Minimally invasive surgery for suspected early-stage ovarian cancer; a cost-effectiveness study.

OBJECTIVE: While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses. DESIGN: Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management. METHODS: The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings. MAIN OUTCOME MEASURES: The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs). RESULTS: MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses. CONCLUSION: MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses. TWEETABLE ABSTRACT: MIS is a cost-effective management strategy for women with suspicious ovarian masses.

Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer.

For women with breast cancer who undergo mastectomy, immediate breast reconstruction (IR) offers a cosmetic and psychological advantage. We evaluated the association between demographic, hospital, surgeon and insurance factors and receipt of IR. We conducted a retrospective hospital-based analysis with the Perspective database. Women who underwent a mastectomy for invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) from 2000 to 2010 were included. Logistic regression analysis was used to determine factors predictive of IR. Analyses were stratified by age (<50 vs. ≥ 50) and IBC versus DCIS. Of the 108,992 women with IBC who underwent mastectomy, 30,859 (28.3 %) underwent IR, as compared to 6,501 (44.2 %) of the 14,710 women with DCIS who underwent mastectomy underwent IR. In a multivariable model for IBC, increasing age, black race, being married, rural location, and increased comorbidities were associated with decreased IR. Odds ratios (OR) of IR increased with commercial insurance (OR 3.38) and Medicare (OR 1.66) insurance (vs. self-pay), high surgeon-volume (OR 1.19), high hospital-volume (OR 2.24), and large hospital size (OR 1.20). The results were identical for DCIS, and by age category. The absolute difference between the proportion of patients who received IR with commercial insurance compared to other insurance, increased over time. Immediate in-hospital complication rates were higher for flap reconstruction compared to implant or no reconstruction (15.2, 4.0, and 6.1 %, respectively, P < .0001). IR has increased significantly over time; however, modifiable factors such as insurance status, hospital size, hospital location, and physician volume strongly predict IR. Public policy should ensure that access to reconstructive surgery is universally available.

Use of dietary supplements in the United States, 1988-94.

OBJECTIVES: This report presents estimates of the prevalence of use of dietary supplements among the U.S. population by various demographic and descriptive characteristics, the number of products taken, and types of supplements taken by broad product-type categories. METHODS: The third National Health and Nutrition Examination Survey (NHANES III) is a nationally representative survey of the civilian, noninstitutionalized U.S. population, 2 months of age or over. Participants were asked about their use of vitamin and/or mineral supplements in the past month. Many also reported use of other dietary supplements. RESULTS: Approximately 40 percent of the population took dietary supplements during the month prior to the interview. Females (44 percent) were more likely to take a supplement than males (35 percent). Non-Hispanic white persons (43 percent) were more likely to take supplements than non-Hispanic black persons (30 percent) and Mexican American persons (29 percent). Children 1-5 years of age were major users of supplements. Among adults 20 years of age and older, there was a trend toward increasing use of dietary supplements with age. Higher levels of education, income, and self-reported health status were all positively related to supplement use. Sixty-seven percent of supplement users took only one supplement, with the majority of them taking a combination vitamin/mineral product (46 percent). CONCLUSIONS: A substantial proportion of the U.S. population takes vitamins, minerals, and/or other dietary supplements.

Prediction of an anti-IgE binding site on IgE.

A combination of computation techniques have been used to determine the binding site and amino acid residues on IgE that are critical for binding to a therapeutic anti-IgE. Homology modeling was used to model parts of IgE and of an antibody that binds to IgE. Docking simulations using shape descriptions were then carried out using the models to determine which residues in the IgE are involved in the binding interaction. The anti-IgE has been determined to bind close to some of the residues that are believed to be in the Fc(epsilon)RI receptor site on IgE, therefore preventing IgE from binding to Fc(epsilon)RI on mast cells and basophils and causing the release of pharmacologic mediators from these cells. Experiments have been suggested to verify the binding site and the residues involved in binding to anti-IgE.

Gun-related violence in and around inner-city schools.

OBJECTIVE: To assess the degree to which inner-city high school students are victimized by threat of or actual firearm attack. DESIGN: Cross-sectional survey. SETTING: Ten inner-city high schools in five cities in four states. PARTICIPANTS: A total of 1653 male and female inner-city high school students responding anonymously. SELECTION PROCEDURES: Volunteer, convenience sample. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Twenty-three percent of respondents were classified as victims. Major variables predicting victimization levels were gender, number of siblings, exposure to violence outside of school, and personal violence-related attributes. Only one in 10 victimizations appeared to be random (ie, not predicted by these variables). CONCLUSIONS: Violence in school is brought into, rather than generated by, the school. Victimized students have characteristics that put them at higher risk of victimization than other students. Given the large number of victimizations and the large number of respondents with risk characteristics, intervention at the individual level seems ineffective. Instead, alteration of community social structure and culture appears to be the appropriate, although difficult, avenue of change for gun-related victimization levels.

Assessment of paracervical nerve block anaesthesia during labour.

An assessment of paracervical nerve block anaesthesia was made in 118 women during labour using 0.5% bupivacaine with 1:200,000 parts of adrenaline added. The 82 multiparae were each given a single block and the 36 primigravidae a continuous block to try to provide the sole means of analgesia throughout the first stage of labour.Only 48% of the primigravidae required no other form of analgesia, as against 72% of the multiparae.Complications included a 17% incidence of maternal haemorrhage during insertion of the continuous needle, an overall fetal bradycardia rate of 11%, and two perinatal deaths following single paracervical block. It is concluded that the use of continuous paracervical block should be discontinued, and that amide-type local anaesthetic agents should not be used for single paracervical block.