Mendel E. Singer

Sleep Disordered Breathing and Impaired Glucose Metabolism in Normal Weight and Overweight/Obese Individuals: The Sleep Heart Health Study

OBJECTIVE—To characterize the association between sleep-disordered breathing (SDB) and impaired fasting glucose (IFG), impaired glucose tolerance (IGT), combined IFG and IGT, and occult diabetes in individuals of different body habitus. RESEARCH DESIGN AND METHODS—Cross-sectional analysis of 2,588 participants (aged 52–96 years; 46% men) without known diabetes. SDB was defined as respiratory disturbance index ≥10 events/h. IFG, IGT, occult diabetes, and body weight were classified according to recent accepted guidelines. Participants with and without SDB were compared on prevalence and odds ratios for measures of impaired glucose metabolism (IGM), adjusting for age, sex, race, BMI, and waist circumference. RESULTS—SDB was observed in 209 nonoverweight and 1,036 overweight/obese participants. SDB groups had significantly higher adjusted prevalence and adjusted odds of IFG, IFG plus IGT, and occult diabetes. The adjusted odds ratio for all subjects was 1.3 (95% CI 1.1–1.6) for IFG, 1.2 (1.0–1.4) for IGT, 1.4 (1.1–2.7) for IFG plus IGT, and 1.7 (1.1–2.7) for occult diabetes. CONCLUSIONS—SDB was associated with occult diabetes, IFG, and IFG plus IGT, after adjusting for age, sex, race, BMI, and waist circumference. The magnitude of these associations was similar in nonoverweight and overweight participants. The consistency of associations across all measures of IGM and body habitus groups and the significant association between SDB and IFG plus IGT, a risk factor for rapid progression to diabetes, cardiovascular disease, and mortality, suggests the importance of SDB as a risk factor for clinically important levels of metabolic dysfunction.

Impact of interferon free regimens on clinical and cost outcomes for chronic hepatitis C genotype 1 patients

BACKGROUND & AIMS Hepatitis C (HCV) is a common cause of chronic liver disease worldwide. Current standard treatment for genotype-1 patients uses a triple combination of pegylated-interferon alpha (IFN), ribavirin (RBV) and a direct-acting antiviral agent (DAA) with 75-80% sustained virologic response (SVR) rates. The aim is to determine cost-effectiveness of staging-guided vs. treat all HCV genotype-1 patients with interferon-based vs. interferon-free regimens. METHODS A decision analytic Markov model simulating patients until death compared four strategies for treating HCV genotype-1: Triple therapy (IFN, RBV, DAA) with staging-guidance or treat all, and oral IFN-free regimen with staging-guidance or treat all. Strategies with staging initiated treatment at fibrosis stages F2-F4, with staging repeated every 5 years until age 70. The reference case was a treatment-naïve 50-year-old. Analysis was repeated for 50% increase in cost of oral therapy. Effectiveness was measured in quality-adjusted life years (QALYs). RESULTS Treatment of all patients with oral IFN-free regimen was the most cost-effective strategy, with an ICER of

Air pollution and emergency department visits for asthma among Ohio Medicaid recipients, 1991-1996.

15,709/QALY at baseline cost of oral therapy. The ICER remained below

Cost effectiveness of screening for hepatitis C virus in asymptomatic, average-risk adults

50,000/QALY in sensitivity analyses for baseline and +50% cost of oral therapy scenarios. The treat all strategy was also the most effective strategy; associated with the lowest risk of developing advanced liver disease. CONCLUSIONS Treating all HCV patients with oral IFN-free regimen reduced the number of patients developing advanced liver disease and increased life expectancy. Additionally, IFN-free regimen without staging may be the most cost-effective approach for treating HCV genotype-1 patients. The efficacy and safety of these regimens must be confirmed using randomized clinical trials.

Utility of repeated praziquantel dosing in the treatment of schistosomiasis in high-risk communities in Africa: A systematic review

We examined the effects of nitrogen dioxide (NO(2)), ozone (O(3)), particulate matter of <10 microm aerodynamic diameter (PM(10)), and sulfur dioxide (SO(2)) on asthmatics ages 5-34 years enrolled in Medicaid in Cincinnati, Cleveland, and Columbus, OH (N=5416). Our study period was for the summer months, June-August, from July 1, 1991 to June 30, 1996. We preformed Poisson regression analyses for the number of daily emergency department (ED) visits for asthma in each city and on the aggregate data controlling for time trends and minimum temperature. We found a 12% increased likelihood of an asthma ED visit per 50 microg/m(3) increase in PM(10) in Cleveland [95% confidence interval (CI)=0-27%] and a 35% increase per 50 microg/m(3) increase in SO(2) in Cincinnati (95% CI=9-21%). When data were analyzed for all three cities combined, the risk of an ED visit increased for all pollutant increases and specifically by 12% (95% CI=1-23%) per 50 microg/m(3) increase in SO(2). Attributable risk estimates show a five times greater impact on Cleveland over Cincinnati or Columbus. Between 1991 and 1996, air pollutants in Cincinnati, Cleveland, and Columbus increased ED visits for asthmatics enrolled in Medicaid.

Cost-effectiveness of hematologic growth factors for anemia occurring during hepatitis C combination therapy.

PURPOSE To estimate the cost effectiveness of screening for hepatitis C in asymptomatic, average-risk adults. METHODS We used a Markov decision analysis model to estimate the lifetime cost effectiveness of three screening strategies: (1) initial screening for hepatitis C antibody by third-generation enzyme-linked immunosorbent assay (ELISA), followed by confirmatory testing for hepatitis C virus ribonucleic acid (RNA) using polymerase chain reaction (PCR); (2) initial screening for hepatitis C virus RNA by PCR only; and (3) the current practice of not screening. The patient population comprised a hypothetical cohort of average-risk adults presenting to their regular primary health care provider for routine physical examination. The main outcome measure was cost per additional quality-adjusted life-year (QALY) gained. RESULTS The no screening strategy was the dominant strategy in the baseline analysis. The model was most sensitive to the reduction in quality of life related to patient awareness of hepatitis C infection. Screening with ELISA and PCR was preferred when this value was <0.01 and was cost effective if more than half of the patients who tested positive for hepatitis C actually initiated treatment, or if the annual rate of progression to cirrhosis was greater than 2.5%. Screening with PCR only was never cost effective. CONCLUSIONS This analysis does not support the widespread screening for hepatitis C among asymptomatic, average-risk adults.

Public health impact and cost effectiveness of mass vaccination with live attenuated human rotavirus vaccine (RIX4414) in India: model based analysis.

Background Controversy persists about the optimal approach to drug-based control of schistosomiasis in high-risk communities. In a systematic review of published studies, we examined evidence for incremental benefits from repeated praziquantel dosing, given 2 to 8 weeks after an initial dose, in Schistosoma-endemic areas of Africa. Methodology/Principal Findings We performed systematic searches of electronic databases PubMed and EMBASE for relevant data using search terms ‘schistosomiasis’, ‘dosing’ and ‘praziquantel’ and hand searches of personal collections and bibliographies of recovered articles. In 10 reports meeting study criteria, improvements in parasitological treatment outcomes after two doses of praziquantel were greater for S. mansoni infection than for S. haematobium infection. Observed cure rates (positive to negative conversion in egg detection assays) were, for S. mansoni, 69–91% cure after two doses vs. 42–79% after one dose and, for S. haematobium, 46–99% cure after two doses vs. 37–93% after a single dose. Treatment benefits in terms of reduction in intensity (mean egg count) were also different for the two species—for S. mansoni, the 2-dose regimen yielded an weighted average 89% reduction in standardized egg counts compared to a 83% reduction after one dose; for S. haematobium, two doses gave a 93% reduction compared to a 94% reduction with a single dose. Cost-effectiveness analysis was performed based on Markov life path modeling. Conclusions/Significance Although schedules for repeated treatment with praziquantel require greater inputs in terms of direct costs and community participation, there are incremental benefits to this approach at an estimated cost of

The cost-effectiveness of strategies to assess gastroesophageal reflux as an exacerbating factor in asthma

153 (S. mansoni)–

Cost Effectiveness of Facility-Based Care, Home-Based Care and Mobile Clinics for Provision of Antiretroviral Therapy in Uganda

211 (S. haematobium) per additional lifetime QALY gained by double treatment in school-based programs. More rapid reduction of infection-related disease may improve program adherence, and if, as an externality of the program, transmission can be reduced through more effective coverage, significant additional benefits are expected to accrue in the targeted communities.

Intergenerational Volunteering and Quality of Life for Persons With Mild to Moderate Dementia: Results From a 5-Month Intervention Study in the United States

In hepatitis C virus (HCV)‐infected patients who develop anemia during combination therapy, erythropoietic growth factors maintain higher drug treatment levels compared to ribavirin dose reduction, which may lead to an increase in treatment response rates. This study estimated the cost‐effectiveness of growth factor therapy in maintaining anemic HCV‐infected patients on target drug levels during combination therapy. A decision analysis using a Markov model was developed with 7 health states: Sustained viral response, chronic HCV, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, and death. Data sources included population‐based studies of growth factor therapy, previously published estimates of costs and natural history of hepatitis C, and recent prospective studies. Our reference case was a 45‐year‐old Caucasian man with HCV infection (genotype 1, 2, or 3) who developed anemia while undergoing combination therapy with ribavirin and pegylated interferon. We compared growth factor injections (darbepoetin alpha or epoetin alpha) during combination therapy with standard ribavirin dose reduction. Compared to a ribavirin dose reduction strategy, the cost of darbepoetin per additional quality‐adjusted life‐year was