Venom immunotherapy compared with no venom immunotherapy for insect sting allergy Patient or population: adults and children with a previous allergic reaction to an insect sting Setting: allergy ref erral units in USA (3 trials), Netherlands (2 trials), Italy, and Australia Intervention: venom im m unotherapy Comparison: no venom im m unotherapy Outcomes Illustrative comparative risks* (95% CI) Relative effect (95% CI) No of Participants (studies) Quality of the evidence (GRADE) Comments Assumed risk Corresponding risk No venom immunotherapy Venom immunotherapy Any systemic reaction to an insect sting Follow-up: between 6 weeks and 4 years Low-risk population RR 0.10 (0.03 to 0.28) 206 (7) ⊕⊕⊕⊕ high a-83 per 1000 8 per 1000 (2 to 23) M edium-risk population 398 per 1000 40 per 1000 (12 to 111) High-risk population 724 per 1000 72 per 1000 (22 to 203) Large local reaction Follow-up: between 12 weeks and 4 years Low-risk population RR 0.41 (0.24 to 0.69) 112 (5) ⊕⊕⊕ moderate b-3 Venom immunotherapy for preventing allergic reactions to insect stings (Review)

An electronic version of this title, in Adobe Acrobat format, is available for downloading free of charge for personal use from the HTA website (www.hta.ac.uk). A fully searchable DVD is also available (see below).Printed copies of HTA journal series issues cost £20 each (post and packing free in the UK) to both public and private sector purchasers from our despatch agents.Non-UK purchasers will have to pay a small fee for post and packing. For European countries the cost is £2 per issue and for the rest of the world £3 per issue. How to order:-fax (with credit card details) -post (with credit card details or cheque) -phone during office hours (credit card only).Additionally the HTA website allows you to either print out your order or download a blank order form. Contact details are as follows:Synergie UK (HTA Department) Digital House, The Loddon Centre Wade Road Basingstoke Hants RG24 8QW Email: orders@hta.ac.uk Tel: 0845 812 4000 -ask for 'HTA Payment Services' (out-of-hours answer-phone service) Fax: 0845 812 4001 -put 'HTA Order' on the fax header Payment methods Paying by chequeIf you pay by cheque, the cheque must be in pounds sterling, made payable to University of Southampton and drawn on a bank with a UK address.Paying by credit card You can order using your credit card by phone, fax or post. SubscriptionsNHS libraries can subscribe free of charge. Public libraries can subscribe at a reduced cost of £100 for each volume (normally comprising 40-50 titles). The commercial subscription rate is £400 per volume (addresses within the UK) and £600 per volume (addresses outside the UK). Please see our website for details. Subscriptions can be purchased only for the current or forthcoming volume.How do I get a copy of HTA on DVD?Please use the form on the HTA website (www.hta.ac.uk/htacd/index.shtml). HTA on DVD is currently free of charge worldwide.The website also provides information about the HTA programme and lists the membership of the various committees. NIHR Health Technology Assessment programmeThe Health Technology Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care. The research findings from the HTA programme directly influence decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC). HTA findings also help to improve the quality of clinical practice in the NHS indirectly in that they form a key component of the 'National Knowledge Service' . The HTA programme is needs led in that it fills gaps in the evidence needed by the NHS. There are three routes to the start of projects. First is the commissioned route. Suggestions for research are ...

No abstract

We read with interest the commentary by Ru€ eff et al. (1) regarding our health economic appraisal of Pharmalgen â wasp and bee venom immunotherapy (VIT) for the National Institute for Health and Care Excellence (NICE) (2). We are grateful to the authors for highlighting the surprising results of our analysis to the European allergy community and would like to respond to the critique of our approach.Our main finding was that VIT is not considered to be cost-effective, when only the direct costs of fatal and nonfatal anaphylaxis outcomes are considered. The reasons for this are that for most people, wasp and bee stings are uncommon; nonfatal anaphylaxis is not an expensive outcome; and even in those with a prior systemic sting reaction, subsequent fatal sting anaphylaxis is rare (2). So although VIT is effective for preventing systemic reactions to stings (3), one needs to apply the treatment to a very large number of individuals to create any significant cost savings via anaphylaxis prevention. In contrast, if one takes quality of life (QoL) improvement associated with VIT into consideration, VIT becomes cost-effective for even modest improvements in QoL. This is because the QoL benefit affects most patients, whether or not they have any further stings (4). The practice implication is that when deciding which patient should have VIT, we should not simply assess for risk of anaphylaxis but also consider patients' anxiety about future reactions and the impact of this on their daily life. In patients who are not anxious about future stings, the cost-effectiveness of the treatment is in doubt (5). This message from our recent assessments of the clinical-(3) and cost-effectiveness (2) of VIT has been expressed and interpreted with clarity in the resulting NICE guidance (6), which is similar to existing European guidance (Table 1).We respectfully disagree with the criticisms raised by Ru€ eff et al. (1). They suggest the outcomes of our health economic analysis were predictablethis certainly seems so with the benefit of hindsight, but the outcomes could not have been so clearly quantified or relied upon without undertaking this rigorous piece of work. The authors suggest we should have assumed a QoL benefit for health economic assessment in the 'base case scenario'. The NICE appraisal process, for which this research was commissioned, recommends use of a preference-based QoL measure that can be mapped to generic health states in the general population (e.g EQ-5D) (7). Because we did not identify studies evaluating the effect of VIT on such measures, we could not quantify the expected QoL benefit. We did however take into consideration the likelihood of a QoL benefit in our analyses and conclusions, based on the evidence that disease-specific quality of life improves with treatment (4), and this is reflected in the NICE guidancethat VIT can be considered cost-effective in patients with anxiety related to future stings (6). Finally the authors suggest that we should have made assumptions around the possibility of long-te...

Most patients with bowel cancer are symptomatic at the time of the diagnosis. They may present with a change in bowel habit, bleeding per rectum, abdominal pain, anaemia, weight loss or bowel obstruction. Colonic carcinoma can also be diagnosed incidentally during screening programs. Moreover, it may be incidentally detected in CT scans being performed for other indications or encountered during surgery for other causes. Some patients with colonic bowel ischaemia have associated large bowel cancer, where the ischaemic segment is usually proximal to the tumour and not necessarily associated with bowel obstruction. We are presenting a rare case of incidental malignant colonic polyp detected in a resected ischaemic large bowel in an 88-year-old gentleman. This was a very small tumour that was not visible macroscopically or detectable by imaging. Pathological examination of non-tumour colorectal resection specimens, as in this case, should include careful macroscopic examination and sequential block selection along the length of the colon, and where there is diffuse mucosal abnormality, block selection at 100mm interval is also advised. Attention to and block selection from any suspicious-looking area is warranted in all cases of non-tumour colorectal resections if such microscopic-sized malignancies of the type seen in our patient are to be picked up.