Estudio exploratorio sobre gastrostomía en pacientes con enfermedades neurológicas: utilidad e impacto

IntroductionPercutaneous endoscopic gastrostomy (PEG) is a useful intervention for patients with impaired swallowing and a functional gastrointestinal system. Neurological diseases that cause neuromotor dysphagia, brain tumors, and cerebrovascular disease are the most frequent indications; complications are rare, and morbidity and mortality rates are low.ObjectiveTo describe the usefulness of PEG in patients with neurological diseases, and its impact on care, survival, and costs and benefits.Material and methodsWe performed a retrospective observational study, reviewing clinical files of patients hospitalised at the National Institute of Neurology and Neurosurgery (years 2015-2017) who underwent PEG placement.ResultsThe sample included 51 patients: 62.7% were women and the mean (SD) age was 54.4 (18.6) years (range, 18-86). Diagnosis was tumor in 37.3% of cases and cerebrovascular disease in 33.3%. Sixteen patients (33.3%) died and 11 presented minor complications. The PEG tube remained in place for a mean of 9.14 months; in 52.9% of patients it was removed due to lack of improvement and/or tolerated oral intake, with removal occurring after a mean of 5.1 (4.4) months. Among patients’ family members, 78.4% reported a great benefit, 43.1% reported difficulty caring for the PEG, and 45.1% reported complicated care in general. The monthly cost of maintaining the PEG was €175.78 on average (range, 38.38-293.45).Discussion and conclusionsThis preliminary study reveals that PEG was well indicated in patients with neurological diseases, with survival rates similar to those reported in other studies with long follow-up periods. In patients with cerebrovascular disease, the PEG tube remained in place a mean of 9.14 months, during recovery of swallowing function; however, the cost is high for our population.     

Cost-Savings Analysis of Renal Scintigraphy,Stratified by Renal Function Thresholds: Mercaptoacetyltriglycine Versus Diethylene Triamine Penta-Acetic Acid

PurposeTo determine the financial implications of switching technetium (Tc)-99m mercaptoacetyltriglycine (MAG-3) to Tc-99m diethylene triamine penta-acetic acid (DTPA) at certain renal function thresholds before renal scintigraphy.MethodsInstitutional review board approval was obtained, and informed consent was waived for this HIPAA-compliant, retrospective, cohort study. Consecutive adult subjects (27 inpatients; 124 outpatients) who underwent MAG-3 renal scintigraphy, in the period from July 1, 2012 to June 30, 2013, were stratified retrospectively by hypothetical serum creatinine and estimated glomerular filtration rate (eGFR) thresholds, based on pre-procedure renal function. Thresholds were used to estimate the financial effects of using MAG-3 when renal function was at or worse than a given cutoff value, and DTPA otherwise. Cost analysis was performed with consideration of raw material and preparation costs, with radiotracer costs estimated by both vendor list pricing and proprietary institutional pricing. The primary outcome was a comparison of each hypothetical threshold to the clinical reality in which all subjects received MAG-3, and the results were supported by univariate sensitivity analysis.ResultsAnnual cost savings by serum creatinine threshold were as follows (threshold given in mg/dL): $17,319 if ≥1.0; $33,015 if ≥1.5; and $35,180 if ≥2.0. Annual cost savings by eGFR threshold were as follows (threshold given in mL/min/1.73 m²): $21,649 if ≤60; $28,414 if ≤45; and $32,744 if ≤30. Cost-savings inflection points were approximately 1.25 mg/dL (serum creatinine) and 60 mL/min/1.73m² (eGFR). Secondary analysis by proprietary institutional pricing revealed similar trends, and cost savings of similar magnitude. Sensitivity analysis confirmed cost savings at all tested thresholds.ConclusionsReserving MAG-3 utilization for patients who have impaired renal function can impart substantial annual cost savings to a radiology department.     

Cost‐effectiveness of treating vascular leg ulcers with UrgoStart® and UrgoCell® Contact

Although chronic wounds have a high socio‐economic impact, data on comparative effectiveness of treatments are rare. UrgoStart^® is a hydroactive dressing containing a nano‐oligosaccharide factor (NOSF). This study aimed at evaluating the cost‐effectiveness of this NOSF‐containing wound dressing in vascular leg ulcers compared with a similar neutral foam dressing (UrgoCell^® Contact) without NOSF. Cost‐effectiveness analysis from the perspective of the German statutory health care system was performed using a decision tree model for a period of 8 weeks. Cost and outcome data were derived from the clinical study ‘Challenge’ suggesting a response rate (≥40% wound size reduction) of UrgoStart^® of 65·6% versus 39·4% for the comparator. In the treatment model, effect‐adjusted costs of €849·86 were generated after 8 weeks for treatment with UrgoStart^® versus €1335·51 for the comparator resulting in an effect‐adjusted cost advantage of €485·64 for UrgoStart^®. In linear sensitivity analyses, the outcomes were stable for varying assumptions on prices and response rates. In an 8‐week period of treatment for vascular leg ulcers, UrgoStart^® shows superior cost‐effectiveness when compared with the similar neutral foam dressing without any active component (NOSF). As demonstrated within a randomised, double‐blind clinical trial, UrgoStart^® is also more effective in wound area reduction than the neutral foam dressing. Wound healing was not addressed in this clinical trial. Follow‐up data of 12 months to allow for reulceration assessment were not generated.     

Hierarchical polymer coating for optimizing the antifouling and bactericidal efficacies

The bacteria-repellent and bactericidal functionalities in a single system are generally need to be carefully optimized in order to obtain the highest antibacterial performance. In this study, the controlled SI-PIMP strategy was developed for creating hierarchical polymer brushes possessing the bacteria-repellent and bactericidal functionalities. To obtain a bactericidal surface with minimal interference to its nonfouling property, optimization studies were conducted by facilely tailoring the surface density of the quaternary ammonium compound moieties through control over the monomer concentration. An optimal hierarchical polymer coating showed potent protein and bacteria repellence as well as certain bactericidal property. The longlasting antibacterial performance was also achieved due to the good balance between the dual functionalities. The tenability of the hierarchical polymer coating is applicable to surface chemistries for biosensors, molecular imaging, and biomedical applications.     

Effect of mu and kappa opioids on injury-induced microglial accumulation in leech CNS: involvement of the nitric oxide pathway

Damage to the leech or mammalian CNS increases nitric oxide (NO) production and causes accumulation of phagocytic microglial cells at the injury site. Opioids have been postulated to modulate various parameters of the immune response. Morphine and leech morphine-like substance are shown to release NO and suppress microglial activation. Regarding the known immuno-modulatory effects of selective mu and kappa ligands, we have assessed the effect of these agents on accumulation of microglia at the site of injury in leech CNS. Leech nerve cords were dissected, crushed with fine forceps and maintained in different concentrations of opiates in culture medium for 3 h and then fixed and double stained with Hoechst 33258 and monoclonal antibody to endothelial nitric oxide synthase (NOS). Morphine and naloxone (> or =10(-3) M) but not selective mu agonist, DAMGO [d-Ala2, N-Me-Phe-Gly5(ol)-enkephalin] and antagonist, CTAP [D-Phe-Cys-Tyr-D-Trp-Arg-Thr-Pen-Thr-NH2] inhibited the microglial accumulation. The effect of morphine was abrogated by pre-treatment with naloxone and also non-selective NOS inhibitor, l-NAME [N(omega)-nitro-l-arginine-methyl-ester; 10(-3) M] implying an NO-dependent and mu-mediated mechanism. These results are similar to properties of recently found mu-3 receptor in leech, which is sensitive to alkaloids but not peptides. Both selective kappa agonist, U50,488 [3,4-dichloro-N-methyl-N-(2-(1-pyrrolidinyl)cyclohexyl)-benzeneacetamide; > or =10(-3) M], and antagonist, nor-binaltorphimine (nor-BNI; > or =10(-3) M), inhibited the accumulation. The effect of nor-BNI was reversed by l-NAME. Immunohistochemistry showed decreased endothelial NOS expression in naloxone and U50,488-treated cords. Since, NO production at the injury site is hypothesized to act as a stop signal for microglias, opioid agents may exert their effect via changing of NO gradient along the cord resulting in disruption of accumulation. These results suggest an immuno-modulatory role for mu and kappa opioid receptors on injury-induced microglial accumulation which may be mediated via NO.     

Halloysite nanotubes‐induced Al accumulation and oxidative damage in liver of mice after 30‐day repeated oral administration

Halloysite (Al₂Si₂O₅(OH)₄·nH₂O) nanotubes (HNTs) are natural clay materials and widely applied in many fields due to their natural hollow tubular structures. Many in vitro studies indicate that HNTs exhibit a high level of biocompatibility, however the in vivo toxicity of HNTs remains unclear. The objective of this study was to assess the hepatic toxicity of the purified HNTs in mice via oral route. The purified HNTs were orally administered to mice at 5, 50, and 300 mg/kg body weight (BW) every day for 30 days. Oral administration of HNTs stimulated the growth of the mice at the low dose (5 mg/kg BW) with no liver toxicity, but inhibited the growth of the mice at the middle (50 mg/kg BW) and high (300 mg/kg BW) doses. In addition, oral administration of HNTs at the high dose caused Al accumulation in the liver but had no marked effect on the Si content in the organ. The Al accumulation caused significant oxidative stress in the liver, which induced hepatic dysfunction and histopathologic changes. These findings demonstrated that Al accumulation‐induced oxidative stress played an important role in the oral HNTs‐caused liver injury.     

铁调素通过降低铁蓄积干预绝经后骨质疏松症的研究进展

绝经后骨质疏松症是常见的全身代谢性疾病之一,越来越多的研究表明铁代谢与骨质疏松症的关系密切。绝经后女性常常合并铁蓄积状态,铁蓄积为绝经后骨质疏松症的独立危险因素之一,而铁调素作为机体铁代谢和铁稳态的主要调节者,通过铁调素降低铁蓄积可能成为干预绝经后骨质疏松症的新靶点之一。因此本文拟对铁调素通过降低铁蓄积干预绝经后骨质疏松症的研究进展做一综述,以期为绝经后骨质疏松症的治疗及新药开发提供理论参考依据。     

Surgical instrument standardization – A pilot cost consciousness curriculum for surgery residents

IntroductionSurgical cost is astronomical in the US and instrument standardization is one potential mechanism for cost savings. This study describes a core competency based, multidisciplinary curriculum and evaluates resident attitudes towards operating room equipment standardization.Materials and methodsAs part of a quality improvement initiative, surgery residents participated in an hour-long mixed curriculum consisting of brief didactics and small group exercises. Participants developed an equipment standardization plan for laparoscopic appendectomy and cholecystectomy. Participants also completed surveys to assess their attitudes towards 11 potential barriers to implementation as “improves, no change, or worsens”.ResultsFifteen general surgery residents participated. In general, participants felt that standardization improves or does not change metrics including surgeon autonomy, resident training experience, and patient safety.ConclusionOur pilot curriculum addresses a gap in resident education about surgical cost. Residents generally regard equipment standardization as either improving or not changing hospital metrics.     

临床路径下急性脑梗死药物治疗方案的成本-效果分析

目的分析临床路径下急性脑梗死药物治疗的成本-效果,为临床合理用药提供参考。方法采用回顾性分析法对本市4家综合医院2012年1月²013年6月入住的630例患者筛选分为3组,即Z(中成药物)组210例、H(化学药物)组210例、L(联合用药)组210例。应用药物治疗疗程均为14 d,运用药物经济学中成本-效果分析。结果 3组治疗方案的人均成本分别为:3 235.8元、3 695.04元、4 605.8元;显效率分别为:65.24%、77.14%、92.86%。结论 3种治疗方案中L1组最佳。