A trial-based cost-effectiveness analysis of topical 5-fluorouracil vs. imiquimod vs. ingenol mebutate vs. methyl aminolaevulinate conventional photodynamic therapy for the treatment of actinic keratosis in the head and neck area performed in the Netherlands.

BACKGROUND: Actinic keratosis (AK) is a common premalignant skin condition that might have the ability to progress into squamous cell carcinoma. Due to the high incidence of AK, treatment of this disease significantly impacts healthcare spending. OBJECTIVES: To determine which commonly prescribed field-directed treatment is the most cost-effective, when comparing 5-fluorouracil (5-FU) 5%, imiquimod (IMQ) 5%, ingenol mebutate (IM) 0·015% and methyl aminolaevulinate photodynamic therapy (MAL-PDT) for AK in the head and neck region. METHODS: We performed an economic evaluation from a healthcare perspective. Data were collected alongside a single-blinded, prospective, multicentre randomized controlled trial with 624 participants in the Netherlands. The outcome measure was expressed as the incremental cost-effectiveness ratio, which is the incremental costs per additional patient with ≥ 75% lesion reduction compared with baseline. This trial was registered at ClinicalTrials.gov, number NCT02281682. RESULTS: The trial showed that 5-FU was the most effective field treatment for AK in the head and neck region. Twelve months post-treatment, the total mean costs for 5-FU were significantly lower (€433) than the €728, €775 and €1621 for IMQ, IM and MAL-PDT, respectively. The results showed that 5-FU was a dominant cost-effective treatment (more effective and less expensive) compared with the other treatments, 12 months post-treatment. CONCLUSIONS: Based on these results, we consider 5-FU 5% cream as the first-choice treatment option for multiple AKs in the head and neck area. What's already known about this topic? Due to the increasing incidence of actinic keratosis (AK), the recommended treatment results in a considerable socioeconomic burden for (dermatological) healthcare. Although cost-effectiveness modelling studies have been performed in which different treatments for AK were compared, a prospective clinical trial comparing four frequently prescribed treatments on effectiveness and resource consumption within a time horizon of 12 months has never been conducted. What does this study add? This is the first study examining the cost-effectiveness of 5-fluorouracil 5% cream, imiquimod 5% cream, ingenol mebutate 0·015% gel and methyl aminolaevulinate photodynamic therapy, with data collected in a randomized controlled trial over a time horizon of 12 months. We found that 5-fluorouracil was a dominant cost-effective treatment (more effective and less costly), based on data from the Netherlands. Linked Comment: Steeb et al. Br J Dermatol 2020; 183:612.

Rabies control in KwaZulu-Natal, South Africa.

PROBLEM: Urbanization, large dog populations and failed control efforts have contributed to continuing endemicity of dog-mediated rabies in KwaZulu-Natal province, South Africa. APPROACH: From 2007 to 2014 we used a OneHealth approach to rabies prevention, involving both the human and animal health sectors. We implemented mass vaccination campaigns for dogs to control canine rabies, and strategies to improve rabies awareness and access to postexposure prophylaxis for people exposed to rabies. LOCAL SETTING: A rabies-endemic region, KwaZulu-Natal is one of the smallest and most populous South African provinces (estimated population 10 900 000). Canine rabies has persisted since its introduction in 1976, causing an average of 9.2 human rabies cases per annum in KwaZulu-Natal from 1976 to 2007, when the project started. RELEVANT CHANGES: Between 2007 and 2014, the numbers of dog vaccinations rose from 358 611 to 395 000 and human vaccines purchased increased form 100 046 to 156 996. Strategic dog vaccination successfully reduced rabies transmission within dog populations, reducing canine rabies cases from 473 in 2007 to 37 in 2014. Actions taken to reduce the incidence of canine rabies, increase public awareness of rabies and improve delivery of postexposure prophylaxis contributed to reaching zero human rabies cases in KwaZulu-Natal in 2014. LESSONS LEARNT: Starting small and scaling up enabled us to build strategies that fitted various local settings and to successfully apply a OneHealth approach. Important to the success of the project were employing competent, motivated staff, and providing resources, training and support for field workers.

Treatment of superficial basal cell carcinoma by topical photodynamic therapy with fractionated 5-aminolaevulinic acid 20% vs. two-stage topical methyl aminolaevulinate: results of a randomized controlled trial.

BACKGROUND: Basal cell carcinoma (BCC) is the most common type of skin cancer and incidence rates are increasing. Photodynamic therapy (PDT) is a frequently used treatment, especially for superficial BCC (sBCC). Two topical photosensitizing agents are currently used to treat sBCC, namely 5-aminolaevulinic acid (ALA) and its ester, methyl aminolaevulinate (MAL). Previous research showed a high efficacy for ALA-PDT using a twofold fractionated illumination scheme in which two light fractions of 20 J cm-2 and 80 J cm-2 were delivered 4 h and 6 h after ALA application. OBJECTIVES: To evaluate whether twofold ALA-PDT is superior to conventional MAL-PDT for sBCC. METHODS: We performed a single-blind, randomized, multicentre trial in the Netherlands. RESULTS: Overall, 162 patients were randomized either to conventional MAL-PDT or twofold ALA-PDT. After 12 months, a total of six treatment failures occurred following ALA-PDT and 13 treatment failures occurred following MAL-PDT. The 12-month cumulative probability of remaining free from treatment failure was 92·3% [95% confidence interval (CI) (83·7-96·5)] for ALA-PDT and 83·4% (95% CI 73·1-90·0) for MAL-PDT (P = 0·091). CONCLUSIONS: The twofold ALA-PDT scheme resulted in fewer recurrences, although the difference between both treatment groups was not statistically significant. However, ALA-PDT resulted in higher pain scores and more post-treatment side-effects compared with MAL-PDT.

Global rabies control: the role of international organisations and the Global Strategic Plan to eliminate dog-mediated human rabies.

International partners are united to reach the shared goal of zero dog-mediated human rabies deaths by 2030, worldwide. Under the Tripartite collaboration, the World Health Organization, the World Organisation for Animal Health and the Food and Agriculture Organization of the United Nations are prioritising rabies as a model for 'One Health' in action. In 2015, the Global Rabies Conference led to the development of the Global Framework for the Elimination of Dog-Mediated Human Rabies. This long-term strategy centres around five pillars of rabies elimination (STOP-R): i) Sociocultural; ii) Technical; iii) Organisational; iv) Political; and v) Resources. Together with their partners, the Tripartite are working to operationalise the Framework through: i) engaging communities to build rabies awareness; ii) strengthening human and animal health systems, surveillance, and providing proof of concept that rabies elimination is feasible; iii) promoting intersectoral and regional collaboration; iv) advocating for political engagement and support; and v) building the case for investment through public-private partnerships and a Global Strategic Plan to end human deaths from dog-mediated rabies. By creating an enabling environment for countries to prioritise rabies and implement existing tools, the Tripartite are committed to catalysing change, empowering nations and providing the necessary support to consign rabies to the history books.

Les partenaires internationaux agissent de concert afin d'atteindre l'objectif de réduire à zéro le nombre de décès dus à la rage humaine transmise par les chiens dans le monde d'ici 2030. Dans le cadre de leur collaboration tripartite, l'Organisation mondiale de la santé, l'Organisation mondiale de la santé animale et l'Organisation des Nations Unies pour l'alimentation et l'agriculture ont fait de la rage la maladie phare de leur action gouvernée par le principe « Une seule santé ¼. En 2015, la Conférence mondiale sur la rage a abouti à la création du Cadre stratégique mondial d'élimination de la rage humaine transmise par les chiens. Cette stratégie à long terme repose sur cinq piliers visant l'élimination de la rage (STOP-R) : i) aspects socioculturels ; ii) aspects techniques ; iii) aspects organisationnels ; iv) aspects politiques ; v) ressources. Avec ses partenaires, la Tripartite met tout en oeuvre pour rendre ce cadre opérationnel, notamment à travers i) la participation des communautés à des activités de sensibilisation sur la rage ; ii) le renforcement des systèmes de santé humaine et animale, l'application de la surveillance et la démonstration de la faisabilité de l'élimination de la rage ; iii) la promotion de la collaboration intersectorielle et régionale ; iv) l'appel actif en faveur d'un engagement et d'un soutien politiques ; v) la justification de la rentabilité des investissements à travers des partenariats public-privé et un plan d'activités pour l'élimination mondiale de la rage. En créant un environnement propice permettant aux pays de prioriser la rage et de mettre en application les instruments existants, la Tripartite s'est engagée à dynamiser le changement, à donner aux pays les capacités d'agir et à fournir le soutien nécessaire pour que le rage soit un jour reléguée dans les livres d'histoire.

Una serie de asociados internacionales trabajan codo a codo para alcanzar el objetivo común de que para 2030 no haya en el mundo ninguna persona que muera de rabia transmitida por perros. Como parte de una alianza tripartita, la Organización Mundial de la Salud (OMS), la Organización Mundial de Sanidad Animal (OIE) y la Organización de las Naciones Unidas para la Alimentación y la Agricultura (FAO) están otorgando prioridad a la lucha antirrábica como modelo para poner en práctica los postulados de «Una sola salud¼. En 2015, la conferencia mundial dedicada a la lucha contra la rabia culminó con la elaboración de un marco estratégico mundial para eliminar la rabia humana transmitida por perros. Se trata de una estrategia a largo plazo (STOP-R) edificada en torno a cinco grandes pilares: i) aspectos socioculturales; ii) aspectos técnicos; iii) aspectos organizativos; iv) políticas; y v) recursos. Junto con sus colaboradores, la alianza tripartita trabaja para llevar ese marco a la práctica: i) haciendo participar a las comunidades en la sensibilización respecto de la rabia; ii) fortaleciendo los sistemas sanitarios y zoosanitarios, efectuando labores de vigilancia y demostrando empíricamente que la eliminación de la rabia es un objetivo factible; iii) promoviendo la colaboración intersectorial y regional; iv) presionando para lograr el compromiso y apoyo políticos; y v) aportando argumentos en defensa de la inversión por la vía de alianzas publicoprivadas y elaborando un plan de trabajo para la eliminación de la rabia a escala mundial. La alianza tripartita, al crear condiciones propicias para que los países otorguen prioridad a la rabia y apliquen las herramientas existentes, está impulsando el cambio, dotando a las naciones de capacidad de acción y prestando el apoyo necesario para conseguir que un día la rabia quede relegada a los libros de historia.

Economic comparison of common treatment protocols and J5 vaccination for clinical mastitis in dairy herds using optimized culling decisions.

This study used an existing dynamic optimization model to compare costs of common treatment protocols and J5 vaccination for clinical mastitis in US dairy herds. Clinical mastitis is an infection of the mammary gland causing major economic losses in dairy herds due to reduced milk production, reduced conception, and increased risk of mortality and culling for infected cows. Treatment protocols were developed to reflect common practices in dairy herds. These included targeted therapy following pathogen identification, and therapy without pathogen identification using a broad-spectrum antimicrobial or treating with the cheapest treatment option. The cost-benefit of J5 vaccination was also estimated. Effects of treatment were accounted for as changes in treatment costs, milk loss due to mastitis, milk discarded due to treatment, and mortality. Following ineffective treatments, secondary decisions included extending the current treatment, alternative treatment, discontinuing treatment, and pathogen identification followed by recommended treatment. Average net returns for treatment protocols and vaccination were generated using an existing dynamic programming model. This model incorporates cow and pathogen characteristics to optimize management decisions to treat, inseminate, or cull cows. Of the treatment protocols where 100% of cows received recommended treatment, pathogen-specific identification followed by recommended therapy yielded the highest average net returns per cow per year. Out of all treatment scenarios, the highest net returns were achieved with selecting the cheapest treatment option and discontinuing treatment, or alternate treatment with a similar spectrum therapy; however, this may not account for the full consequences of giving nonrecommended therapies to cows with clinical mastitis. Vaccination increased average net returns in all scenarios.

Intelligent speed assistance for serious speeders: the results of the Dutch Speedlock trial.

One of the most important policy questions regarding Intelligent Speed Assistance (ISA) is whether or not it should be implemented, and if so how. In 2010 the Dutch Ministry of Infrastructure and the Environment decided to perform a field operational test to investigate the possibility of using ISA as a penalty system for serious speed offenders. This paper presents the results of this research, focusing on the effects on road safety. The results show that the two types of ISA systems that were tested have a huge effect on driver behavior and have the potential to improve road safety by reducing the level of speeding, mean speed, as well as the standard deviation of speed. However, the users show little sign of learning after the systems are turned off. Moreover, the serious offenders frequently use the emergency button to override the system which might seriously affect the efficacy of the system.

Studies on reconstituted partially purified glycerophosphate acyltransferase from Escherichia coli.

Solubilized glycerophosphate acyltransferase from Escherichia coli was reconstituted in small unilamellar vesicles consisting of phosphatidylcholine/phosphatidylglycerol in a molar ratio of 4:1. Glycerol 3-phosphate, trapped inside these vesicles, cannot be acylated by the enzyme upon addition of extra-vesicular palmitoyl-CoA. Thus, substrate-binding sites and active sites are asymmetrically oriented in the model membrane. When up to 10 mol/100 mol lysophosphatidic acid was incorporated in the vesicles a decrease in glycerophosphate acyltransferase activity is observed at amounts exceeding 1 mol% lysophosphatidate. Similar experiments, using lysophosphatidylcholine and phosphatidic acid, suggest the decrease to result from an increase in negative surface charge. Reconstituted glycerophosphate acyltransferase exhibits a preference for palmitoyl-CoA over oleoyl-CoA. This preference increases considerably at elevated temperatures. The glycerophosphate acyltransferase could, therefore, participate in the temperature-dependent changes in the fatty acid composition of the phospholipids in E. coli.

Facilitated utilization of endogenously synthesized lysophosphatidic acid by 1-acylglycerophosphate acyltransferase from Escherichia coli.

Complete separation of glycerophosphate acyltransferase and 1-acylglycerophosphate acyltransferase from Escherichia coli was obtained by sequential extraction with Triton X-100. Solubilized glycerophosphate acyltransferase was reconstituted by the cholate dispersion and gel filtration method in small unilamellar vesicles. 1-Acylglycerophosphate acyltransferase could not be solubilized from the membranes and was used in endogenous membrane fragments after detergent removal. Mixing of the two preparations and subsequent incubation in the presence of glycerol 3-phosphate, palmitoyl-CoA and oleoyl-CoA resulted in the efficient synthesis of phosphatidic acid. Inclusion of exogenous lysophosphatitic acid in the assay medium resulted in a dilution of the newly synthesized lysophosphatidate. By contrast, the synthesis of phosphatidic acid from glycerol 3-phosphate by the acyltransferases present in native membrane vesicles was barely influenced by the presence of exogenous lysophosphatidic acid. When comparing the utilization of membrane-associated 14C-labeled and newly generated 3H-labeled lysophosphatidic acid, the latter appeared to be the preferred substrate. These results indicate that lysophosphatidic acid, synthesized by glycerophosphate acyltransferase, is utilized by 1-acylglycerophosphate acyltransferase without prior mixing with the total membrane-associated pool of lysophosphatidic acid, and suggest a close proximity of the two enzymes in native E. coli membranes. This property of the acyltransferases is lost upon separation and reconstitution of enzyme activities.

Characterization of reconstituted partially purified glycerophosphate acyltansferase from Escherichia coli.

A modification of the method of Snider and Kennedy (J. Bacteriol. (1977) 130, 1072-1083) was worked out to solubilize sn-glycero-3-phosphate acyltransferase from whole cells by Triton X-100. The solubilized preparation was used for a systematic study of the reconstitution of enzymatic activity as observed by addition of phospholipid vesicles. Although enzymatic activity was regained by addition of vesicles and not by addition of multilayered liposomes, subsequent Sepharose 4B chromatography revealed the enzyme to be incorporated in large lipid aggregates of undefined structures. Incorporation of glycerophosphate acyltransferase in single bilayer vesicles composed of phosphatidylcholine and phosphatidylglycerol (4:1) was obtained after removal to Triton X-100 from the enzyme solution, co-dispersion of enzyme and phospholipids with cholate and Sephadex G-50 gel filtration of this mixture to remove cholate. The optimal conditions for this reconstitution procedure with respect to phospholipid/protein and phosphatidylcholine/phosphatidylglycerol ratio were established. The active site of glycero-3-phosphate acyltransferase in the reconstituted system was localized for at least 90% at the outside surface of the vesicle, as revealed by proteolysis experiments under conditions of vesicle intactness as shown by C-NMR experiments. The reconstituted systems produced only lysophosphatidate from sn-[14C]glycero-3-phosphate and palmitoyl-CoA and showed identical apparent Km for sn-glycero-3-phosphate and identical pH- and temperature-dependencies as the enzyme in isolated Escherichia coli membranes.

Localization of glycerophosphate acyltransferase in Escherichia coli.

sn-Glycero-3-phosphate acyltransferase (EC 2.3.1.15) the first enzyme involved in phospholipid biosynthesis, is known to be associated with the cytoplasmic membrane of Escherichia coli. The localization of this enzyme in the transverse plane of the membrane was investigated by proteolysis of intact and lysed spheroplasts and by inhibition of glycerol 3-phosphate transport into intact cells in the presence of azide. Glycerophosphate acyltransferase was found to be resistant to proteolysis by trypsin in intact spheroplasts, whereas its enzymatic activity could be destroyed completely by trypsin in lysed spheroplasts. These results are in line with a localization of the acyltransferase at the inner aspect of the cytoplasmic membrane. Sodium azide was shown to have no inhibitory effect on glycerophosphate acyltransferase activity. Lack of incorporation of glycero phosphate into the phospholipids of glycerol phosphate transport-negative cells and inhibition of this incorporation in wild-type and glycerol 3-phosphate transport-constitutive cells by azide support a cytoplasmic-oriented localization of the glycerophosphate acyltransferase.