Assuntos
COVID-19 , Padrões de Prática Médica/tendências , Cirurgiões/tendências , Procedimentos Cirúrgicos Vasculares/tendências , Boston , Prestação Integrada de Cuidados de Saúde/tendências , Procedimentos Cirúrgicos Eletivos/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Sistema de Registros , Fatores de TempoRESUMO
BACKGROUND: The care of patients with critical limb ischemia (CLI) and tissue loss is notoriously challenging and expensive. We evaluated the cost-effectiveness of various management strategies to identify those that would optimize value to patients. METHODS: A probabilistic Markov model was used to create a detailed simulation of patient-oriented outcomes, including clinical events, wound healing, functional outcomes, and quality-adjusted life-years (QALYs) after various management strategies in a CLI patient cohort during a 10-year period. Direct and indirect cost estimates for these strategies were obtained using transition cost-accounting methodology. Incremental cost-effectiveness ratios (ICERs), in 2009 U.S. dollars per QALYs, were calculated compared with the most conservative management strategy of local wound care with amputation as needed. RESULTS: With an ICER of $47,735/QALY, an initial surgical bypass with subsequent endovascular revision(s) as needed was the most cost-effective alternative to local wound care alone. Endovascular-first management strategies achieved comparable clinical outcomes but at higher cost (ICERs ≥$101,702/QALY); however, endovascular management did become cost-effective when the initial foot wound closure rate was >37% or when procedural costs were decreased by >42%. Primary amputation was dominated (less effectiveness and more costly than wound care alone). CONCLUSIONS: Contemporary clinical effectiveness and cost estimates show an initial surgical bypass is the most cost-effective alternative to local wound care alone for CLI with tissue loss and can be supported even in a cost-averse health care environment.
Assuntos
Custos de Cuidados de Saúde , Isquemia/patologia , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Amputação Cirúrgica/economia , Estudos de Coortes , Análise Custo-Benefício , Procedimentos Endovasculares/economia , Humanos , Isquemia/economia , Cadeias de Markov , Anos de Vida Ajustados por Qualidade de Vida , Recuperação de Função Fisiológica , Resultado do Tratamento , Enxerto Vascular/economia , CicatrizaçãoRESUMO
BACKGROUND Fundus albipunctatus is a retinal dystrophy caused by a mutation in the gene encoding 11-cis-retinol dehydrogenase which delays the recovery of rod photoreceptor cells from light stimulation leading to night blindness. A recent study of a mouse model of fundus albipunctatus treated with 9-cis-retinal showed an improvement in visual function and structure. METHODS Seven patients with fundus albipunctatus were given a daily food supplement of four capsules containing high-dose 9-cis-beta-carotene for 90 days. The subjects were tested before and after treatment by visual field and electroretinogram in both eyes. This non-randomised prospective phase I study was registered at http://www.clinicaltrials.gov (NCT00478530). RESULTS All patients showed significant improvements in peripheral visual field (mean deviation improved from -4.77+/-2.0 to -3.28+/-2.28, p=0.009, t test) and a highly significant improvement in rod recovery rates measured electroretinographically (maximal scotopic b-wave amplitude responses, improved from 197+/-49 muV to 292+/-48 muV, p<0.001, t test). No complications or side effects were observed. CONCLUSION Oral treatment with 9-cis-beta-carotene led to reversal of a human retinal dystrophy. This potential therapy is readily available and should be evaluated in retinal dystrophies of similar mechanisms such as various types of retinitis pigmentosa.
Assuntos
Suplementos Nutricionais , Oftalmopatias Hereditárias/tratamento farmacológico , Degeneração Retiniana/tratamento farmacológico , Vitaminas/uso terapêutico , beta Caroteno/uso terapêutico , Administração Oral , Adolescente , Adulto , Eletrorretinografia , Oftalmopatias Hereditárias/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Degeneração Retiniana/fisiopatologia , Resultado do Tratamento , Acuidade Visual/efeitos dos fármacos , Campos Visuais/efeitos dos fármacos , Adulto JovemRESUMO
PURPOSE: To compare the rate of epithelial healing of corneal erosion in an animal model with 2 commercial formulations of fourth-generation fluoroquinolones: 0.3% gatifloxacin and 0.5% moxifloxacin. METHODS: Corneal erosions, 6 mm in diameter, were created in 28 rabbit eyes. The rabbits were randomized to receive topical gatifloxacin, moxifloxacin, or nonpreserved saline. Drops were administered every 15 minutes for 1 hour, then hourly for 3 hours, and then 4 times daily until the erosion reepithelialized. Eyes were examined with fluorescein drops and photographed every 12 hours with a cobalt blue-filtered light. When reepithelialization was observed, the rabbits were euthanized, and their eyes were enucleated for histopathologic evaluation. RESULTS: Reepithelialization of the corneal erosions was fastest in the saline-treated eyes (57.3 +/- 8 hours), followed by moxifloxacin (62.7 +/- 11.7 hours) and gatifloxacin (66 +/- 8.5 hours). These differences in the time to closure of the erosions among the 3 groups were not statistically significant. Although significant differences were found among the healing progression curves when all 3 groups were compared (P = 0.042), the difference between the 2 antibiotic-treated groups was not significant. CONCLUSIONS: Only slight differences in epithelial healing rates were found between the gatifloxacin-, moxifloxacin-, and saline-treated groups, suggesting that the 2 fluoroquinolones may have an equivalent role as prophylactic treatment of trauma- or surgery-induced corneal erosions.