Geographical and ecological analyses of childhood acute leukaemias and lymphomas in north-west England

Childhood leukaemias and lymphomas have been associated with exposure to environmental factors, including infections, which show geographical variation. This study examined the geographical distribution of the incidence of acute leukaemia and lymphoma using Manchester Children's Tumour Registry (MCTR) data 1976-2000. A total of 910 children were included, all of whom had histologically and/or cytologically verified leukaemia or lymphoma. At the time of their diagnoses, all the children were aged 0-14 years and were resident in the counties of Greater Manchester or Lancashire. Standardized morbidity ratios were calculated. Poisson regression was used to examine the relationship between incidence rates and small-area (census ward) population density, ethnic composition and deprivation index. There was a monotonic relationship between acute lymphoblastic leukaemia (ALL) incidence and population density (P = 0.05). Higher rates were seen in more densely populated areas. There was evidence for a monotonic relationship between the incidence of the mixed cellularity subtype of Hodgkin's disease (HD) and the Townsend deprivation score (P = 0.001). Markedly higher incidence was associated with greater levels of unemployment and household overcrowding. The results for ALL and mixed cellularity HD support the involvement of environmental factors, such as infections, in disease aetiology.     

Otitis media with effusion in Nigerian children with cleft palate: incidence and risk factors

Otitis media with effusion is common in children with cleft palate, and the aim of this study was to find out its incidence and risk factors in Nigerians. We prospectively studied 84 patients (42 with cleft palate and 42 control subjects); 27 were male and 15 female, who were age and sex matched with control subjects. The extent and size of the clefts were measured using a dental cast and Vernier calipers, and the otitis media was diagnosed with otoscopy and tympanometry. The mean (SD) age of the groups was 11 (7) months (range 1–33). Twelve children in the cleft group had otitis media compared with three in the control group. Infants and boys were more likely to be affected. There was a significant association between age (p = 0.02), sex (p = 0.01), and size of cleft (p = 0.00). However, only the size of the cleft was confirmed to be an independent predictor, with children who had extremely wide clefts being more likely to develop otitis media than those with narrow clefts (OR = 8.71, 95%CI = 1.07 to 70.5).We conclude that the incidence of otitis media with effusion was higher among children with cleft palate than among those who did not have a cleft. Infants had a higher incidence than older children, and boys had a higher incidence than girls. Age, sex, and the size of the palatal cleft were significantly associated with otitis media, but not the extent of clefting.     

Medical tourism and bariatric surgery: who pays?

Introduction

The objective of this study was to determine the short-term cost impact that medical tourism for bariatric surgery has on a public healthcare system. Due to long wait times for bariatric surgery services, Canadians are venturing to private clinics in other provinces/countries. Postoperative care in this population not only burdens the provincial health system with intervention costs required for complicated patients, but may also impact resources allotted to patients in the public clinic.

Methods

A chart review was performed from January 2009 to June 2013, which identified 62 medical tourists requiring costly interventions related to bariatric surgery. Secondarily, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, necessary interventions, and associated costs. A threshold analysis was used to compare costs of medical tourism to those from our institution.

Results

A conservative cost estimate of $1.8 million CAD was calculated for all interventions in 62 medical tourists. The survey established that 25 Albertan general surgeons consulted 59 medical tourists per year: a cost of approximately $1 million CAD. Medical tourism was calculated to require a complication rate ≤28 % (average intervention cost of $37,000 per patient) to equate the cost of locally conducted surgery: a rate less than the current supported evidence. Conducting 250 primary bariatric surgeries in Alberta is approximately $1.9 million less than the modeled cost of treating 250 medical tourists returning to Alberta.

Conclusions

Medical tourism has a substantial impact on healthcare costs in Alberta. When compared to bariatric medical tourists, the complication rate for locally conducted surgery is less, and the cost of managing the complications is also much less. Therefore, we conclude that it is a better use of resources to conduct bariatric surgery for Albertan residents in Alberta than to fund patients to seek surgery out of province/country.     

The RUSH2A Study: Dark-Adapted Visual Fields in Patients With Retinal Degeneration Associated With Biallelic Variants in the USH2A Gene

PurposeTo measure visual fields using two-color dark-adapted chromatic perimetry in a subset of participants in the Rate of Progression of USH2A-related Retinal Degeneration (RUSH2A), a study of USH2A-mediated syndromic (USH2) and autosomal recessive nonsyndromic retinitis pigmentosa, determine percentage retaining rod function, and explore relationships between dark-adapted visual fields (DAVF) and rod function from ERG and full-field stimulus thresholds (FST).MethodsFull-field rod mean sensitivity, number of rod loci, maximum sensitivity, DAVF full-field hill of vision (DAVF V_TOT), and 30° hill of vision (DAVF V₃₀) were measured in one eye for DAVF ancillary study participants (n = 49). Loci where cyan relative to red sensitivity was more than 5 dB on dark-adapted chromatic perimetry were considered rod mediated. Correlation coefficients between the DAVF measures and standard clinical measures were estimated, as were kappa statistics (κ) for agreement between DAVF and other measures of rod function.ResultsOf 49 participants tested with DAVF, 38 (78%) had evidence of rod function, whereas 15 (31%) had measurable rod ERGs. DAVF maximum sensitivity was highly correlated with FST white thresholds (r = −0.80; P < .001). Although not statistically significant, the number of rod loci and DAVF V_TOT were lower in eyes with longer disease duration by 0.82 (95% confidence interval, −1.76, 0.12) loci/year and 0.59 (95% confidence interval, −1.82, 0.64) dB-steradians/year, respectively.ConclusionsRod-mediated function on FST and DAVF is present in many patients with symptomatic USH2A-related retinal degeneration, including some without measurable rod ERGs. RUSH2A longitudinal data will determine how these measures change with disease progression and whether they are useful for longitudinal studies in inherited retinal degenerations.     

Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy

Background:

Optimized perioperative care within an enhanced recovery after surgery (ERAS) protocol is designed to reduce morbidity after surgery, resulting in a shorter hospital stay. The present study evaluated this approach in the context of sleeve gastrectomy for patients with morbid obesity.

Methods:

Patients were allocated to perioperative care according to a bariatric ERAS protocol or a control group that received standard care. These groups were also compared with a historical group of patients who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient.

Results:

Of 116 patients included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group (1 day) than in the control (2 days; P < 0·001) and historical (3 days; P < 0·001) groups. It was also shorter in the control group than in the historical group (P = 0·010). There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS (P = 0·010) and control (P = 0·018) groups.

Conclusion:

The ERAS protocol in the setting of bariatric surgery shortened hospital stay and was cost‐effective. There was no increase in perioperative morbidity. Registration number: NCT01303809 ( http://www.clinicaltrials.gov ). Copyright © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

CAGS AND ACS EVIDENCE BASED REVIEWS IN SURGERY. 45: Cost-effectiveness of bariatric surgery for severely obese adults with diabetes

Objective: To analyze the cost-effectiveness of bariatric surgery in severely obese adults who have diabetes. Base case: Patients with body mass index (BMI) ≥ 35 who have diabetes. Methods: The Centre for Disease Control (CDC)-RTI Diabetes Cost-Effectiveness Model, which is a Markov simulation model of disease progression and cost-effectiveness for type 2 diabetes, was expanded to consider the effects of bariatric surgery. Interventions considered: Gastric bypass and gastric banding compared with usual diabetes care. Outcomes considered: Diabetes-related and surgical complications, diabetes remission and relapse rates, deaths, costs and quality of life. Results: Bariatric surgery increased quality-adjusted life years (QALYs) and increased costs. Bypass surgery had cost-effectiveness ratios of $7 000 per QALY and $12 000 per QALY for severely obese patients with newly diagnosed and established diabetes, respectively. Gastric banding had cost-effectiveness ratios of $11 000 per QALY and $13 000 per QALY, respectively. In sensitivity analyses, the cost-effectiveness ratios were most affected by assumptions about the direct gain in quality of life and by BMI reduction following surgery. Conclusion: The analysis indicates that gastric bypass and gastric banding are cost-effective methods of reducing mortality and diabetes-related complications in severely obese adults with diabetes.