RESUMO
The article Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?, written by K. L. Ong, D. P. Beall, M. Frohbergh, E. Lau, and J. A. Hirsch was originally published electronically on the publisher's internet portal.
RESUMO
The 5-year period following 2009 saw a steep reduction in vertebral augmentation volume and was associated with elevated mortality risk in vertebral compression fracture (VCF) patients. The risk of mortality following a VCF diagnosis was 85.1% at 10 years and was found to be lower for balloon kyphoplasty (BKP) and vertebroplasty (VP) patients. INTRODUCTION: BKP and VP are associated with lower mortality risks than non-surgical management (NSM) of VCF. VP versus sham trials published in 2009 sparked controversy over its effectiveness, leading to diminished referral volumes. We hypothesized that lower BKP/VP utilization would lead to a greater mortality risk for VCF patients. METHODS: BKP/VP utilization was evaluated for VCF patients in the 100% US Medicare data set (2005-2014). Survival and morbidity were analyzed by the Kaplan-Meier method and compared between NSM, BKP, and VP using Cox regression with adjustment by propensity score and various factors. RESULTS: The cohort included 261,756 BKP (12.6%) and 117,232 VP (5.6%) patients, comprising 20% of the VCF patient population in 2005, peaking at 24% in 2007-2008, and declining to 14% in 2014. The propensity-adjusted mortality risk for VCF patients was 4% (95% CI, 3-4%; p < 0.001) greater in 2010-2014 versus 2005-2009. The 10-year risk of mortality for the overall cohort was 85.1%. BKP and VP cohorts had a 19% (95% CI, 19-19%; p < 0.001) and 7% (95% CI, 7-8%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the NSM cohort, respectively. The BKP cohort had a 13% (95% CI, 12-13%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the VP cohort. CONCLUSIONS: Changes in treatment patterns following the 2009 VP publications led to fewer augmentation procedures. In turn, the 5-year period following 2009 was associated with elevated mortality risk in VCF patients. This provides insight into the implications of treatment pattern changes and associated mortality risks.
Assuntos
Fraturas por Compressão/mortalidade , Fraturas por Osteoporose/mortalidade , Fraturas da Coluna Vertebral/mortalidade , Vertebroplastia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Comorbidade , Feminino , Fraturas por Compressão/cirurgia , Humanos , Estimativa de Kaplan-Meier , Cifoplastia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Mortalidade/tendências , Fraturas por Osteoporose/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Projetos de Pesquisa/normas , Medição de Risco/métodos , Fraturas da Coluna Vertebral/cirurgia , Estados Unidos/epidemiologiaRESUMO
SUMMARY: In patients in the Direct Assessment of Nonvertebral Fractures in Community Experience (DANCE) observational study with and without a prior vertebral or hip fracture, the incidence of nonvertebral fractures was lower with >6 months of teriparatide treatment than during the first 6 months. INTRODUCTION: Clinical evidence on the effect of teriparatide in patients with prior fracture is limited. In the DANCE observational study, the incidence of nonvertebral fragility fractures (NVFX) decreased significantly in patients receiving teriparatide for >6 months (6-24 months) versus >0 to ≤6 months (reference period). METHODS: We performed a post hoc analysis to assess the effect of teriparatide 20 µg/day in patients who entered DANCE with prior vertebral or hip fractures. The incidence of patients experiencing a NVFX for four 6-month intervals during and after treatment was compared with the reference period. RESULTS: Overall, 4085 patients received ≥1 dose of teriparatide. Of 3720 with sufficient data for efficacy analysis, 692 had prior vertebral fracture, including 179 with previous kyphoplasty/vertebroplasty; 290 had prior hip fracture. These patients were older, and those with prior vertebral fractures had more comorbid conditions at baseline than those without prior vertebral fractures. The incidence of patients experiencing NVFX declined over time in all patient groups. The fracture incidence rate declined 49 and 46%, respectively, in patients with and without prior vertebral fracture and was 63 and 46% lower in patients with previous kyphoplasty/vertebroplasty and without prior vertebral fracture. NVFX declined 43 and 48% in patients with and without prior hip fracture. The reduced incidence over time was consistent in the subgroups (all interaction p values >0.05). Patients with prior fracture were more likely to experience serious adverse events. CONCLUSION: The incidence of NVFX decreased over time in patients receiving teriparatide in DANCE regardless of prior fracture status.
Assuntos
Conservadores da Densidade Óssea/uso terapêutico , Osteoporose/tratamento farmacológico , Fraturas por Osteoporose/prevenção & controle , Teriparatida/uso terapêutico , Conservadores da Densidade Óssea/efeitos adversos , Feminino , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/prevenção & controle , Humanos , Incidência , Masculino , Osteoporose/epidemiologia , Fraturas por Osteoporose/epidemiologia , Recidiva , Fraturas da Coluna Vertebral/epidemiologia , Fraturas da Coluna Vertebral/prevenção & controle , Teriparatida/efeitos adversos , Estados Unidos/epidemiologiaRESUMO
We reviewed all peer-reviewed papers analysing the cost-effectiveness of vertebroplasty and balloon kyphoplasty for osteoporotic vertebral compression fractures. In general, the procedures appear to be cost effective but are very dependent upon model input details. Better data, rather than new models, are needed to answer outstanding questions. Vertebral augmentation procedures (VAPs), including vertebroplasty (VP) and balloon kyphoplasty (BKP), seek to stabilise fractured vertebral bodies and reduce pain. The aim of this paper is to review current literature on the cost-effectiveness of VAPs as well as to discuss the challenges for economic evaluation in this research area. A systematic literature search was conducted to identify existing published studies on the cost-effectiveness of VAPs in patients with osteoporosis. Only peer-reviewed published articles that fulfilled the criteria of being regarded as full economic evaluations including both morbidity and mortality in the outcome measure in the form of quality-adjusted life years (QALYs) were included. The search identified 949 studies, of which four (0.4 %) were identified as relevant with one study added later. The reviewed studies differed widely in terms of study design, modelling framework and data used, yielding different results and conclusions regarding the cost-effectiveness of VAPs. Three out of five studies indicated in the base case results that VAPs were cost effective compared to non-surgical management (NSM). The five main factors that drove the variations in the cost-effectiveness between the studies were time horizon, quality of life effect of treatment, offset time of the treatment effect, reduced number of bed days associated with VAPs and mortality benefit with treatment. The cost-effectiveness of VAPs is uncertain. In answering the remaining questions, new cost-effectiveness analysis will yield limited benefit. Rather, studies that can reduce the uncertainty in the underlying data, especially regarding the long-term clinical outcomes of VAPs, should be conducted.
Assuntos
Fraturas por Osteoporose/economia , Fraturas da Coluna Vertebral/economia , Vertebroplastia/economia , Análise Custo-Benefício , Fraturas por Compressão/economia , Fraturas por Compressão/cirurgia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Cifoplastia/economia , Fraturas por Osteoporose/cirurgia , Qualidade de Vida , Fraturas da Coluna Vertebral/cirurgiaRESUMO
The treatment of painful vertebral compression fractures has changed substantially since the introduction of vertebroplasty in the mid-1980s and balloon kyphoplasty in the late 1990s. Both procedures were widely accepted with the vertebral fractures treated reaching 150,000 per annum in 2009 prior to the publication of 2 randomized controlled trials comparing vertebroplasty with a sham treatment published in the New England Journal of Medicine in August 2009. Since then, there has been a flood of information on vertebral augmentation and balloon kyphoplasty. It is worth evaluating this information especially because it relates to current recommendations that are often followed blindly by medical and administrative groups unfamiliar with either the procedure or the high level of evidence surrounding vertebral augmentation. To streamline the evaluation of some current recommendations, we limited the analysis to the recommendations found on UpToDate.com. This Web site is an evidence-based, peer-reviewed source of information available for patients, doctors, health insurance companies, and population-based medical decision-making.
Assuntos
Fraturas por Compressão/cirurgia , Internet , Cifoplastia , Fraturas da Coluna Vertebral/cirurgia , Vertebroplastia , Medicina Baseada em Evidências , Humanos , Disseminação de Informação , Resultado do TratamentoRESUMO
Milk-alkali syndrome can be caused by ingesting large amounts of calcium carbonate. Coincident with the promotion of calcium carbonate as treatment for both dyspepsia and osteoporosis, milk-alkali syndrome is now a common cause of hypercalcemia severe enough to require admission to the hospital. The syndrome accounted for less than 2% of such admissions before 1990, but from 1990 through 1993, it was the cause of hypercalcemia for over 12% of these patients. Only primary hyperparathyroidism and hypercalcemia of malignancy (excluding multiple myeloma) are more common. The diagnosis of milk-alkali syndrome is made almost entirely based on the patient's history; careful attention to dietary practices and over-the-counter drug use is required, as numerous over-the-counter medications contain calcium carbonate. Modern assays for PTH demonstrate the expected suppression of PTH by hypercalcemia. Nonetheless, measurement of PTH must be performed in a timely manner as treatment with intravenous saline may result in hypocalcemia and elevated PTH soon after admission. Given the pathophysiology of milk-alkali syndrome compared to other causes of hypercalcemia, hypocalcemia with rebound hyperparathyroidism is probably unique to milk-alkali syndrome.
Assuntos
Carbonato de Cálcio/efeitos adversos , Hipercalcemia/induzido quimicamente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização , Humanos , Hipercalcemia/sangue , Hipercalcemia/fisiopatologia , Ensaio Imunorradiométrico , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Estudos RetrospectivosRESUMO
Reconstruction of three-dimensional images is performed either by scanner-based systems or by independent computers. The advantages of a stand-alone system include compatibility with multiple imaging modalities, more advanced technology, and increased user interaction. This report illustrates the use of a stand-alone system for the less commonly utilized purpose of three-dimensional reconstruction of abdominal soft tissues. It further demonstrates the merit of three-dimensional imaging as an important diagnostic adjunct and as a valuable source of preoperative surgical information.
Assuntos
Aneurisma Ilíaco/diagnóstico por imagem , Processamento de Imagem Assistida por Computador , Tomografia Computadorizada por Raios X/métodos , Obstrução Ureteral/diagnóstico por imagem , Idoso , Angiografia , Humanos , Aneurisma Ilíaco/complicações , Masculino , Ultrassonografia , Obstrução Ureteral/complicações , UrografiaAssuntos
Esclerose Lateral Amiotrófica/complicações , Demência/diagnóstico por imagem , Lobo Frontal/irrigação sanguínea , Circulação Cerebrovascular , Cisteína/análogos & derivados , Demência/etiologia , Feminino , Lobo Frontal/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Compostos de Organotecnécio , Compostos Radiofarmacêuticos , Tomografia Computadorizada de Emissão de Fóton ÚnicoAssuntos
Neoplasias Ósseas/diagnóstico por imagem , Síndrome de Gardner/diagnóstico por imagem , Osteoma/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adenoma/diagnóstico por imagem , Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Adulto , Osso e Ossos/diagnóstico por imagem , Humanos , Masculino , CintilografiaAssuntos
Tumor Carcinoide/diagnóstico por imagem , Neoplasias Duodenais/diagnóstico por imagem , Somatostatina/análogos & derivados , Tomografia Computadorizada de Emissão de Fóton Único , Adulto , Tumor Carcinoide/complicações , Tumor Carcinoide/metabolismo , Neoplasias Duodenais/complicações , Neoplasias Duodenais/metabolismo , Gastrinas/metabolismo , Humanos , Masculino , Síndrome de Zollinger-Ellison/complicaçõesAssuntos
Medicina de Família e Comunidade/estatística & dados numéricos , Reforma dos Serviços de Saúde , Médicos/estatística & dados numéricos , Escolha da Profissão , Reforma dos Serviços de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde , Humanos , Internato e Residência/estatística & dados numéricos , Medicina/estatística & dados numéricos , Formulação de Políticas , Atenção Primária à Saúde/estatística & dados numéricos , Prática Profissional , Especialização , Estados UnidosRESUMO
High quality MR images of the gastrointestinal tract are now obtainable using a T2-weighted fast SE MR sequence with half-Fourier acquisition of data (the HASTE sequence). This fast sequence can acquire a set of images in a single breath hold and is insensitive to peristalsis-related artifact. It can be used with other imaging modalities in defining bowel obstruction and is accurate in determining the presence of bowel dilation and level of obstruction and in differentiating obstructing tumor from other causes of obstruction.
Assuntos
Obstrução Intestinal/diagnóstico , Imageamento por Ressonância Magnética/métodos , Humanos , Intestinos/patologiaRESUMO
OBJECTIVE: Our objective was to identify reasons for the difficulty in diagnosing retained intrapericardial sponges and to determine ways to improve diagnostic accuracy. CONCLUSION: All three intrapericardially retained sponges were in the posterior pericardium, a region not visible to the surgeon. Radiographic detection of the sponges on standard anteroposterior projections is difficult because of exposure factors, other confusing linear markers, and metallic densities such as sternal sutures. However, knowledge of the typical location of a lost sponge and use of lateral radiographic projections may aid in early detection of this rare complication.
Assuntos
Corpos Estranhos/diagnóstico por imagem , Pericárdio , Tampões de Gaze Cirúrgicos , Idoso , Ponte de Artéria Coronária , Corpos Estranhos/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , RadiografiaRESUMO
AIM: To compare the accuracy of fast magnetic resonance (MR) imaging using the half-Fourier single shot turbo spin echo (HASTE) sequence with helical computed tomography (CT) in diagnosing bowel obstruction. MATERIALS AND METHODS: Prospective evaluation of 44 patients with clinical evidence of bowel obstruction was conducted using various investigations including HASTE MR and helical CT. MR was performed with a Siemens 1.5 Tesla MR Imaging System and CT was performed with one of two Siemens ARHP CT systems using helical technique. MR acquisition allowed data to be gathered in 6-10 minutes and no contrast media were administered. CT imaging consisted of consecutive helical CT through the abdomen and pelvis with oral and intravenous contrast medium used when indicated. Bowel dilation along with the presence and level of obstruction were determined. RESULTS: Twenty-eight patients had bowel obstruction confirmed at laparotomy or by radiographic assessment. Of these, 25 had small bowel obstruction and three had colonic obstructions. The obstruction was due to fibrous adhesions in nine patients, metastases or primary carcinoma in seven, Crohn's disease in four, hernias in two, and inflammation or abscess in two. Other causes of obstruction included lymphoma, intussusception and anastomotic stricture. The cause of obstruction was correctly diagnosed by CT in 71%, and by MR in 95% of cases. The sensitivity, specificity and accuracy for HASTE MR imaging was 95%, 100% and 96% respectively as compared to 71%, 71% and 71% for helical CT. CONCLUSION: Fast MR imaging using the HASTE sequence is more accurate than helical CT in diagnosing bowel obstruction.
Assuntos
Obstrução Intestinal/diagnóstico , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/diagnóstico , Feminino , Humanos , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/patologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: Our aim was to determine whether fast MR imaging using the half-Fourier acquisition single-shot turbo spin-echo (HASTE) MR sequence is accurate for diagnosis of small-bowel obstruction. MATERIALS AND METHODS: Forty-three nonconsecutive patients with suspected small-bowel obstruction were evaluated with HASTE MR imaging during a 12-month period. Images were retrospectively assessed for the presence, level, and cause of bowel obstruction. Data were compared with results of conventional radiography and findings at surgery when available. RESULTS: Of the 43 patients imaged, 29 patients had small-bowel obstruction revealed by unenhanced or contrast-enhanced radiography or by CT. Surgical confirmation was available in 21 patients. Small-bowel obstruction was shown by HASTE MR imaging in 26 (90%) of these 29 patients. HASTE MR images showed the correct level of obstruction in 19 (73%) of the 26 patients and showed the cause of obstruction in 13 (50%) of the 26 patients. CONCLUSION: With a high degree of accuracy, HASTE MR imaging can show the presence and level of small-bowel obstruction.
Assuntos
Obstrução Intestinal/diagnóstico , Intestino Delgado , Imageamento por Ressonância Magnética/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
The objective of the study was to assess the frequency of the use of chest computed tomography in 385 adults hospitalized with community-acquired pneumonia and determine whether the computed tomography examinations yielded additional diagnostic information. Also, if additional information was obtained, the study determined whether it changed the patient's treatment plan.
Assuntos
Hospitalização , Pneumonia Bacteriana/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adulto , Idoso , Infecções Comunitárias Adquiridas/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia Torácica/estatística & dados numéricosRESUMO
We have assessed the effect of 10:1 lossy (JPEG) compression on six board-certified radiologists' ability to detect three commonly seen abnormalities on chest radiographs. The study radiographs included 150 chest radiographs with one of four diagnoses: normal (n = 101), pulmonary nodule (n = 19), interstitial lung disease (n = 19), and pneumothorax (n = 11). Before compression, these images were printed on laser film and interpreted in a blinded fashion by six radiologists. Following an 8-week interval, the images were reinterpreted on an image display workstation after undergoing 10:1 lossy compression. The results for the compressed images were compared with those of the uncompressed images using receiver operating characteristic (ROC) analyses. For five of six readers, the diagnostic accuracy was higher for the uncompressed images than for the compressed images, but the difference was not significant (P > .1111). Combined readings for the uncompressed images were also more accurate when compared with the compressed images, but this difference was also not significant (P = .1430). The sensitivity, specificity, and accuracy values were 81.5%, 89.2%, and 86.7% for the compressed images, respectively, as compared with 78.9%, 94.5%, and 89.3% for the uncompressed images. There was no correlation between the readers' accuracy and their experience with soft-copy interpretation; the extent of radiographic interpretation experience had no correlation with overall interpretation accuracy. In conclusion, five of six radiologists had a higher diagnostic accuracy when interpreting uncompressed chest radiographs versus the same images modified by 10:1 lossy compression, but this difference was not statistically significant.