Cost-effectiveness of abatacept,rituximab, and TNFi treatment after previous failure with TNFi treatment in rheumatoid arthritis: a pragmatic multi-centre randomised trial

IntroductionFor patients with rheumatoid arthritis (RA) whose treatment with a tumour necrosis factor inhibitor (TNFi) is failing, several biological treatment options are available. Often, another TNFi or a biological with another mode of action is prescribed. The objective of this study was to compare the effectiveness and cost-effectiveness of three biologic treatments with different modes of action in patients with RA whose TNFi therapy is failing.MethodsWe conducted a pragmatic, 1-year randomised trial in a multicentre setting. Patients with active RA despite previous TNFi treatment were randomised to receive abatacept, rituximab or a different TNFi. The primary outcome (Disease Activity Score in 28 joints) and the secondary outcomes (Health Assessment Questionnaire Disability Index and 36-item Short Form Health Survey scores) were analysed using linear mixed models. Cost-effectiveness was analysed on the basis of incremental net monetary benefit, which was based on quality-adjusted life-years (calculated using EQ-5D scores), and all medication expenditures consumed in 1 year. All analyses were also corrected for possible confounders.ResultsOf 144 randomised patients, 5 were excluded and 139 started taking abatacept (43 patients), rituximab (46 patients) or a different TNFi (50 patients). There were no significant differences between the three groups with respect to multiple measures of RA outcomes. However, our analysis revealed that rituximab therapy is significantly more cost-effective than both abatacept and TNFi over a willingness-to-pay range of 0 to 80,000 euros.ConclusionsAll three treatment options were similarly effective; however, when costs were factored into the treatment decision, rituximab was the best option available to patients whose first TNFi treatment failed. However, generalization of these costs to other countries should be undertaken carefully.

Trial registration

Netherlands Trial Register number NTR1605. Registered 24 December 2008.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0630-5) contains supplementary material, which is available to authorized users.     

Diversity of natural enemies in Central Otago,New Zealand apple orchards: a practical measure of sustainability in pest management?

The diversity of the arthropod fauna in apple orchards in Central Otago was recorded from 1994 to 1999 using beating trays, pitfall traps, and sticky traps and the data analysed by the Shannon–Wiener Index. Three different fruit production systems were compared, conventional (CFP), integrated (IFP), and biological (BFP), to determine whether total arthropod diversity and/or the diversity of natural enemies (predators and parasitoids) could be used to measure the sustainability of their pest management practices. The contribution of natural enemies to the diversity indices was also examined to determine if they reflected the key species essential for sustainable pest management. The diversity of natural enemies in beating trays was found to be the measure most sensitive to changes in pest management. The diversity of both the total arthropod fauna and natural enemies was much lower under CFP than under either IFP or BFP, due to the use of broad-spectrum pesticides. This practice made the CFP programme unsustainable and it is no longer used. During the transition from CFP to IFP, the diversity indices rose to become similar to that in the BFP programme by the third season. The introduction of frequent applications of fungicides in BFP, including lime sulphur, appeared to reduce total arthropod and natural enemy diversity. Falls in the diversity indices for natural enemies were shown to reflect reduced numbers, range, and evenness of natural enemies but not necessarily the key species known to be critical for sustainable pest management. It is proposed that a Shannon–Wiener Index for natural enemies in beating trays of 0.2 or less in summer is strongly indicative of unsustainable pest management in Otago apple orchards. On the other hand, indices of 0.3–0.8, as found under IFP and BFP, do not give unequivocal or quantitative indications of the sustainability of pest management. A suite of other measures of sustainability are more useful, notably combining lower pesticide use, reduced pest damage and presence at harvest, the greater roles of key natural enemies, more effective plant resistance to pests and diseases, and higher profitability.     

Biased estimates of clonal evolution and subclonal heterogeneity can arise from PCR duplicates in deep sequencing experiments

Accurate allele frequencies are important for measuring subclonal heterogeneity and clonal evolution. Deep-targeted sequencing data can contain PCR duplicates, inflating perceived read depth. Here we adapted the Illumina TruSeq Custom Amplicon kit to include single molecule tagging (SMT) and show that SMT-identified duplicates arise from PCR. We demonstrate that retention of PCR duplicate reads can imply clonal evolution when none exists, while their removal effectively controls the false positive rate. Additionally, PCR duplicates alter estimates of subclonal heterogeneity in tumor samples. Our method simplifies PCR duplicate identification and emphasizes their removal in studies of tumor heterogeneity and clonal evolution.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-014-0420-4) contains supplementary material, which is available to authorized users.     

Study of agreement between LDL size as measured by nuclear magnetic resonance and gradient gel electrophoresis

LDL particle size can be measured by gradient gel electrophoresis (GGE) and NMR. The agreement between the two methods has not been extensively evaluated. Therefore, we measured LDL size by NMR and GGE in 324 individuals (152 with type 1 diabetes and 172 controls). The Spearman correlation between both methods was 0.39 [95% confidence interval (CI) = 0.29, 0.48]. The average difference was 5.38 nm (NMR being smaller), but it increased with increasing LDL size. Less than 50% of people classified as pattern B on GGE were classified as pattern B on NMR (kappa = 0.31; 95% CI = 0.17, 0.45). Agreement was lower for diabetic subjects compared with controls, for women compared with men, and for subjects with triglycerides less than 1.30 mmol/l compared with subjects with triglycerides greater than 1.30 mmol/l. External validation showed that cholesteryl ester transfer rate was related to LDL size on GGE in all subgroups and to LDL size on NMR only in men and nondiabetic subjects. Our findings show that agreement between NMR- and GGE-based LDL size is far from perfect and is not consistent across subgroups of patients. In particular, the two methods should not be assumed to be interchangeable in women and diabetic subjects. Whether NMR or GGE predicts cardiovascular disease risk better has not yet been evaluated.     

Sustained rheumatoid arthritis remission is uncommon in clinical practice

Introduction

Remission is an important goal of therapy in rheumatoid arthritis (RA), but data on duration of remission are lacking. Our objective was to describe the duration of remission in RA, assessed by different criteria.

Methods

We evaluated patients from the Brigham and Women''s Rheumatoid Arthritis Sequential Study (BRASS) not in remission at baseline with at least 2 years of follow-up. Remission was assessed according to the Disease Activity Score 28-C-reactive protein (DAS28-CRP4), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) scores, and the recently proposed American College of Rheumatology (ACR)/European League against Rheumatism (EULAR) criteria for remission. Analyses were performed by using Kaplan-Meier survival curves.

Results

We identified 871 subjects with ≥2 years of follow-up. Of these subjects, 394 were in remission at one or more time-points and not in remission at baseline, according to at least one of the following criteria: DAS28-CRP < 2.6 (n = 309), DAS28-CRP < 2.3 (n = 275), SDAI (n = 168), CDAI (n = 170), and 2010 ACR/EULAR (n = 158). The median age for the 394 subjects at entrance to BRASS was 56 years; median disease duration was 8 years; 81% were female patients; and 72% were seropositive. Survival analysis performed separately for each remission criterion demonstrated that < 50% of subjects remained in remission 1 year later. Median remission survival time was 1 year. Kaplan-Meier curves of the various remission criteria did not significantly differ (P = 0.29 according to the log-rank test).

Conclusions

This study shows that in clinical practice, a minority of RA patients are in sustained remission.     

Identifying differentially methylated genes using mixed effect and generalized least square models

Background  

DNA methylation plays an important role in the process of tumorigenesis. Identifying differentially methylated genes or CpG islands (CGIs) associated with genes between two tumor subtypes is thus an important biological question. The methylation status of all CGIs in the whole genome can be assayed with differential methylation hybridization (DMH) microarrays. However, patient samples or cell lines are heterogeneous, so their methylation pattern may be very different. In addition, neighboring probes at each CGI are correlated. How these factors affect the analysis of DMH data is unknown.     

Genotypic comparison ofPantoea agglomeransplant and clinical strains

Background  

Pantoea agglomeransstrains are among the most promising biocontrol agents for a variety of bacterial and fungal plant diseases, particularly fire blight of apple and pear. However, commercial registration ofP. agglomeransbiocontrol products is hampered because this species is currently listed as a biosafety level 2 (BL2) organism due to clinical reports as an opportunistic human pathogen. This study compares plant-origin and clinical strains in a search for discriminating genotypic/phenotypic markers using multi-locus phylogenetic analysis and fluorescent amplified fragment length polymorphisms (fAFLP) fingerprinting.     

Historical biogeography and the evolution of the latitudinal gradient of species richness in the Papionini (Primata: Cercopithecidae)

We apply historical biogeography techniques to the macaques, baboons and their relatives (Primata: Papionini) and relate the inferred history of range shifts, and associated evolutionary events, to the latitudinal distribution of extant species, which is strongly tropical. The results of reversible parsimony, weighted ancestral area and dispersal-vicariance analyses all agree that Central Africa was part of the range of the ancestor of the tribe. Tropical regions with high current species richness (Central Africa, South-east Asia, Indonesia) have: (1) had a relatively long history of occupation, (2) experienced both a greater number and a greater average rate of speciation events and (3) given rise to more dispersal events to other regions. However, nested sister-taxon comparisons across the tribe show no overall association between differences in latitude and differences in rates of cladogenesis. Our historical reconstructions are largely consistent with previous hypotheses and fossil data, and suggest that both the passage of time since colonization and rates of cladogenesis have enhanced tropical species richness. Historical biogeography may thus considerably aid understanding of this and other spatial problems in macroecology.  © 2005 The Linnean Society of London, Biological Journal of the Linnean Society , 2005, 85 , 235–246.