A cost-effectiveness analysis of consolidation immunotherapy with durvalumab in stage III NSCLC responding to definitive radiochemotherapy in Switzerland.

BACKGROUND: Consolidation immunotherapy with the programmed death ligand 1 (PD-L1) inhibitor durvalumab improves survival in patients with stage III non-small-cell lung cancer responding to radiochemotherapy. The aim of this study was to assess the cost-effectiveness of durvalumab in Switzerland based on the most recent PACIFIC survival follow-up. MATERIALS AND METHODS: We constructed a Markov model based on the 3-year follow-up data of the PACIFIC trial and compared consolidation durvalumab with observation. We used published utility values and assessed costs for treatment strategies from the perspective of the Swiss health care payers. Cost-effectiveness was tested both in the intention-to-treat population of the PACIFIC trial unselected for PD-L1 tumor expression and in patients with PD-L1-expressing tumors (≥1%). RESULTS: In the unselected/PD-L1-positive patients, durvalumab showed an incremental effectiveness of 0.76/1.18 quality-adjusted life year (QALY) and incremental costs of Swiss Francs (CHF) 67 239/78 177, resulting in incremental cost-effectiveness ratios of CHF 88 703/66 131 per QALY gained, respectively. The most influential factors for the incremental cost-effectiveness ratio were the utility before first progression, costs for durvalumab, and the hazard ratio for overall survival under durvalumab versus observation. The cost-effectiveness of durvalumab was better than CHF 100 000 per QALY gained in 75% of the simulations in probabilistic sensitivity analysis. CONCLUSION: Assuming a willingness-to-pay threshold of CHF 100 000 per QALY gained, consolidation durvalumab is likely to be cost-effective both in patients with inoperable stage III non-small-cell lung cancer (NSCLC) unselected for PD-L1 status and in patients with PD-L1-expressing tumors in Switzerland.

Single-channel properties of neuronal GABAA receptors from mice lacking the 2 subunit.

1. The aim of this study was to define the biophysical properties contributed by the gamma2 subunit to native single GABAA receptors. 2. Single-channel activity was recorded from neurones of wild-type (gamma2+/+) mice and compared with that from mice which were heterozygous (gamma2+/-) or homozygous (gamma2-/-) for a targeted disruption in the gamma2 subunit gene of the GABAA receptor. Unitary currents were evoked by low concentrations of GABA (0.5-5 microM) in membrane patches from acutely isolated dorsal root ganglion (DRG) neurones (postnatal day 0) and by 1 microM GABA in patches from embryonic hippocampal neurones which were cultured for up to 3 weeks. 3. GABAA receptors from DRG and hippocampal neurones of gamma2+/+ and gamma2+/- mice displayed predominantly a conductance state of 28 pS and less frequently 18 and 12 pS states. In gamma2-/- mice, conductance states mainly of 12 pS and less frequently of 24 pS were found. 4. The mean open duration of the 28 pS state in gamma2+/+ GABAA receptors (1.5-2.6 ms) was substantially longer than for the 12 pS state of gamma2-/- GABAA receptors (0.9-1.2 ms) at all GABA concentrations. For gamma2+/+ and gamma2-/- channels, the mean open duration was increased at higher GABA concentrations. 5. Open duration frequency distributions of 28 and 12 pS receptors revealed the existence of at least three exponential components. Components with short mean durations declined and components with long mean durations increased in relative frequency at higher GABA concentration indicating at least two binding sites of GABA per 28 and 12 pS receptor. 6. Shut time frequency distributions revealed at least four exponential components of which two were identified as intraburst components in 28 pS and one in 12 pS GABAA receptors. 7. The mean burst duration and the mean number of openings per burst increased in 28 and 12 pS GABAA receptors with increasing GABA concentration. At least two burst types were identified: simple bursts consisting of single openings and complex bursts of five to six openings in 28 pS but only two to three openings in 12 pS GABAA receptors. 8. We conclude that the gamma2 subunit enhances the efficacy of GABA by determining open conformations of high conductance and long lifetime, and by prolonging the time receptors remain in the activated bursting state.

Decreased GABAA-receptor clustering results in enhanced anxiety and a bias for threat cues.

Patients with panic disorders show a deficit of GABAA receptors in the hippocampus, parahippocampus and orbitofrontal cortex. Synaptic clustering of GABAA receptors in mice heterozygous for the gamma2 subunit was reduced, mainly in hippocampus and cerebral cortex. The gamma2 +/- mice showed enhanced behavioral inhibition toward natural aversive stimuli and heightened responsiveness in trace fear conditioning and ambiguous cue discrimination learning. Implicit and spatial memory as well as long-term potentiation in hippocampus were unchanged. Thus gamma2 +/- mice represent a model of anxiety characterized by harm avoidance behavior and an explicit memory bias for threat cues, resulting in heightened sensitivity to negative associations. This model implicates GABAA-receptor dysfunction in patients as a causal predisposition to anxiety disorders.

Postsynaptic clustering of major GABAA receptor subtypes requires the gamma 2 subunit and gephyrin.

Most fast inhibitory neurotransmission in the brain is mediated by GABAA receptors, which are mainly postsynaptic and consist of diverse alpha and beta subunits together with the gamma 2 subunit. Although the gamma 2 subunit is not necessary for receptor assembly and translocation to the cell surface, we show here that it is required for clustering of major postsynaptic GABAA receptor subtypes. Loss of GABAA receptor clusters in mice deficient in the gamma 2 subunit, and in cultured cortical neurons from these mice, is paralleled by loss of the synaptic clustering molecule gephyrin and synaptic GABAergic function. Conversely, inhibiting gephyrin expression causes loss of GABAA receptor clusters. The gamma 2 subunit and gephyrin are thus interdependent components of the same synaptic complex that is critical for postsynaptic clustering of abundant subtypes of GABAA receptors in vivo.

Neural control of hindleg steering in flight in the locust

Corrective flight steering with the hindlegs was investigated in intact tethered flying locusts inside a wind tunnel as well as in animals dissected for intracellular recording and showing fictive flight activity. In intact tethered flying animals, activity in the second coxal abductor muscle (M126) was highly correlated with hindleg steering and was coupled to the elevator phase of the flight cycle. Fictive flight and steering could also be elicited in animals dissected for intracellular recording of motoneurones innervating M126. During fictive flight activity, motoneurones 126 were rhythmically excited in the elevator phase, presumably from central elements of the neuronal oscillator generating the flight motor pattern, as is the case for motoneurones innervating wing muscles. During fictive straight flight, this input was subthreshold, and it could be demonstrated that simulated deviation from the flight course resulted in recruitment of motoneurones 126. Statistical analysis of the latencies of fast muscle spikes in M126 and in one wing elevator muscle showed that both received common input during flight steering. One source of this common input was identified as the sensory information from the lateral ocelli, which play an important role in the detection of course deviation. The experiments demonstrated that processing in the sensory-motor system for hindleg steering is probably organized in a very similar way to that responsible for steering with the wings.