The reality of economics for oncologists

This article outlines the historical development of health economics and its present role in oncology related health technology assessments (HTAs). Despite concerns about the prices and immediate costs of new anticancer medicines for indications such as breast cancer overall spending on such treatments is affordable and offers long term value for money in countries such as the US, Canada and those of Western Europe. Oncologists wishing to protect the interests of current and future patients with both advanced and earlier stage cancers may be regarded as having a responsibility to understand the nature of health economic evaluations, and to be actively involved in decisions affecting access to current treatments and future levels of investment in incrementally improving therapies.     

Pharmako?konomie in der Uroonkologie

The QALY (quality-adjusted life year) is often used in pharmacoeconomic evaluations. It combines the two dimensions 'quality of life' and 'life expectancy' into one index. Quality of life is expressed as a utility, corresponding to a value between 0 (death) and 1 (perfect health). Life expectancy is then multiplied by the utility corresponding to the quality of life of the respective life time. Accordingly, 1 QALY corresponds to 1 year in perfect health (1 year multiplied by utility 1) or 2 years with a quality of life reduced by 50% (2 years multiplied by utility 0.5). Results of pharmacoeconomic evaluations are often reported as additional costs in relation to the added value of a new treatment, expressed as cost per additional QALY gained for the patient with the new therapeutic intervention. The main advantage of the QALY concept is its validity for all patients and indications. And the use of benefit measures which are not restricted to a specific indication is most important for resource allocation, i.e. to avoid that varying amounts of money are paid for the same health benefit in different disease areas.     

Indikationsprüfung neuer Prothesenpassteile bei Oberschenkelamputierten

Leg prostheses designed for normal walking, standing and climbing stairs are prostheses that serve as the direct replacement of the missing body part and its absent features. The disability should be compensated as far as possible. The aim of treatment is ultimately to be on an equal par with a healthy person. In particular, the development of electronic control concepts in prosthetic knee joints allows an extended compensation of the disability, which the insured persons are entitled to claim if it comprehensively impacts on everyday life. There is an increasing need for the statutory accident insurance to check the indications of modern microprocessor-controlled prosthetic components, partly due to the rising costs. With the testing the insurance companies have the possibility of providing the amputee with a really appropriate means and to perform the necessary quality assurance, also in order to justify the high costs of modern prosthetics. Last but not least the treatment also has to be economically sound. For this purpose, the proof of a measurable significant advantage by using the new tools is required. During a hospital stay an extensive gait analysis and testing in a walking course is first performed with the existing prosthetics. After a test fitting with the new prosthetic part and instructions in use, the tests are repeated with the new prosthesis. The comparison of test results allows a professionally founded statement regarding the medical necessity of a provision with new prosthetic components based on years of experience, standardized test methods and objective test results.     

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.     

Oncoplastic principles in breast conserving surgery

Oncoplastic surgery (OP) represents a major advance in breast cancer surgery. It is based on three principles: ideal oncology surgery with free margins and adequate local control of disease, immediate breast reconstruction and symmetry, with the transposition of plastic surgery techniques into breast cancer surgery. Its original focus was to improve the quality of life of patients undergoing oncological treatments that can be more effective from the aesthetic-functional point of view than the traditional breast conserving techniques. As it happens with all changes of paradigms, it brings new challenges for the traversal formation of all involved in the treatment of breast cancer. Besides that, it opens to new perspectives of surgical research related to the aesthetic results, quality of life and local control, as well as optimization of operative timing and reduction of both adverse effects and costs. The aim of this review was to present the principles of this approach and the main techniques applied, evaluating its indications and limits in conservative breast cancer surgery.     

Advances in orthopaedic outcomes research

As the field of orthopaedic surgery continues to expand in terms of indications and technologies, there has been increasing emphasis placed on validated patient-derived outcome measures in clinical orthopaedic research. As concerns mount regarding rising health care costs, declining quality, and variability in clinical practice patterns, outcome measures become important tools in assessing quality. Furthermore, outcome measures can be utilized to justify the clinical benefits of existing and new diagnostic modalities and surgical interventions. This review provides a brief overview of traditional outcomes approaches in orthopaedics followed by a discussion of the current trend toward patient-centered outcomes research and its role in the emerging field of cost-effectiveness analysis in orthopaedics.     

Robotic Pancreatic Resections: Feasibility and Advantages

The robot is an innovative tool to perform complex pancreatic resections. It upgrades conventional laparoscopy by adding specific ergonomic technical details (e.g., EndoWrist). Robotic complex pancreatic operations such as pancreaticoduodenectomy can be carried out safe with equal oncological results, morbidity, and mortality compared to open procedures. The patients benefit from less blood loss, decreased hospitalization, and all other benefits of minimally invasive surgery. Nevertheless, the robot has some limitations like missing haptic feedback and the high costs. It has to find its indications beneath conventional laparoscopic procedures, which is currently extensively discussed. But the available technology is certainly convincing, and a further improvement can be expected which will increase its widespread in the future.     

Temporary pulsatile ventricular assist devices and biventricular assist devices.

BACKGROUND: During the past years several systems for mechanical circulatory support have become available. In this study we describe our experience with short-term and mid-term application of the ABIOMED and Thoratec device. METHODS: Since 1990 the ABIOMED BVS and since 1992 the Thoratec VAD have been applied to 75 and 103 patients, respectively, with postcardiotomy heart failure, as a bridge-to-transplant procedure, and with different other indications. RESULTS: In the ABIOMED collective 25 of 50 patients (50%) with postcardiotomy heart failure and 1 of 4 patients with miscellaneous other indications could be discharged from hospital, 7 of 14 bridge-to-transplant patients (50%) underwent transplantation with a posttransplant survival of 86%. In the Thoratec collective 6 of 10 patients (60%) with postcardiotomy heart failure and 4 of 8 patients (50%) with miscellaneous indications could be discharged from hospital, 48 bridge-to-transplant patients (74%) underwent transplantation with a posttransplant survival of 90%. CONCLUSIONS: The results show the versatility of the Thoratec VAD for short-term and mid-term application in patients with postcardiotomy heart failure and as a bridge-to-transplant procedure. The use of the ABIOMED device is not indicated for bridging patients to transplantation. Although in case of postcardiotomy heart failure, Thoratec is also superior to ABIOMED, the high costs of the Thoratec VAD limits its wide acceptance in this patient cohort.     

Utilidad del estudio molecular de nódulos tiroideos con citología indeterminada

Even though cytology remains the gold standard to assess the nature of thyroid nodules, up to 30% of the results are indeterminate (Bethesda III and IV). In these cases, current guidelines recommend performing diagnostic surgery, which proves malignancy in only 15-30% of cases. A more precise method is needed to avoid unnecessary surgeries, surgical complications and costs in the process of diagnosing indeterminate nodules. Complementary use of molecular profiling tests seems to help in this complex scenario. We present a review of the current literature on the usefulness of molecular profiling of thyroid nodules so as to define its indications, costs and usability for clinical practice.     

Mini-percutaneous nephrolithotomy

Standard percutaneous nephrolithotomy is highly effective for the removal of renal calculi. However, significant morbidity has been associated with this procedure. Consequently, many urologists inappropriately defer to a less effective procedure to reduce patient morbidity. This practice may increase the total number of procedures needed for treatment and result in a substantial increase in health care costs. Mini-percutaneous nephrolithotomy using a 13F ureteroscopy sheath is described to reduce the morbidity associated with standard percutaneous nephrolithotomy while maintaining its efficiency and effectiveness for stone removal. The indications and technique for mini-percutaneous nephrolithotomy and our results are summarized.     

Lateral Intercostal Artery Perforator (LICAP) flap for lateral breast defect reconstruction

Lateral breast defect after partial mastectomy is a difficult challenge. Pedicled perforator flap is a new indication for breast surgery. Perforator flaps and fat tissue transplant are new concepts in this kind of reconstruction. Lateral intercostal artery perforator (LICAP) flap has been used for a lot of indications. It can be used for lateral breast defect reconstruction. This flap provides several advantages: minimal donor site morbidity, advantages in flap shaping, better aesthetic results and higher patient satisfaction. The aim of this paper is to present indications of LICAP flap. We discuss its advantages and its limits in lateral breast reconstruction after partial mastectomy. LICAP flap provides a new solution instead of conventional flaps.     

Low molecular weight heparins in the long-term treatment of venous thromboembolism

Low molecular weight heparins (LMWHs) have extensively replaced unfractionated heparin (UFH) in both thromboprophylaxis and initial treatment of venous thromboembolism (VTE) and their use for such indications is now well established. This paper reviews the role of LMWHs in the long-term treatment of VTE. Venous thrombosis, although a very frequent occurrence in everyday practice, still remains controversial in its treatment. Available literature comparing different LMWHs with UFH and oral anticoagulants (OAs) is presented. Comparison and evaluation of the effectiveness, safety and costs of alternative treatments are also made. The differences of various LMWHs are discussed and the need for separate clinical trials for every single LMWH is highlighted.     

Percutaneous angioplasty in the treatment of iliac artery stenosis

PTA represents a slightly invasive method for treatment of iliac arteries stenoses. The Authors present their experience about this topic and discuss current indications in the use of this technique. They believe that beyond the already defined indications, such as treatment of short stenoses, transluminal angioplasty can be employed for long stenoses too, eventually combined with limited surgical procedures. They stress the importance of combining traditional PTA with new percutaneous or intraoperative Argon Laser technology, that surely will contribute to broad its indications and to improve its results.     

Cardiac Pacing in Japan

A general update on pacemakers and cardiac pacing in Japan in 1981 is presented, including costs, prepacing studies, follow-up, pacing center activity, average number of first implants per million inhabitants, age of patients at first implantation, clinical indications for pacing, etiology, prepacing electrocardiogram, pacemaker hardware, electrode leads, electrocardiogram indications for pacing, indications for generator or electrode changes, and extended application of pacing. The author's data are compared with those obtained by the survey of the Seventh World Symposium on Cardiac Pacing.     

Hardware removal: indications and expectations

Although hardware removal is commonly done, it should not be considered a routine procedure. The decision to remove hardware has significant economic implications, including the costs of the procedure as well as possible work time lost for postoperative recovery. The clinical indications for implant removal are not well established. There are few definitive data to guide whether implant removal is appropriate. Implant removal may be challenging and lead to complications, such as neurovascular injury, refracture, or recurrence of deformity. When implants are removed for pain relief alone, the results are unpredictable and depend on both the implant type and its anatomic location. Current literature does not support the routine removal of implants to protect against allergy, carcinogenesis, or metal detection. Surgeons and patients should be aware of appropriate indications and have realistic expectations of the risks and benefits of implant removal.     

Le fratture mediali: quando e quale protesi

Femoral neck fractures in the elderly are frequent, represent a serious health care problem, and have a significant impact on health costs. Reconstruction options using hip arthroplasty include bipolar hemiarthroplasty (HA) and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques.     

Hospital cost categories of one-stage versus two-stage management of common bile duct stones

Background  

In the era of cost-conscious healthcare, hospitals are focusing on costs. Analysis of hospital costs per cost category may provide indications for potential cost-saving measures in the management of common bile duct stones (CBDS) with gallbladder in situ.     

Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spine and Adult Deformity: Surgical Technique and the Evidence

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has become an increasingly popular technique utilized for the treatment of lumbar pathology. MIS-TLIF has exhibited a wide range of indications in both lumbar degenerative disease and adult spinal deformity. Due to its reduction in soft tissue trauma, this technique has also been demonstrated to minimize operative blood loss and postoperative pain when compared to open spinal fusions. Additionally, patient reported outcomes and fusion rates following MIS-TLIF have been promising. The present review investigates the current literature regarding MIS-TLIF techniques, outcomes, complications, and costs.     

Klinik und Praxis der Lasermedizin

Background

The implementation of laser medicine in a practice for aesthetic surgery makes sense, especially if the surgical possibilities of the practice are thus extended or efficiently supplemented.

Objective

The aim of this article is the presentation of the essential indications for surgical lasers and potential ways of integrating them into a surgical practice.

Results

It is advantageous for patients if surgeons use lasers to operate with less risks, less stress and fewer risks of complications. The method is associated with lower costs and shorter downtimes for patients and laser medicine makes it possible to develop new operation techniques for previously untreatable indications.