Tag Archives: Q-VD(OMe)-OPh

br Discussion Several factors prompted the need

Several factors prompted the need for a pharmacoeconomic evaluation of IC and MEM. These included an institutional review of antimicrobial restriction and concerns about usage and costs. Most importantly, interchanging MEM with IC was thought to be able to lead to a cost saving of more than two million Saudi Riyals, as the acquisition costs of IC were noted to be less than those for MEM (SAR70.4 versus SAR 151.26 per vial). In addition, published pharmacoeconomic evaluations are limited in Saudi Arabia (Al Aqeel and Al-Sultan, 2012). To our knowledge, no published pharmacoeconomic evaluations comparing IC and MEM in adult patients have been conducted in Saudi Arabia. There have been several international Q-VD(OMe)-OPh pharmacoeconomic evaluations done (Attanasio et al., 2000; Edwards et al., 2006; Badia et al., 1999), but with conflicting results. Using data based on the local perspective therefore had the potential to provide insight into the factors influencing local practice and medicines selection. Government institutions in Saudi Arabia, providing free medical treatment, may adopt similar costing strategies that are unique to this Q-VD(OMe)-OPh region .
At a dose of 500mg q6h (cost=SAR 281.60 per day), IC is an attractive alternative to MEM 1 gram q8h (cost=SAR 453.78 per day), particularly in mild to moderate infections.
The overall ADEs were not significantly different between the groups. It was found, though, that ADEs were under-reported. Although more patients had gastrointestinal ADEs in the MEM group, this was not significantly different when compared to IC. These were mainly antibiotic-associated diarrhoea, resulting in C. difficile culture being taken. One patient on IC experienced a seizure. Concern about this adverse effect has prompted the avoidance of IC among health care workers in our hospital. It must be pointed out that Hoffman et al. found no difference in seizure rates between patients treated with IC and MEM (Hoffman et al., 2009). These authors noted that elderly patients, patients with low body weight, at risk of CNS disease, those with a history of seizure and those with renal dysfunction appear to be at increased risk of drug-related seizures. On this basis, the patient in our cohort who developed seizures was at increased risk. This study excluded patients with bacterial meningitis, due to this population being at risk for seizures. In addition, our hospital guidelines (MNGHA, 2012) do not advocate the use of IC in those at increased risk of seizures and in patients with poor renal function. Our study, in agreement with Hoffman et al. Hoffman et al. (2009) did not show significant differences in ADEs associated with IC or MEM.
Total hospital days, especially the total CCU days, in the IC group were significantly higher. The longer CCU days were believed to influence costing, especially in the IC group. Patients varied significantly in regard to the number of CCU days. Independent sample t-tests showed no significant difference in terms of mean daily hospital costs and step-down costs. However the GW costs in the IC group was significantly lower in the IC group compared to MEM (p=0.016). Although total CCU costs were higher, cost per day was not statistically different between the two groups, except in terms of the GW days. More patients in the MEM group spent a greater number of days in the GW unit, which drove up mean costs in this group.
The mean total daily costs of vials in the IC group were much lower than in the MEM group (SAR 250.63 vs. 393.48). This was expected, as the cost of IC, given 4 times daily, would result in daily costs of SAR 281.60 versus MEM, given 3 times daily, at SAR 453.78. The mean costs in our study were mean costs reflecting dose changes as well. In the institution, a previous unpublished study showed that this difference in acquisition costs could result in a savings of more than SAR 2 million riyals per year, if IC was used instead of MEM. This makes IC an attractive choice as a carbapenem in patients with moderate to severe infections. Despite significant differences in acquisition costs, laboratory culture costs, pharmacist and pharmacy aide costs, the total average costs per day was not significantly different between the 2 groups (SAR 4784.46 IC and SAR 4390.13 MEM, p=0.370).

Finally in the same four patients

Finally, in the same four patients, the IVC diameter was simultaneously estimated in three different sections by means of three corresponding moving M-lines controlled by the same algorithm. The results are illustrated in Figure 9. Note that the time course of IVC diameter varies in different sections in the same subject, indicating that different portions of the IVC exhibit different pulsatility. As a consequence, the CIs estimated in the three positions are characterized by great variability, although with some difference among the four patients.

The assessment of IVC dimensions on the basis of US scans is potentially affected by movements of the vein, which occur mainly in the craniocaudal direction, as a result of respiratory activity (Blehar et al. 2012). To avoid respiration-related movements, in a recent study the recordings were performed on patients maintaining a short apnea, thus limiting analysis of oscillations to the cardiac component (Nakamura et al. 2013). Another possibility is to manually make single measurements at the same location using B-mode cine loops rather than M-mode (Lyon et al. 2005; Wallace et al. 2010). However, this approach, based on discrete measurements, cannot provide continuous monitoring of IVC diameter.
In this study, an image processing algorithm is described that operates on longitudinal scans of the IVC (B-mode clip) and, based on reference points arbitrarily selected by the user, is able to follow IVC displacement in time. In this way, diameter changes of a given IVC section can be monitored irrespective of IVC longitudinal movements, and the analysis can be oriented to both cardiac- and respiratory-related oscillations. The algorithm was validated in a series of simulations in which translation, rotation, distortion of the IVC and additive noise were progressively implemented. The results indicated the following. (i) Simulated displacement of the IVC generated, in fact, movement artifacts in diameter estimation performed along a fixed M-line (as provided by most commercial devices operating in M-mode). (ii) The algorithm is able to eliminate most of the movement artifacts by performing the measurement along the moving M-line, which follows the IVC displacements. (iii) Relatively small errors expressed in terms of the average RMS of measured-simulated diameter may, however, result in large changes in the estimated CI. (iv) The movement related errors depend not only on the extent of the movement, but also on the individual longitudinal IVC profile, as well as on the chosen M-line (compare subject 2 in Figs. 7 and 8).


The increasing life span in industrial countries leads to an aging population, and thus, disorders of old age become more relevant. Osteoporosis is the most prevalent metabolic bone disease and one of the most frequent diseases in the elderly Q-VD(OMe)-OPh (Jones et al. 1994; Warming et al. 2002). It is characterized by bone loss and, hence, increased risk of fractures, which can cause immobilization (Hall et al. 1999) and increased mortality (Center et al. 1999). Because a large proportion of the population (about 39% of the women older than 50 in Germany [Häussler et al. 2007]) have osteoporosis, high-quality diagnosis, prognosis and therapy monitoring are essential. Today, the clinical gold standard for these tasks is the assessment of areal bone mineral density (aBMD) of the hip and spine by dual X-ray absorptiometry (DXA).
Dual X-ray absorptiometry of the spine or hip and quantitative ultrasound (QUS) measurements at the heel permit estimation of osteoporotic fracture risk with comparable performance (Bauer et al. 2007; Hans et al. 1996; Pinheiro et al. 2006). Therapy monitoring is also relevant, but here the performance of QUS methods remains controversial (Blake and Fogelman 2007; Krieg et al. 2008). DXA monitoring of the spine (Faulkner 1998) is more sensitive compared with that of the hip, as the vertebrae consist mainly of cancellous bone, which is more responsive to changes in bone metabolism because of the larger surface compared with cortical bone. However, degenerative changes of the vertebrae—that is, calcifications, especially those on or near the outer surface of the cortex of the vertebrae—are a major source of error, which limits the potential to use spinal DXA for monitoring (Guglielmi et al. 2005). In addition, drugs such as bisphosphonate minimize fracture risk even if no or only minimal changes in aBMD are measured (Chapurlat et al. 2005; Watts et al. 2004). In contrast to DXA, ultrasound, as a mechanical wave, is influenced by other aspects and is related to bone microstructure and stiffness (Goossens et al. 2008; Hodgskinson et al. 1997; Nicholson et al. 1998). Nevertheless, it is unclear if ultrasound measurements can yield more information about the development of fracture risk during therapy. Some longitudinal studies of different therapies did not prove the feasibility of using QUS for monitoring (Frost et al. 2001; Gonnelli et al. 2002, 2006; Sahota et al. 2000). One contributing factor might be the poor (long-term) precision of current QUS devices as criticized by the International Society for Clinical Densitometry (ISCD) (Krieg et al. 2008). Furthermore, adequate studies reporting the ability of QUS to monitor therapy are lacking, although the ISCD recognized some evidence of this potential. QUS at the heel seems to be better suited for this task than QUS assessments at other sites (e.g., radius and phalanges) because of a stronger response to anti-resorptive treatment of the QUS parameters at this site (Krieg et al. 2008). The common QUS parameters measured by commercial devices at the heel include the apparent speed of sound (SOS) and broadband ultrasound attenuation (BUA). Gonnelli et al. (2002) reported a five times higher monitoring time interval for BUA compared with SOS in monitoring bisphosphonate treatment. Therefore, in this study we focused on SOS as the more sensitive parameter of changes in bone status. The sensitivity to detect changes is related to responsiveness (i.e., changes in the reading of the given method over a specific interval) and the long-term precision error (Glüer 1999). Thus, increases in sensitivity may be obtained by decreasing errors in precision. Common error sources in QUS include repositioning of the foot along with the placement of the region of interest (ROI) and the temperature of the coupling medium as well as of the soft tissue (Njeh et al. 1999). The device developed in our lab (foot ultrasound scanner [FUS]) was constructed using innovative design features with the aim of minimizing the impact of these issues by using an ultrasound array to generate an image, mechanics for adjusting the ultrasound incident beam angle, temperature stabilization of the coupling medium and a sensor to measure the temperature of the foot. The FUS was built and tested to assess whether achievement of substantial improvements in SOS mid-term precision compared with commercially available devices is feasible and to estimate the impact of the design features introduced on the precision of calcaneal QUS.