Carcinoma of the ampulla of Vater: Sonographic and CT diagnosis

Twenty patients with carcinoma of the ampulla of Vater were studied with sonography (N = 9) or both sonography and CT (N = 11). The tumor was shown by sonography in 16 patients (80%) as a small, round or oval, fairly well delineated mass in between the dilated distal common bile duct and duodenum which was delineated owing to luminal fluid or gas (N = 13); or as a polypoid mass within the dilated distal common bile duct resulting in abrupt obstruction (N = 3). In the remaining four patients, the mass was not delineated. Bile ducts were dilated down to the level of mass or ampullary region in all cases (100%), while the pancreatic duct was dilated in five cases (45%). We believe that sonography is the technique of initial choice in the diagnosis of carcinoma of the ampulla of Vater by identifying the mass at the distal end of the dilated common bile duct and/or pancreatic duct.     

MRI of Budd-Chiari syndrome

A retrospective study was undertaken to reassess the various magnetic resonance imaging (MRI) features of Budd-Chiari syndrome (BCS). MRI examinations of 22 patients with pathologically confirmed BCS were studied. Spin-echo (SE) T1- (TR = 300–450 ms/TE = 12–15 ms), and SE T2-weighted (TR = 1600–2000 ms/TE = 30–60/90–120 ms) MRI images were obtained in all patients. Gradient-recalled-echo (GRE) images (TR = 7–60 ms/TE = 3–19 ms, flip angle = 10–40°) were obtained in 14 patients. MRI showed thrombosis of three or two hepatic veins in 19 (86%) and 3 (14%) patients, respectively. Spontaneous intrahepatic anastomoses was depicted in five (23%) patients. Ascites appeared in 15 patients (68%). Thrombosis or external compression of the inferior vena cava (IVC) by an enlarged caudate lobe was depicted in six (27%) and five (23%) patients, respectively. Prominent azygos and hemiazygos veins were demonstrated in seven (32%) patients (six of whom had thrombosis of the IVC). MRI showed hepatomegaly in all patients and enlarged caudate lobe in 18 (82%) patients. SE T1- and SE T2-weighted MRI images revealed inhomogeneous signal intensity of hepatic parenchyma in 14 (64%) patients. SE T1- and SE T2-weighted MRI images showed homogeneous signal intensity of hepatic parenchyma in eight (36%) patients. Our results demonstrate that BCS displays various features on MRI images, and such information is important for diagnosis.     

Intraperitoneal seeding from hepatoma

We report three cases of intraperitoneal seeding from hepatoma. Manifestation of intraperitoneal seeding from hepatoma were intraperitoneal masses (N = 2) and peritoneal thickening (N = 1). Main vascular feeder to intraperitoneal masses was omental branches of the gastroduodenal artery and/or the superior mesenteric artery.     

Isolated gastric varices: Ultrasound detection

Isolated gastric varices (IGV) (resulting from varying etiologies) were diagnosed in six patients using ultrasound examination of the wall of the fluid-filled stomach. Small gastric varices are seen as circular or linear anechoic channels within the gastric wall without a significant intraluminal projection. Large varices are seen as anechoic, lobulated “bulging masses” projecting into the fluid-filled lumen of the stomach. Doppler technique assists in confirming the vascular nature of these lesions and thus avoids confusion with other hypoanechoic lesions of the gastric wall. The technique is simple, noninvasive, and extremely useful in diagnosing IGV in patients investigated for recurrent undiagnosed gastrointestinal bleeding.     

Peritoneal mesothelioma: Sonographic findings in nine cases

Ultrasonographic findings in nine cases of peritoneal mesothelioma are presented. The most common findings were sheetlike or nodular peritoneal thickening, soft tissue masses, fixation of the intestinal loops, mesenteric thickening, and minimal ascites which was disproportional to the degree of tumor dissemination. The authors found that abdominal sonography, using 3.75–7.5 MHz transducers, is a useful imaging method for diagnosis of peritoneal mesothelioma in high-risk groups.     

Euro depreciation and trade asymmetries between Germany and Italy versus the US: industry-level estimates

Since April 2014 to March 2015, the European Central Bank expansionary monetary policy instigates a huge depreciation of the euro in terms of dollar. According to the mainstream monetary theory, these dynamics should make the exports cheaper and at the same time make the imports more expensive. Has real depreciation of the euro helped in the improvement of European countries’ trade balances? Following the main methodologies in the recent literature, our study analyses the effects of this depreciation both for Italy and Germany towards the US. We use industry-level data at monthly frequency. The results are different from each bilateral relationship. We find that 11 industries register a long-run improvement (8 for Italy and 3 for Germany). The J-curve effect is proven just in six cases, always for Italy. The inverted J-curve effect is proven in eight cases, four for Germany, and four for Italy. These results seem to be an indirect demonstration of the structural asymmetries between German and Italian economies: German economic system is more able to be competitive with a strong currency, than Italy.     

Radionuclide esophageal transit test: Detection of esophageal dysmotility and reflux in noncardiac chest pain

Thirty-one patients with substernal chest pain but with normal coronary angiographic findings and 25 normal volunteers were included in our study. Esophageal motility—including esophageal mean transit time (MTT), residual fraction (RF), and retrograde index (RI) of the two groups—were evaluated by the radionuclide esophageal transit test. The results showed that among patients with noncardiac chest pain (NCP), 48% have a longer MTT, 39% have a higher RF, and 58% have a higher RI than normal volunteers. We found that esophageal disorders are a common source of noncardiac chest pain, and that radionuclide esophageal transit test is a simple noninvasive screening method to detect esophageal dysmotility or gastroesophageal reflux in such cases.     

The unification of Ronald W. Shephard's duality theory

Ronald W. Shephard developed four fundamental duality theorems. They relate the following four pairs of representations of the technology: cost function-input distance function, revenue function-output distance function, indirect cost function-indirect input distance function, and indirect revenue function-indirect output distance function. In this paper we show that all eight of these representations are equivalent. The implication of this equivalence is that there are twenty-four duality theorems and four inverse relationships involving Shephard's eight representations of technology.     

Comorbidity and economic burden among moderate-to-severe psoriasis and/or psoriatic arthritis patients in the US Department of Defense population

Aims: To examine the comorbidity and economic burden among moderate-to-severe psoriasis (PsO) and/or psoriatic arthritis (PsA) patients in the US Department of Defense (DoD) population.

Materials and methods: This retrospective cohort claims analysis was conducted using DoD data from November 2010 to October 2015. Adult patients with ≥2 diagnoses of PsO and/or PsA (cases) were identified, and the first diagnosis date from November 2011 to October 2014 was defined as the index date. Patients were considered moderate-to-severe if they had ≥1 non-topical systemic therapy or phototherapy during the 12 months pre- or 1 month post-index date. Patients without a PsO/PsA diagnosis during the study period (controls) were matched to cases on a 10:1 ratio based on age, sex, region, and index year; the index date was randomly selected. One-to-one propensity score matching (PSM) was conducted to compare study outcomes in the first year post-index date, including healthcare resource utilization (HRU), costs, and comorbidity incidence.

Results: A total of 7,249 cases and 72,490 controls were identified. The mean age was 48.1 years. After PSM, comorbidity incidence was higher among cases, namely dyslipidemia (18.3% vs 13.5%, p?<?.001), hypertension (13.8% vs 8.7%, p?<?.001), and obesity (8.8% vs 6.1%, p?<?.001). Case patients had significantly higher HRU and costs, including inpatient ($2,196 vs $1,642; p?<?.0016), ambulatory ($8,804 vs 4,642; p?<?.001), emergency room ($432 vs $350; p?<?.001), pharmacy ($6,878 vs $1,160; p?<?.001), and total healthcare costs ($18,311 vs $7,795; p?<?.001).

Limitations: Claims data are collected for payment purposes; therefore, such data may have limitations for clinical research.

Conclusions: During follow-up, DoD patients with moderate-to-severe PsO and/or PsA experienced significantly higher HRU, cost, and comorbidity burden.     

Bile leakage as a complication of liver biopsy in liver transplants

Four liver transplant recipients with intrahepatic bile duct leakage following liver biopsy are described. Two patients were clinically suspected of having a bile leak, one of whom had bile peritonitis. All four patients had elevated liver enzyme levels. In three patients, cholangiography showed contrast media leakage into the peritoneum through the needle biopsy tract; one leak was totally intraparenchymal. All patients had varying degrees of biliary obstruction. The differential diagnosis of bile leakage posttransplantation should include recent liver biopsy.     

Knock-out for descriptive utility or experimental-design error?

Using an experimental design of stating equivalent probabilities for 252 stimulus lottery pairs, Chechile and Cooke (1997) alleged to have refuted generic-utility theory which itself comprises many modern utility theories. The present paper systematically investigates the feasibility of the Chechile-Cooke experimental design using numerical methods. We examine 1,277 utility setups (involving 17 parameter sets for four probability-weighting functions and 11 parameter sets for three component utility functions) which represent ten different utility theories. Our results demonstrate that on average for more than one third of all stimulus lottery pairs no equivalent probabilities exist. That is, the Chechile-Cooke experimental design prevents subjects from stating their true probability equivalents. Therefore, they cannot claim to have refuted generic-utility theory and the members of its family.This paper was submitted to theJournal of Risk and Uncertainty on January 14, 1999. It was, however, rejected on April 16, 1999.     

Economic impact of different preparations of leuprolide acetate in the management of advanced prostate cancer

This study aimed to compare the economic impact of 1-,3-and 6-monthly preparations of leuprolide acetate, a luteinising hormone-releasing hormone agonist (LHRHa), in the treatment of prostate cancer.

Using three published open-label multicentre clinical trials involving the use of each of the three LHRHa preparations, a cost minimisation analysis was undertaken.

The mean annual costs of managing advanced prostate cancer patients with the 1-,3-and 6-monthly preparations were e2,839 (standard deviation (sd) e233), e1,777 (sd e1 95) and e1,567 (sDe204), respectively.

The study concludes that, despite a higher unit price, use of the 6-monthly formulation of leuprolide acetate provides the lowest cost treatment option, the cost driver being the reduction in the number of treatments required. Germany was used as a case study to highlight the impact of health policies on the adoption of such cost optimisation treatment options in prostate cancer patients.     

Defecography: Results in 55 patients and impact on clinical management

We reviewed the medical records and defecograms in 55 consecutive patients to determine the impact of results of defecography on clinical management. Main indication for defecography was constipation, present in 40 (73%) of 55 patients. In the remaining 15 patients, indications included obstructed defecation (5), incontinence (5), and miscellaneous symptoms (5). Defecography evaluated pelvic floor motion by assessing changes in the anorectal angle (ARA) and anorectal junction (ARJ) during various maneuvers, extent of evacuation, and structural abnormalities. Patients were grouped based on results of defecography as being normal (26) or abnormal (29). Comparison of measurements of the ARA and ARJ with various maneuvers showed no significant differences between the two groups. Clinical impact was determined by analyzing therapy done following defecography and subsequent patient response. In the normal group, 15 patients were managed medically, seven surgically, and four lost to follow-up. Clinical improvement occurred in 13 (59%) of 22 patients, with similar results between medical (60%) and surgical (57%) therapy. In the abnormal group, 16 had medical management, seven surgical therapy, and six lost to follow-up. Clinical improvement occurred in 13 (57%) of 23 patients but surgical therapy showed more improvement. In conclusion, most standard measurements of the ARA and ARJ were of no value in determining abnormality. Results of defecography did not alter selection of medical or surgical therapy, and had little impact on patient response to therapy.     

Primary esophageal lymphoma in AIDS

In a patient with acquired immunodeficiency syndrome (AIDS) and primary esophageal lymphoma, esophagography and computed tomography (CT) demonstrated a large ulcerated mass involving the distal esophagus. Although rare, the diagnosis of esophageal lymphoma should be considered in patients at risk for AIDS when the radiologic findings are not typical for infectious esophagitis or Kaposi's sarcoma.     

Costs of hospital visits among patients with deep vein thrombosis treated with rivaroxaban and LMWH/warfarin

Background:

For many years, the standard of care for patients diagnosed with deep vein thrombosis (DVT) has been low-molecular-weight heparin (LMWH) bridging to an oral Vitamin-K antagonist (VKA). The availability of new non-VKA oral anticoagulants (NOAC) agents as monotherapy may reduce the likelihood of hospitalization for DVT patients.

Objective:

To compare hospital visit costs of DVT patients treated with rivaroxaban and LMWH/warfarin.

Methods:

A retrospective claim analysis was conducted using the MarketScan Hospital Drug Database for care provided between January 2011 and December 2013. Adult patients using rivaroxaban or LMWH/warfarin with a primary diagnosis of DVT during the first day of a hospital visit were identified (i.e., index hospital visit). Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients. The hospital-visit cost difference between these groups was evaluated for the index hospital visit, as well as for total hospital-visit costs (i.e., including index and subsequent hospital visit costs).

Results:

All rivaroxaban users (n?=?134) in the database were well-matched with four LMWH/warfarin users (n?=?536). The mean hospital-visit costs were $5257 for the rivaroxaban cohort and $6764 in the matched-cohort of patients using LMWH/warfarin. The $1508 cost difference was statistically significant between cohorts (95% CI?=?[?$2296; ?$580]; p-value?=?0.002). Total hospital-visit costs were lower for rivaroxaban compared to LMWH/warfarin users within 1, 2, 3, and 6 months after index visit (significantly lower within 1 and 3 months, p-values <0.05)

Limitations:

Limitations were inherent to administrative-claims data, completeness of baseline characteristics, adjustments restricted to observational factors, and lastly the sample size of the rivaroxaban cohort.

Conclusion:

The availability of rivaroxaban significantly reduced the costs of hospital visits in patients with DVT treated with rivaroxaban compared to LMWH/warfarin.     

丹参川芎嗪注射液对脑血栓患者凝血功能和神经及运动功能恢复的影响

目的探讨丹参川芎嗪注射液对脑血栓患者凝血功能和神经及运动功能恢复的影响。方法选取鞍山市中心医院铁东院区2018年6月至2020年6月收治的84例脑血栓患者作为研究对象,采用随机数字表法将其分为对照组与观察组,各42例。对照组给予双嘧达莫治疗,观察组在对照组基础上加用丹参川芎嗪注射液治疗,比较两组凝血功能、血流动力学、氧化应激、神经及运动功能改善情况。结果治疗后,两组凝血功能指标明显改善,且观察组凝血酶时间、活化部分凝血活酶时间、凝血酶原时间显著长于对照组,差异有统计学意义(P<0.05)。治疗后,两组氧化应激各指标较治疗前明显改善,且观察组丙二醛(MDA)低于对照组,谷胱甘肽过氧化物酶(GSH-Px)、超氧化物歧化酶(SOD)高于对照组,差异有统计学意义(P<0.05)。治疗后,两组血流动力学各指标较治疗前明显改善,且观察组大脑中动脉平均血流速度(Vm)高于对照组,阻力指数(RI)、搏动指数(PI)低于对照组,差异有统计学意义(P<0.05)。治疗后,观察组美国国立卫生研究院卒中量表(NIHSS)评分低于对照组,Fuel-Meyer评分高于对照组,差异有统计学意义(P<0.05)。结论双嘧达莫治疗脑血栓的同时,应用丹参川芎嗪注射液治疗能够有效改善患者凝血功能及血流状况,减轻氧化应激,提高神经及运动功能。     

Length of stay and economic consequences with rivaroxaban vs enoxaparin/vitamin K antagonist in patients with DVT and PE: findings from the North American EINSTEIN clinical trial program

Objective:

Venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [(PE]) represents a substantial economic burden to the healthcare system. Using data from the randomized EINSTEIN DVT and PE trials, this North American sub-group analysis investigated the potential of rivaroxaban to reduce the length of initial hospitalization in patients with acute symptomatic DVT or PE.

Methods:

A post-hoc analysis of hospitalization and length-of-stay (LOS) data was conducted in the North American sub-set of patients from the randomized, open-label EINSTEIN trial program. Patients received either rivaroxaban (15?mg twice daily for 3 weeks followed by 20?mg once daily; n?=?405) or dose-adjusted subcutaneous enoxaparin overlapping with (guideline-recommended ‘bridging’ therapy) and followed by a vitamin K antagonist (VKA) (international normalized ratio?=?2.0–3.0; n?=?401). The open-label study design allowed for the comparison of LOS between treatment arms under conditions reflecting normal clinical practice. LOS was evaluated using investigator records of dates of admission and discharge. Analyses were carried out in the intention-to-treat population using parametric tests. Costs were applied to the LOS based on weighted mean cost per day for DVT and PE diagnoses obtained from the Healthcare Cost and Utilization Project dataset.

Results:

Of 382 patients hospitalized, 321 (84%), had acute symptomatic PE; few DVT patients required hospitalization. Similar rates of VTE patients were hospitalized in the rivaroxaban and enoxaparin/VKA treatment groups, 189/405 (47%) and 193/401 (48%), respectively. In hospitalized VTE patients, rivaroxaban treatment produced a 1.6-day mean reduction in LOS (median?=?1 day) compared with enoxaparin/VKA (mean?=?4.5 vs 6.1; median?=?3 vs 4), translating to total costs that were $3419 lower in rivaroxaban-treated patients.

Conclusion:

In hospitalized North American patients with VTE, treatment with rivaroxaban produced a statistically significant reduction in LOS. When treating DVT and PE patients, clinicians should consider newer anti-coagulants with less complex treatment regimens.     

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.