The Role of Noninvasive Endpoints in Predicting Long-Term Outcomes in Pulmonary Arterial Hypertension

Background

Until recently, many clinical trials in patients with pulmonary arterial hypertension (PAH) evaluated exercise capacity with 6-minute walk distance (6MWD) as the primary endpoint. Common secondary endpoints include PAH functional class (FC), which assesses symptoms, and either brain natriuretic peptide (BNP) or the inactive N-terminal cleavage product of its prohormone (NT-proBNP), which assesses cardiac function.

Objective

Examine the relationships among 6MWD, FC, and BNP/NT-proBNP measured at baseline or follow-up with long-term outcomes in PAH studies.

Methods

Relevant literature from January 1990 to April 2018 were obtained by searching PubMed, Embase, and Cochrane. Articles in English reporting on associations between 6MWD, FC, or BNP/NT-proBNP and outcomes in PAH were identified. Each endpoint was evaluated individually. Prespecified inclusion and exclusion criteria were applied at level 1 (titles/abstracts) and level 2 (full-text review).

Results

The database search yielded 836 unique records; 65 full-text articles were reviewed. Twenty-five studies were eligible for inclusion. Findings supported the importance of measuring PAH noninvasive endpoints in predicting long-term outcomes. Patients with shorter or decreased 6MWD, poor (III/IV) or declining FC (e.g., from II to III), or elevated or increasing BNP/NT-proBNP had a higher risk of death and costly events (e.g., hospitalization, lung transplant). FC also predicted health care resource utilization and costs. Collectively, these endpoints establish risk groups that predict likelihood of complications from PAH or death.

Conclusion

Assessment of 6MWD, FC, and BNP/NT-proBNP provides low-cost, efficient, and noninvasive means of predicting long-term health and economic outcomes in patients with PAH.

     

Identifying Patients with Group 3 Pulmonary Hypertension Associated with COPD or ILD Using an Administrative Claims Database

Lung - Group 3 pulmonary hypertension (PH) describes a subpopulation of patients with PH due to chronic lung disease and/or hypoxia, with chronic obstructive pulmonary disease (COPD) and...     

Economic burden and comorbidities of attention-deficit/hyperactivity disorder among pediatric patients hospitalized in the United States

Background  

This retrospective database analysis used data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) to examine common primary diagnoses among children and adolescents hospitalized with a secondary diagnosis of attention- deficit/hyperactivity disorder (ADHD) and assessed the burden of ADHD.     

Sexual function after total hip arthroplasty

Eighty-six patients who had successful total hip replacement completed questionnaires on their sexual activity. Preoperatively, 46% of patients attributed significant sexual difficulties to their hip disease, whereas only 1% felt that their hips remained a significant source of problems postsurgery. The majority (55%) of patients were able to resume intercourse one to two months postoperation. Male patients were statistically more likely to resume intercourse sooner than their female counterparts. Patients were also questioned about which coital positions they found comfortable after arthroplasty. The supine position (patient on bottom) was the most preferred. The next most comfortable position for males was prone (patient on top), yet for female it was sidelying on the nonoperative hip. In addition, 89% of patients desired more information regarding sexual function postarthroplasty, preferably in the form of a booklet. Therefore, a booklet was written specifically for postoperative patients and their sexual partners.     

The cost and effectiveness of adherence‐improving interventions for antihypertensive and lipid‐lowering drugs*

Aims: Adherence to cardiovascular medications is poor. Accordingly, interventions have been proposed to improve adherence. However, as intervention‐associated costs are rarely considered in full, we sought to review the effectiveness and costs associated with different adherence‐improving interventions for cardiovascular disease therapies. Methods: We reviewed MEDLINE to update a prior review of interventions to improve adherence with antihypertensive and/or lipid‐lowering therapy covering January 1972 to June 2002, to add studies published from July 2002 to October 2007. Eligible studies evaluated ≥ 1 intervention compared with a control, used measures other than self‐report, reported significant improvement in adherence and followed patients for ≥ 6 months. Effectiveness was measured as relative improvement (RI), the ratio of adherence in the intervention group to the control group. Costs were calculated based on those reported in the analysis, if available or estimated based on resource use described. All costs were truncated to 6 months and adjusted to 2007 US$. Results: Of 755 new articles, five met all eligibility criteria. Combining with the prior review gave 23 interventions from 18 studies. RI in adherence ranged from 1.11 to 4.65. Six‐month intervention costs ranged from $10 to $142 per patient. Reminders had the lowest effectiveness (RI: 1.11–1.14), but were least costly ($10/6 months). Case management was most effective (RI: 1.23–4.65), but the most costly ($90–$130/6 months). Conclusions: Generally, we found a positive association between intervention costs and effectiveness. Therefore, consideration of intervention costs, along with the benefits afforded to adherence, may help guide the design and implementation of adherence‐improving programs.     

Methodologies used in cost-effectiveness models for evaluating treatments in major depressive disorder: a systematic review

Background

Decision makers in many jurisdictions use cost-effectiveness estimates as an aid for selecting interventions with an appropriate balance between health benefits and costs. This systematic literature review aims to provide an overview of published cost-effectiveness models in major depressive disorder (MDD) with a focus on the methods employed. Key components of the identified models are discussed and any challenges in developing models are highlighted.

Methods

A systematic literature search was performed to identify all primary model-based economic evaluations of MDD interventions indexed in MEDLINE, the Cochrane Library, EMBASE, EconLit, and PsycINFO between January 2000 and May 2010.

Results

A total of 37 studies were included in the review. These studies predominantly evaluated antidepressant medications. The analyses were performed across a broad set of countries. The majority of models were decision-trees; eight were Markov models. Most models had a time horizon of less than 1 year. The majority of analyses took a payer perspective. Clinical input data were obtained from pooled placebo-controlled comparative trials, single head-to-head trials, or meta-analyses. The majority of studies (24 of 37) used treatment success or symptom-free days as main outcomes, 14 studies incorporated health state utilities, and 2 used disability-adjusted life-years. A few models (14 of 37) incorporated probabilities and costs associated with suicide and/or suicide attempts. Two models examined the cost-effectiveness of second-line treatment in patients who had failed to respond to initial therapy. Resource use data used in the models were obtained mostly from expert opinion. All studies, with the exception of one, explored parameter uncertainty.

Conclusions

The review identified several model input data gaps, including utility values in partial responders, efficacy of second-line treatments, and resource utilisation estimates obtained from relevant, high-quality studies. It highlighted the differences in outcome measures among the trials of MDD interventions, which can lead to difficulty in performing indirect comparisons, and the inconsistencies in definitions of health states used in the clinical trials and those used in utility studies. Clinical outcomes contributed to the uncertainty in cost-effectiveness estimates to a greater degree than costs or utility weights.     

A two-stage full-arch ridge expansion technique: review of the literature and clinical guidelines

Ridge expansion techniques have been acknowledged to offer several advantages in the correction of ridge deformities. The expanded defect heals in a similar manner to an extraction socket. In selected cases patients can wear their dentures after surgery. Secondary surgical sites are not a prerequisite, and simultaneous implant placement can be achieved during ridge expansion. The limitation of this technique lies in its inability to create bone vertically. Therefore, it is not indicated for the correction of vertical defects. The application of the split ridge expansion technique has been reported in the literature as it pertains to partially edentulous deficient ridges. The purpose of this article was to present the application of the split ridge expansion technique in the fully edentulous maxilla and discuss the distinction between the immediate or one-stage approach and the delayed or two-stage approach. Histologic results are discussed. Two case reports demonstrate the results that can be obtained with this technique.     

Intraoperative detection of laparoscopic bladder injury

We report a case of bladder perforation during laparoscopic gynaecological surgery that was detected intraoperatively by gaseous distention of the urinary bag. The anaesthetist can help detect intraoperative laparoscopic bladder injury by checking the bladder catheter collection bag for gaseous distension. In this clinical report, gaseous distention of the urinary bag was the only indication of intraoperative laparoscopic bladder injury and resulted in immediate intervention and surgical repair. Intraoperative bladder injury repair will result in decreased surgical morbidity, and if performed laparoscopically may result in decreased hospital stay.     

Advanced concepts in implant dentistry: creating the "aesthetic site foundation"

To obtain optimal and predictable aesthetics, deficiencies caused by soft and particularly hard tissue loss can be managed by various methods, such as orthodontic tooth eruption, socket preservation, and guided bone regeneration. However, in complex cases, these methods are often insufficient. Here, the authors introduce advanced concepts in aesthetic implant dentistry, such as "Aesthetic Site Foundation", "Aesthetic Guided Bone Regeneration" and "Implant Rectangle" that will guide the clinician in the quest to optimal aesthetic outcomes.