Health outcomes and costs of ischemic stroke patients in Finland.

OBJECTIVES: Stroke case fatality is decreasing over time. Less, however, is known about patients' health-related quality of life (HRQoL), quality-adjusted life years (QALYs), and costs. We studied all these with two data sets collected in Finland 10 years apart. METHODS: A total of 468 and 355 first-ever ischemic stroke patients were followed up 1 year in two studies (Study 1 in 1989-1991 and Study 2 in 2001-2003). Case fatality, HRQoL measured by the 15D, QALYs, costs, and first-year cost/QALY were compared. Regression analysis was used to examine the effects of various factors on QALYs. RESULTS: In the later study, the case fatality rates were lower and the mean 15D scores higher. During the follow-up year, patients experienced on average 0.519 (95% CI 0.453-0.555) and 0.646 (95% CI 0.613-0.680) QALYs in Study 1 and Study 2, respectively (P < 0.001). Age, modified Rankin Scale before stroke onset, acute phase Scandinavian Stroke Scale, and the study group explained the variance of QALYs. The first-year mean total costs were 10 626 € and 14 603 € and the mean cost/QALY 20 474 € and 22 605 € in Study 1 and Study 2, respectively. The incremental cost-effectiveness ratio of Study 2 compared with Study 1 was 31 315 € without and 60 684 € with patient characteristics standardization. CONCLUSIONS: Stroke patients' improved outcome is clear, but it remains uncertain to what extent it is attributable to the development of care. More research is needed to study the cost-effectiveness of stroke care.

Quantitative 1H nuclear magnetic resonance diffusion spectroscopy of BT4C rat glioma during thymidine kinase-mediated gene therapy in vivo: identification of apoptotic response.

We have investigated the effects of thymidine kinase-mediated gene therapy in a malignant rat BT4C glioma by using 1H nuclear magnetic resonance spectroscopy in vivo. Ganciclovir has been successfully used in thymidine kinase gene therapy as treatment for various experimental malignancies. The cell damaging effect seems to be mediated by apoptosis, optimally leading to eradication of tumor tissue. In this study, we show that ganciclovir treatment of tumors transfected with the herpes simplex thymidine kinase gene causes profound changes in water, metabolites, and macromolecules observable by diffusion spectroscopy. During treatment, a 50% reduction from 0.14 +/- 0.01 x 10(-9) m2/s in the apparent diffusion coefficient of choline-containing compounds can be observed, concomitant with a 219% increase in the apparent diffusion coefficient of the rapidly diffusing water component. These changes are associated with an increase in the relative fraction of this water component from 87 to 94%. The apparent diffusion coefficients of the slowly diffusing water component and macromolecules remain unaltered. The results imply a reduction in cell size and number, a significant increase in intracellular viscosity, and a possible reduction in the hydrodynamic radii of macromolecular components, which are ascribed as biophysical signatures for apoptotic cell death.

Beta-galactosidase gene transfer to human malignant glioma in vivo using replication-deficient retroviruses and adenoviruses.

Both retro- and adenovirus-mediated gene therapy have been suggested as a novel approach to the treatment of malignant brain tumors. However, little information is available about the gene transfer efficiency in human malignant glioma in vivo. We compared the feasibility and safety of retrovirus- and adenovirus-mediated beta-galactosidase gene transfer in human malignant glioma. Beta-galactosidase gene was transferred to 10 patients with malignant glioma via a catheter inserted into the tumor. The catheter was left in place until the tumor resection. To maximize gene transfer efficiency, gene transfer vectors (BAG retroviruses, titer, 6 x 10(5) CFU; and adenoviruses, titer from 3 x 10(8) to 3 x 10(10) PFU) were injected into the tumor via the catheter once a day for three consecutive days, followed by tumor resection 1-2 days later. Tumor was resected in such a way that the catheter was still in place inside the tumor, which permitted accurate histological analysis of the transduced tumors. X-Gal staining for beta-galactosidase activity was used to study gene transfer efficiency and distribution of the marker gene. Beta-galactosidase gene transfer was well tolerated with both vectors. Except for two patients with clear increases in serum adenovirus antibody titers, no adverse tissue responses or systemic complications were noticed in any of the patients. Gene transfer was successful in all patients. Gene transfer efficiency varied between <0.01 and 4% with retroviruses and between <0.01 and 11% with adenoviruses. However, the transgene activity was not evenly distributed in the tumors. Both glioma cells and endothelium in the tumor blood vessels were transduced with retro- and adenovirus vectors. In conclusion, the safety and feasibility of in vivo gene transfer to human malignant glioma was established with retro- and adenovirus vectors. Adenoviruses were more efficient than retroviruses in achieving in vivo gene transfer. Transduction of endothelial cells may have important consequences for the proposed treatment strategies and selection of treatment genes. The results justify clinical gene therapy trials for malignant glioma.

Monitoring thymidine kinase and ganciclovir-induced changes in rat malignant glioma in vivo by nuclear magnetic resonance imaging.

We have used high resolution magnetic resonance imaging to monitor malignant rat BT4C gliomas in vivo following herpes simplex virus thymidine kinase gene and ganciclovir (GCV) treatment. Twenty-six female BDIX rats were used for the study including four controls. Serial magnetic resonance imaging was performed every 72 hours to quantify tumor volume, transverse relaxation time (T2) ,and apparent diffusion constant (ADC) of water in the tumors and in the contralateral brain. GCV treatment was given twice a day, intraperitoneally, for 21 days. The gliomas exhibited low T2 and ADC values (before treatment), compared to normal brain, indicating the presence of high cell density tumors. Following GCV treatment, a regional increase in T2 and ADC was observed as early as day 4 of the treatment, even though the tumor volume was still increasing. These observations suggested evolution of local necroses which were confirmed by histology. In a group of five tumor bearing rats, retrovirus-producing packaging cell injections were given intratumorally to mimic clinically relevant gene therapy. In these cases, only small and short-lasting T2 and ADC elevations were found following GCV treatment without an effect on the overall tumor growth and outcome. Our results show that quantitative magnetic resonance imaging including T2 and ADC, is superior to robust volume measurements in predicting an early response to retrovirus-mediated gene therapy in vivo.