RESUMO
BACKGROUND: Many follow-up guidelines for patients with high-risk melanoma include expensive imaging studies, serum biomarkers and regular visits to the dermatologist, with little attention to cost-effectiveness. OBJECTIVES: To establish the cost-effectiveness of chest-abdomen-pelvis computed tomography (CT) and brain magnetic resonance imaging (MRI) in a follow-up protocol for patients at high risk of relapse. METHODS: This was a prospective single-centre cohort study of 290 patients with clinicopathological American Joint Committee on Cancer (AJCC) stage IIB, IIC and III melanoma. Patients had a body CT scan and brain MRI every 6 months and were withdrawn from the study after completing a 5-year follow-up or when metastases were detected. A cost-effectiveness analysis for each follow-up radiological procedure was performed. RESULTS: Patients underwent 1805 body CT scans and 1683 brain MRIs. Seventy-six metastases (26·2%) were identified by CT or MRI. CT scan was cost-effective in the first 4 years (cost-effectiveness ratio 4710·70-14 437·10/patient with metastasis); brain MRI was cost-effective during the first year (cost-effectiveness ratio 14 090·60/patient with metastasis). Limitations included lack of survival analysis and comparisons with willingness-to-pay thresholds. CONCLUSIONS: Six-monthly CT scan of the chest, abdomen and pelvis is a cost-effective technique for the early detection of metastases in the first 4 years of follow-up in patients with AJCC stage IIC and III melanoma, and in the first 3 years in patients with AJCC stage IIB melanoma. In addition, brain MRI has been shown to be cost-effective only in the first year of follow-up in patients with AJCC stage IIC and III melanoma.
Assuntos
Assistência ao Convalescente/economia , Neoplasias Encefálicas/diagnóstico por imagem , Melanoma/diagnóstico por imagem , Recidiva Local de Neoplasia/diagnóstico por imagem , Neoplasias Cutâneas/diagnóstico por imagem , Assistência ao Convalescente/métodos , Assistência ao Convalescente/normas , Idoso , Neoplasias Encefálicas/secundário , Análise Custo-Benefício , Feminino , Humanos , Imageamento por Ressonância Magnética/economia , Imageamento por Ressonância Magnética/normas , Masculino , Melanoma/economia , Melanoma/secundário , Melanoma/cirurgia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/economia , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Fatores de Tempo , Tomografia Computadorizada por Raios X/economia , Tomografia Computadorizada por Raios X/normasRESUMO
Scarce scientific evidence is available to define the precise effects that certain drugs might have on embryonic and fetal development if taken by pregnant women with psoriasis, given the ethical concerns that preclude enrolling such women in clinical trials. The little information on the use of biologics during gestation that has been published is based on retrospective and observational studies, and experience with these drugs in this context in psoriasis is still very limited. The literature seems to suggest that biologic therapy is safe during pregnancy, but there is no certainty. This detailed review of accumulated experience with biologic therapy during pregnancy relies mainly on descriptions of the management of other types of rheumatic disease, although the use of these agents in psoriasis is growing steadily.
Assuntos
Anormalidades Induzidas por Medicamentos/etiologia , Antirreumáticos/efeitos adversos , Produtos Biológicos/efeitos adversos , Complicações na Gravidez/tratamento farmacológico , Psoríase/tratamento farmacológico , Anormalidades Induzidas por Medicamentos/prevenção & controle , Animais , Antirreumáticos/farmacocinética , Antirreumáticos/uso terapêutico , Produtos Biológicos/farmacocinética , Produtos Biológicos/uso terapêutico , Feminino , Feto/efeitos dos fármacos , Humanos , Recém-Nascido , Leite Humano/química , Gravidez , Efeitos Tardios da Exposição Pré-Natal , Medição de Risco , Fator de Necrose Tumoral alfa/antagonistas & inibidoresRESUMO
Psoriasis is a complex inflammatory disease, and in women the incidence is high in child-bearing years. Treatment during pregnancy presents genuine challenges since management requires adequate assessment of the extent of disease, comorbidity, and potential risk to the fetus. Scientific evidence is scarce on the effects that certain drugs have on fetal development given the ethical concerns about enrolling pregnant women in clinical trials. This review presents up-to-date information on the course of psoriasis during gestation and discusses associated conditions and the therapeutic protocols recommended for use during pregnancy.
Assuntos
Complicações na Gravidez , Psoríase , Feminino , Humanos , Guias de Prática Clínica como Assunto , Gravidez , Complicações na Gravidez/tratamento farmacológico , Psoríase/tratamento farmacológico , Fatores de RiscoAssuntos
Carcinoma Basocelular/tratamento farmacológico , Carcinoma Basocelular/patologia , Diterpenos/uso terapêutico , Síndrome do Hamartoma Múltiplo/tratamento farmacológico , Síndrome do Hamartoma Múltiplo/patologia , Microscopia Confocal/instrumentação , Neoplasias Cutâneas/tratamento farmacológico , Neoplasias Cutâneas/patologia , Idoso de 80 Anos ou mais , Monitoramento de Medicamentos , Humanos , Masculino , Microscopia , Fatores de TempoRESUMO
INTRODUCTION: Different protocols have been used to follow up melanoma patients in stage I-II. However, there is no consensus on the complementary tests that should be requested or the appropriate intervals between visits. Our aim is to compare an ultrasound-based follow-up with a clinical follow-up. PATIENTS AND METHODS: Analysis of two prospectively collected cohorts of melanoma patients in stage IB-IIA from two tertiary referral centres in Barcelona (clinical-based follow-up [C-FU]) and Turin (ultrasound-based follow-up [US-FU]). Kaplan-Meier curves were used to evaluate distant metastases-free survival (DMFS), disease-free interval (DFI), nodal metastases-free survival (NMFS) and melanoma-specific survival (MSS). RESULTS: A total of 1149 patients in the American Joint Committee on Cancer stage IB and IIA were included in this study, of which 554 subjects (48%) were enrolled for a C-FU, and 595 patients (52%) received a protocolised US-FU. The median age was 53.8 years (interquartile range [IQR] 41.5-65.2) with a median follow-up time of 4.14 years (IQR 1.2-7.6). During follow-up, 69 patients (12.5%) in C-FU and 72 patients (12.1%) in US-FU developed disease progression. Median time to relapse for the first metastatic site was 2.11 years (IQR 1.14-4.04) for skin metastases, 1.32 (IQR 0.57-3.29) for lymph node metastases and 2.84 (IQR 1.32-4.60) for distant metastases. The pattern of progression and the total proportion of metastases were not significantly different (P = .44) in the two centres. No difference in DFI, DMFS, NMFS and MSS was found between the two cohorts. CONCLUSION: Ultrasound-based follow-up does not increase the survival of melanoma patients in stage IB-IIA.
Assuntos
Linfonodos/diagnóstico por imagem , Melanoma/diagnóstico por imagem , Neoplasias Cutâneas/diagnóstico por imagem , Ultrassonografia , Adulto , Idoso , Progressão da Doença , Intervalo Livre de Doença , Feminino , Humanos , Itália , Estimativa de Kaplan-Meier , Linfonodos/patologia , Metástase Linfática , Masculino , Melanoma/mortalidade , Melanoma/secundário , Melanoma/terapia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Fatores de Risco , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/terapia , Espanha , Fatores de Tempo , Resultado do TratamentoAssuntos
Serviço Hospitalar de Anestesia , Anestesiologia , Corpo Clínico Hospitalar/provisão & distribuição , Área Carente de Assistência Médica , Médicos/provisão & distribuição , Anestesiologia/educação , Coleta de Dados , Previsões , Administradores Hospitalares , Humanos , Internato e Residência/estatística & dados numéricos , Pessoa de Meia-Idade , Assistentes Médicos/provisão & distribuição , Aposentadoria , Espanha , Inquéritos e Questionários , Recursos HumanosRESUMO
Severe pain is a frequent symptom in the Guillain Barré syndrome and can be intense, long lasting and with no response to the usual analgesics, including parenteral opiates. Epidural analgesia using morphine chloride in low doses has satisfactorily relieved pain in this disease in nine patients.