Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism

BACKGROUND: Controversy exists concerning the best treatment for asymptomatic primary hyperparathyroidism (PHPT) when the National Institutes of Health consensus conference criteria for parathyroidectomy are not met. We hypothesized that parathyroidectomy would be more cost-effective than observation or pharmacologic therapy for these patients. METHODS: Cost-effectiveness analysis was performed comparing treatment strategies for asymptomatic PHPT. Treatment outcomes, their probabilities, and costs were identified on the basis of literature and cost database review. Outcomes were weighted by using established quality-of-life utility factors. Sensitivity analysis was used to examine the uncertainty of costs and utility estimates in the model. RESULTS: The incremental cost-effectiveness ratio for parathyroidectomy was US dollars 4778 per quality-adjusted life year (QALY) gained. Operation remained cost-effective until the average cost of parathyroidectomy increased from the estimated value of US dollars 4778 to US dollars 14,650. Pharmacologic therapy was not cost-effective unless the annual cost of therapy decreased from an estimated US dollars 7406 (for cinacalcet) to US dollars 221. Parathyroidectomy ceases to be preferred over monitoring if a quality-of-life difference is not demonstrable after curative operation. CONCLUSIONS: Parathyroidectomy is more cost-effective than observation for managing asymptomatic PHPT patients who do not meet National Institutes of Health criteria for parathyroidectomy. Furthermore, pharmacologic therapies with a greater than US dollars 221 annual cost were not cost-effective in this model.     

The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy

OBJECTIVE: To evaluate the incidence of urinary tract injury due to hysterectomy for benign disease. STUDY DESIGN: Patients were enrolled prospectively from 3 sites. All patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign disease underwent diagnostic cystourethroscopy. RESULTS: Four hundred seventy-one patients participated. Ninety-six percent (24/25) of urinary tract injuries were detected intraoperatively. There were 8 cases of ureteral injury (1.7%) and 17 cases of bladder injury (3.6%). Ureteral injury was associated with concurrent prolapse surgery (7.3% vs 1.2%; P = .025). Bladder injury was associated with concurrent anti-incontinence procedures (12.5% vs 3.1%; P = .049). Abdominal hysterectomy was associated with a higher incidence of ureteral injury (2.2% vs 1.2%) but this was not significant. Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy. CONCLUSION: The incidence of urinary tract injury during hysterectomy is 4.8%. Surgery for prolapse or incontinence increases the risk. Routine use of cystoscopy during hysterectomy should be considered.     

Changes in the freezing protocol for human zygotes alter embryonic development and pregnancy rates

OBJECTIVE: To determine the effect of various freezing protocols on postthaw development and pregnancy rates resulting from transfer of human zygotes. DESIGN: Prospective study. SETTING: Tertiary care center. PATIENT(S): Couples undergoing assisted reproductive technology (ART) procedures who wished to have their excess zygotes cryopreserved. INTERVENTION(S): We cryopreserved zygotes with one of three protocols. MAIN OUTCOME MEASURE(S): Post-thaw survival and development of the zygotes as well as pregnancy rate after transfer of these zygotes. RESULT(S): A 3-minute hold time after seeding, followed by a final preplunging temperature of -180 degrees C, resulted in a clinical pregnancy rate of 28.6%. In contrast, a 15-minute postseed hold time and a -30 degrees C final chamber temperature resulted in a 37.3% clinical pregnancy rate. When we combined the protocols to provide a 15-minute postseed holding time and a -180 degrees C before plunging into liquid nitrogen, we achieved a 69.6% clinical pregnancy rate. CONCLUSION(S): By increasing the postseeding hold time and decreasing the temperature of the freezing chamber before plunging the zygotes into liquid nitrogen, significant improvements can be made in postthaw development and pregnancy rates.     

Clinical consequences of first-trimester growth discordance in twins

OBJECTIVES: To evaluate the clinical consequences of size discordance in the first-trimester of pregnancy in twins. STUDY DESIGN: This study was performed in a university tertiary referral centre. Nineteen pairs of twins identified as discordant were compared with 41 concordant twins. The rates of intrauterine growth restriction (IUGR), congenital malformations, and growth discordance in late pregnancy and at delivery were compared using chi-squared test and Fisher's exact test. RESULTS: There was not a significant difference in the rate of congenital malformations between the studied groups. The rates of IUGR and fetal growth discordance in late pregnancy were significantly higher in the first-trimester discordant group (57.2 and 35.7%, respectively) than in the control group (24.4 and 7.3%; P = 0.03 and 0.02, respectively). CONCLUSIONS: First-trimester growth discordant twins have an increased risk of IUGR and growth discordance in late pregnancy, and therefore they are a high-risk subgroup among multiple pregnancies.     

1D5 and 6F11: An immunohistochemical comparison of two monoclonal antibodies for the evaluation of estrogen receptor status in primary breast carcinoma

The optimal monoclonal antibody to examine steroid hormone receptor status of primary breast carcinoma has yet to be defined. Estrogen receptor status was evaluated in 592 cases using routinely prepared paraffin-embedded tissue samples from primary breast carcinomas with the 1D5 (DAKO, Carpinteria, CA) and 6F11 (Novocastra, Newcastle upon Tyne, England) monoclonal antibodies. The stains were compared, assessing the percentage of positive cells stained and their intensity. They also were examined for nonspecific cytoplasmic staining and fixation artifact. In addition, a cost analysis for their production was performed. Overall, 1D5 and 6F11 showed a 97.5% concordance rate. 6F11 stained a significantly higher percentage of cells (P < .0001), more intensely (P < .0001), with less nonspecific cytoplasmic staining (P < .0001). There was no significant difference in fixation artifact between the 2 clones. The cost of antibody used for preparing a 1D5-stained slide was 86% more than for preparing a 6F11-stained slide (dollars 14.27 vs dollars 7.67).     

Methylmalonic aciduria without vitamin B12 deficiency in an adult sibship.

Two brothers 62 and 70 years old, without evidence of vitamin B12 lack, excreted 12 to 115 mg of methylmalonic acid daily (normal, less than 9 mg per day). Neither had anemia or hepatic dysfunction, and serum vitamin B12 concentrations ranged from 369 to 800 pg per milliliter. The propositus, the younger brother, continued to excrete excessive methylmalonate, 103 to 115 mg per day, after 2000 mug of parenterally administered vitamin B12 at the fifth and 11th months of study. Leukocyte activities of the cobalamin-linked enzyme methylmalonyl coenzyme A mutase were respectively reduced in the propositus and his brother, to 0.04 and 0.11 nmoles of 3-(14)-C Ls methylmalonyl coenzyme A metabolized per hour per milligram of leukocyte protein (normal, 0.286 +/- 0.079 [S.D.]). These activities were not enhanced by 2 mug of 5'-deoxyadenosylcobalamin added to the assays. A heritable benign form of adult methylmalonic aciduria rather than vitamin B12 lack best explains these findings.