Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States.

OBJECTIVES: Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS: Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS: Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION: Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

Polyvinylsulfonic acid: A Low-cost RNase inhibitor for enhanced RNA preservation and cell-free protein translation.

The effectiveness and economics of polyvinyl sulfonic acid (PVSA) as a ribonuclease inhibitor for in vitro systems is reported. PVSA was shown to inhibit RNA cleavage in the presence of RNase A as well as in the presence of Escherichia coli lysate, suggesting that PVSA can act as a broader ribonuclease inhibitor. In addition, PVSA was shown to improve the integrity of mRNA transcripts by up to 5-fold in vitro as measured by their translational viability. Improved preservation of mRNA transcripts in the presence of PVSA under common RNA storage conditions is also reported. A cost comparison with commercially available RNAse inhibitors indicates the economic practicality of PVSA which is approximately 1,700 times less expensive than commonly used ribonuclease inhibitors. PVSA can also be separated from RNA by alcohol precipitation for applications that may be sensitive to the presence of PVSA.

Treatment of large and giant intracranial aneurysms: cost comparison of flow diversion and traditional embolization strategies.

OBJECTIVE: Flow diversion has emerged as a promising strategy for management of intracranial aneurysms. The purpose of this study was to determine whether treatment of large and giant aneurysms with the pipeline embolization device (PED) is more economical than traditional embolization strategies. METHODS: We identified 30 consecutive aneurysms larger than 10 mm that were treated with PED at our institution. For each aneurysm treated with PED, theoretical coil embolization was performed by filling volume in a consistent, stepwise fashion until a packing density of 25% was reached. Prices of all equipment and implants were taken from price lists provided by each manufacturer. RESULTS: Median aneurysm volume was 0.90 cm(3). Overall procedure cost was lower with the PED (mean, $23,911) vs. coiling ($30,522, P = .06). Above the median aneurysm volume, PED treatment was significantly less expensive than coiling even if multiple PEDs were used (P = .006). However, below the median aneurysm volume, PED treatment was significantly more expensive than coiling (P = .009). Treatment with multiple PEDs was not cost-beneficial compared with coiling, even above the median aneurysm volume. Potential savings associated with the PED were highly dependent on the type of embolic agent used. CONCLUSIONS: The cost of initial treatment of large and giant aneurysms with PED is economically favorable compared to traditional embolization techniques. However, any potential cost benefit depends on aneurysm volume, coil type, and number of PEDs used. Accordingly, PED therapy is more expensive than coiling in aneurysms <0.9 cm(3) or when multiple devices are used.

IMPROVDENT: improving dentures for patient benefit. A crossover randomised clinical trial comparing impression materials for complete dentures.

BACKGROUND: According to the UK Adult Dental Health Survey (2009) 15% of adults aged 65-74, 30% aged 75-84 and 47% aged >85 years are edentulous and require complete dentures. Patients' quality of life and nutrition status are affected by poor dentures. The quality of the dental impression is the most important issue for improving the fit and comfort of new dentures. There is paucity of RCT evidence for which impression material is best for complete dentures construction. This study aims to compare two impression materials for effectiveness and cost effectiveness. METHODS/DESIGN: IMPROVDENT is a double-blind crossover trial comparing the use of alginate and silicone, two commonly used denture impression materials, in terms of patient preference and cost-effectiveness. Eighty five edentulous patients will be recruited and provided with two sets of dentures, similar in all aspects except for the impression material used (alginate or silicone). Patients will try both sets of dentures for a two-week period, unadjusted, to become accustomed to the feel of the new dentures (habituation period). Patients will then wear each set of dentures for a period of 8 weeks (in random order) during which time the dentures will be adjusted for optimum comfort. Finally, patients will be given both sets of dentures for a further two weeks to wear whichever denture they prefer (confirmation period).Patients will be asked about quality of life and to rate dentures on function and comfort at the end of each trial period and asked which set they prefer at the end of the habituation period (unadjusted denture preference) and confirmation period (adjusted denture preference). A health economic evaluation will estimate incremental cost-effectiveness ratios of producing dentures from the two materials. A qualitative study will investigate the impact of dentures on behaviour and quality of life. FUNDING: IMPROVDENT is funded by NIHR RfPB (PB-PG-0408-16300). DISCUSSION: This trial aims to provide evidence on the costs and quality of dentures cast from two different commonly used impression materials; the intention is to significantly impact on the quality of denture production within NHS dentistry. TRIAL REGISTRATION: ISRCTN Register: ISRCTN01528038 UKCRN Portfolio ID: 8305.

Proposal of a synthetic ethylene-vinyl acetate bench model for surgical foundations learning: suture training.

Due to ethical and legal aspects involved in the handling of cadavers and animals the synthetic simulators are an alternative for learning how to suture technique plus the practice of various procedures such as incision and surgical flap. In this context, this paper describes and propose the use of a synthetic model manufactured from plates of ethylene-vinyl acetate (EVA) to teach primary surgical skills in medical students with no previous exposure to surgery. The model that provides the convenience of being easily reproducible, allowing the students in training can thus improve their skills before applying the technique in clinical practice.

The impact of pharmaceutical company funding on results of randomized trials of nicotine replacement therapy for smoking cessation: a meta-analysis.

AIMS: To assess whether source of funding affected the results of trials of nicotine replacement therapy (NRT) for smoking cessation. METHODS: We reviewed all randomized controlled trials included in the Cochrane review. There were insufficient non-industry trials of the newer products for these to be included. We included 90 trials of either the nicotine gum (52) or nicotine patch (38). They comprised 18 238 treatment and 16 235 control participants. Forty-nine showed evidence of industry support (18 gum, 31 patch). RESULTS: Industry (31 of 49, 63%) compared with non-industry (seven of 41, 17%, P < 0.001) supported a higher proportion of nicotine patch studies and had larger sample sizes (479 versus 268, P = 0.04). Twenty-five (51%) industry trials reported statistically significant (P < 0.05) results, compared with nine (22%) non-industry trials (OR = 3.70, 95% CI = 1.46-9.35). This difference was not explained by trial characteristics. Industry-supported trials had a pooled odds ratio of 1.90 (1.67-2.16), compared with 1.61 (1.43-1.80) for other studies (chi(2) = 3.6, P = 0.058). There was evidence of funnel-plot asymmetry among industry trials (t = 4.35, P < 0.001), but not among other trials, indicating that several small null-effect industry trials may not have reached publication. After imputation adjustment, the odds ratio for industry trials reduced to 1.64 (1.43-1.89) and the overall NRT odds ratio reduced from 1.73 (1.60-1.90) to 1.62 (1.49-1.77). CONCLUSIONS: Compared with independent trials, industry-supported trials were more likely to produce statistically significant results and larger odds ratios. These differences persisted after adjustment for basic trial characteristics. Although we had no data on the amount of funding for each trial, it is possible that more resources led to higher treatment compliance and therefore greater efficacy in industry-supported trials. Differences can also possibly be explained by publication bias with several small, null-effect industry studies not having reached publication. After adjustment for this possible bias, results for industry trials were lower and similar to non-industry results. Similarly, the overall estimate of the net effect for these products reduces to about 5% attributable 1-year successes. This remains of considerable public health benefit. Registration of clinical trials has become mandatory in many countries since most of the trials considered here were conducted, and this should reduce the potential for publication bias in future.

Substitutes for tobacco smoking: a behavioral economic analysis of nicotine gum, denicotinized cigarettes, and nicotine-containing cigarettes.

Both pharmacological and nonpharmacological stimuli may be responsible for the reinforcement and maintenance of tobacco smoking. The present study examined the self-administration of nicotine gum, denicotinized cigarettes, and nicotine-containing cigarettes utilizing a behavioral economic design in order to investigate the pharmacological and nonpharmacological aspects of cigarette smoking. Cigarette-deprived, dependent smokers worked for cigarette puffs and nicotine gum in daily operant sessions. In one phase, nicotine-containing cigarettes were available at increasing unit prices across sessions. Three phases replicated these sessions with nicotine gum, denicotinized cigarettes, or both, concurrently available at a constant unit price. As nicotine-containing cigarette unit price increased, consumption decreased. However, as nicotine-containing cigarette unit price increased, nicotine gum and denicotinized cigarette consumption increased. Consumption of nicotine gum, but not denicotinized cigarettes, diminished when all three reinforcers were concurrently available. Concurrently available denicotinized cigarettes, but not nicotine gum, caused a statistically significant reduction in nicotine-containing cigarette consumption. In another phase, denicotinized cigarettes were available at increasing unit prices across sessions while nicotine gum was concurrently available at a constant unit price. This phase demonstrated that nicotine content had no reliable effect on cigarette or nicotine gum consumption. These results suggest that denicotinized cigarettes are a more effective alternative reinforcer than nicotine gum, indicating that nonpharmacological stimuli of smoking merit attention in smoking cessation treatment. Furthermore, these findings indicate that alternative reinforcement would be most effective in smoking cessation treatment when combined with high prices for cigarettes.

Wastage of a silicone impression material in a general practice setting: a comparison between hand and automixing methods.

A practice-based, randomised, controlled trial has been undertaken to investigate the wastage of impression material when recording full arch one-stage, polyvinyl siloxane impressions using four techniques: putty and automix light viscosity material, putty and automix regular viscosity material, putty and tubed light viscosity material, and putty and tubed regular viscosity material. A total of 100 maxillary impressions, comprising 25 recorded using each of the four techniques, were obtained according to a predetermined scheme for randomisation. All material wasted in dispensing, mixing and applying each impression was determined by repeated weighing. Statistical comparisons of the mean weights of material wasted for each type of impression revealed that significantly (P < 0.01) less wastage occurred with the automix techniques. It is concluded that automix impression techniques may, in more extensive studies, be found to be more cost effective than tubed impression material techniques when recording impressions of the type investigated.