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Objective. Comparing activity of 2 regimens combining oxaliplatin to bolus modulated fluorouracil as second line treatment in advanced pancreatic adenocarcinoma pretreated with gemcitabine-containing schedule. Methods. Forty eight patients with advanced pancreatic adenocarcinoma were randomly assigned to receive either FU 500 mg/m2 IV bolus weekly ×6 weeks plus leucovorin 500 mg/m2 IV weekly for 6 weeks during each 8-week cycle plus oxaliplatin 85 mg/m2 IV on weeks 1, 3, and 5 of each 8-week (FLOX) OR receive weekly intravenous infusions of oxaliplatin 40 mg/m2, 5-FU 500 mg/m2, and leucovorin 250 mg/m2 (3 weeks on, 1 week off). Results. Non progression (PR+SD) was found in 33.5% for first regimen and 29% for second regimen, and 37.5% had clinical benefit (FLOX regimen) compared to 50% in 3-weeks regimen. The median TTP was 3.9,4 months respectively. Median OS was 8, 9 months for both regimens. Only one case in 3-weeks arm suffered from grade IV diarrhea. Two cases > grade 2 neutropenia were observed; one in each treatment groups. Grade 3 anemia was recorded in 3 patients (2 in FLOX arm, one in 3-weeks arm). Conclusions. Both regimens showed encouraging efficacy, acceptable toxicity, and clinical benefit. [ABSTRACT FROM AUTHOR]

Background: To evaluate the cost-effectiveness of growth hormone (GH) treatment (Genotropin®) compared with no GH treatment in adults with GH deficiency in a Swedish societal setting. Methods: A Markov-type cost-utility simulation model was constructed and used to simulate, for men and women, morbidity and mortality for GH-treated and -untreated individuals over a 20-year period. The calculations were performed using current available prices concerning morbidity-related healthcare costs and costs for Genotropin®. All costs and treatment effects were discounted at 3%. Costs were expressed in Euro (1€ = 9.03 SEK). GH-treated Swedish patients (n = 434) were identified from the KIMS database (Pfizer International Metabolic Database) and untreated patients (n = 2135) from the Swedish Cancer Registry and the Hospital Discharge Registry. Results: The results are reported as incremental cost per quality-adjusted life year (QALY) gained, including both direct and indirect costs for GH-treated versus untreated patients. The weighted sum of all subgroup incremental cost per QALY was €15,975 and €20,241 for men and women, respectively. Including indirect cost resulted in lower cost per QALY gained: €11,173 and €10,753 for men and women, respectively. Key drivers of the results were improvement in quality of life, increased survival, and intervention cost. Conclusions: The incremental cost per QALY gained is moderate when compared with informal thresholds applied in Sweden. The simulations suggest that GH-treatment is cost-effective for both men and women at the €55,371 (SEK 500,000--the informal Swedish cost-effectiveness threshold) per QALY threshold. [ABSTRACT FROM AUTHOR]

Background Laparoscopic inguinal hernia repair has been widely adopted. While the clinical advantages and disadvantages are well-quantified, the economic cost is less well-studied. Methods A retrospective audit and case review of a single-centre public hospital consecutive case series was performed using data captured from real-time stock usage tracking technology and review of electronic medical records. Results Laparoscopic inguinal hernia repair requires 11-min (21%) extra theatre time and costs $1268 (370%) more for single-use disposable equipment and prostheses. Conclusions Laparoscopic inguinal hernia repair does not require significantly more theatre time, but has a higher short-term in-hospital cost. Repair technique should be tailored according to patient factors. [ABSTRACT FROM AUTHOR]

Purpose. Improved outcomes and cost savings achieved at a large hospital through a drug utilization benchmarking and reporting initiative are described. Summary. Using the University HealthSystem Consortium (UHC) Clinical Resource Manager (CRM) database, the University of Kansas Hospital identified nine target areas (based on Medicare Severity Diagnosis- Related Group) in which the hospital's drug-utilization practices were deemed suboptimal relative to those of other UHC member facilities with similar caseloads. The pharmacy department developed a CRM template for generating customized reports comparing the hospital's performance on various drug-utilization metrics with that of top-performing peers (i.e., institutions achieving the best patient care outcomes in terms of mortality and length of stay) in the nine target areas. A pre-post comparison of drug-utilization data collected before and after implementation of the reporting initiative indicated improved outcomes in all nine initially selected target areas, with estimated cumulative annualized cost savings of about $900,000. The CRM-generated reports are now distributed semiannually to attending physicians and other hospital leaders via electronic and hard-copy means, focusing on variances from UHC top-performer and overall UHC averages in the use of higher-cost drugs. The reporting initiative has generally fostered enhanced physician-pharmacist collaboration in the investigation of identified drug-utilization variances and implementation of practice changes. Conclusion. By evaluating service-specific trends of internal drug utilization against external benchmarks and emulating prescribing practices at top-performing institutions, an academic medical center has achieved improved patient care outcomes and cost savings. [ABSTRACT FROM AUTHOR]

The HIV pandemic continues to be one of our greatest contemporary public health threats. Policy makers in many middle- and low-income countries are in the process of scaling up HIV prevention, treatment and care services in the context of a reduction in international HIV funding due to the global economic downturn. In order to scale up services that are sustainable in the long term, policy makers and implementers need to have access to robust and contemporary strategic information, including financial information on expenditure and cost, in order to be able to plan, implement, monitor and evaluate HIV services. A major problem in middle- and low-income countries continues to be a lack of basic information on the use of services, their cost, outcome and impact, while those few costing studies that have been performed were often not done in a standardized fashion. Some researchers handle this by transposing information from one country to another, developing mathematical or statistical models that rest on assumptions or information that may not be applicable, or using top-down costing methods that only provide global financial costs rather than using bottom-up ingredients-based costing. [ABSTRACT FROM AUTHOR]

Nucleoside reverse transcriptase inhibitors (NRTIs) remain a critical component of therapy for HIV-infected patients. The drugs are effective, relatively inexpensive and an important component of antiretroviral therapy (ART), particularly in areas where the introduction of effective therapy has been delayed. They are an essential part of initial therapy for HIV and for prevention of mother-to-child transmission; however, toxicities and resistance may limit their use. The role for pre-exposure prophylaxis (PrEP) to reduce sexual transmission of HIV is still undefined, but this use may have a significant impact on NRTI resistance worldwide, most particularly in areas where subtype C predominates. With increasing prevalence of resistant HIV, the approval of new agents that are effective against resistant virus, and those that use novel cellular targets, are essential. Large studies are now in progress examining the safety and efficacy of NRTI-sparing regimens, but results are not currently available. NRTIs may lose relevance in the not distant future unless steps are put in place to reduce the development and spread of NRTI- resistant viruses, and new NRTIs with minimal toxicity are developed that have a novel resistance profile. This article describes the principal NRTIs, their mechanism of action, and resistance and selected toxicities of the class and of the individual drugs. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) is associated with significant economic burdens to both patients and the healthcare system, but pharmaceutical cost analyses are uncommon despite drug therapy being a cornerstone of CKD management. Methods: This observational, retrospective review of drug cost distribution at a single tertiary care pediatric nephrology program in Canada was conducted on prevalent patients with CKD aged 1 month to 20 years, between 1 January and 31 December 2009. Results: The time-adjusted annual pharmaceutical cost of our cohort ( n = 148) was just below US $250,000 with a cost per patient per year of $1,800. The highest costs were in the growth and nutrition category, followed by anemia, hypertension and bone metabolism. Total drug cost per patient increased as CKD stage advanced. Adherence was not demonstrated in any drug category, and the mean daily pill burden was nine (range 2-23). Conclusions: This study has shown that while the annual pharmaceutical costs on a per patient basis are similar between children and adults, the cost distribution is very different. An increase in awareness of the unique needs of the pediatric population should allow for more cost-effective financial planning in pediatric CKD clinics. [ABSTRACT FROM AUTHOR]

The article discusses Osteoporosis, which is characterized by low bone mass with microarchitectural disruption and skeletal fragility, common in aging women due to progressive post-menopausal bone loss. It suggests that with Bone mass density (BMD) screening and fractural risk assessment (FRAX), healthcare providers can implement effective intervention before fracture occurs. It also provides information on pharmacological and lifestyle therapy.

Objective: To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT). Design: Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59). Methods:We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Results: Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior. Discussion: Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective. [ABSTRACT FROM AUTHOR]

Orphan drugs are intended for diseases with a very low prevalence, and many countries have implemented legislation to support market access of orphan drugs. We argue that it is time to revisit the special market access status of orphan drugs. Indeed, evidence suggests that there is no societal preference for treating rare diseases. Although society appears to assign a greater value to severity of disease, this criterion is equally relevant to many common diseases. Furthermore, the criterion of equity in access to treatment, which underpins orphan drug legislation, puts more value on health improvement in rare diseases than in common diseases and implies that population health is not maximized. Finally, incentives for the development, pricing and reimbursement of orphan drugs have created market failures, including monopolistic prices and the artificial creation of rare diseases. We argue that, instead of awarding special market access status to orphan drugs, there is scope to optimize research and development (R&D) of orphan drugs and to control prices of orphan drugs by means of, for example, patent auctions, advance purchase commitments, pay-as-you-go schemes and dose-modification studies. Governments should consider carefully the right incentive strategy for R&D of orphan drugs in rare diseases. [ABSTRACT FROM AUTHOR]

Intraocular pressure (IOP) reduction is currently the only therapeutic approach demonstrated to preserve visual function in patients with glaucoma. The first line of glaucoma treatment consists of topical IOP-lowering medications, usually initiated as monotherapy. A significant proportion of patients require more than one medication to reach a target IOP at which optic nerve damage will not progress. As prostaglandin analogues (PGAs) are the most effective class for reducing IOP, one of the other commonly used classes (β-adrenoceptor antagonist [β-blocker], carbonic anhydrase inhibitor or α2-adrenoceptor agonist) is frequently combined with a PGA. In the last decade, the use of fixed combinations containing two medications in a single bottle has steadily increased. Fixed combinations have the potential to simplify the dosing regimen, increase patient adherence, avoid the washout effect of the second drop on the first medication instilled, decrease exposure to preservatives and, sometimes, reduce the cost of treatment. Clinical trials have evaluated PGA-based fixed combinations versus unfixed combinations (individual components administered concomitantly) or versus individual monotherapies; however, any advantage that the fixed combinations may have in terms of IOP-lowering efficacy is still debated. For these reasons, the PGA-based fixed combinations are not approved by regulatory authorities in some countries, such as the US. We review the published studies evaluating the efficacy and tolerability of the IOP-lowering unfixed and fixed combination therapies with PGAs. Regarding unfixed combinations, the review shows that α2-adrenergic agonists-PGA and carbonic anhydrase inhibitor-PGA combinations seem to be at least as effective at reducing IOP as the β-blocker-PGA combinations. As for the fixed combinations, the review shows that the three PGA-timolol fixed combinations are more effective than their component medications used separately as monotherapy and are better tolerated than the three respective prostaglandins. The three PGA-timolol fixed combinations are less effective at reducing IOP than the unfixed combinations but are better tolerated. The advantage of the fixed combinations in terms of patient adherence and persistence is supported by a very small number of studies and remains to be more accurately determined. Most studies, but not all, seem to show that PGA-timolol fixed combinations are more effective than other available β-blocker fixed combinations (dorzolamide-timolol fixed combinations) at reducing IOP and are similarly tolerated [ABSTRACT FROM AUTHOR]

The article offers recommendations for the treatment of adults suffering with minimal change disease (MCD). Topics discussed include use of drugs corticosteroids for treatment of nephrotic syndrome, cyclophosphamide in frequently relapsing MCD and maintaining initial high dose of corticosteroids. It suggests treating MCD patients who have acute kidney injury (AKI) with renal replacement therapy.

Purpose: To analyze the changes in pain severity and associated costs resulting from resource utilization and reduced productivity in patients with gabapentin-refractory peripheral neuropathic pain who switched to pregabalin therapy in primary care settings in Spain. Patients and Methods: This is a post hoc analysis of a 12-week, multicentre, noninterventional cost-of-illness study. Patients were included in the study if they were over 18 years of age and had a diagnosis of chronic, treatment-refractory peripheral neuropathic pain. The analysis included all pregabalin-naïve patients who had previously shown an inadequate response to gabapentin and switched to pregabalin. Severity of pain before and after treatment with pregabalin, alone or as an add-on therapy, was assessed using the Short-Form McGill Pain Questionnaire (SF-MPQ) and its related visual analogue scale (VA). Healthcare resource utilization, productivity (including lost-workday equivalents [LWDE]), and related costs were assessed at baseline and after pregabalin treatment. Results: A total of 174 patients switched to pregabalin had significant and clinically relevant reductions in pain severity (mean [SD] change on SF-MPQ VA scale, −31.9 [22.1]; P < 0.05 vs. baseline; effect size, 1.87). Reduction in pain was similar with both pregabalin monotherapy and add-on therapy. Significant reductions in healthcare resource utilization (concomitant drug use [in pregabalin add-on group], ancillary tests, and unscheduled medical visits) were observed at the end of trial. Additionally, there were substantial improvements in productivity, including a reduction in the number of LWDE following pregabalin treatment (−18.9 [26.0]; P < 0.0001). These changes correlated with substantial reductions in both direct (−652.9 ± 1622.4 €; P < 0.0001) and indirect healthcare costs (−851.6 [1259.6] €; P < 0.0001). Conclusions: The cost of care in patients with gabapentin-refractory peripheral neuropathic pain appeared to be significantly reduced after switching to pregabalin treatment, alone or in combination with other analgesic drugs, in a real-life setting. [ABSTRACT FROM AUTHOR]

Background: Autologous chondrocyte implantation (ACI) involves the use of a periosteal patch (ACI-P) as a cover for transplanted chondrocytes. Theoretically, this periosteal patch provides mesenchymal stem cells and growth factors that encourage chondrocyte development/differentiation. However, there is a significant rate of graft hypertrophy with the use of periosteum compared with using a type I/III collagen patch (ACI-C). This type I/III collagen patch, although not approved by the United States Food and Drug Administration for ACI, has been used extensively in Europe and in an “off-label” nature in the United States as a cover during ACI.Purpose: To examine the cost effectiveness of ACI and determine whether ACI-C is more cost effective than ACI-P.Study Design: Economic and decision analysis; Level of evidence, 2.Methods: Outcome data and complication rates from patients undergoing ACI (ACI-P and ACI-C) were derived from the best evidence in the literature. Costs were determined by examining the typical patient charges undergoing ACI at a local orthopaedic hospital. The costs, results, and complication rates were used to develop a decision analysis model comparing ACI-P to ACI-C.Results: The cost of ACI-P was $66,752 and for ACI-C was $66,939.50 ($187.50 difference). The cost per quality-adjusted life year (QALY) for ACI-P was $9466 compared with $9243 for ACI-C. Sensitivity analysis was performed regarding the additional cost of the type I/III collagen patch ($780) in ACI-C as well as the rate of graft hypertrophy after ACI-P (25%). This analysis revealed that the cost of the type I/III collagen patch would have to reach $1721, or the rate of graft hypertrophy after ACI-P reduced to almost 11%, before ACI-P became more cost effective than ACI-C.Conclusion: This cost-effectiveness analysis reveals that, while both ACI-P and ACI-C are cost effective, ACI-C is slightly more cost effective than ACI-P. This is likely secondary to the significant rate of patch-related complications associated with ACI-P, which is significantly reduced with ACI-C. Although the model is very sensitive to differences in outcomes between ACI-P and ACI-C, there is no high-quality evidence to suggest that there is a significant difference between the two. Thus, ACI-P becomes more cost effective if the cost of the type I/III collagen membrane is significantly increased or if the rate of graft hypertrophy after ACI-P were to be markedly reduced. [ABSTRACT FROM PUBLISHER]

Abstract: Background: The clinical benefits of dual antiplatelet treatment (aspirin + clopidogrel) in the management of acute coronary syndromes (ACS) are well established. However, clopidogrel is a prodrug that requires hepatic activation. Concerns regarding its delayed onset of action, variability in antiplatelet effects, and prolonged recovery of platelet function after discontinuation have prompted the development of P2Y12 receptor antagonists. Ticagrelor is the most recently developed P2Y12 receptor antagonist available in the United States. Ticagrelor is a nonthienopyridine antiplatelet agent and is the first reversible oral antagonist of the P2Y12 receptors. Objective: This article reviews the pharmacology, clinical efficacy, and tolerability of ticagrelor use in management of ACS. Methods: Peer-reviewed clinical trials, review articles, and relevant treatment guidelines published from 1966 to March 15, 2012, were identified from the MEDLINE and Current Content databases using the search terms ticagrelor, ACS, pharmacokinetics, pharmacodynamics, pharmacoeconomics, and cost-effectiveness. Citations from available articles were also reviewed for additional references. Results: Nine pharmacokinetics/pharmacodynamics studies in humans and 1 clinical study were identified. In addition, the findings from 6 subanalyses based on the clinical study were included. Compared with clopidogrel, ticagrelor was associated with a significantly reduced composite rate of death from cardiovascular causes, myocardial infarction, or stroke (ticagrelor, 9.8%; clopidogrel, 11.7%; hazard ratio [HR] = 0.84; 95% CI, 0.77–0.92; P < 0.001). The difference in the rates of major bleeding was not significant (ticagrelor, 11.6%; clopidogrel, 11.2%). Ticagrelor was associated with a higher rate of non–coronary artery bypass graft surgery related major bleeding (4.5% vs 3.8%; P = 0.03), including fatal intracranial bleeding (0.1% vs 0.01%; P = 0.02), and fewer cases of other types of fatal bleeding (0.1% vs 0.3%; P = 0.03). Other adverse events reported with ticagrelor use included dyspnea (13.8%), headache (6.5%), and bradyarrhythmia (5.8%). The effects of ticagrelor have not been compared to those of other antiplatelet agents, including prasugrel. Conclusions: Based on the findings from the present review, ticagrelor provides reversible inhibition of adenosine diphosphate–induced platelet aggregation, with a faster onset of action than clopidogrel, and is effective in the treatment of patients with ACS. More data are required to definitively position ticagrelor with respect to other antiplatelet agents, including prasugrel. [Copyright &y& Elsevier]

Purpose: Practice guidelines do not recommend the routine use of colony-stimulating factors when there is a low risk (10%) of febrile neutropenia (FN). We prospectively determined whether expert peer-to-peer consultation with prescribing oncologists would improve adherence to guidelines and whether there would be any adverse events associated with that adherence. Methods: Commencing in March 2010, we reviewed requests for pegfilgrastim from 22 community oncology practices comprising 78 physicians providing service to approximately 97,000 Medicare members. Paid claims data on all chemotherapy and supportive care medications were reviewed from fourth quarter (Q4) 2009 through third quarter (Q3) 2010. In total, 82 patients received pegfilgrastim. If the prescribed chemotherapy was associated with a low risk (< 10%) for FN, then a peer review was initiated. The treating physician made the final decision to use, or not use, pegfilgrastim, and no denials were issued. Results: A total of 245 units (1 unit = 6 mg) of pegfilgrastim were administered during the four quarters analyzed. Use in the low-risk category decreased from 52 units in Q4 2009 to 15 units in Q3 2010. The per-member per-month (PMPM) cost of pegfilgrastim decreased across quarters, with an average cost of $1.07 PMPM for Q4 2009 and $0.57 PMPM for Q3 2010. No studied patient was admitted for neutropenic fever. Conclusion: Active expert peer-to-peer consultation with prescribing oncologists can promote adherence to guidelines and potentially lead to significant cost reductions without significant risk of neutropenic fever, with or without hospitalization, for patients with cancer. [ABSTRACT FROM AUTHOR]

Purpose: The use of anticancer drugs (chemotherapies) is an important determinant of national spending trends. Recent policies have aimed to accelerate generic entry among chemotherapies to generate cost savings. Methods: We examined the effects of generic entry on the choice of chemotherapy for the treatment of metastatic colorectal cancer (MCRC) between 2006 and 2009 using autoregressive-moving average modeling with case control. A nationally representative sample of oncologists and patients with cancer (age ≥ 65 years) was employed to estimate the magnitude and significance of the impact of the generic entry of irinotecan in February 2008 on the number of administrations of irinotecan compared with oxaliplatin. Results: The generic entry of irinotecan resulted in a 17% to 19% decrease (P < .001) in use among elderly patients with MCRC compared with oxaliplatin. The results were robust to multiple sensitivity checks. Conclusion: This study provides novel and robust estimates of the decline in use of a chemotherapy to treat a common cancer in the elderly after patent expiration. The results suggest estimates from a previous Office of the Inspector General report of the potential savings derived from the generic entry of irinotecan for public payers are an overestimate, likely confounded by oncologists' response to financial incentives, changes in scientific evidence, and promotional activities. As calls for improving the quality and cost efficiency of oncology increase, future empirical work is needed to examine the responsiveness of oncologists' treatment decision making to incentives among patients of all ages and insurance types. [ABSTRACT FROM AUTHOR]

Purpose. Patient safety and cost-control benefits achieved through a medical center's conversion to commercial fluids for continuous renal-replacement therapy (CRRT) are described. Summary. In keeping with national patient safety recommendations, a medical center undertook a quality-improvement initiative to increase the standardization of CRRT fluids and associated patient care practices. After a feasibility study to ascertain CRRT fluid usage patterns and baseline costs, an appropriate commercial product was selected. The transition was implemented over several months in a three-phase process entailing (1) conversion to a commercial product for regional citrate anticoagulation, (2) changing the standard formula on preprinted orders to one that modeled a commercial product, and (3) conversion to the actual commercial product as the standard. Thorough education of all parties involved, as well as modifications to preprinted orders, occurred during each phase of the project. The use of the commercial product reduced the need for pharmacy compounding of CRRT fluids by more than 80%. A postconversion cost analysis indicated sharp reductions of product and labor (i.e., compounding) expenses relative to estimated baseline costs, with estimated total savings of at least $399,290 during the first six months after the conversion initiative. Implementation challenges included the need to manually adjust the potassium content of the commercial CRRT fluid and the need to provide i.v. supplementation of phosphorus and magnesium to some patients receiving the fluid. The initiative emphasized the need for institution-specific research and planning before conversion initiatives targeting CRRT fluids and other critical therapies, as well as proper education and training of all parties involved. Conclusion. The standardization of CRRT fluids using commercially available products improved a medical center's compliance with patient safety standards and yielded substantial cost savings. [ABSTRACT FROM AUTHOR]

Objective. To characterize the impact of etanercept (ETN) in AS on cost, work productivity and quality of life (QoL).Methods. A Phase 4, open-label, multi-centre (UK, Scandinavia) extension study in AS. Eligible subjects (n = 84) were treated for 36–52 weeks with ETN 50 mg s.c. once weekly. Analysis included direct costs (transformed out-patient and in-patient care elements), indirect costs (sick leave and lost working days), efficacy and QoL.Results. Annualized direct and indirect costs decreased (55.5%, P &leq; 0.008) during ETN treatment, as did out-patient and in-patient episodes (physiotherapist/physician visits, P = 0.012). Work productivity and QoL increased.Conclusion. ETN therapy significantly reduces direct and indirect health-care costs and increases work ability and QoL in AS.Trial Registration. EUDRACT, https://eudract.ema.europa.eu/, 2006-001061-42. [ABSTRACT FROM PUBLISHER]

Trastuzumab is a recombinant humanized monoclonal antibody that selectively targets the extra-cellular domain of the HER2 receptor. It was approved by the FDA in September 1998 as the first targeted therapy for HER2-positive metastatic breast cancer, and has since led to significant improvements in the overall prognosis for patients with HER2-positive metastatic disease. The favourable benefit/risk profile associated with palliative trastuzumab has been demonstrated in a number of clinical trials that examined trastusumab as monotherapy or in combination with chemotherapy, endocrine therapy and other HER2 targeted agents. The clinical benefits of trastuzumab, however should also be examined within the context of its significant drug acquisition costs. This review highlights the significant findings from the landmark clinical trials of trastuzumab for metastatic HER2-positive breast cancer, and the potential "value for money" associated with its use in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Factor VIIa (recombinant) has an off-label use to control life-threatening bleeding that is refractory to other measures and was shown to decrease transfusion requirements. Objective: The primary objective of this study was to assess the safety and effectiveness of factor VIIa (recombinant) on blood transfusion requirements and coagulation parameters when used in patients whose bleeding was uncorrected by other means. The pharmacoeconomic impact for any discrepancy from our protocol was evaluated. Secondary outcomes included 4-hour and 28-day mortality, as well as safety of this agent in terms of thromboembolic complications. Materials and Methods: We retrospectively evaluated patients who received recombinant-activated factor VII (rFVIIa) for uncontrolled bleeding from June 2008 to April 2011. The medical records of 33 patients were evaluated. Coagulation parameters and blood products were determined 24 hours before and 24 hours after administration of rFVIIa, and the results compared. Patients were also screened for any thromboembolic complications. Results: Administration of rFVIIa reduced blood transfusion requirements and improved coagulation parameters significantly (P<0.05). No thromboembolic complications were reported. Most of the dosing was consistent with those recommended in our institutional protocol, with discrepancies resulting in an average cost of $56 058. Moreover, pH was reported in only 67% of patients. All patients treated with rFVIIa survived up to 4 hours after receiving this agent, while the 28-day mortality was 24% (8/33). Conclusion: The use of rFVIIa appears to be safe and effective in promoting hemostasis, as evident from reducing transfusion requirements and improving the coagulation variables. [ABSTRACT FROM AUTHOR]

Abstract: Background: Fidaxomicin, a macrolide antibiotic, was the first medication for the management of Clostridium difficile infections (CDI) to be approved by the US Food and Drug Administration in more than 20 years. Objective: This article reviews published literature on fidaxomicin for management of CDI, including its chemistry, spectrum of activity, pharmacokinetic properties, pharmacodynamics, therapeutic efficacy, adverse events, dosing, administration, and pharmacoeconomic considerations. Methods: Pertinent English-language literature was reviewed through searches of MEDLINE, EMBASE, and BIOSIS from 1975 through September 2011. Reference lists of identified publications and published abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy meetings were also reviewed. Search terms included, but were not limited to, fidaxomicin, difimicin, lipiarmycin, tiacumicin B, OPT-80, Clostridium spp, and diarrhea. Results: A total of 79 publications were identified and 10 were excluded; 6 review articles and 4 abstracts that were later published as articles. Fidaxomicin''s in vitro profile is favorable compared with oral metronidazole and vancomycin, with minimum inhibitory concentrations against C difficile that are 2 dilutions lower. From the 2 published Phase III trials, fidaxomicin was deemed to be noninferior in the treatment of mild to moderate CDI compared with oral vancomycin. Recurrence rates for all strains of CDI were lower with fidaxomicin than vancomycin. Adverse events associated with fidaxomicin were similar to placebo, with nausea and vomiting being the most common. Although no pharmacoeconomic studies have compared fidaxomicin with metronidazole or vancomycin, the current price exceeds $2500 (US) per treatment course. Conclusions: Reports suggest that fidaxomicin is noninferior to oral vancomycin in the treatment of mild or moderate CDI, although no published comparisons with metronidazole exist to date. Additionally, fidaxomicin improved outcomes compared with oral vancomycin in terms of rates of relapse and recurrent CDI, and in patients who might require concomitant antibiotics. Prospective, randomized studies comparing fidaxomicin with metronidazole in the treatment of mild or moderate CDI, as well as against vancomycin for severe CDI, should be undertaken to clarify the exact role of fidaxomicin in clinical practice. [Copyright &y& Elsevier]

Restoration of form and function after burn injury remains challenging, but emerging laser and pulsed light technologies now offer hope for patients with hypertrophic scars, which may be associated with persistent hyperemia, chronic folliculitis, intense pruritis, and neuropathic pain. In addition to impairing body image, these scars may limit functional recovery, compromise activities of daily living, and prevent return to work. Three different platforms are now poised to alter our reconstructive algorithm: (1) vascular-specific pulsed dye laser (PDL) to reduce hyperemia, (2) ablative fractional CO2 laser to improve texture and pliability of the burn scar, and (3) intense pulsed light (IPL) to correct burn scar dyschromia and alleviate chronic folliculitis. In this paper, we will provide an overview of our work in this area, which includes a systematic review, a retrospective analysis of our preliminary experience, and interim data from our on-going, prospective, before-after cohort trial. We will demonstrate that laser- and light-based therapies can be combined with each other safely to yield superior results, often at lower cost, by reducing the need for reconstructive surgery. Modulating the burn scar, through minimally invasive modalities, may replace conventional methods of burn scar excision and yield outcomes not previously possible or conceivable. [ABSTRACT FROM AUTHOR]

Abstract: A total of 24 well-defined PKB/Akt1 inhibitors were used to generate pharmacophore models applying Catalyst/HypoGen program. The best ranked model (Hypo_1) was then validated by cost analysis, prediction capability, Cat-Scramble and receiver operating characteristic (ROC) studies. Then, pharmacophore-based virtual screening combined with docking study was performed to search an in-house compound database. Nine preferable hits 75–80, HTS-02143, BTB-14740 and HTS-08006 were prepared and biologically evaluated. Several compounds were identified as good PKB/Akt1 inhibitors, suggesting that Hypo_1 would be reliable and useful in virtual screening. Flow cytometric and western blotting analysis on compounds 79 and 80 further demonstrated that the inhibition of phosphorylation of PKB/Akt1 and its substrates (such as GSK3β) was responsible for their cytotoxic activities. [Copyright &y& Elsevier]

The article presents a cohort study which evaluates the cost-effectiveness of spinal cord stimulation (SCS) for failed back surgery syndrome (FBSS) among workers' compensation recipients. The study was participated by 158 FBS patients which were enrolled into three treatment entities such as trial SCS with or without permanent device implant, pain clinic evaluation with or without treatment, and the usual care. The study concluded that SCS is not cost-effective since SCS has high procedure cost.

Study design:A prospective study.Objectives:To determine the cost of acute phase of injury (ASCI) among spinal cord-injured patients managed conservatively in Nigeria.Settings:Gwagwalada, Abuja.Methods:Over a 1-year period (1 January 2009 to 31 December 2009), the cost of ASCI of consecutive spinal cord-injured patients, gainfully employed preinjury, who paid the hospital bill directly from their purses and could estimate their daily income, and who were managed conservatively for 6 weeks before discharge to rehabilitation, was prospectively examined.Results:A total of 34 cases of spinal cord-injured patients with a mean age of 35.4±12.8 years were included in this study. The mean cost of ASCI over 6 weeks was $1598.29, an average of 6.4-232.8% of patients' annual income where >50% of the people live on less than a dollar a day. The mean cost of hospitalization was 14.9% of the total cost of ASCI in this study. It was significantly more expensive to treat tetraplegics compared with paraplegics.Conclusion:This study identified the cost of acute phase of spinal cord injury in Nigeria to assist clinicians in planning treatment that could reduce financial burden on the patients but optimize patients' care. [ABSTRACT FROM AUTHOR]

Purpose: In recent years, colorectal cancer surgery has benefitted from new techniques such as laparoscopy and robotic surgery. However, many treatment disparities exist among different centers for patients affected by the same kind of tumors. Methods: Forty-five (41%) open (OCO) vs. 30 (28%) laparoscopic (LCO) vs. 34 (31%) robotic-assisted (RCO) colectomies and 34 (40%) open (ORR) vs. 52 (60%) robotic (ROR) rectal resections performed during a 15-month period, in elective setting, were compared. Patients presenting contraindications for minimally invasive procedures were excluded from the study, so that all the enrolled patients were suitable for either of the surgical procedures. Results: Overall morbidity rates were similar among groups. Perioperative mortality was nil. No significant differences were noted as for total number of lymph nodes harvested between arms. Mean time (days) to first bowel movement to gas was 3.3 vs. 2.3 vs. 2.6 for OCO, LCO, and RCO, respectively ( p < 0.001), and 3.3 vs. 2.0 for ORR and ROR, respectively ( p = 0.003). Among several European Organization in Research and Treatment of Cancer QLQ-C30 functional scales considered only physical functioning was significantly better at 30 days for RCO vs. OCO (96.3 ± 10 RCO vs. 85.5 ± 12.6 OCO; p = 0.015). Robotic surgery was much more expensive in comparison to open as well as laparoscopic procedures. Conclusions: Laparoscopic and robotic surgeries for colorectal cancer present both the same advantages in comparison to open procedures in terms of faster recovery. However, our data do not seem to support the routine use of RCO as a cost-effective procedure. [ABSTRACT FROM AUTHOR]

Purpose: Rasburicase is a recombinant urate oxidase enzyme generally reserved for the treatment or prevention of hyperuricemia in patients that are at high risk of developing tumor lysis syndrome (TLS). The primary objective of this study is to evaluate and characterize the outcomes of patients receiving low dose rasburicase for treatment or prophylaxis of hyperuricemia secondary to TLS.Patients/Methods: A retrospective chart review between April 1, 2007 and September 31, 2008 was completed. All adult patients who received a dose of 0.05mg/kg with either a leukemia or lymphoma diagnosis in addition to at least two TLS risk factors: WBC ≥ 50 × 109/L, LDH 2 × ULN, uric acid ≥ 8 mg/dl, SCr ≥ 1.5 mg/dl were included. Forty-eight patients received rasburicase for prophylaxis (n = 18) or treatment (n = 30) of TLS.Results: Forty patients achieved and maintained a uric acid less than 8 mg/dL, 24 h after receipt of a single dose of rasburicase without the requirement for renal replacement therapy. A statistically significant decrease in UA was achieved in all patients when compared to baseline (p < 0.001). Cost analysis revealed a $ 1.96 million (96%) direct cost savings for the 48 patients in this study when compared to the cost of manufacturer’s dosing recommendation.Conclusions: Low dose rasburicase was efficacious and cost effective for both prophylaxis and treatment of TLS. Administration of a single dose of 0.05mg/kg of rasburicase was sufficient in correcting uric acid levels for most patients. [ABSTRACT FROM PUBLISHER]

Purpose: To assess the value of granulocyte colony-stimulating factors (G-CSF) in promoting recovery from established episodes of febrile neutropenia (FN) after chemotherapy in cancer patients.Method: The literature was searched using the MEDLINE, EMBASE, BIOSIS, and IPA databases. Reference lists from the retrieved papers and hand searches of relevant journals complemented the search. Eleven randomized controlled trials were selected for review.Result: G-CSF use in established FN appears to be limited to a small reduction in neutropenia duration, length of hospitalization, and duration of antibiotic use. Overall, there are no significant reductions in time to neutrophil recovery and fever resolution. The cost analyses performed do not show significant cost savings.Conclusion: Granulocyte colony-stimulating factors (G-CSF) are biological agents typically used for prevention of febrile neutropenia (FN) or as adjunctive treatment with antibiotics of established FN. Most clinical guidelines discourage the general use of G-CSF for adjunctive treatment of ongoing neutropenic fever; however, its use in special situations, such as high-risk for infectious complications or adverse prognostic factors, is advised. G-CSF should be reserved for high-risk cancer patients, in accordance with the results of this review. This recommendation needs to be taken with caution in view of the disparities and methodological flaws found among trials. It is necessary to design further trials appropriately, well-powered and focused on high-risk patients. Moreover, it is necessary to perform an appropriate economic evaluation for this setting. [ABSTRACT FROM PUBLISHER]

Objective: Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults. Methods: Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs. Results: Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) ( p¼0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms. Conclusion: Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms. [ABSTRACT FROM AUTHOR]

Background and aim: This study attempts to estimate the socioeconomic differences between three major alternatives for the management of upper and lower ureteral lithiasis. Material and methods: Two hundred and forty patients with upper and lower ureteral lithiasis, have been studied retrospectively, divided in six equal groups of forty. These patients have been treated either by extracorporeal shockwave lithotripsy (SWL), or with ureteroscopy with semirigid ureteroscope and the use of pneumatic lithoclast, or with ureteroscopy with flexible ureteroscope and the use of Holmium YAG Laser. For cost calculation, the reimbursement fee paid by insurance to the hospital was taken into account. For the estimation of the social burden, the length of hospital stay and the number of outpatient visits have been included as countable parameters. Results: The percentage of effective stone removal for upper ureter was 81.0% for SWL, 62.5% for ureteroscopy with semirigid ureteroscope and the use of pneumatic lithoclast and, 82.5% for ureteroscopy with flexible ureteroscope and the use of Holmium YAG Laser. The same percentages for lower ureter were 82.5%, 92.5% and 97.5% respectively. The cost of stone removal for both the upper and lower ureter using extracorporeal lithotripsy was significantly higher compared to the other two procedures (median cost for upper ureter 828 € vs 474.50 € and 396 € respectively, and for lower ureter 826 € vs 396 € and 271 €, p<0.001). Regarding the social aspect, SWL is mainly an outpatient procedure, requiring a short hospital stay (for upper ureter 1.63 vs 2.48 and 2.45 respectively and for lower ureter 1.35 vs 2.43 and 2.13days), but needing more and prevailing clinic visits (for upper ureter 1.43 vs 1.45 and 1 respectively and for lower ureter 1.45 vs 1.15 and 0.55 visitsgive numbers, compare), both in outpatient and in accident and emergency (A&E) department. Conclusion: The increase in the expenses with regard to health management indicates the necessity of cost accounting the health programs including the medical procedures as a means to improve the relation between cost and benefit. [ABSTRACT FROM AUTHOR]

Patients with benign paroxysmal positional vertigo (BPPV) often require multiple appointments for treatment with Epley manoeuvres. Waiting times for medical follow up can be very long. To reduce waiting times and increase availability of ENT outpatients' appointments, a nurse-led dizziness clinic (NLDC) to follow up BPPV patients was established. Prospective audit of 99 consecutive patients attending the NLDC, at which patients are assessed and treated, was conducted. Non-responders are redirected for further medical review. 99 patients were seen in 200 appointments in the NLDC from July 2007 to May 2009. The mean time to NLDC was 16 days. 67 patients were discharged from the NLDC free of symptoms. Cost analysis revealed savings of £3,800. A survey of NLDC attendees revealed that the care they received was rated as excellent, very good or good by 92% of patients. In conclusion, the NLDC is an innovation which increases availability of ENT outpatient appointments. This is acceptable to patients and is a natural extension of the roles of ENT nurse practitioners which could be implemented in other ENT departments. [ABSTRACT FROM AUTHOR]

AbstractBackground:Many patients with type 2 diabetes mellitus (T2DM) are not able to maintain adequate HbA1ccontrol (<7.0%), even at maximal dosage levels of one or two oral agents, and are at increased risk for diabetes-related complications.Objective:To estimate the cost-effectiveness of a once-daily GLP-1 analog Victoza [Novo Nordisk] versus a thiazolidinedione (TZD), rosiglitazone in patients with T2DM. Both treatment groups included background therapy with glimepiride.Research design and methods:The CORE Diabetes Model (CDM) was used to project and compare 35-year clinical and economic outcomes associated with liraglutide 1.2  mg  +  glimepiride and liraglutide 1.8  mg  +  glimepiride versus rosiglitazone 4  mg  +  glimepiride. Baseline cohort characteristics (HbA1c(8.4%), age, duration of disease, sex, body-mass index (BMI), blood pressure, and lipids) were based on the Liraglutide Effect and Action in Diabetes-1 (LEAD-1) trial.Outcomes:Primary outcomes included life expectancy (LE), quality-adjusted life-years (QALYs), total costs and incremental cost-effectiveness ratios (ICERs).Results:When compared to rosiglitazone, liraglutide 1.2  mg and 1.8  mg increased mean LE by 0.968 and 1.041 years, and QALYs by 0.764 and 0.837, respectively. Total lifetime costs increased by $26  094 for liraglutide 1.2  mg versus rosiglitazone, and by $47  041 for liraglutide 1.8  mg versus rosiglitazone. ICERs for liraglutide 1.2  mg versus rosiglitazone and 1.8  mg versus rosiglitazone were $34  147 and $56  190, respectively.Conclusions:Compared to rosiglitazone 4  mg plus glimepiride, liraglutide (particularly at the 1.2-mg dose) plus glimepiride is a cost-effective treatment option for improving glucose control in T2DM. Limitations include the projection of short term efficacy results from randomized control trials to longer time horizons. In addition, clinical acceptance and overall use of rosiglitazone in the treatment of diabetes has continued to fall since publication of the clinical trial upon which this modeling analyses was based. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The provision of a complex lower-limb trauma service has significant resource implications. This financial burden is not recognised by the current fixed price tariff system (Payment by Results). The aim of this study was to compare the actual costs of treatment with reimbursement. Methods: We conducted a prospective study in two large regional plastic surgery centres in the UK, Salisbury Foundation Trust (SFT) and the Frenchay Hospital, Bristol (FH). The total cost of treatment for consecutive patients with complex lower limb trauma requiring free tissue transfer was calculated and compared with the Health Resource Group (HRG) tariff. Results: A cost analysis was performed on 20 patients (10 Salisbury, 10 Frenchay) with open tibial fractures (all grade IIIb Gustillo & Anderson) requiring free-flap reconstruction (15 anterolateral thigh (ALT) flaps, one serratus, one latissimus dorsi (LD), one scapular and two gracilis). The mean treatment cost of performing a free flap was £12792±£970 SEM (SFT) and £10953±£650 (FH). In both centres, the cost was more than double the HRG tariff (£4220 SFT, £4892 FH, p <0.05). Conclusions: Our study highlights the considerable disparity between the cost of managing patients with severe lower-limb trauma and the remuneration by Primary Care Trusts (PCTs). Accurate cost analysis of these cases will allow hospital trusts to negotiate appropriate tariffs with PCTs and develop services, which are cost neutral. [Copyright &y& Elsevier]

Bortezomib, thalidomide and lenalidomide can be aimed at treating patients with newly diagnosed multiple myeloma (both eligible and ineligible for transplantation) as well as those with relapsed or refractory disease. This review analysed the available clinical and economic data on these three drugs. Irrespective of which of the three agents is considered, the magnitude of the benefit in newly diagnosed cases (transplanted or non-transplanted) tends to be between 10 and 20 months per patient in terms of progression-free survival or survival; the survival benefit is smaller in relapsed or refractory disease. In addition, a single-institution observational analysis evaluated the outcomes in nearly 3000 consecutive patients examined between 1971 and 2006. The survival in patients diagnosed between 2001 and 2006 was longer than that observed in patients diagnosed between 1994 and 2000. This finding supports the conclusion that novel agents provide a survival improvement compared with traditional therapy. Formal cost-effectiveness studies on these three agents are still lacking. A MEDLINE search retrieved only four short papers or letters and no fulllength analysis. Hence, the cost effectiveness of these agents needs further investigation, with separate assessments of the different therapeutic settings. In a simplified analysis, we tried to contrast the average cost of treatment for each of the novel agents versus their respective benefit, expressed in quality-adjusted survival. Despite its preliminary nature, our assessment indicates that the cost effectiveness of these three agents is likely to be within commonly accepted pharmacoeconomic thresholds. [ABSTRACT FROM AUTHOR]

Objective: To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued.Design: Prospective cohort study in which women were followed for 18 months.Setting: Eight infertility practices.Patient(s): Three hundred ninety-eight women recruited from infertility practices.Intervention(s): Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used.Main Outcome Measure(s): Per-person and per-successful-outcome costs.Result(s): Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher--$61,377 for IVF, for example--reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not.Conclusion(s): Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment. [ABSTRACT FROM AUTHOR]

Aim: To describe a new and simple bicanalicular silicone intubation technique, which can be used during dacryocystorhinostomy (DCR) surgery.Method: In this method, a lacrimal canula is used to pass the silicone tube through the lacrimal canaliculi. A 26-Gauge curved lacrimal canula is inserted into one end of a silicone tube with an inner diameter of 0.50 mm and outer diameter of 0.94 mm. The lacrimal puncta are enlarged using a one-snip procedure. The canula is introduced together with the tube into the punctum and advanced to the rhinostomy site. Here, the tube is detached from the canula by a forceps and the canula retracted. The other canaliculus is intubated in a similar manner. The tubes are passed out through the rhinostomy site and nose, and tied inside the nose.Result: Silicone intubation was performed in 32 DCR procedures in 30 patients (revision DCR in 13 eyes, primary DCR in 10 eyes, canalicular DCR in 7 eyes, and endonasal DCR in 2 eyes) using the described method. No significant difficulty was encountered in any case. During the follow-up, a slit punctum developed in 1 eye and prolapsus of the tube at the medial canthus in another eye; no other complication was observed.Conclusion: This method eliminates the need for retrieval of a metal leader from the lacrimal canaliculi and rhinostomy site and facilitates silicone intubation during DCR. It is a relatively nontraumatic and inexpensive method that may be an alternative to the other intubation methods. [ABSTRACT FROM AUTHOR]

For relapsed or refractory multiple myeloma (RRMM), a series of novel agents (thalidomide, bortezomib and lenalidomide) has emerged during the latest decade, but their use in routine clinical practice is not well documented as well as the cost of RRMM. Our aim is to review the therapeutic management of such patients in France and to estimate the associated costs. A retrospective cohort study, based on chart reviews, was conducted in French Haematology Departments over the period 2004-2007 and the associated direct costs estimated. One hundred and two patients with a relapse after first-line therapy were selected from five centres. The average follow-up from diagnosis or the date of first relapse to death or to the latest news was respectively 56·25 and 23·53 months. Novel agents were used in 73% of all cases, and in all cases of first relapse. Thalidomide and bortezomib were respectively the most frequently used second-line (57%) and third-line treatments (44%). The average number of lines of treatment received per patient as from first relapse was 2·75 (min 1; max 8) and the mean direct cost per month was estimated at 3130 € after the first relapse. This cost was represented in greater part by the cost of chemotherapy drugs (66%). The use of novel agents such as thalidomide, bortezomib and lenalidomide for RRMM is highly prevalent in France from the first relapse. The associated medical cost is substantial mainly due to the cost of the new agents. [ABSTRACT FROM AUTHOR]

The article presents a study that showed the economic disease burden of measles in Japan and the effectiveness of the vaccination through benefit cost analysis. In the study measles patients were examined and measles vaccine was given to them. Data was analyzed and it was seen that through vaccination measles patients would be zero. Cost for measels treatment and vaccination were estimated respectively and it was found that cost of measels treatment is much more than the cost of vaccine.

Background: Emergency treatment of bleeding esophageal varices (BEV) in cirrhotic patients is of prime importance because of the high mortality rate surrounding the episode of acute bleeding. Nevertheless, there is a paucity of randomized controlled trials of emergency surgical therapy and no reports of the costs of any of the widely used forms of emergency treatment. The important issue of direct costs of care was examined in a randomized controlled trial that compared endoscopic sclerotherapy (EST) to emergency portacaval shunt (EPCS).Methods: Two hundred eleven unselected consecutive patients with ultimately biopsy-proven cirrhosis and endoscopically proven acute BEV were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic workup was completed, and EST or EPCS was initiated within 8 h. Criteria for failure of EST or EPCS were clearly defined, and crossover rescue treatment was applied, when primary therapy failed. Ninety-six percent of patients underwent more than 10 years follow-up, or until death. Complete charges for all aspects of care were obtained continuously for more than 10 years.Results: Direct charges for all aspects of care were significantly lower in patients treated by EPCS than in patients treated by emergency EST followed by long-term repetitive sclerotherapy. Charges per patient, per year of treatment, and per year in each child's risk class were significantly lower in patients randomized to EPCS. Charges in patients who failed endoscopic sclerotherapy and underwent a rescue portacaval shunt were significantly higher than the charges in both the unshunted sclerotherapy patients and the patients randomized to EPCS. This result was particularly noteworthy given the widespread practice of using surgical portacaval shunt as rescue treatment only when all other forms of therapy have failed.Conclusions: In this randomized controlled trial of emergency treatment of acute BEV, EPCS was significantly superior to EST with regard to direct costs of care as reflected in charges for care as well as in survival rate, control of bleeding, and incidence of portal-systemic encephalopathy. These results provide support for the use of EPCS as a first line of emergency treatment of BEV in cirrhosis. [ABSTRACT FROM AUTHOR]

Objectives: This study describes patients presenting for CranioSacral treatment, the conditions they present with, and the impact of treatment on both their symptoms and lives. Design: The records of 157 patients treated with Upledger CranioSacral Therapy (UCST) were reviewed. Seventy-three (73) patients had been treated by 10 different practitioners working independently and 84 patients were treated by a single practitioner working within the National Health Service. Results: Patients' ages ranged from neonates to 68 years. Seventy-four percent (74%) of patients reported a valuable improvement in their presenting problem. Sixty-seven percent (67%) also reported a valuable improvement in their general well-being and/or a second health problem. Outcome by diagnostic groups suggested that UCST is particularly effective for patients with headaches and migraine, neck and back pain, anxiety and depression, and unsettled babies. Seventy percent (70%) of patients on medication decreased or discontinued it, and patients' average general practitioner consultation rate fell by 60% in the 6 months following treatment. Conclusions: The study suggests that further research into UCST as a treatment modality would be valuable for the abovementioned problems in particular. [ABSTRACT FROM AUTHOR]

Background: The literature suggests that the prevalence of atrial fibrillation (AF) may be lower in Asian countries than in Western countries. Nevertheless, AF remains a significant public health problem in the region. The burden of AF, the experiences of previous trials and the lack of data on AF and its management in Asia Pacific highlight the need for a comprehensive prospective study of AF management. Methods: The REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation Asia Pacific (RecordAF-AP) is a prospective, observational survey of the management of recently diagnosed AF patients with 1-year follow-up in 8 countries across Asia Pacific. Eligible patients presenting with AF, treated or not, will be included in the registry and data will be recorded prospectively during follow-up visits at 6 and 12 months. Results: RecordAF-AP will recruit more than 3000 patients. Study recruitment commenced in April 2009 and the final results anticipated at the end of 2011. Conclusions: RecordAF-AP will assess the real-life management of AF patients in Asia Pacific, including a comparison of clinical outcomes in rhythm versus rate control strategies, providing much needed insight into the costs, treatment choices and clinical outcomes of AF patients in this region. [ABSTRACT FROM AUTHOR]

Objective: To compare the cost-effectiveness of treatment options in three patients with haemophilia A and low titer inhibitors. Methodology: We used a longitudinal before-and-after design that was conducted in two phases assessed retrospectively: Phase I was 6 months preceding the introduction of recombinant activated factor VII (rFVIIa), during which patients received on-demand usual care with plasma derived factor VIII regimes, phase two was 6 month treatment on rFVIIa. We determined the clinical response and the cost of treatment with NovoSeven in three patients with low titer inhibitors to factors VIII compared with other treatment regime previously used in these patients (Plasma derived factor VIII). Results: Total number of bleeding episodes, re-treatments and need of hospitalization were 21, 11 and 12 in phase 1 vs. 19, 0 and 0 in phase two respectively. Total cost of rFVIIa and plasma derived factor VIII treatment was USD 98600 vs. USD 77000. Conclusion: rFVIIa is clinically effective. It resulted in 100% reduction in the number of re-treatments, hospitalization and 21.9% reduction in the total cost compared to treatment with plasma derived factor VIII regime. [ABSTRACT FROM AUTHOR]

Healthcare providers continue to seek improved methods for preventing, detecting and treating diseases that affect human survival and quality of life. At the same time, there will always be financial constraints because of limited societal resources. Many of the discussions on how to provide economically sound solutions to this challenge have not fully engaged the input of clinicians in the field. The purpose of this review is to increase economic knowledge for clinicians. We cover healthcare cost elements and methods used to assign value to a health outcome. We outline the challenges in conducting economic studies in the field of infectious diseases. Finally, we discuss the meaning of efficiency from multiple perspectives, and how the concept of economic externalities applies to infectious diseases. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of pegfilgrastim on engraftment, hospital stay and resources in patients with Hodgkin's and non-Hodgkin's lymphoma after conditioning with high-dose BEAM followed by autologous peripheral blood stem cell transplantation (APBSCT) compared with filgrastim. Methods: We reviewed patient charts and our prospective transplantation database for clinical data from the post-transplant period. An integrated cost analysis, including the use of blood products and length of hospital stay, was also performed. Results: Fourteen (26%) patients with Hodgkin's lymphoma and 40 (74%) patients with non-Hodgkin's lymphoma were analyzed. Thirty-four (68%) patients received single-dose pegfilgrastim (6 mg), and 20 (32%) patients received daily filgrastim (5 μg/kg) after APBSCT. No differences were observed regarding duration of neutropenia grade 4 (pegfilgrastim median 7 days/filgrastim median 8 days; p = 0.13), thrombocytopenia grade 4 (7/9.5 days, respectively; p = 0.21), fever (4.5/2 days; p = 0.057), intravenous antibiotic treatment (11/10 days; p = 0.75) or length of hospital stay (16.5/16 days; p = 0.27) between the groups. The use of pegfilgrastim resulted in 12% higher treatment-related costs when compared to filgrastim, without reaching statistical significance (p = 0.38). Conclusion: Pegfilgrastim appears to be equivalent to filgrastim after high-dose BEAM followed by APBSCT in the treatment of lymphoma patients. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: There is little written on the financial cost of burns care. This project examined three major paediatric burns of 30–40% total body surface area (%TBSA) admitted to the South West Paediatric Burns Service in Bristol, and calculated the cost per patient of acute inpatient treatment. A list of costs was established for theatre time, bed time, medications and fluids, dressings, invasive procedures, therapy services and investigations. The time period was the initial inpatient stay, from admission to the burns service, to first discharge. Staff in the relevant managerial and purchasing departments provided additional information about charging. We calculated a mean cost per patient of £63,157.22 (range £55,354.79–£74,494.24). Our results suggest that current income achieved for a major paediatric burn underestimates the actual financial burden of treatment. The North Bristol NHS Trust tariff cost for a “major burn, third degree of more than 19% TBSA, or affecting multiple body regions with significant graft” is £17,797 (2009). The fact that our costs are almost certainly an underestimate in themselves serves to reinforce this view. We hope that the data presented here can provide some guidance and understanding in the funding of burns care, a complex and difficult area to cost. [Copyright &y& Elsevier]

This paper investigates 10 socio-demographic and case characteristic variables as predictors of use of evidence-based practice and non-evidence-based practice in the treatment of psychological trauma. A national random sample of 2,400 trauma treatment specialists in all 50 states and the District of Columbia were sent surveys with a response rate of 29.6% (N = 711) usable surveys returned. Stepwise regressions conducted on evidence-based practice use indicated that special trauma training, older age, and higher percentage of PTSD on the case load were the only significant predictors of evidence-based practice use. Implications for trauma practices are indicated. [ABSTRACT FROM AUTHOR]

Abstract: Background: The aim of this study was to calculate and analyze the cost of treatment for stage IV pressure ulcers. Methods: A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed up for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated. Results: Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts were reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during 1 admission, and $124,327 for community-acquired ulcers over an average of 4 admissions. Conclusions: The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce health care expenditures by millions of dollars. [ABSTRACT FROM AUTHOR]

The purpose of this article is to raise nurses' awareness of the significance and potential public health impact of combat-related blast-induced neurotrauma (BINT) in U.S. troops returning from Afghanistan and Iraq. A comprehensive review of the current literature on BINT was completed by the author, based primarily on combat-related blast exposure in the military population. She found that it is necessary to theorize about potential etiologies for mild traumatic brain injury in the military population since the literature suggests that neurological and psychological trauma resulting from military duty may be linked to exposure to blasts. Identification of potential risk factors for BINT in the military population provides direction for scientific inquiry into this emerging phenomenon. Gaps in current knowledge and its health implications for future scientific study in nursing are presented. [ABSTRACT FROM AUTHOR]