Giant inguinal scrotal vesical hernia

Presentation of one case of scrotal hernia in a man of 64 years old patient. Diagnosed by cistography and ultrasound and treated by herniorraphy and posterior transuretral litolaplaxy of a vesical litiasis and RTU of prostate. Postoperative urography showed normal vesical morphology.     

Comparative effectiveness of catheter ablation strategies for rhythm control in patients with atrial fibrillation: a meta-analysis

Background

Pulmonary vein isolation (PVI) forms the basis of catheter ablation strategies for atrial fibrillation (AF). Ablation of additional sites has been used to increase the efficacy of ablation procedures in restoring and maintaining normal sinus rhythm.

Objective

The aim of this paper was to compare the effectiveness of PVI versus PVI plus adjuvant atrial ablations (PVI+) in patients with AF.

Methods

A systematic search using bibliographic databases and gray literature was undertaken. Randomized and non-randomized controlled trials evaluating clinical efficacy, effectiveness, or safety of ablation procedures in adults with AF were included in this review.

Results

Of 3,204 potential citations identified by the original search, 21 randomized controlled trials and three non-randomized trials were included. Meta-analysis results reveal that in the first year after ablation, AF patients who underwent PVI+ strategies had a significantly higher rate of maintaining sinus rhythm than those who underwent PVI alone (RR 1.10, 95?% CI 1.02, 1.17). However, a subgroup meta-analysis was statistically significant for only PVI+ left atrial (LA) linear ablations (RR 1.16, 95?% CI 1.04, 1.29). The pooled success rates were higher in PVI+ group for both paroxysmal (RR 1.14, 95?% CI 1.06, 1.24) and non-paroxysmal AF (RR 1.53, 95?% CI 1.10, 2.14).

Conclusion

PVI+ strategies, particularly PVI+ LA ablations, appear to result in higher success rates than PVI alone in the first year after the procedure. Studies of longer duration are needed to evaluate the long-term benefits and safety of different adjunctive ablation approaches for rhythm control in AF patients.     

Impact of melatonin, zaleplon, zopiclone, and temazepam on psychomotor performance

INTRODUCTION: Modern military operations may require pharmaceutical methods to sustain alertness and facilitate sleep in order to maintain operational readiness. In operations with very limited sleep windows, hypnotics with very short half-lives (e.g., zaleplon, t(1/2) 1 h) are of interest, while with longer sleep opportunities, longer acting agents (e.g., zopiclone, temazepam (t(1/2) 4-6 hours) may be used. This study was designed to compare the effect of a single dose of zaleplon, zopiclone, temazepam, and melatonin on psychomotor performance and to quantify the post-ingestion time required for return to normal performance. METHOD: There were 23 subjects (9 men, 14 women), 21-53 yr of age, assessed for psychomotor performance on 2 test batteries (4 tasks) that included a sleepiness questionnaire. Psychomotor testing was conducted prior to, and for 7 h after, ingestion of a single dose of each of placebo, zaleplon 10 mg, zopiclone 7.5 mg, temazepam 15 mg, and time-released melatonin 6 mg. The experimental design was a double-blind cross-over with counter-balanced treatment order. RESULTS: Zaleplon, zopiclone, and temazepam impaired performance on all four tasks: serial reaction time (SRT), logical reasoning (LRT), serial subtraction (SST), and multitask (MT). Melatonin did not impair performance on any task. The time to recovery of normal performance for SRT during the zaleplon, zopiclone and temazepam conditions were 3.25, 6.25, and 5.25 h respectively; for LRT were 3.25, >6.25, and 4.25 h; for SST were 2.25, >6.25, and 4.25 h, and for MT were 2.25, 4.25, and 3.25 h. The recovery time to baseline subjective sleepiness levels for zaleplon, zopiclone, temazepam, and melatonin were 4.25, >6.25, 5.25, and >4.25 h, respectively. CONCLUSIONS: In spite of a prolonged period of perceived sleepiness, melatonin was superior to zaleplon in causing no impact on performance. The remaining drugs listed in increasing order of performance impact duration are zaleplon, temazepam, and zopiclone.     

Hospital selection for unit cost estimates in multicentre economic evaluations. Does the choice of hospitals make a difference?

OBJECTIVE: The objectives of this study were (i) to develop a conceptual framework for selecting hospitals for unit cost estimates in national and international multicentre trials and (ii) to test the impact of alternative hospital selection on the cost results. DESIGN AND SETTING: Within the conceptual framework, the following considerations which can be used when selecting a sample of hospitals for unit cost estimates in multicentre trials were identified: the number of hospitals; the sampling method; and the desired level of geographical subanalysis. Results from a recently completed international multicentre trial were used to explore changes in cost results obtained by using alternative methods of selecting and stratifying hospitals for unit cost estimates. PATIENTS AND PARTICIPANTS: The study included 5041 women from 72 hospitals in 6 countries with prelabour rupture of the membranes at term. INTERVENTIONS: The women were randomly assigned to induction of labour with intravenous oxytocin, induction of labour with prostaglandin E2 gel, or expectant management for up to 4 days with labour induced if complications developed. MAIN OUTCOME MEASURES AND RESULTS: Across each of the 4 management strategies of the study, the method of selecting and stratifying hospitals resulted in a 30 to 55% difference between the lowest and highest median unit cost estimates. In some cases, the relative ranking of the least to most expensive strategy varied across methods of hospital selection. The statistical comparisons across strategies found that the method used had a substantial impact on the conclusions of the economic evaluation. CONCLUSIONS: Unit cost information should be collected from as many hospitals as possible. Multivariate hospital cost studies are needed to identify important cost drivers that will assist with hospital selection in the future.     

A note on the estimation of confidence intervals for cost-effectiveness when costs and effects are censored.

BACKGROUND: The relation between methodological advances in estimation of confidence intervals (CIs) for incremental cost-effectiveness ratios (ICER) and estimation of cost effectiveness in the presence of censoring has not been explored. The authors address the joint problem of estimating ICER precision in the presence of censoring. METHODS: Using patient-level data (n = 168) on cost and survival from a published placebo-controlled trial, the authors compared 2 methods of measuring uncertainty with censored data: 1) Bootstrap with censor adjustment (BCA); 2) Fieller's method with censor adjustment (FCA). The authors estimate the FCA over all possible values for the correlation (rho) between costs and effects (range = -1 to + 1) and also examine the use of the correlation between cases without censoring adjustment (i.e., simple time-on-study) for costs and effects as an approximation for rho. RESULTS: Using time-on-study, which considers all censored observations as responders (deaths), yields 0.64 life-years gained at an additional cost of 87.9 for a cost per life-year of 137 (95% CI by bootstrap -5.9 to 392). Censoring adjustment corrects for the bias in the time-on-study approach and reduces the cost per life-year estimate to 132 (=72/0.54). Confidence intervals with censor adjustment were approximately 40% wider than the base-case without adjustment. Using the Fieller method with an approximation of rho based on the uncensored cost and effect correlation provides a 95% CI of (-48 to 529), which is very close to the BCA interval of (-52 to 504). CONCLUSIONS: Adjustment for censoring is necessary in cost-effectiveness studies to obtain unbiased estimates of ICER with appropriate uncertainty limits. In this study, BCA and FCA methods, the latter with approximated covariance, are simple to compute and give similar confidence intervals.