Economic appraisal of laser applications in medicine

Laser applications are developing rapidly in medicine. Virtually every specialty of surgery, and a number of medical specialties, are using the laser for several conditions, and the number of conditions treated seems to grow every day. This fact is of concern to policy-makers in a time of limited resources for health care. Increasingly, health policy decisions are guided by costeffectiveness studies of medical applications. This paper reviews evidence of cost-effectiveness for a number of relatively mature laser applications. In general, although available studies are suggestive of benefit, effectiveness has been demonstrated for relatively few laser applications. Little reliable cost information has been developed, although out-patient therapy and shortened length of stay in hospital seem to be demonstrated for several conditions.     

激光治疗寻常痤疮疗效和安全性的系统评价

目的评价不同类型激光治疗寻常痤疮的疗效和安全性,以便为临床应用选择最佳方案提供依据。方法采用Cochrane系统评价的方法,计算机检索Medline、Embase、Cochrane对照实验注册资料库、中国生物医学文献数据库、中文科技期刊数据库、中国期刊全文数据库,检索时间截至2009年6月,纳入中英文激光治疗寻常痤疮的随机对照实验（RCT）。结果共纳入符合标准的论文12篇,临床治疗367例,由于缺乏临床同质性,只能进行描述性分析。各型激光治疗寻常痤疮,炎症性皮损计数改善明显,不良反应限于治疗部位的暂时性红斑水肿及可以耐受的与治疗相关的疼痛。结论各型激光治疗寻常痤疮安全、有效、便利。有局部不良反应。需进行更多高质量、大样本的随机对照实验,以证实激光治疗寻常痤疮的作用和地位。     

Economic evaluations of interventions for the prevention and treatment of osteoporosis: a structured review of the literature

Economic evaluations are increasingly being used by decision-makers to estimate the cost-effectiveness of interventions. The objective of this study was to conduct a structured review of economic evaluations of interventions to prevent and treat osteoporosis. Articles were identified independently by two reviewers through searches on MEDLINE, the bibliographies of reviews and identified economic models, and expert opinion, using predefined inclusion and exclusion criteria. Data on country, type and level of interventions, type of fractures, interventions, study population and the authors stated conclusions were extracted. Forty-two relevant studies were identified. The majority of studies (71%) were conducted in Sweden, the UK and the US. The main interventions investigated were hormone replacement therapy (27%), bisphosphonates (17%) and combinations of vitamin D and calcium (16%). In 38% of studies, hip fracture was the sole fracture outcome. Eighty-eight percent (88%) of studies investigated female populations only. A relatively large number of economic evaluations were identified in the field of osteoporosis. Major changes have recently occurred in the treatment of this disease, following the publication of the results of the Womens Health Initiative trial. Methodological developments in economic evaluations, such as the use of probabilistic sensitivity analysis and cost-effectiveness acceptability curves, have also taken place. Such changes are reflected in the studies that were reviewed. The development of economic models should be an iterative process that incorporates new information, whether clinical or methodological, as it becomes available.     

Measurements of argon laser light attenuation in the skin ‘in vivo’ using a unique animal model

A dorsal skin flap chamber model for microcirculation studies permits direct irradiation of subcutaneous arterioles and venules ‘in vivo’ as well as irradiation of the same vessels through the skin of unanaesthetized hamsters. A system has been developed to permit vital and video microscopy while selected vessels of the microvascular system are being irradiated. Information relating to light attenuation in the skin can be obtained by comparing the response curves of irradiation aimed directly to the blood vessels to those of laser light delivered to vessels through the skin. Selected vessels have been irradiated with the argon laser (488 nm and 514.5 nm) adjusting the power to deliver radiant exposures 1 to 55 J cm⁻² on a 250 μm diameter spot during a 20 ms irradiation time and embolized or stationary coaguli are produced in response to the irradiation. The radiant exposure threshold for production of embolized coaguli when irradiation is directed at the surface of the skin is 1.45 times larger than the threshold when the vessel is directly irradiated. The skin to vessel threshold ratio for the production of stationary coaguli is 1.39. Higher doses are required through the skin because of light attenuation due to absorption and scattering. These ratios are compared with the predictions of two light distribution models based on Beer's law and the Monte Carlo solution of the radiative transfer equation.     

Getting men's health onto a policy agenda - charting the development of a National Men's Health Policy in Ireland

In January 2009, the Department of Health and Children in Ireland published a national men's health policy. The policy was developed following an extensive research and consultation process. The need for a specific policy focus on men's health was identified in Ireland's National Health Strategy in 2001. This prompted the Department of Health and Children to fund a 3-year men's health research project, the findings of which were launched at the first National Conference on men's health in Ireland, which took place in December 2004. An inter-Departmental and multi-sectoral Steering Group was appointed to oversee the development of the policy. Under the terms of reference of the Steering Group, an extensive and nationwide consultation process was undertaken with all relevant stakeholders. The findings from this consultation process, together with an extensive review of the evidence underpinning the issues raised, were then translated into concrete policy recommendations and actions. These recommendations and actions address a broad range of men's health issues and have implications in terms of gender-mainstreaming men's health across a number of government departments. This paper will describe the background to the policy, outline the methodologies and key principles used for policy development and summarise the key policy recommendations. It will also reflect on some of the key lessons learned and on the challenges in terms of making the policy succeed.     

逆行经硬性软性输尿管镜下钬激光治疗60岁以上老年患者完全性鹿角形肾结石11例分析

目的 报道逆行经硬性软性输尿管镜下钬激光治疗60岁以上老年患者完全性鹿角形肾结石的经验并评价其效果。方法 本院2012年1月一2013年5月治疗11例老年单侧完全性鹿角形肾结石患者,年龄60~77岁,平均 67±7.2岁。11例主诉为严重肉眼血尿。术前留置7Fr Bard 输尿管支架1周。术中首先应用Olympus 8/9Fr硬性输尿管镜和科医人100+W钬激光机粉碎视野内结石部分,然后换成7.9Fr软性输尿管镜粉碎剩余结石,手术时间控制在120分钟内。术后常规留置7Fr D-J管3个月。术后3个月末查KUB评估结石排净率,仍残留较大结石的,行第二次手术碎石。结果 本组11例均安全经受手术,手术成功率100%。硬性软性输尿管镜一期碎石取石成功1例,10例需两次手术碎石,两次手术总净石率为10/11(90.9%)。未发生手术并发症。结论 逆行交替应用硬性软性输尿管镜联合钬激光治疗完全性鹿角形肾结石对60岁以上患者心血管循环系统影响小,净石率高,并发症少,也易于被患者接受,可作为治疗老年患者完全性鹿角形肾结石的首选术式之一。     

Risk factors for urinary incontinence in both sexes. Analysis of a health screening project.

PURPOSE: The aim of this study was to identify factors related to urinary incontinence in both sexes by analysing almost 2.500 individuals participating in a health screening project in the area of Vienna. MATERIALS AND METHODS: An incontinence questionnaire (Bristol LUTS questionnaire) was included to health investigations. During this investigation (a) a medical history; (b) a physical investigation; (c) sociodemographic parameters including smoking, eating and drinking habits, and (d) urine and blood study including 14 parameters were obtained. The parameters collected during this health investigation were correlated to the presence of urinary incontinence to identify potential risk factors for urinary incontinence. RESULTS: 1,262 women (49.7+/-13.6 years) and 1,236 men (48.6+/-13.0 years) were analyzed. In the female population, 26.3% reported on episodes of urinary incontinence during the past 4 weeks. Among other factors, age (correlation coefficient [r] = 0.22), body mass index (r = 0.20), urgency (r = 0.16), feeling of incomplete bladder emptying (r = 0.21), previous uro-gynecological surgery and fasting blood glucose correlated significantly to urinary incontinence. Five percent of men were incontinent, age (r = 0.12), urgency (r = 0.16), nocturia (r = 0.16), feeling of incomplete emptying (r = 0.16), reduced uroflow (r = 0.18) and previous prostatectomy (r = 0.11) correlated to the presence of urinary incontinence. In both sexes, smoking habits and the education level revealed no association. CONCLUSIONS: The high prevalence of urinary incontinence, its socioeconomic implications, the continuously ageing population and the fact that a number of potential risk factors, particularly in women, have been identified suggest that targeted prevention is a major task for the future.     

Low back pain in general practice: cost-effectiveness of a minimal psychosocial intervention versus usual care

An intervention that can prevent low back pain (LBP) becoming chronic, may not only prevent great discomfort for patients, but also save substantial costs for the society. Psychosocial factors appear to be of importance in the transition of acute to chronic LBP. The aim of this study was to compare the cost-effectiveness of an intervention aimed at psychosocial factors to usual care in patients with (sub)acute LBP. The study design was an economic evaluation alongside a cluster-randomized controlled trial, conducted from a societal perspective with a follow-up of 1 year. Sixty general practitioners in 41 general practices recruited 314 patients with non-specific LBP of less than 12 weeks’ duration. General practitioners in the minimal intervention strategy (MIS) group explored and discussed psychosocial prognostic factors. Usual care (UC) was not protocolized. Clinical outcomes were functional disability (Roland–Morris Disability Questionnaire), perceived recovery and health-related quality of life (EuroQol). Cost data consisted of direct and indirect costs and were measured by patient cost diaries and general practitioner registration forms. Complete cost data were available for 80% of the patients. Differences in clinical outcomes between both the groups were small and not statistically significant. Differences in cost data were in favor of MIS. However, the complete case analysis and the sensitivity analyses with imputed cost data were inconsistent with regard to the statistical significance of this difference in cost data. This study presents conflicting points of view regarding the cost-effectiveness of MIS. We conclude that (Dutch) general practitioners, as yet, should not replace their usual care by this new intervention.     

Thermal damage of blood vessels in a rat skin-flap window chamber using indocyanine green and a pulsed alexandrite laser: A feasibility study

The design criteria and feasibility of specifically targeting blood vessels for thermal damage by using a pulsed alexandrite infra-red laser to heat an intravascularly injected infra-redabsorbing dye, namely indocyanine green (ICG), is demonstrated. Theoretical calculations map the distribution of light and heat in and around the subcutaneous blood vessels in a rat skin-flap window chamber as functions of dye concentration, vessel size, and vessel depth. Theoretical calculations showed that an injected dose of 6–24 mgkg⁻¹ of ICG and a 120-μs, 1-J cm⁻² alexandrite laser pulse at a wavelength of 785 nm would be sufficient to achieve selective vascular damage to a depth of at least 0.15 cm. Feasibility experiments were performed which illustrated that an irradiation of 1.27 J cm⁻² of skin flaps in uninjected control rats showed no evidence of vascular damage while vascular damage was seen in skin flaps using an experimental protocol of 12 mg kg⁻¹ i.v. of ICG and an energy fluence of 0.76 J cm⁻². This procedure could conceivably prove useful in the treatment of vascular lesions or cancer.     

Health care system and medical education in Canada. 1. Review of the health care context in a time of change

Over the past three decades Canada has developed an exemplary system of universal health care. However, current financial constraints threaten to undermine the very foundation of the system that represents Canada's respect for social justice. The first of these two articles (Part 1) discusses the unique characteristics of the system, a comparative view of universal health care systems, the reaction of the medical profession to governmental control, and finally the funding and manpower shortages that are compelling a review of the values and organization that have sustained the system thus far. The second article (Part 2) reviews the organization and funding of medical education and the impact of some critical changes in the health care system on postgraduate medical education. Issues related to new licensure and certification requirements, changing population demographics and approaches to health care delivery, manpower needs, and the attitude and expectations of the public are discussed.

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Resumen En los tres últimos decenios el Canadá ha desarrollado un sistema ejemplar de cobertura universal de la salud. Sin embargo, las actuales limitaciones de orden financiero amenazan con minar los fundamentos mismos del sistema que caracteriza el respeto que profesa el Canadá por la justicia social.El primero de estos dos artículos (Parte I) discute las características muy peculiares del sistema, un panorama comparativo de los sistemas universales de cobertura de salud, la reacción de la profesión médica al control gubernamental y, por último, las restricciones en cuanto a financiación y capital humano que obligan a revisar los valores y la organización que han mantenido al sistema hasta ahora.El segundo artículo (Parte II) revisa la organización y el financiamiento de la educación médica y el impacto de algunos cambios críticos en el sistema de atención de la salud sobre la educación médica de postgrado.Se revisan los asuntos relativos a los nuevos requisitos para licencia y certificación, las variaciones en demografía y los enfoques sobre provisión de servicios, las necesidades de recursos humanos y las actitudes y expectativas de la población.

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Résumé Au cours de ces trois dernières décennies, le Canada a développé un système de Santé universel exemplaire. Les problèmes de contraintes pécuniaires risque, cependant, de déstabiliser les bases de ce système qui par ailleurs caractérise bien le respect de ce pays pour la justice sociale. Le premier de ces deux article (part 1) décrit les caractéristiques assez uniques du système, fait une comparaison entre les autres systèmes de santé existant dans le monde, analyse la réaction du corps médical envers le contrôle du système qu'exigent les gouvernements, et enfin, expose comment la réduction en fonds et en hommes influence les valeurs et organisation qui ont fait fonctionner ces systèmes jusqu'à présent. Le deuxième article (part 2) résume le financement et l'organisation de la formation médicale, ainsi que l'impact que certains changements du système de santé auront sur l'enseignement post-universitaire. En particulier sont abordés les problèmes de certification, de validation de diplômes, l'influence des changements des caractéristiques de la population et la prise en charge des patients, les besoin en médecins, et les attentes du public de la profession médicale.

     

Screening for diabetic retinopathy in primary care with a mobile fundal camera--evaluation of a South African pilot project.

BACKGROUND AND AIMS: In South Africa diabetes makes a significant contribution to the burden of disease. Diabetic retinopathy is a leading cause of adult blindness, and screening can reduce the incidence. This project aimed to implement and evaluate a new service for retinal screening that uses a non-mydriatic mobile fundal camera in primary care. This is the first time such a service has been evaluated in an African primary care context. METHODS: The service was implemented as an operational research study at three community health centres and data were collected to evaluate the operational issues, screening, reporting and referral of patients. RESULTS: Out of 400 patients screened 84% had a significantly reduced visual acuity, 63% had retinopathy (22% severe nonproliferative, 6% proliferative and 15% maculopathy), 2% of eyes could not be screened and 14% of patients required dilatation. Referral was necessary in 27% of cases for cataracts, in 7% for laser treatment and in 4% for other specialist services. Repeat photography was needed in 8% and urgent follow-up in 12%. A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. CONCLUSION: Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician should be able to photograph almost 10,000 patients a year.     

Immunisation in a rural setting. The EPI as a vital arm of primary health care

Immunisation forms an integral part of any health care system. In certain areas in the western Cape the immunisation cover has been analysed over several years. This data indicates an effective immunisation programme in these areas. Promotive, preventive and curative services are effectively provided within the limitations of the conditions pertaining in the areas.     

Open‐label clinical trial comparing the clinical and economic effectiveness of using a polyurethane film surgical dressing with gauze surgical dressings in the care of post‐operative surgical wounds

Surgical site infection (SSI) is a common postoperative complication and can cause avoidable morbidity and excessive costs for the health service. Novel dressings, designed specifically for postoperative wounds, can help to reduce the risk of SSI and other complications such as blistering. This study compared the use of a new polyurethane film surgical dressing (Opsite Post‐Op Visible, Smith & Nephew, Hull, UK) with gauze and tape in the management of postoperative wounds. The results show that the polyurethane film dressing results in a significant reduction in SSI (1·4% versus 6·6%, P = 0·006) as well as a reduction in other postoperative wound complications (e.g. blistering and erythema). Economic analysis conducted alongside the study suggests that these improved outcomes can be achieved at a lower treatment cost than gauze and tape dressings. The modest incremental cost of the polyurethane film surgical dressing is easily offset by the reduction in the costs related to treating SSI and other wound complications associated with gauze and tape dressings.     

Developing a model of source-specific interpersonal conflict in health care

Nurses work in complex social environments, and conflict may arise with fellow coworkers, their supervisor, physicians or the patients and family they care for. Although much research has documented the negative effects of conflict on nurses, no research to date has examined the comparative effect that conflict from all four sources can have on nurses. The purpose of this study is to test a model of workplace conflict where the negative effect of conflict on nurses will be experienced via emotional exhaustion. We test the mediator model by analysing the cross-sectional data collected within one hospital (N1=182) and cross-validating those results in a second hospital (N2=161). The pattern of results was largely consistent across the two samples indicating support for a mediated model of workplace conflict for physician, supervisor and patient. Conflict with other nurses, however, did not have a relationship with either emotional exhaustion or other personal and organizational outcomes. The theoretical and practical implications of the current findings, as well as the limitations and future research directions, are discussed.     

Use and safety of percutaneous tracheostomy in intensive care. Report of a postal survey of ICU practice

A brief questionnaire was sent to 231 clinical directors of intensive care units in England and Wales to investigate the use of percutaneous tracheostomy. There was a 76% response rate. Percutaneous tracheostomies were in use in 78.4% of units. The Ciaglia technique was the most commonly used, with 31.3% routinely using fibreoscopy as part of their technique. Only 12% of units routinely provided long-term follow up of their percutaneous tracheostomies. Overall, 78.4% thought that percutaneous tracheostomy was safe and 66.7% considered percutaneous tracheostomy to be the technique of choice for Intensive Care patients. Percutaneous tracheostomy is now a well-established technique. However, the limited use of fibreoscopy and the lack of long-term follow-up are areas of concern.