The Use of Cost‐Effectiveness Analysis for Pediatric Immunization in Developing Countries

Context: Developing countries face critical choices for introducing needed, effective, but expensive new vaccines, especially given the accelerated need to decrease the mortality of children under age five and the increased immunization resources available from international donors. Cost‐effectiveness analysis (CEA) is a tool that decision makers can use for efficiently allocating expanding resources. Its use in developing countries, however, lags behind that in industrialized countries. Methods: We explored how CEA could be made more relevant to immunization policymaking in developing countries by identifying the limitations for using CEA in developing countries and the impact of donor funding on the CEA estimation. We conducted a comprehensive literature search using formal search protocols and hand searching indexed and gray literature sources. We then systematically summarized the application of CEA in industrialized and developing countries through thematic analysis, focusing on pediatric immunization and methodological and contextual issues relevant to developing countries. Findings: Industrialized and developing countries use CEA differently. The use of the Disability‐Adjusted Life Year (DALY) outcome measure and an alternative generalized cost‐effectiveness analysis approach is restricted to developing countries. In pediatric CEAs, the paucity of evaluations and the lack of attention to overcoming the methodological limitations pertinent to children's cognitive and development distinctiveness, such as discounting and preference characterization, means that pediatric interventions may be systematically understudied and undervalued. The ability to generate high‐quality CEA evidence in child health is further threatened by an inadequate consideration of the impact of donor funding (such as GAVI immunization funding) on measurement uncertainty and the determination of opportunity cost. Conclusions: Greater attention to pediatric interventions and donor funding in the conduct of CEA could lead to better policies and thus more worthwhile and good‐value programs to benefit children's health in developing countries.     

Chylous ascites in cirrhosis: A case report and review of the literature

Chylous ascites is an uncommon clinical entity which results from the accumulation of fat, predominantly chylomicrons, in the ascitic fluid. Conventional treatment methods are unsatisfactory. A patient is reported with chylous ascites associated with cirrhosis and portal hypertension in whom the ascites, the renal insufficiency and the fluid and electrolyte disturbances were corrected by the insertion of a Denver peritoneovenous shunt.     

An analysis of the relationship between bile duct stones and periampullary duodenal diverticula

Previous studies have suggested a relationship between bile duct stones and periampullary duodenal diverticula. The aim of the present study was to examine this association in more detail, including step-wise logistic regression to identify independent predictors for the presence of diverticula. Clinical, endoscopic and radiological data were analysed from 794 consecutive subjects with bile duct stones; 44 with primary duct stones (without gall-bladder stones) and 750 with bile duct stones associated with current or previous gall-bladder stones. Frequencies of diverticula in subjects with bile duct stones were compared with those in age-matched controls who had undergone upper gastrointestinal endoscopy using a side-viewing endoscope (n = 100) or who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic cancer (n = 100). The frequencies of diverticula in subjects with primary duct stones (70%) and bile duct stones with current or previous gall-bladder stones (25%) were significantly higher than in both control groups (7 and 8%, respectively). When subjects with bile duct stones were analysed by step-wise logistic regression, age and bile duct diameter were independent predictors of the presence of diverticula, but diverticula were unrelated to gender, mode of presentation, number of bile duct stones and outcome after endoscopic sphincterotomy. A significant association exists between duodenal diverticula and bile duct stones, perhaps because diverticula predispose to stone formation through the combined effects of bile stasis and bacterial contamination of bile.     

Modulation of Healthy Pig Coronary Arteries by Self-Expanding Stents

Objectives: To evaluate the expansion ratio of a self-expanding stem over time, and the chronic effect of stent pressure on the vessel wall . Methods: Self-expanding stents, developed by Medtronic Inc. (Minneapolis, MN, USA) and the Rouen group (Letac, Cribier, France), were implanted in 21 normal pig coronary arteries. Animals were sacrificed after recatheterization at 1 day (group I, n = 4), I week (group 2, n = 3), 3 weeks (group 3, n = 5), or 8 weeks (group 4, n = 4). Histological morphometry of the vessel medial and neointimal layers was performed. Changes were related to the, stent diameter and. its force on the vessel wall . Results: The stent expansion ratio gradually increased from 73% to 93% after 8 weeks, which implicates that radial force decreased concomitantly from 0.10 N to 0.03 N. Media compression under the rods ranged from 4l%-66% immediately after stent implantation. The mean compression was unrelated to stent expansion and remained nearly the same (40%-50%) during follow-up. Individual media rod compression ranged from 5%-95%. The neointimal layer on top of the rods increased until the third week after stent implant (neointimal thickness 211 ± 108 μm). The layer significantly decreased at 8 weeks (neointimal thickness 65 ± 9 μm). The cross-sectional neointimal area increased gradually only at the end of the stent during the 8-week follow-up . Conclusions: The self-expanding stent implanted in normal pig coronary arteries reached a gradual relaxation state 8 weeks after implantation due to the persistent radial force. This radial force induces medial wall compression, which was only positively related to the thickness of the neointimal layer at 3 weeks after implant . (J Interven Cardiol 1996;9:45–52)     

Clinical Features of Multiple Glomus Tumors

BACKGROUND While glomus tumors are usually solitary, multiple glomus tumors do occur. The purpose of this study was to review the clinical characteristics and outcomes in a series of patients with multiple glomus tumors presenting to our institution.
METHODS A retrospective review of patients with multiple glomus tumors seen at our institution over the past 25 years was performed.
RESULTS Twenty-two patients with multiple glomus tumors were identified. Initial diagnosis was blue rubber nevus syndrome and hemangioma in 10 and 7 patients, respectively. The mean duration from onset of symptoms until correct diagnosis was 14.6 years. Involvement of an extremity was noted in 90.9% of the patients. An autosomal dominant pattern of inheritance was noted in 13 of 22 patients. The classic triad of symptoms in solitary glomus tumors—pain, pinpoint tenderness, and cold hypersensitivity—was noted in only 1 of the 22 patients; pain and pinpoint tenderness were simultaneously identified in 14 patients, 8 with visible lesions but no symptoms. Symptoms were relieved by surgical excision in most patients.
CONCLUSION Patients with multiple glomus tumors are frequently misdiagnosed. Proper recognition and diagnosis would lead to improved management.     

The Psychostimulant Check‐Up: A pilot study of a brief intervention to reduce illicit stimulant use

Introduction and Aims. This study is to test the acceptability of a single‐session ‘check‐up’ intervention for psychostimulant users and document participants' subsequent progress in reducing psychostimulant use and related harms. Design and Methods. The design was pre‐experimental single‐group repeated measures. Eighty participants received the Psychostimulant Check‐Up, with 62% completing a 3 month follow up. Results. Participants were predominantly young adult methamphetamine users. The majority indicated that the Check‐Up answered their questions, increased their awareness of services, and they would recommend it to their friends. At follow up, there was a significant reduction in self‐reported methamphetamine use, the number of self‐reported psychostimulant‐related negative consequences experienced in the previous month and rates of injecting: 62% self‐reported at least a 1 g reduction in methamphetamine use. Discussion and Conclusions. The intervention was well accepted and the majority of those who received it subsequently made meaningful reductions in psychostimulant use and related harm. The intervention offers sufficient promise to warrant a randomised trial to establish whether improvements were specific to the intervention.[Smout MF, Longo M, Harrison S, Minniti R, Cahill S, Wickes W, White JM. The Psychostimulant Check‐Up: A pilot study of a brief intervention to reduce illicit stimulant use. Drug Alcohol Rev 2009]