. The duration of the twitch was dramatically reduced by BDM in a dose-dependent fashion with no significant change in the time course of the underlying Ca2+ transients. The abbreviation of twitch force duration was much greater than expected for the observed reduction in peak force by this agent. 4. The mechanism of the inhibition of force by BDM was explored by examining the relationship between twitch force and Ca2+ transients at various values of external [Ca2+]. In the presence of BDM, the steepness of the relationship between peak force and peak [Ca2+]i was reduced compared to control conditions. As a result, significant elevation in the [Ca2+]i transient was unable to reverse the reduction in force observed in the presence of BDM. 5. The direct inhibitory effects of BDM on the contractile system were examined using ryanodine tetani in intact trabeculae to measure the steady-state force-[Ca2+]i relationship. In contrast to the effects on twitch force at 5 mM BDM, maximal force was only reduced to 71% of control. Furthermore, the [Ca2+]i required for half-maximal activation (Ca50) was increased while the Hill coefficient was reduced slightly by BDM. 6. BDM dramatically slowed the rate of rise of tetanic force. At maximal activation, the time required to reach 90% maximal force was prolonged by a factor of 3-8 in the presence of 5 mM BDM. This suggests that the observed reduction in twitch force and steady-state force may result from slowed kinetics of cross-bridge attachment, consistent with recent biochemical studies. 7. The contribution of altered cross-bridge kinetics to the effects of BDM was investigated using a co-operative cross-bridge model of the contractile system. Changing the rate constants for cross-bridge attachment in the model to mimic the reported biochemical effects of BDM reproduced the observed effects of BDM.(ABSTRACT TRUNCATED AT 400 WORDS)

Myofilament Ca2+ sensitivity in intact versus skinned rat ventricular muscle.

The Ca2+ sensitivity of myofilaments was compared before and after skinning in the same rat trabeculae at a diastolic sarcomere length of 2.2 to 2.3 microns. Trabeculae from rat right ventricle were loaded with fura-2 salt by iontophoretic microinjection, and [Ca2+]i was determined from the epifluorescence at 510 nm when excited at 340 and 380 nm. Steady-state activation was achieved by stimulating the muscle at 10 Hz after 10 to 20 minutes of application of ryanodine (5 mumol/L). The muscles were then skinned with Triton X-100 (1%) for 15 to 25 minutes and subsequently activated with solutions containing varied [Ca2+]. The intact force-[Ca2+] relation was highly cooperative (Hill coefficient, 4.87 +/- 0.35; n = 10), with a low [Ca2+]i required for half-maximal activation (K1/2) (0.62 +/- 0.03 mumol/L). After skinning, the Hill coefficient fell to 2.72 and the K 1/2 shifted rightward to 2.2 mumol/L in the presence of 1.2 mmol/L free Mg2+. Because of uncertainty regarding the appropriate [Mg2+], we measured [Mg2+]i at 0.72 +/- 0.06 mmol/L (n = 11) with Mg-fura-2 salt. When activating solutions were modified to contain [Mg2+] = 0.5 mmol/L, the force-[Ca2+] relation was shifted to the left (K 1/2 = 0.93 +/- 0.1, n = 10) with a Hill coefficient of 3.75 +/- 0.37, but the changes were not sufficient to superimpose with the intact force-[Ca2+] relation (P < .05 versus intact). These results suggest that, despite the significant effect of Mg2+ on the force-[Ca2+] relation in skinned muscles, the Ca2+ responsiveness of the myofilaments is still altered by skinning.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative roles of intracellular Ca2+ and pH in shaping myocardial contractile response to acute respiratory alkalosis.

During acute respiratory alkalosis, myocardial contractility initially increases but then declines toward control levels. To elucidate the mechanism of this response, two parallel strategies were adopted: isovolumic left ventricular developed pressure (DP) and intracellular pH (pHi) were measured in isolated ferret hearts using 31P-nuclear magnetic resonance spectroscopy, and isometric developed tension (DT) and intracellular Ca2+ concentration ([Ca2+]i) were measured in ferret papillary muscles using microinjected fura 2 salt. When hypocapnia was induced by sudden introduction of perfusate equilibrated with 2% CO2 (from 5% CO2 in control), DP increased to a maximum of 120 +/- 3% (SE; n = 7) of control within 40 s. Afterward, DP decreased toward control levels, reaching a new steady state in 2-3 min. In contrast, pHi increased from control (7.11 +/- 0.01) only after 30 s of hypocapnia and reached a peak of 7.25 +/- 0.02 between 80 and 100 s. Thus pHi lagged behind contractility. In contrast to pHi, [Ca2+]i changed in parallel with DT: when DT reached a maximum (251 +/- 63% of control; n = 5) during hypocapnia, the amplitude of [Ca2+]i transients also peaked (190 +/- 22% of control; n = 5). A simulation of contractile force based on our measurements of pHi and [Ca2+]i, along with published Ca(2+)-tension relations, described adequately the changes in developed force during hypocapnia. These results indicate that the biphasic changes in [Ca2+]i, coupled with an out-of-phase change in pHi, underlie the biphasic response of myocardial contractility to hypocapnia.

Regulation of intracellular calcium in cardiac muscle.

We have investigated the regulation of intracellular free calcium in heart muscle using the free acid form of the Ca2+ indicator fura-2 iontophoretically microinjected into rat cardiac trabeculae or ferret papillary muscles. This method shows great promise in elucidating a number of crucial questions in cardiac excitation-contraction coupling.