Treatment of aberrant facial nerve regeneration with botulinum toxin A

purpose To assess the effect and efficacy of botulinum toxin type A (BTX-A) at reducing and maintaining eyelid synkinesia in aberrant facial nerve regeneration, while concurrently observing for the presence of side effects to differing treatment doses. methods A prospective interventional study of five patients with eyelid synkinesia resulting from aberrant regeneration of the facial nerve. Patients were treated with injections of either 120, 80 or 40 units of BTX-A (Dysport) into the orbicularis oculi. Objective and subjective reduction in synkinesia, maintenance of response and presence of side effects were recorded. results All five patients had improvement of the synkinesia with BTX-A treatment. Lower doses were found to be as effective as higher doses. Mean duration of abolished synkinesia was three months. Two patients developed a ptosis which resolved spontaneously. None of the patients treated with the lowest dose of 40 units developed a ptosis. conclusion Low-dose BTX-A has a lower incidence of ptosis and is effective in the treatment of aberrant facial nerve regeneration.     

Clinical efficacy and predictors of outcomes of repeat hepatectomy for recurrent hepatocellular carcinoma – A systematic review

BackgroundPrimary hepatectomy is an accepted treatment for primary hepatocellular carcinoma (HCC) with good long-term survival, but high rates of recurrence. This review aims to evaluate the safety and efficacy of repeat hepatectomy for recurrent HCC after initial hepatectomy.MethodsElectronic searches identified 22 eligible studies comprising of 1125 patients for systematic review. Studies with >10 patients, adopting repeat hepatectomy treatment for recurrent HCC initially treated with hepatectomy were selected for inclusion. A predetermined set of data comprising demographic details, morbidity and mortality indices and survival outcomes were collected for every study and tabulated.ResultsMajority of patients selected for repeat hepatectomy had Child-Pugh A (median 94%, range 40–100). Intrahepatic recurrence occurred at a median of 22.4 (range 12–48) months in this patient cohort with single nodule recurrences comprising of 70% of cases. The median mortality rate was 0% (range 0–6%). Prolonged ascites was observed in a median of 4% (range 0–32%), bleeding in 1% (range 0–9%), bile leak in 1% (range 0–6%) and liver failure in 1% (range 0–2%). The median disease-free survival was 15 (range 7–32) months and median overall survival was 52 (range 22–66) months. Median 3-year and 5-year survival was 69% (range 41–88%) and 52% (range 22–83%) respectively. Recurrences occurring 12–18 months after initial hepatectomy was consistently associated with improved survival.ConclusionSynthesized data from observational studies of repeat hepatectomy suggests that this treatment approach for recurrent HCC is safe and achieves long-term survival. Standardization of criteria for repeat hepatectomy and a randomized trial are warranted.     

Course of dermal ulcers and musculoskeletal involvement in systemic sclerosis patients in the scleroderma lung study

Objective

To evaluate changes in vascular and musculoskeletal involvement in subjects in the Scleroderma Lung Study, a multicenter, double‐blind, randomized, controlled trial comparing placebo treatment with oral cyclophosphamide (CYC) for 1 year in systemic sclerosis patients with interstitial lung disease. Subjects were then followed off the study agent for an additional 12 months.

Methods

The following parameters were noted at baseline and every 6 months for each patient: digital tip ulcers, other dermal ulcers, joint swelling, joint tenderness, large joint contractures, muscle tenderness, muscle weakness, oral aperture, hand extension, and fist closure.

Results

A total of 158 patients were enrolled from 13 centers in the US; 79 were randomized to the CYC group and 79 to the placebo group. There were no differences in dermal ulcer and musculoskeletal measures between the CYC and placebo groups at baseline and 12 and 24 months. Improvement in percent predicted forced vital capacity was associated with improvement in the Rodnan skin thickness score (P < 0.05) at 12 and 24 months, and with increased mean oral aperture at 24 months (P = 0.005).

Conclusion

These data document the frequency and course of these vascular and musculoskeletal features over time, therefore providing essential information for sample size calculations and magnitude of effect in future clinical trials. There was no treatment effect of CYC on the vascular and musculoskeletal features described.     

If you try to stop smoking,should we pay for it? The cost–utility of reimbursing smoking cessation support in the Netherlands

Background Smoking cessation can be encouraged by reimbursing the costs of smoking cessation support (SCS). The short‐term efficiency of reimbursement has been evaluated previously. However, a thorough estimate of the long‐term cost–utility is lacking. Objectives To evaluate long‐term effects of reimbursement of SCS. Methods Results from a randomized controlled trial were extrapolated to long‐term outcomes in terms of health care costs and (quality adjusted) life years (QALY) gained, using the Chronic Disease Model. Our first scenario was no reimbursement. In a second scenario, the short‐term cessation rates from the trial were extrapolated directly. Sensitivity analyses were based on the trial's confidence intervals. In the third scenario the additional use of SCS as found in the trial was combined with cessation rates from international meta‐analyses. Results Intervention costs per QALY gained compared to the reference scenario were approximately €1200 extrapolating the trial effects directly, and €4200 when combining the trial's use of SCS with the cessation rates from the literature. Taking all health care effects into account, even costs in life years gained, resulted in an estimated incremental cost–utility of €4500 and €7400, respectively. In both scenarios costs per QALY remained below €16 000 in sensitivity analyses using a life‐time horizon. Conclusions Extrapolating the higher use of SCS due to reimbursement led to more successful quitters and a gain in life years and QALYs. Accounting for overheads, administration costs and the costs of SCS, these health gains could be obtained at relatively low cost, even when including costs in life years gained. Hence, reimbursement of SCS seems to be cost‐effective from a health care perspective.     

Systematic multidisciplinary approach to reporting perinatal mortality: Lessons from a five-year regional review

Background:  Because of differences in reporting criteria throughout the world, comparing perinatal mortality rates and identifying areas of concern can be complicated and imprecise.
Aims:  To detail the systematic approach to reporting perinatal deaths and to identify any significant differences in outcomes in the Australian Capital Territory (ACT).
Methods:  Review of perinatal deaths from 2001 to 2005 in the ACT using the Australian and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM) and the Australian and New Zealand Neonatal Death Classification (ANZNDC) systems.
Results:  ACT residents' perinatal mortality rate was 10.6 per 1000 total births, fetal death rate 7.5 per 1000 total births and neonatal death rate 3.2 per 1000 live births. The three leading antecedent causes of perinatal death were congenital anomalies, spontaneous preterm birth and unexplained antepartum death. The three leading causes of neonatal death were extreme prematurity, cardiorespiratory disorders and congenital anomalies. Multiple births attributed to 20% (65 of 321) of perinatal deaths. Perinatal autopsy was performed in 50% of cases, but in only 64% of unexplained antepartum deaths.
Conclusions:  Causes of perinatal death for the ACT and surrounding New South Wales region are similar to other states using this classification system. The following are considered important lessons to promote accurate perinatal mortality reporting: (i) a universal reporting system for Australia utilising a multidisciplinary team; (ii) a high perinatal autopsy rate, especially in the critical area of antepartum death with no identifiable cause; and (iii) standardised definitions for avoidability. Attention to these areas may prompt further research and changes in practice to further reduce perinatal mortality.     

The dosimetric impact of supraclavicular nodal irradiation on the thyroid gland in patients with breast cancer

PurposeThe thyroid is not routinely considered an organ at risk in supraclavicular (SC) nodal radiation therapy (RT) for breast cancer. We compared the dosimetric impact of the following 2 RT planning techniques on the thyroid: (1) conventional single anterior field to encompass the SC nodal volume defined clinically; and (2) 3-dimensional conformal radiation therapy (3DCRT) planning to encompass the computed tomography (CT)-contoured SC nodal volume.Methods and MaterialsThe thyroid, SC nodal volumes, and organs at risk were contoured on the planning CT of 20 patients who received 50 Gy in 2-Gy daily fractions to the breast or chest wall, and SC nodes. Comparisons of dosimetric parameters between the techniques were performed: thyroid, mean and maximum dose, V5, V30, and V50 (percentage of thyroid receiving ≥ 5 Gy, ≥ 30 Gy, and ≥ 50 Gy, respectively); SC nodal volume, homogeneity index (HI, percentage volume receiving 95%-107% of prescribed dose); and maximum doses of spinal cord and brachial plexus. Anatomic characteristics that influenced the dose distributions were investigated.ResultsThe 3DCRT planning technique significantly increased all thyroid dosimetric measures (mean dose 17.2 Gy vs 26.7 Gy; maximum dose 48.5 Gy vs 51.9 Gy; V5 45.7% vs 64.9%; V30 33.7% vs 48%; and V50 0.6% vs 26.7%; P < .001). It improved HI for the SC nodal volumes (P < .001) but resulted in higher maximum doses to the spinal cord (6.1 Gy vs 30 Gy) and brachial plexus (43.2 Gy vs 51.4 Gy). The thyroid volume and depth of SC nodes did not influence the thyroid dose distribution. The depth of SC nodes impacted on the HI of SC nodal volumes in the conventional technique (P = .004).ConclusionsThe 3DCRT planning improved dosimetric coverage of the SC nodal volume but increased thyroid radiation doses. The potential adverse effects of incidental thyroid irradiation should be considered while improving dosimetric coverage in SC nodal irradiation for breast cancer.     

Intraoperative hyperthermic intraperitoneal chemotherapy after cytoreductive surgery in ovarian cancer peritoneal carcinomatosis: systematic review of current results

Background  

Advanced and recurrent ovarian cancer results in extensive spread of tumor on the peritoneal surfaces of the abdomen and pelvis. We collectively review studies in the literature that report the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer peritoneal carcinomatosis.     

PCV16 Smoking Related Costs in the United States

Smoking is a high-risk behavior that affects the health and economic welfare of society. Thus, it is important to quantify the economic burden smoking places on social institutions in the United States.
OBJECTIVE: The purpose of this review paper is to analyze smoking cost studies and to provide estimates that represent the economic costs of smoking from different perspectives of society, and as a whole.
METHODS: Current Contents (1996–), Health Star (1970–), and Medline (1966–) databases were searched through the use of pertinent subject headings and key words: tobacco use, smoking, cost, and economics. The internet was utilized to identify potential sources of epidemiological and cost information on smoking. Recent cost-of-illness studies using different methodologies: human capital, incidence, and prevalence were chosen for review based on their relevance.
RESULTS: Preliminary results indicate that the published cost studies available underestimate the "true" costs of smoking. The most current articles approximate annual direct medical costs to health care payers of $50 billion (1993); inflating to 1997 equals $59 billion or $1,200 per smoker. Although the latest cost studies do not attempt to estimate indirect costs, past studies have found indirect costs to be 1.5–2 times the direct costs. Therefore, using direct and indirect costs we estimate total smoking costs to be $150 billion (1993); inflating to 1997 equals $176 billion or $3,500 per smoker.
CONCLUSION: Quantifying the cost of smoking is a difficult task due to tobacco use infiltrating many aspects of life and the dependency of cost on perspective. Cost-of-illness studies provide cost estimation data which can be useful in aiding decision-makers who are allocating health care resources.