Commentary on “Outpatient laser ablation of non-muscle-invasive bladder cancer: Is it safe,tolerable and cost-effective?” Wong KA,Zisengwe G,Athanasiou T,O׳Brien T,Thomas K,The Urology Centre,Guys and St. Thomas' NHS Foundation Trust.: BJU Int 2013; 112(5):561–7. doi:10.1111/bju.12216. [Epub 2013 Jul 2]

ObjectivesTo evaluate the safety, tolerability and effectiveness of outpatient (office-based) laser ablation (OLA), with local anaesthetic, for non-muscle-invasive bladder cancer (NMIBC) in an elderly population with and without photodynamic diagnosis (PDD). To compare the cost-effectiveness of OLA of NMIBC with that of inpatient cystodiathermy (IC).Patients and methodsWe conducted a prospective cohort study of patients with NMIBC treated with OLA by one consultant surgeon between March 2008 and July 2011. A subgroup of patients had PDD before undergoing OLA. Safety and effectiveness were determined by complications (In the immediate post operative period, at three days and at three months), patient tolerability (visual analogue score) and recurrence rates. The long-term costs and cost-effectiveness of OLA and IC of NMIBC were evaluated using Markov modeling.ResultsA total of 74 OLA procedures (44 white-light, 30 PDD) were carried out in 54 patients. The mean (range) patient age was 77 (52-95) years. More than half of the patients had more than three comorbidities. Previous tumour histology ranged from G1pTa to T3. One patient had haematuria for 1 week which settled spontaneously and did not require hospital admission. There were no other complications. The procedure was well tolerated with pain scores of 0-2/10. Additional lesions were found in 21% of patients using PDD that were not found using white light. At 3 months, the percentage of patients who had recurrence after OLA with white light and OLA with PDD were 10.6 and 4.3%, respectively. At 1 year, 65.1% and 46.9% of patients had recurrence. The cost of OLA was found to be much lower than that of IC (£538 vs £1474), even with the addition of PDD (£912 vs £1844). Over the course of a patient?s lifetime, OLA was more clinically effective, measured in quality-adjusted life-years (QALY), than IC (0.147 [sd 0.059]) and less costly (£2576.42 [sd £7293.07]). At a cost-effectiveness threshold of £30,000/QALY, as set by the National Institute for Health and Care Excellence, there was an 82% probability that OLA was cost-effective.ConclusionsThis is the first study to demonstrate the long-term cost-effectiveness of OLA of NMIBC. The results support the use of OLA for the treatment of NMIBC, especially in the elderly.     

Comparison of indirubin concentrations in indigo naturalis ointment for psoriasis treatment: a randomized,double‐blind,dosage‐controlled trial

Corticosteroids are commonly used topical (applied to the skin) therapies in psoriasis; although beneficial, there are concerns about their prolonged use and there is a need for effective alternatives. Many herbal remedies have been used topically, although evidence for their benefit is often limited. Indigo naturalis has been used for several years in Chinese traditional medicine; unfortunately, when taken by mouth it can cause gastro‐intestinal side effects or liver damage. Previous studies have shown it may be effective, as a crude ointment or a refined preparation, containing the active ingredient indirubin, which causes less skin staining than the crude preparation. Indirubin has anti‐inflammatory properties and reduces the excessive turnover of cells called keratinocytes in the outermost layer of skin, the epidermis, which is seen in psoriasis. The authors, based in Taiwan, aimed to find the optimal concentration of indirubin in a topical preparation. They recruited 109 adults with psoriasis affecting less than 20% body surface area. The subjects received different concentrations of indirubin (ranging from 10 to 200 μg/g) for an 8 week treatment period, followed by a further 12 week monitoring period. The researchers measured the Psoriasis Area and Severity Index (PASI) before and after treatment, which is a measurement of how severe a person's psoriasis is. 200 μg/g was the most effective concentration: in this group 56.5% of patients achieved a 75% improvement and 30.4% a 90% improvement in PASI score, with a reduction of itching. The improvement was maintained after discontinuing treatment. No major side effects were observed, although skin irritation occurred in some patients, even on the lowest dose. Clearly this study needs confirmation, but the authors propose that topical indirubin is beneficial in psoriasis, with an efficacy between that of a topical medicine called calcipotriol and the combination of calcipotriol with a potent corticosteroid, but with less toxicity than the latter.