Surgical treatment of CM2 and syringomyelia in a series of 231 myelomeningocele patients

A series of 231 consecutive patients with myelomeningocele was reviewed for what concerns the Chiari II malformation. This was present in 228 subjects (98.8%), but was symptomatic in 74 patients (31.5%) and required surgery just in 26 cases (11.4%). First treatment was addressed to hydrocephalus which was always associated. Shunting reverted the symptoms in 12 patients, but failed in 14 who required craniocervical decompression. Mortality consisted of two cases (one early and one delayed). All the remaining patients achieved satisfactory results.     

Italian guidelines on the systemic treatments of moderate‐to‐severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence‐based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.     

Is preoperative investigation of the thyroid justified in patients undergoing parathyroidectomy for hyperparathyroidism?

BACKGROUND: The finding of coexisting nodular thyroid disease during neck exploration for hyperparathyroidism (HPT) is reported to range from 20%-60%. Thus, the surgeon may encounter a second, unrelated lesion during open parathyroidectomy. Furthermore, with the recent introduction of minimally invasive surgery for HPT, the entire neck may not be explored, and it is important to know the potential risk of missing significant, concurrent thyroid disease. The diagnosis and timely treatment of associated thyroid abnormalities is desirable because a delay in operating would result in increased morbidity associated with a second neck exploration. DESIGN: We examined our 25-year experience at a large tertiary academic medical center, to determine the incidence and type of concurrent thyroid disease seen in patients with HPT. The computerized records of the Department of Pathology, from 1974-1999, were reviewed for patients with primary HPT who underwent surgery. RESULTS: A review of records from 580 patients who underwent surgery for primary HPT showed 103 (18%) patients with concomitant thyroid disease at surgery. All 103 underwent thyroid resection at the time of parathyroidectomy. Thyroid histology showed: 12 (12%): well-differentiated papillary carcinomas, 31 (30%): follicular adenomas, 49 (48%): nodular hyperplasias, 8 (8%): chronic lymphocytic thyroiditis, 1 benign cyst, 1 metastasis, and 1 normal. CONCLUSIONS: Synchronous thyroid disease was found in 18% of primary HPT patients undergoing surgery, and 12% of thyroid lesions were malignant. The overall malignancy rate was 2%. All primary malignancies found were papillary carcinomas, of which 7 of 12 (58%) were microcarcinomas. The significant association of simultaneous pathology in the two glands justifies preoperative thyroid imaging and fine-needle aspiration (FNA) biopsy to determine the best surgical approach for patients with HPT.     

Economic evaluation of strategies for managing women with equivocal cytological results in Brazil

In Brazil, current management of women with screening results of atypical squamous cells of undetermined significance (ASC-US) is to offer repeat testing at 6-month intervals. Alternative management strategies that have been adopted in many high-income settings are to offer immediate colposcopy referral or to utilise human papillomavirus (HPV) DNA testing as a triage for colposcopy referral, and to consider different strategies according to women's age. The objective of our study was to evaluate the lifetime cost effectiveness in terms of cost per years of life saved (YLS) of these alternative strategies for a middle income setting. A Markov model was developed using data from the Ludwig-McGill cohort and calibrated to independent observational datasets and local cost estimates obtained. In the base-case analysis, repeat cytology was the least costly strategy but also the least effective. Based on the WHO threshold for very cost-effective interventions, HPV triage for women above 30 years-old was the strategy with the highest probability of being cost effective. HPV triage including younger women with ASCUS results would also be a cost-effective option. Whilst there was a slight further gain in effectiveness with immediate colposcopy referral, it was also more expensive and did not appear to be cost effective. Threshold analysis indicated that an HPV test would have to be more than twice as expensive as a cytology test for HPV triage to no longer be cost effective. In conclusion, our results indicate that in middle income settings HPV triage is likely to be the optimal strategy for managing women presenting with ASC-US results.     

Uncertainty in environmental health impact assessment: Quantitative methods and perspectives

Environmental health impact assessment models are subjected to great uncertainty due to the complex associations between environmental exposures and health. Quantifying the impact of uncertainty is important if the models are used to support health policy decisions. We conducted a systematic review to identify and appraise current methods used to quantify the uncertainty in environmental health impact assessment. In the 19 studies meeting the inclusion criteria, several methods were identified. These were grouped into random sampling methods, second-order probability methods, Bayesian methods, fuzzy sets, and deterministic sensitivity analysis methods. All 19 studies addressed the uncertainty in the parameter values but only 5 of the studies also addressed theuncertainty in the structure of the models. None of the articles reviewed considered conceptual sources of uncertainty associated with the framing assumptions or the conceptualisation of the model. Future research should attempt to broaden the way uncertainty is taken into account in environmental health impact assessments.     

Comprehensive review of the diagnosis and treatment of biliary tract cancer 2012. Part I: diagnosis-clinical staging and pathology

Biliary tract cancers (gallbladder cancer, intra- and extra-hepatic cholangiocarcinoma, and selected periampullary cancers) accounted for 12,760 new cases of cancer in the USA in 2010. These tumors have a dismal prognosis with most patients presenting with advanced disease. Early, accurate diagnosis is essential, both for potential cure where possible and for optimal palliative therapy in all others. This review examines the currently available and emerging technologies for diagnosis and treatment of this group of diseases.     

Cervical cancer screening among HIV-infected women: an economic evaluation in a middle-income country

Due to the recent widespread availability of highly active antiretroviral therapy (HAART) in middle-income countries, there has been an increase in life expectancy for women on HAART, but no corresponding decrease in cervical cancer incidence. This study evaluates the optimal cervical cancer screening strategy for HIV-infected women in a middle-income country. We developed a mathematical model, which simulates the natural history of the HPV infection, as well as the HIV-mediated immunosupression among women in Brazil. Our model was calibrated using data from the IPEC/FIOCRUZ Women's HIV-infected cohort. The model compares the lifetime effects, costs and cost-effectiveness of strategies combining cytology, HPV DNA test and colposcopy at different screening intervals for different CD4 count strata (27 strategies in total). We found that the strategy with the best cost-effectiveness profile (cost-effectiveness ratio-U$4,911/year of life saved [YLS] and probability of being cost-effective-86%) was HPV testing followed by cytology triage every year for all HIV infected women, considering a very cost-effective threshold given by Brazil's GDP per capita (US$8,625/YLS). The results were robust to changes in the input parameters as demonstrated in one-way, scenario, threshold and probabilistic sensitivity analysis. Our study indicates that annual HPV testing followed by cytology triage for all HIV-infected women is likely to be very cost-effective in a middle-income country like Brazil. The results reflect the synergic effect of using a highly sensitive screening test (HPV DNA test) in sequence with a highly specific test (cytology).