顽固性肾绞痛的急诊输尿管镜治疗分析

目的 探讨急诊输尿管镜下碎石取石术治疗输尿管结石并顽固性绞痛的临床应用价值.方法 对 120 例输尿 管结石并顽固性绞痛患者输尿管镜下碎石取石治疗,其中上段结石 20 例,中段结石 36 例,下段结石 64 例.结果 上、中、下段结石治疗成功率分别为 80.0%(16/20)、94.4%(34/36)、96.9%(62/64),未出现输尿管穿孔、断裂、菌血症 等严重并发症.结论 输尿管结石并顽固性绞痛急诊输尿管镜下治疗是安全有效微创的治疗方法.     

Radiation therapy remains the key cost driver of oncology inpatient treatment

Abstract

Objective:

Current radiation therapy capacities in Serbia and most of Eastern Europe are heavily lagging behind population needs. The primary study aim was assessment of direct costs of cancer medical care for patients suffering from cancer with assigned radiotherapy-based treatment protocols. Identification of key cost drivers and trends during 2010–2013 comparing brachytherapy and teleradiotherapy was a secondary objective of the study.

Methods:

Retrospective, bottom-up database analysis was conducted on electronic discharge invoices. Payer’s perspective has been adopted with a 1-year long time horizon. Total sample size was 2544 patients during a 4-years long observation period (2010–2013). The sample consisted of all patients with confirmed malignancy disorder receiving inpatient radiation therapy in a large university hospital.

Results:

Diagnostics and treatment cost of cancer in the largest Western Balkans market of Serbia were heavily dominated by radiation therapy related direct medical costs. Total costs of care as well as mean cost per patient were steadily decreasing due to budget cuts caused by global recession. The paradox is that at the same time the budget share of radiotherapy increased for almost 15% and in value-based terms for €109 per patient (in total €109,330). Second ranked cost drivers were nursing care and imaging diagnostics. Costs of high-tech visualizing examinations were heavily dominated by nuclear medicine tests.

Conclusion:

The budget impact of radiation oncology to the large tertiary care university clinics of the Balkans is likely to remain significant in the future. Brachytherapy exhibited a slow growth pattern, while teleradiotherapy remained stable in terms of value-based turnover of medical services. Upcoming heavy investment into the national network of radiotherapy facilities will emphasize the unsatisfied needs. Huge contemporary budget share of radiotherapy coupled with rising cancer prevalence brings this issue into the hot spot of the ongoing cost containment efforts by local governments.     

Years of life lost due to metastatic melanoma in 12 countries

Background:

Regionally or distantly metastatic melanoma (stages IIIB/C and IV) place a high burden on society. To quantify this burden, this study estimated years of life lost (YLL) per patient for adults with metastatic melanoma in 12 countries in 2014.

Methods:

General population growth and life expectancy were estimated from the Organization for Economic Co-operation and Development data and life tables for each country. Incidence of melanoma and mortality rates for the disease were based on GLOBOCAN and US registry data. The prevalence of metastatic melanoma was calculated using mortality rates and survival data from patients with melanoma. YLL per patient was estimated by the difference between the disease-free life expectancy and the life expectancy with metastatic melanoma.

Results:

YLL per patient were as follows: Australia, men?=?19.9 years, women?=?22.7 years; Brazil, 16.3, 19.8; Canada, 19.4, 22.3; France, 18.8, 23.1; Germany, 18.3, 20.8; Italy, 19.3, 22.7; Mexico, 17.2, 19.0; the Netherlands, 18.5, 21.5; Spain, 19.2, 23.1; Sweden 19.4, 22.0; the UK, 18.7, 21.2; and the US, 17.9, 20.6.

Conclusions:

The burden of metastatic melanoma as measured by YLL is substantial in all 12 countries; although there is variation across countries and between men and women.     

Cost-effectiveness of six months versus 1-year adjuvant trastuzumab in HER2 positive early breast cancer in Egypt

Abstract

Introduction: Breast cancer is the most prevalent cancer among women in Egypt. Trastuzumab is administered with chemotherapy for patients with HER2-positive advanced breast cancer (HER2?+?ve ABC) in the metastatic and adjuvant settings resulting in improved treatment outcomes, and long-term follow-up. Some studies have evaluated whether equivalent outcomes can be achieved with reduced treatment duration. This study evaluates the cost-effectiveness of 6-month versus 1-year trastuzumab treatments from payer perspective over a 10 year time horizon.

Methods: A half-cycle corrected Markov model was developed with five mutually exclusive health states; patient with HER2?+ve ABC, disease-free survival (DFS), local or regional relapse, metastatic relapse, and death. A cycle length of 6 months was applied, direct medical costs including cost of treatments, day-care, surgery, health states and follow-up visits were collected, and indirect costs such as lost productivity were not estimated. The transition probabilities and utilities were extracted from published literature, and deterministic sensitivity analyses were conducted.

Results: Among the HER2?+ve ABC patient population in Egypt, the total QALYs of the 6-month trastuzumab were estimated to be 2.99 compared with 2.93 for the 1-year trastuzumab which resulted in a difference of 0.06 QALYs. The total costs were EGP 271,647 ($106,947) and EGP 381,248 ($150,097), respectively. These costs yielded an ICER of –109,600 EGP/QALY (–43,149 $/QALY) for the 6-month trastuzumab. The 6-month trastuzumab is a dominant strategy when compared to 1-year trastuzumab, resulting in improved effectiveness at a reduced cost. All analyses results confirmed the dominance of 6-month trastuzumab and our model robustness.

Conclusions: This study concluded that 6-month trastuzumab is a cost-effective option when compared to 1-year trastuzumab in patients with HER2?+ve ABC in Egypt. Our findings provide health care decision makers with additional insights to best allocate available resources concurrently with the improvement of the Egyptian patient’s outcomes.     

Trends in Market Concentration of Australian Industries

A host of industrialised countries have seen concentration in their industries grow. This trend is fuelling concerns about falling competition. This article focuses on the changing pattern of market concentration in Australia from 2002 to 2017. On average, market concentration has been rising. However, beneath the aggregate statistics, the pattern is rather mixed, with concentration falling in several sectors. The study also detects a pattern of strong productivity growth alongside a shift towards capital intensive operation and increasing trade where concentration is growing. Overall, the implications of these findings point to the possibility that rising market concentration in some industries is technology driven and not due to a lack of competition.     

Adverse event-related costs for systemic metastatic breast cancer treatment among female Medicaid beneficiaries

Objective: This retrospective study compared the real-world incidence and costs of systemic treatment-related adverse events (AEs) in patients with metastatic breast cancer in a Medicaid population.

Methods: Insurance claims data for adult women who received biologic or chemotherapy (± hormonal therapy) for metastatic breast cancer between 2006–2013 were extracted from the Truven Health MarketScan^® Multi-State Medicaid database. Incidence of AEs (per 100 person years) and average monthly AE-related healthcare costs (per-patient-per-month) during each line of therapy (first or later lines) were estimated. The association between AEs and total all-cause healthcare costs was estimated using multivariable regression.

Results: A total of 729 metastatic breast cancer patients were analyzed. Hematological (202.3 per 100 person years) and constitutional AEs (289.6 per 100 person years) were the most common class of AEs reported. Unadjusted per-patient-per-month AE-related expenditure by class were highest for hematological AEs ($1524), followed by gastrointestinal ($839) and constitutional AEs ($795), with anemia ($942), nausea/vomiting ($699), and leukopenia/neutropenia ($550) having incurred the highest total AE-related costs. Adjusted total all-cause monthly costs increased with the number of AEs ($19,701 for >7 AEs, $16,264 for 4???6 AEs, and $13,731 for 1???3 AEs) compared to no AEs ($5908) (all p?Conclusions: Among metastatic breast cancer patients treated with systemic therapy in a Medicaid population, AEs were associated with significant increases in costs, which increased with the number of AEs experienced. Therapies associated with a lower incidence of AEs may reduce cost burden and improve patient outcomes.     

Carcinoma of the gallbladder: CT findings in 50 cases

Fifty patients with histologically proven carcinoma of the gallbladder were examined by computed tomography (CT). The gallbladder masses were categorized into two broad groups: group 1 (74%) included patients in whom the gallbladder was identified along with a mass lesion; and group 2 (26%), where a large mass was present in the gallbladder fossa with no identifiable gallbladder. Group 1 was further divided into three types according to the nature of the tumor: Type 1, mass almost filling the entire gallbladder lumen; Type 2, a polypoidal mass projecting into the lumen; type 3, an infiltrating tumor seen as focal or diffuse wall thickening. Liver involvement, in the form of localized invasion in the vicinity of the primary gallbladder malignancy, was the most common associated finding (80%). Other ancillary features included presence of calculi, lymphadenopathy, and biliary obstruction. CT was found useful for characterizing and defining the extent of carcinoma of the gallbladder. However, it may not consistently demonstrate involvement of the gastrointestinal tract, omentum, and abdominal wall. CT can also be used for aspiration/biopsy guidance of the gallbladder mass in selected cases.     

The economic advantages of response in the treatment of advanced breast cancer

Summary

The introduction of a new class of drugs, the taxoids, has dramatically improved the outlook for patients with advanced, metastatic breast cancer. Second-line monotherapy with the most effective taxoid, docetaxel, in patients with anthracycline-resistant metastatic breast cancer, shows an overall response rate up to 55% in this patient population. Increased response rate is associated with improved quality of life for these patients.

We carried out a cost analysis to determine the economic benefits of being in a response state compared with the other health states associated with advanced breast cancer: stable, progressive or terminal disease.

We found that the cost of care for responders is 40% of that for early progressive disease and just over a third of that for late progressive disease. The costs associated with stable disease are only a little less than those for progressive disease, and are more than double the costs for patients who have responded to chemotherapy. The costs during terminal disease are the highest, and are more than nine times those associated with caring for responders.

Our findings confirm other studies which demonstrate that the cost of chemotherapy can be offset against the reduction in costs incurred for patients who remain in healthier states for longer. The key parameter determining the economic efficiency of treatments for advanced breast cancer is response rate.     

经尿道等离子体前列腺切除联合去势术治疗晚期前列腺癌并膀胱出口梗阻25例报告

目的 探讨经尿道等离子体前列腺切除治疗晚期前列腺癌所致膀胱出口梗阻的效果.方法 选取我院2012年3月至2013年4月收治的25例晚期前列腺癌并膀胱出口梗阻患者,采用电凝功率为80W、电切功率为160W的等离子体双极电切系统,膀胱冲洗液采用生理盐水,灌注时间控制在1～2h.结果 本组患者平均切除（42.6±12.8）g前列腺组织,平均手术时间为65min.膀胱冲洗24～48h,术后置管3～7d,平均（4.5±1.8）d.术后继发1例暂时性尿失禁,3例尿道外口狭窄,1例尿路感染伴血尿.25例患者在拔管之后可自行排尿.结论 TUPKVP具有并发症少、不易引起TUR综合症、止血效果好、安全性高等优点,可以对尿路梗阻进行有效地缓解,是一种姑息性治前列腺癌的措施,能够大幅度提高生活质量和延长患者生命,值得在临床上大量应用.     

Patients' migration across regions: the case of Italy

This article analyses patient mobility across Italian regions. A modified gravity model of patient migration is specified and estimated using panel observations covering mobility and other main regional quality indicators over the period 1994–1997. Despite the high level of aggregation due to data constraints, the empirical findings show that in Italy there is wide scope for quality-driven mobility while income determines the quality of the service offered.     

Entry and pricing on Broadway

This article investigates the pricing decisions of Broadway shows. We find evidence that incumbent Broadway shows lower prices several weeks prior to the opening of a new show. In addition, prices are lower when the threat of competition, due to more entrants, is larger. A decomposition suggests that prices are more important than quantities for changes in revenue prior to entry and that this pattern reverses after entry occurs.     

Roundworm obstruction: Sonographic diagnosis

We describe the sonographic findings in five pediatric patients with roundworm obstruction. All patients were referred with a clinical diagnosis of acute appendicitis. On ultrasonography (US), an individual worm, when viewed along its longitudinal axis, appeared as a hypoechoic tubular structure with well-defined, echogenic walls. Frequently, the individual body segments could be distinctly visualized. The alimentary canal of the worm was seen either as a single central echogenic line (when in a collapsed state) or as two parallel hyperechoic bands with a hypoechoic center (when distended). When examined transaxially, the individual worm resembled a target with its circular, echogenic body wall and its central dot-like alimentary canal. On prolonged scanning, the worms always showed curling movements. In two patients, a bolus of worms mixed with fecal matter and air produced an unusual appearance of a complex, echogenic mass (helminthoma). Although, an individual worm occasionally resembled an inflammed appendix, visualization of the alimentary canal and individual body segments along with its curling movements helped establish the correct diagnosis. All patients promptly responded to a hypertonic saline enema and no patient was subjected to surgery. Sonographic findings in roundworm obstruction are fairly characteristics to advocate the routine use of sonography for diagnosing this entity.     

Redesigning nursing work in long-term care environments

The authors present a highly statistically oriented argument for examining work attitudes and activities among three groups of caregivers [RNs, RPNs, and HCAs] working in long-term care. The investigators used both work sampling, written surveys, and interviews with a sample of 46 caregivers in a large university-affiliated LTC facility in Toronto, Canada. While RNs stated their strong affinity for direct patient care activities, they perform the lowest percentage of direct care, chiefly due to their accountability for planning and coordinating the care provided by others. The HCAs who provided the bulk of direct patient care "valued it the least," apparently finding little gratification with this aspect of their role. This study suggests that there is a need to examine and clarify work roles and perceptions for all caregivers as part of any work redesign process. A higher level of RN involvement in direct patient care activities, along with "attention to enhancing the importance" of these activities for staff employed in the HCA role, could be beneficial.     

Retrospective analysis of patients with advanced or metastatic gastric cancer in Colombia

Abstract

Aims: To assess patient and disease characteristics, treatment patterns, and associated costs in patients with advanced or metastatic gastric cancer (A/MGC) in Colombia, in both the public and private hospitals.

Materials and methods: A total of 145 patients who had received first-line chemotherapy treatment (platinum analog and/or a fluoropyrimidine) and were followed for at least 3 months after the last administration of a first-line cytotoxic agent were eligible for inclusion. Case-report forms were elaborated based on the patients’ medical records from three Colombian hospitals. Estimates of treatment costs were calculated using unit costs from the participating hospitals.

Results: Of the 145 patients, more than half (64.83%) were male, 79.56% were diagnosed with metastatic stage IV disease (mean age = 58.14?years). Prior to MGC diagnosis, 31.71% of the patients being operated on received a total gastrectomy; 66.9% of the patients received a doublet therapy, of which 5-fluorouracil (5-FU) in combination with cisplatin was the standard treatment (14%), followed by combination with leucovorin (12%). Only around 10% of the patients responded to first-line treatment. Out of 41.38% of the patients who received a second-line treatment, 71.67% were still administered a platinum analog and/or fluoropyrimidine. During the follow-up period, 52% of the patients progressed and 20% achieved stable disease. Best supportive care mostly consisted of outpatient visits after last line-therapy (72.41%), palliative radiotherapy (18.6%), and surgery (37.2%).

Limitations and conclusions: Gastric cancer is one of the main causes of cancer-related death in Colombia, as most of the patients are diagnosed at an advanced stage, when prognosis is poor. Treatment patterns are highly heterogeneous. Second-line treatments were mostly initiated with paclitaxel, capecitabine, irinotecan, or cisplatin.     

Estimating healthcare resource use associated with the treatment of metastatic melanoma in eight countries

Objectives Studies reporting healthcare resourse use (HRU) for melanoma, one of the most costly cancers to treat, are limited. Using consistent, robust methodology, this study estimated HRU associated with the treatment of metastatic melanoma in eight countries.

Methods Using published literature and clinician input, treatment phases were identified: active systemic treatment (pre-progression); disease progression; best supportive care (BSC)/palliative care; and terminal care. HRU elements were identified for each phase and estimates of the magnitude and frequency of use in clinical practice were obtained through country-specific Delphi panels, comprising healthcare professionals with experience in oncology (n?=?8).

Results Medical oncologists are the key care providers for patients with metastatic melanoma, although in Germany dermato-oncologists also lead care. During the active systemic treatment phase, each patient was estimated to require 0.83–2 consultations with a medical oncologist/month across countries; the median number of such assessments in 3 months was highest in Canada (range?=?3.5–5) and lowest in France, the Netherlands and Spain (1). Resource use during the disease progression phase was intensive and similar across countries: all patients were estimated to consult with medical oncologists and 10–40% with a radiation oncologist; up to 40% were estimated to require a brain MRI scan. During the BSC/palliative care phase, all patients were estimated to consult with medical oncologists, and most to consult with a primary care physician (40–100%).

Limitations Panelists were from centers of excellence, thus results may not reflect care within smaller hospitals; data obtained from experts may be less variable than data from broader clinical practice. Treatments for metastatic melanoma are continually emerging, thus some elements of our work could be superseded.

Conclusions HRU estimates were substantial and varied across countries for some resources. These data could be used with country-specific costs to elucidate costs for the management of metastatic melanoma.     

妇产科手术致泌尿系统损伤案例分析

目的本文对27例泌尿系统损伤案例进行统计,分析了导致泌尿系统损伤的原因及损伤后的处理方法,并提出了预防泌尿系统损伤的措施。方法对11734例手术引起的27例泌尿系统损伤患者资料进行分析。结果 27例病例中,输尿管损伤10例,膀胱损伤11例,尿道损伤6例,输尿管和膀胱损伤是较多见的症状。结论妇科手术致泌尿系统损伤是较少见但较严重的并发症,术前明确诊断、熟悉盆腔解剖结构、严格手术操作规范是预防损伤的关键,输尿管插管吻合及膀胱修补是其主要治疗措施。     

A Production Analysis of the Manufacturing Industries in Iran

This article is concerned with the estimation of production functions, returns to scale, and measurement of the rate of technical change using panel data. Technical change is represented by single as well as multiple time trends. The underlying production technology is represented in translog functional form. A random effects model with heteroscedastic variances is used. The models are estimated using the generalized least squares method. The disturbances of cross-sectional units are assumed to be correlated over time. Empirically, our focus is on measuring technical change in Iranian manufacturing industries during the period 1971–1993. Empirical results show that single or multiple time trend representations yield different time behavior of technical change. In the multiple time trends model, we observe a sharp decline in the pattern of technical change in 1978 in relation to the political changes. In the single time trend, as expected, the sharp decline cannot be revealed due to the smooth pattern of technical progress during the entire period of study.     

Service-sector competition,innovation and R&D

The central prediction of the Aghion, Bloom, Blundell and Howitt model is an inverted U-shaped relationship between innovation and competition. The model is built on the assumption of a product market and has not yet been tested on the service sector. Using detailed firm-level data on Swedish service-sector firms, we find evidence of an inverse U-shaped relationship for exporting service-sector firms. A further breakdown of innovation expenditures shows that the inverse U-shaped pattern holds for intramural R&D and training, but not for extramural R&D. Finally, the results indicate that as competition increases, small firms tend to seek strategic alliances with competitors, whereas large firms tend to reduce collaboration with competitors. The behavior of large firms can partly be due to their superior capacity to handle innovation projects internally, which will become more important if increased competition results in higher pay-offs to innovation.     

Estimating the time involved in managing the 'unoccupied bed:' a time and motion study

Occupied bed days are often used as a demand indicator when calculating the number of nurses required to provide safe care. However, such calculations fail to take into account the amount of nursing time consumed by the "unoccupied bed." This study used direct observation time-and-motion methods to estimate the time and costs associated with a bed that is unoccupied. The average time taken to complete all of the activities associated with a bed that was unoccupied due to an internal transfer was 8.65 minutes, for a patient discharge 26.27 minutes, and for a patient admission 37.7 minutes. An average daily cost for activities surrounding these patient movements was approximately $386/day (AUD) in registered/enrolled nursing salaries alone. The unoccupied bed is not resource neutral and time associated with its maintenance should be considered when calculating nursing requirements to provide safe care.