4D Parathyroid CT as the Initial Localization Study for Patients with De Novo Primary Hyperparathyroidism

Background

Preoperative localization of parathyroid tumors of primary hyperparathyroidism (pHPT) is required for minimally invasive parathyroidectomy (MIP). Parathyroid four-dimensional computed tomography (4DCT) has mainly been used as an adjunct to other imaging modalities in the remedial setting. 4DCT was evaluated as the initial localization study in de novo patients with pHPT.

Materials and Methods

A total of 87 consecutive patients underwent parathyroidectomy for pHPT from August 2008 to November 2009. 4DCT was introduced as the preferred imaging modality instead of sestamibi with SPECT (SeS) in April 2009. Results of the imaging studies [4DCT, SeS, and ultrasonography (US)], operative and, pathologic findings, and biochemical measurements were evaluated.

Results

In this study, 84% of patients (73 of 87) underwent an US, 59.8% (52 of 87) a SeS, and 38.0% (33 of 87) had a 4DCT. 4DCT had improved sensitivity (85.7%) over SeS (40.4%) and US (48.0%) to localize parathyroid tumors to the correct quadrant of the neck (P < 0.005) as well as to localize (lateralize) the parathyroid lesions to one side of the neck (93.9% for 4DCT vs. 71.2% for US and 61.5% for SeS; P < 0.005). 4DCT correctly predicted multiglandular disease (MGD) in 85.7% (6 of 7) patients, whereas US and SeS were unable to detect MGD in any case. All patients achieved cure based on intraoperative parathyroid hormone (PTH) measurements and normalization of intact PTH and S-Ca during follow-up.

Conclusions

4DCT provides significantly greater sensitivity than SeS and US for precise localization of parathyroid tumors of pHPT. Additionally, it correctly predicted MGD in a majority of patients.     

Mild hypercalcemia: an indication to select 4-dimensional computed tomography scan for preoperative localization of parathyroid adenomas

Background

Technetium sestamibi scanning is the most accepted method of imaging used for preoperative localization of parathyroid adenomas. Four-dimensional computed tomography (4D-CT) scanning is a relatively new localization technique that has not been as rigorously evaluated.

Methods

One hundred thirty-five consecutive patients who underwent preoperative sestamibi scanning, 4D-CT scanning, and parathyroidectomy for primary hyperparathyroidism were evaluated. Patient characteristics, parathyroid gland weights, and the probability of having positive preoperative localization were examined.

Results

Four-dimensional computed tomography scanning was significantly more accurate than sestamibi (73% vs 62%, P = .016). In those with serum calcium levels less than 10.8 mg/dL, 4D-CT scanning was significantly more accurate than sestamibi scanning for the quadrant (45% vs 29%, P = .013) and hemisphere (66% vs 48%, P = .012). Also, 4D-CT scanning was more accurate among patients with parathyroid gland weights less than 500 mg (69% vs 45%, P < .001).

Conclusions

Four-dimensional computed tomography scanning provides better preoperative localization than sestamibi scanning, particularly in patients with mild hypercalcemia and smaller parathyroid adenomas.     

Cost-effectiveness of mediastinal lymph node staging in non–small cell lung cancer

Objective

To assess the cost-effectiveness of various modes of mediastinal staging in non–small cell lung cancer (NSCLC) in a single-payer health care system.

Modeling the Cost-effectiveness of Strategies for Treating Esophageal Adenocarcinoma and High-grade Dysplasia

Objective

This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios.

Methods

A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken.

Results

Over 5?years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0?C3?% produced modest gains, whereas a 20?% reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95?% interval, $1,560?C8,368).

Conclusion

These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett??s esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.     

Frequency and Intensity of Postoperative Surveillance After Curative Treatment of Pancreatic Cancer: A Cost-Effectiveness Analysis

Background

Few data exist to guide oncologic surveillance following curative treatment of pancreatic cancer. We sought to identify a rational, cost-effective postoperative surveillance strategy.

Methods

We constructed a Markov model to compare the cost-effectiveness of 5 postoperative surveillance strategies. No scheduled surveillance served as the baseline strategy. Clinical evaluation and carbohydrate antigen (CA) 19-9 testing without/with routine computed tomography and chest X-ray at either 6- or 3-month intervals served as the 4 comparison strategies of increasing intensity. We populated the model with symptom, recurrence, treatment, and survival data from patients who had received intensive surveillance after multimodality treatment at our institution between 1998 and 2008. Costs were based on Medicare payments (2011 US dollars).

Results

The baseline strategy of no scheduled surveillance was associated with a postoperative overall survival (OS) of 24.6 months and a cost of $3837/patient. Clinical evaluation and CA 19-9 assay every 6 months until recurrence was associated with a 32.8-month OS and a cost of $7496/patient, with an incremental cost-effectiveness ratio (ICER) of $5364/life-year (LY). Additional routine imaging every 6 months incrementally increased total cost by $3465 without increasing OS. ICERs associated with clinic visits every 3 months without/with routine imaging were $127,680 and $294,696/LY, respectively. Sensitivity analyses changed the strategies’ absolute costs but not the relative ranks of their ICERs.

Conclusions

Increasing the frequency and intensity of postoperative surveillance of patients after curative therapy for pancreatic cancer beyond clinical evaluation and CA 19-9 testing every 6 months increases cost but confers no clinically significant survival benefit.     

Incidence and Localization of Ectopic Parathyroid Adenomas in Previously Unexplored Patients

Background

Parathyroidectomy has a success rate of >95 % for cure of primary hyperparathyroidism. In about 6–16 % of cases, one or more hyperfunctioning parathyroid gland(s) are found in an ectopic location. Accurate preoperative imaging can aid in detecting these ectopically located glands and allow a focused surgical approach with an even higher success rate. The objective of this study was to assess the utility of ultrasonography (US) and technetium-99m-sestamibi (MIBI) scans in locating ectopic parathyroid glands in previously unexplored patients who presented with primary hyperparathyroidism.

Methods

We analyzed a total of 1,562 patients who underwent surgery for hyperparathyroidism at our institution from 2000 to 2010. Ectopic parathyroid adenomas were identified in 346 of the patients (22 %). Of the 346 patients, we excluded 144 who underwent reoperations, had four-gland hyperplasia or were missing imaging details. We carefully reviewed the data, including demographics, laboratory values, preoperative localizing imaging details, and operative findings. Preoperative US and MIBI results were compared to the intraoperative findings.

Results

We analyzed 202 patients with ectopic glands for accuracy of preoperative localization. Of these 202 patients, a single adenoma was the most common (89 %) followed by double adenoma (11 %). The ectopic parathyroid glands were predominantly located in the thymus (38 %) followed by 31 % in the retroesophageal region; 18 % were intrathyroidal. Preoperative MIBI scans had a sensitivity of 89 % (161/197), whereas US had a sensitivity of 59 % (35/63) for detecting ectopic glands. Overall, both imaging modalities had a positive predictive value of 90 %, with MIBI correctly predicting ectopic glands best in the thymus, mediastinum, or the retroesophageal space, and US was most accurate at detecting intrathyroidal glands.

Conclusions

Based on the data available at our institution, MIBI has a higher sensitivity than US in correctly localizing ectopic parathyroid adenomas, but the accuracy of detection varies based on location. Both imaging techniques have a high PPV for detecting an ectopic gland. Therefore, imaging with MIBI and US can be complementary, and positive localization of an ectopic gland with either modality is highly accurate and can facilitate a more focused surgical approach.     

C-11-Methionin-PET/CT zur Lokalisation von Nebenschilddrüsenadenomen

Background and objectives

In primary hyperparathyroidism (pHPT) preoperative localization of parathyroid adenomas enables focussed unilateral parathyroidectomy. Ultrasound and sestamibi scintigraphy are the recommended standard procedures for primary diagnostics of pHPT and C-11 methionine positron emission tomography computed tomography (Met-PET/CT) is the latest technique for localization of hyperfunctioning parathyroid glands.

Methods

This review presents the results of Met-PET/CT on the basis of a selective literature search using the keywords “primary hyperparathyroidism and methionine”, “primary hyperparathyroidism and PET”, “parathyroid adenomas and methionine” and “parathyroid adenomas and PET”.

Results

Localization of single gland adenomas can be achieved with Met-PET/CT in 79–91?% of cases. The advantages of this procedure are a high sensitivity even in operations for recurrencies or concomitant thyroid nodules and an accurate detection even with atypical localizations. In multiglandular disease a localization of more than one hyperfunctioning gland remains difficult. Potential limitations of the method include the restricted availability and the relatively high costs of Met-PET/CT.

Conclusions

Using Met-PET/CT hyperfunctioning parathyroid glands can be exactly localized in most patients with pHPT. Indications for this procedure are mostly when preoperative standard tests are negative and in parathyroid surgery for recurrencies.     

Cost-utility of maximal safe resection of WHO grade II gliomas within eloquent areas

Background

Despite the growing use of intraoperative electrical stimulation (IES) mapping for resection of WHO grade II gliomas (GIIG) located within eloquent areas, some authors claim that this is a complex, time-consuming and expensive approach, and not well tolerated by patients, so they rely on other mapping techniques. Here we analyze the health related quality of life, direct and indirect costs of surgeries with and without intraoperative electrical stimulation (IES) mapping for resection of GIIG within eloquent areas.

Methods

A cohort of 11 subjects with GIIG within eloquent areas who had IES while awake (group A) was matched by tumor side and location to a cohort of 11 subjects who had general anesthesia without IES (group B). Direct and indirect costs (measured as loss of labor productivity) and utility (measured in quality adjusted life years, QALYs), were compared between groups.

Results

Total mean direct costs per patient were $38,662.70 (range $19,950.70 to $61,626.40) in group A, and $32,116.10 (range $22,764.50 to $46,222.50) in group B (p?=?0.279). Total mean indirect costs per patient were $10,640.10 (range $3,010.10 to $86,940.70) in group A, and $48,804.70 (range $3,340.10 to $98,400.60) in group B (p?=?0.035). Mean costs per QALY were $12,222.30 (range $3,801.10 to $47,422.90) in group A, and $31,927.10 (range $6,642.90 to $64,196.50) in group B (p?=?0.023).

Conclusions

Asleep-awake-asleep craniotomies with IES are associated with an increase in direct costs. However, these initial expenses are ultimately offset by medium and long-term costs averted from a decrease in morbidity and preservation of the patient’s professional life. The present study emphasizes the importance to switch to an aggressive and safer surgical strategy in GIIG within eloquent areas.     

Cost-Effectiveness Analysis of Intraoperative Radiation Therapy for Early-Stage Breast Cancer

Background

Shortened courses of radiation therapy have been shown to be similarly effective to whole-breast external-beam radiation therapy (WB-EBRT) in terms of local control. We sought to analyze, from a societal perspective, the cost-effectiveness of two radiation strategies for early-stage invasive breast cancer: single-dose intraoperative radiation therapy (IORT) and the standard 6-week course of WB-EBRT.

Methods

We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio over 10 years.

Results

IORT single-dose intraoperative radiation therapy was the dominant, more cost-effective strategy, providing greater quality-adjusted life years at a decreased cost compared with 6-week WB-EBRT. The model was sensitive to health state utilities and recurrence rates, but not costs. IORT was either the preferred or dominant strategy across all sensitivity analyses. The two-way sensitivity analyses demonstrate the need to accurately determine utility values for the two forms of radiation treatment and to avoid indiscriminate use of IORT.

Conclusions

With less cost and greater QALYs than WB-EBRT, IORT is the more valuable strategy. IORT offers a unique example of new technology that is less costly than the current standard of care option but offers similar efficacy. Even when considering the capital investment for the equipment ($425 K, low when compared with the investments required for robotic surgery or high-dose-rate brachytherapy), which could be recouped after 3–4 years conservatively, these results support IORT as a change in practice for treating early-stage invasive breast cancer.     

Cost-effectiveness of Treatment Strategies for Pancreatic Head Adenocarcinoma and Potential Opportunities for Improvement

Background

Generally dismal outcomes have led to a nihilistic attitude toward treating pancreatic cancer, while fiscal constraints have increased scrutiny of treatments costs. Our objective was to compare the cost-effectiveness of various treatment strategies for resectable pancreatic head adenocarcinoma, and to identify opportunities for improved cost effectiveness.

Methods

A decision model compared 6 strategies: no treatment, radiotherapy only, chemotherapy only, chemotherapy plus radiotherapy, surgery alone, and surgery plus adjuvant therapy. Outcomes and probabilities were identified using the National Cancer Data Base, the American Cancer Society National Surgical Quality Improvement Program, and the literature. Costs were estimated using Medicare payment. Incremental cost-effectiveness ratios (ICERs) were calculated, and sensitivity analyses were performed by varying potentially modifiable parameters of the model. Survival was reported in quality-adjusted life-months (QALMs).

Results

Surgery plus adjuvant therapy, chemotherapy alone, and no treatment were the only viable strategies in terms of cost effectiveness. Surgery plus adjuvant therapy versus no treatment demonstrated an incremental cost-effectiveness ratio (ICER) of $7,663/QALM. Theoretically increasing survival in node-negative, margin-negative patients from 14 to 22 QALMs produced the largest reduction in the ICER for surgery plus adjuvant therapy compared to no treatment ($6,386/QALM), whereas reducing the perioperative mortality from 3 to 1?% had only a marginal effect. The ICER was significantly lower for high-performing centers ($5,991/QALM) than for low-performing centers ($9,144/QALM).

Conclusions

Surgery plus adjuvant therapy for resectable pancreatic head adenocarcinoma extends survival, but at considerable expense. Significant cost reductions could be realized by improving treatment outcomes to levels of high-performing centers and development of increasingly effective adjuvant therapies.     

Sestamibi Imaging for Primary Hyperparathyroidism: The Impact of Surgeon Interpretation and Radiologist Volume

Background

Preoperative localization is the first step towards minimally invasive targeted parathyroidectomy. While there are data emphasizing that surgeon experience optimizes operative outcomes, the role of the radiologist??s experience in successful preoperative imaging is unclear. We hypothesized that the accuracy of sestamibi scanning for primary hyperparathyroidism is dependent upon surgeon interpretation and radiologist volume.

Methods

Between January 2000 to August 2009, 1,255 patients underwent parathyroidectomy for hyperparathyroidism at our institution. Of these, 763 had sestamibi scans for primary hyperparathyroidism. All scans were reviewed by surgeons and radiologists blinded, and were correlated with the operative findings and pathological reports. Radiologists were grouped into high volume (>50 cases/year, HV-RAD) or low volume (<50 cases/year, LV-RAD) based upon a database of >6,000 parathyroid cases reported by 89 regional hospitals.

Results

Of the 763 patients, 77?% were female and the mean age was 60?years. Mean baseline calcium and parathyroid hormone levels were 11.2?±?0.03?mg/dl and 133?±?3.27?pg/ml, respectively. The sensitivity of the surgeon (93?%) was higher than both HV (83?%) and LV (72?%) radiologists. Importantly, the positive predictive values were similar: 96?% for surgeon, 93?% for HV-RAD, and 98?% for LV-RAD. As a result, out of 99 scans which were correctly read by the surgeon but not by radiologist, 84 were read as negative by radiologist, 11 on the wrong side of the neck, and 4 on the same side but the wrong gland.

Conclusions

Surgeon interpretation and radiologist volume increase the likelihood of successful preoperative sestamibi parathyroid localization for primary hyperparathyroidism. We recommend that imaging be reviewed by experienced parathyroid surgeons rather than relying on radiological interpretation alone.     

Association between teriparatide adherence and healthcare utilization and costs in real-world US kyphoplasty/vertebroplasty patients

Summary

The objective of this study was to examine the association between teriparatide adherence and healthcare utilization and costs in real-world US kyphoplasty/vertebroplasty (KV) patients. Among KV patients newly initiating teriparatide, significantly increased pharmacy costs associated with high teriparatide adherence were offset by significantly lower inpatient utilization and medical costs.

Introduction

This study seeks to examine the association between teriparatide adherence and healthcare utilization/costs in real-world US KV patients.

Methods

Identified patients from a large US administrative claims database were aged 50+ with KV from 1/1/2002–12/31/2010 (first observed KV?=?index). Included individuals had 6+ months of pre-index continuous enrollment and no pre-index teriparatide, cancer, or Paget’s disease. Follow-up period for patients initiating teriparatide was ≤36 months post-index. Three teriparatide adherence cohorts were constructed using the proportion of days covered (PDC) during the follow-up period: low (PDC?≤?0.5), medium (PDC >0.5–≤?0.8), and high (PDC >0.8). Repeated KV admissions, any inpatient admission, number of inpatient admissions, and per-patient-per-month (PPPM) inpatient, outpatient, pharmacy, and total costs were compared between cohorts. The associations between teriparatide adherence and healthcare utilization/costs were examined using multivariable regression models, adjusting for patient demographics and clinical characteristics.

Results

Included were 1,568 patients (mean age, 75 years; 82 % female): 403 (26 %) had low adherence, 382 (24 %) medium, and 783 (50 %) high. After multivariable adjustment, high adherence was significantly associated with the lowest PPPM inpatient (low?=?$1,287; medium?=?$1,005; high?=?$678) and outpatient (low?=?$1,464; medium?=?$1,244; high?=?$1,077) medical costs, but with increased pharmacy costs (low?=?$752; medium?=?$1,159; high?=?$1,616; all P?<?0.05), leading to similar total costs (low?=?$3,344; medium?=?$3,376; high?=?$3,351) between cohorts; high adherence was also significantly associated with the lowest odds of repeated KV admission, any inpatient admission, and number of inpatient admissions (all P?<?0.05).

Conclusions

Among KV patients initiating teriparatide, significantly increased pharmacy costs associated with high teriparatide adherence were offset by significantly lower inpatient utilization and medical costs.     

To Supplement or Not to Supplement: A Cost-Utility Analysis of Calcium and Vitamin D Repletion in Patients After Thyroidectomy

Background

Postoperative hypocalcemia is the most common complication after thyroidectomy; prevention and treatment remain areas of ongoing debate. The purpose of this study was to determine the incremental cost utility of routine versus selective calcium and vitamin D supplementation after total or completion thyroidectomy.

Methods

A cost-utility analysis using a Markov decision model was performed for a hypothetical cohort of adult patients after thyroidectomy. Routine or selective supplementation of oral calcium carbonate, vitamin D (calcitriol), and intravenous calcium gluconate, when required, was used. Selective supplementation was determined by serum intact parathyroid hormone levels. The incremental cost utility, measured in U.S. dollars per quality-adjusted life-year (QALY), was calculated.

Results

In the base-case analysis, the cost of routine supplementation was $102 versus $164 for selective supplementation. Patients in the routine arm gained 0.002 QALYs compared to patients in the selective arm (0.95936 QALYs vs. 0.95725 QALYs). At the population level, this translates into a savings of $29,365/QALY (95% confidence interval, ?$66,650 to ?$1,772) for routine supplementation. Sensitivity analyses demonstrated that the model was most sensitive to the utility of the hypocalcemic state, postoperative rates of hypocalcemia, and cost of serum parathyroid hormone testing.

Conclusions

Routine oral calcium and calcitriol supplementation in patients after thyroidectomy seems to be less expensive and results in higher patient utility than selective supplementation. Surgeons who have very low rates of hypocalcemia in their patients may benefit less from routine supplementation.     

Cost Effectiveness of Routine Laparoscopic Ultrasound for Assessment of Resectability of Gallbladder Cancer

Background

In addition to a diagnostic laparoscopy (DL), a routine laparoscopic ultrasound (LUS) has been proposed to identify undetected hepatic metastases and/or anatomically advanced disease in patients with T2 or higher gall bladder cancer (GBC) patients planned for surgical resection. It was hypothesized that a routine LUS is not a cost-effective strategy for these patients.

Methods

Decision tree modeling was undertaken to compare DL-LUS vs. DL at the time of definitive resection of GBC (with no prior cholecystectomy). Costs in US dollars (payer’s perspective), quality-adjusted life weeks (QALWs), and incremental cost-effectiveness ratios (ICER) were calculated (horizon: 6 weeks, willingness-to-pay: $1,000/QALW or $50,000/QALY).

Results

DL-LUS was cost effective at the base case scenario (costs: $30,838 for DL vs. $30,791 for DL-LUS and effectiveness 3.81 QALWs DL vs. 3.82 QALW DL-LUS), resulting in a cost reduction of $9,220 per quality-adjusted life week gained (or $479,469 per QALY). DL-LUS became less cost effective as the cost of ultrasound increased or the probability of exclusion from resection decreased.

Conclusions

Routine LUS with DL for the assessment of resectability and exclusion of metastases is cost effective for patients with GBC. Until improvements in preoperative imaging occur to decrease the probability of exclusion, this appears to be a feasible strategy.     

Active Surveillance, Radiofrequency Ablation, or Cryoablation for the Nonsurgical Management of a Small Renal Mass: A Cost-Utility Analysis

Background

Patients with a cortical small (≤4 cm) renal mass often are not candidates for or choose not to undergo surgery. The optimal management strategy for such patients is unclear.

Methods

A decision-analytic Markov model was developed from the perspective of a third party payer to compare the quality-adjusted life expectancy and lifetime costs for 67-year-old patients with a small renal mass undergoing premanagement decision biopsy, immediate percutaneous radiofrequency ablation or percutaneous cryoablation (without premanagement biopsy), or active surveillance with serial imaging and subsequent ablation if needed.

Results

The dominant strategy (most effective and least costly) was active surveillance with subsequent cryoablation if needed. On a quality-adjusted and discounted basis, immediate cryoablation resulted in a similar life expectancy (3 days fewer) but cost $3,010 more. This result was sensitive to the relative rate of progression to metastatic disease. Strategies that employed radiofrequency ablation had decreased quality-adjusted life expectancies (82–87 days fewer than the dominant strategy) and higher costs ($3,231–$6,398 more).

Conclusions

Active surveillance with delayed percutaneous cryoablation, if needed, may be a safe and cost-effective alternative to immediate cryoablation. The uncertainty in the relative long-term rate of progression to metastatic disease in patients managed with active surveillance versus immediate cryoablation needs to be weighed against the higher cost of immediate cryoablation. A randomized trial is needed directly to evaluate the nonsurgical management of patients with a small renal mass, and could be limited to the most promising strategies identified in this analysis.     

Three-Dimensional Metabolic and Radiologic Gathered Evaluation Using VR-RENDER Fusion: A Novel Tool to Enhance Accuracy in the Localization of Parathyroid Adenomas

Background

The aim of this study was to assess the accuracy of a novel imaging modality, three-dimensional (3D) metabolic and radiologic gathered evaluation (MeRGE), for localizing parathyroid adenomas (PAs).

Methods

Consecutive patients presenting with primary hyperparathyroidism who underwent both thin-slice cervical computed tomography (CT) and ^99mTc-sestamibi (MIBI) scanning were included. 3D-CT reconstruction was obtained using VR-RENDER, which was used to perform 3D virtual neck exploration (3D-VNE). The MIBI scan was then fused with the 3D reconstruction to obtain 3D-MeRGE. Sensitivity, specificity, and accuracy were assessed. Parathyroid gland volume and preoperative parathormone (PTH) levels were analyzed as predictive factors of correct localization (i.e., correct quadrant).

Results

A total of 108 cervical quadrants (27 patients) were analyzed. Sensitivities were 79.31, 75.86, 65.51, and 58.61 % with 3D-MeRGE, 3D-VNE, MIBI, and CT, respectively. Specificity was highest with CT (94.93 %) followed by 3D-VNE (92.4 %). MIBI and 3D-MeRGE had the same specificity (88.6 %). 3D-MeRGE and 3D-VNE achieved higher accuracy than MIBI or CT alone. Mean PTH values were significantly higher in patients with lesions that were correctly identified (true positive, TP) than in those whose lesions were missed (false negative, FN) with 3D-VNE (219.60 ± 212.77 vs. 98.75 ± 12.76 pg/ml; p = 0.01) and 3D-MeRGE (217.69 ± 213.76 vs. 09.75 ± 20.48 pg/ml; p = 0.02). The mean parathyroid gland volume difference between TP and FN was statistically significant with all modalities except CT.

Conclusions

3D-MeRGE and 3D-VNE showed high accuracy for localization of PAs. 3D-MeRGE performed better than MIBI or CT alone for detecting small adenomas and those with a low PTH level.     

Intussusception in children: cost-effectiveness of ultrasound vs diagnostic contrast enema

Purpose

The aim of the study was to compare the cost-effectiveness of different imaging strategies for the diagnosis of pediatric intussusception using a decision analytic model.

Methods

A Markov decision model was constructed to model effects of radiation exposure at the time of intussusception in a hypothetical cohort of 2-year-old children. The 2 strategies compared were ultrasound followed conditionally by contrast enema (US/CE) vs contrast enema (CE) alone. The model simulated short-term and long-term outcomes of the patients, calculating the average quality-adjusted life years (QALYs) and health care costs associated with each arm.

Results

The use of ultrasound as a first-line diagnostic modality would result in a decrease of 79.3 and 59.7 cases of radiation-induced malignancy per 100,000 male and female children evaluated, respectively. For male and female children with intussusception, US/CE was both the most costly initial imaging strategy and the most effective compared with CE. The incremental cost-effectiveness ratios of US/CE to CE was $70,100 (boy) and $92,227 (girl) per quality-adjusted life years gained.

Conclusions

In a Markov decision model of pediatric acute intussusception, initial US/CE was both the most costly and the most effective strategy.     

Current trends in surgery for renal hyperparathyroidism (RHPT)—an international survey

Purpose

The indications and results of preoperative localization, surgical strategy, indication for thymectomy, the application of intraoperative parathyroid hormone (PTH) monitoring, cryopreservation, and replantation of cryopreserved parathyroid tissue are not well documented in renal hyperparathyroidism (RHPT). The current trends in surgery for RHPT are to be evaluated in an international online survey.

Methods

Thirty-three questions regarding preoperative localization, surgical management of RHPT, intraoperative PTH monitoring, immediate/delayed autotransplantation (AT), and parathyroid cryopreservation were sent to members of various societies of endocrine surgeons.

Results

The data from 86 responses were analyzed, 61.6 % reported more than 50 parathyroid surgeries per year, and 62.7 % operated on less than 16 patients with RHPT per year. Subtotal or total parathyroidectomy (with/without AT) was the standard procedure in 98.8 % of the cases. Immediate AT was performed in 40.7 % (72.7 % in the forearm). In most patients, the onset of graft function was documented later than 1 week after AT. Cryopreservation was routinely performed in 27.4 %. In 10.7 %, replantation was performed in more than five patients (hypo- or aparathyroidism: n?=?41; fresh graft failure: n?=?13; reoperations: n?=?9). Intraoperative PTH monitoring (in RHPT) was routinely used in 46.2 %. Its influence on surgical strategy was confirmed in 40 %.

Conclusions

The survey reflects the divergent strategies applied for AT, cryopreservation, and PTH monitoring in RHPT.     

Pharmaceutical cost distribution in childhood chronic kidney disease

Background

Chronic kidney disease (CKD) is associated with significant economic burdens to both patients and the healthcare system, but pharmaceutical cost analyses are uncommon despite drug therapy being a cornerstone of CKD management.

Methods

This observational, retrospective review of drug cost distribution at a single tertiary care pediatric nephrology program in Canada was conducted on prevalent patients with CKD aged 1?month to 20?years, between 1 January and 31 December 2009.

Results

The time-adjusted annual pharmaceutical cost of our cohort (n?=?148) was just below US?$250,000 with a cost per patient per year of $1,800. The highest costs were in the growth and nutrition category, followed by anemia, hypertension and bone metabolism. Total drug cost per patient increased as CKD stage advanced. Adherence was not demonstrated in any drug category, and the mean daily pill burden was nine (range 2–23).

Conclusions

This study has shown that while the annual pharmaceutical costs on a per patient basis are similar between children and adults, the cost distribution is very different. An increase in awareness of the unique needs of the pediatric population should allow for more cost-effective financial planning in pediatric CKD clinics.     

Cost-Effectiveness of Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer

Background

A recent randomized trial comparing minimally invasive (MIE) and open esophagectomy for esophageal cancer reported improved short-term outcomes. However, MIE has increased operative costs, and it is unclear whether the short-term benefits of MIE outweigh the increased operative costs. Therefore, the objective of this study was to determine the cost-effectiveness of MIE compared to open esophagectomy for esophageal cancer.

Methods

A decision-analysis model was developed to estimate the expected costs and outcomes after MIE and open esophagectomy from a health care system perspective with a time horizon of 1 year. Costs were represented in 2012 Canadian dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). Probabilistic sensitivity analysis assessed parameter uncertainty.

Results

MIE was estimated to cost $1641 (95 % confidence interval 1565, 1718) less than open esophagectomy, with an incremental gain of 0.022 QALYs (95 % confidence interval 0.021, 0.023). MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82 % probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively.

Conclusions

MIE is cost-effective compared to open esophagectomy in patients with resectable esophageal cancer.