Outcomes and Excess Costs among Patients with Cardiovascular Disease

ObjectiveTo report on two-year cardiovascular (CV) event rates and quantify the cost of cardiovascular disease using the Australian Reduction of Atherothrombosis for Continued Health (REACH) registry.MethodsProspective registry of 2873 patients with multiple risk factors (MRF), coronary artery disease (CAD), cerebrovascular disease (CerVD) and peripheral artery disease (PAD), recruited through 273 Australian general practitioners. Government reimbursement data from 2011 was used to calculate direct health care costs (pharmaceuticals, outpatient and hospitalisation costs). The main outcome of interest was two-year rates and associated excess costs of cardiovascular death, myocardial infarction, stroke, and hospitalisation for cardiovascular procedures.ResultsThe two year follow-up data were available for 2856 (99.4%) patients. Incidence of any hospitalisation and cardiovascular death was highest among those with previous history of PAD at baseline 49% (n = 126), and 5.1% (n = 13). Non-fatal cardiovascular events were highest among the PAD and CAD groups (21.8% (n = 56) and 14.1% (n = 297) respectively). Those with previous history of PAD and CerVD at baseline had the highest likelihood of CV death (OR = 2.53 (95% CI: 1.58–4.08) and OR = 1.61 (1.05–2.46) respectively) in comparison to other groups. Patients with PAD had the highest likelihood of vascular interventions OR = 3.11 (95% CI: 2.09–4.63) at two years. Overall, the mean (SD) direct expenditure over two years of follow-up per person was A$7544 (A$10,758). In the adjusted model, patients with CAD and PAD incurred A$1093 (95% CI A$24 – A$2072) and A$4890 (95% CI A$3105 – A$6869) more in mean total costs compared to patients with MRF.ConclusionsPatients with PAD had the highest likelihood of vascular interventions and CV death, and incurred high excess costs in comparison to other groups.     

Natural orifice transluminal endoscopic surgery for the antireflux process in children

The successful deployment of therapeutic delivery systems with natural orifice transluminal endoscopic surgery (NOTES)-like techniques relies on a combination of technology that must be appropriate, and in children that includes size-specific, close team harmony with surgeons and endoscopists working hand in hand, absence of introduction of infection and other complications, and efficacy that is as good as the conventional approaches. Increasingly, cost will become a factor, and the higher cost of the NOTES-type techniques could be balanced by the potential for shorter stays as inpatients. Already the antireflux transoral incisionless fundoplication procedure has gained some acceptance in the United States, and it remains to be seen if it becomes commonplace in pediatrics. How long it will take for other techniques such as NOTES cholecystectomy, appendectomy, bowel resection, etc., to be adopted in a similar fashion will depend on the ongoing studies that are bearing fruit every year, and also on technological developments such as the so-called NOTES “toolbox.” These are interesting times for pediatric gastrointestinal endoscopy     

Rituximab plus subcutaneous cladribine in patients with extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue: a phase II study by the Arbeitsgemeinschaft Medikament?se Tumortherapie

Currently, there is no standard systemic treatment for extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue. Both rituximab and cladribine have shown some activity in this disease, but the combination has not been tested so far. In view of this, we initiated a phase II study to assess the activity and safety of rituximab and cladribine in patients with histologically verified mucosa-associated lymphoid tissue lymphoma. Treatment consisted of rituximab 375 mg/m² i.v. day 1 and cladribine 0.1 mg/kg s.c. days 1 – 4 every 21 days. In case of complete remission after two courses, another two cycles of therapy were administered, while patients with a partial response or stable disease were scheduled to receive six cycles of treatment. Out of 40 evaluable patients (14 female, 26 male), 39 received treatment as scheduled while one patient died before initiation of therapy and was rated as having progressive disease in the intent-to-treat analysis. Twenty-one patients had gastric lymphoma, while 19 suffered from extragastric mucosa-associated lymphoid tissue lymphoma. Side effects consisted mainly of hematologic toxicity including leukopenia, lymphopenia, anemia and thrombocytopenia. Twenty-three patients had a complete remission (58%) and nine had a partial remission (23%) for an overall response rate of 81%, while five had stable disease (13%) and two progressed during therapy. After a median follow-up of 16.7 months (interquartile range: 15.9 – 18.7 months), 35 patients are alive (88%) while four patients have died and one patient withdrew consent and did not allow further follow up. Our data demonstrate that rituximab plus cladribine is active and safe in patients with mucosa-associated lymphoid tissue lymphoma.     

The Kawa model: The power of culturally responsive occupational therapy

The Kawa (Japanese for river) model, developed by Japanese and Canadian rehabilitation professionals, presents an important and novel alternative to contemporary ‘Western’ models of rehabilitation. Rather than focussing primarily on the individual client, the Kawa model focusses on ‘contexts’ that shape and influence the realities and challenges of peoples' day-to-day lives. The first substantial model of rehabilitation practice developed outside of the West illuminates the transactional quality of human-environment dynamics and the importance of inter-relations of self and others through the metaphor of a river's flow. The model's reflection of Eastern thought and views of nature presents a useful point of comparison to familiar rational and mechanical explanations of occupation and well-being. In this article, the rationale for an alternative model in rehabilitation is presented, followed by an explanation of the structure and concepts of the Kawa model. Implications for culturally responsive practice as well as the model's significance to the advancement of culturally safe rehabilitation worldwide are discussed.     

The parallel effects of a very low molecular weight heparin (CY222) on anti Xa activity and thyroid hormone levels in blood

A very low molecular weight heparin fragment (CY222) was administered by subcutaneous injection to a group of normal volunteers. This drug caused increased anti Xa activity with peak levels being observed two hours after injection. This coincided with changes in thyroid hormone levels especially with a fall in red cell thyroxine levels. Larger doses of CY222 caused a fall in serum total thyroxine and triiodothyronine, a rise in free thyroxine and a fall in TSH levels. It was thought that these findings may be due to the production of a circulating inhibitor of cellular uptake of thyroxine and that this might be related to the elevated levels of serum free fatty acids produced by the heparin.     

The Clinical Diagnosis of Sensory Neuropathy in Elderly People

Minor abnormalities in sensory perception are common in elderly people but the significance of these findings is uncertain. In order to define the most relevant clinical tests for the diagnosis of significant neuropathy in the elderly diabetic patient, quantified perception of vibration, temperature, pain, and light touch was assessed in 200 (100 hospitalized, 100 community) consecutive non-diabetic elderly subjects without apparent neurological disease, using an established scoring system. The changes in sensory perception were similar in the two groups and data were pooled for further analysis. Progressive loss of peripheral sensation was apparent with increasing age (neuropathy deficit score vs age: r = 0.4, p < 0.0001). Loss of vibration perception was particularly marked; deficit scores for vibration were significantly lower in the < 70 years age group than in all the older age groups (vibration score: < 70 years vs 80–84 years mean (95 % CI) 0.89 (0.54) vs 3.02 (0.6), p < 0.0001). In contrast, perception of light touch and pain was relatively preserved in old age. Assessment of vibration perception is of limited value in elderly people since the distinction between ‘normal ageing’ and significant neuropathy is unclear. Perception of light touch and pain are likely to be the most reliable clinical indicators of significant neuropathy in an elderly diabetic population.