Functional Magnetic Resonance Imaging of Cerebral Hemodynamic Responses to Pain Following Thoracic Thrust Manipulation in Individuals With Neck Pain: A Randomized Trial.

OBJECTIVE: The purpose of this study was to examine whether cerebral activation in response to noxious mechanical stimuli varies with thrust manipulation (TM) when compared with sham manipulation (SM) as measured by blood oxygenation level-dependent functional magnetic resonance imaging. METHODS: Twenty-four volunteers (67% female) with complaints of acute or subacute mechanical (nontraumatic) neck pain satisfied eligibility requirements and agreed to participate. Participants were randomized to receive TM to the thoracic spine or SM, and then underwent functional magnetic resonance scanning while receiving noxious stimuli before and after TM or SM. An 11-point numeric pain rating scale was administered pre- and postmanipulation for neck pain and to determine perceptions of pain intensity with respect to neck pain and mechanical stimuli. Blood oxygenation level-dependent functional magnetic resonance imaging recorded the cerebral hemodynamic response to the mechanical stimuli. RESULTS: Imaging revealed significant group differences, with those individuals in the manipulation group exhibiting increased areas of activation (postmanipulation) in the insular and somatosensory cortices and individuals in the sham group exhibiting greater areas of activation in the precentral gyrus, supplementary motor area, and cingulate cortices (P < .05). However, between-group differences on the numeric pain rating scale for mechanical stimuli and for self-reported neck pain were not statistically significant. CONCLUSIONS: This study provides preliminary level 2b evidence suggesting cortical responses in patients with nontraumatic neck pain may vary between thoracic TM and a sham comparator.

Laparoscopic v open donor nephrectomy: a cost-utility analysis of the initial experience at a tertiary-care center.

BACKGROUND AND PURPOSE: Laparoscopic donor nephrectomy (LapDN) offers donors more rapid postoperative recovery and recipients equivalent graft function when compared with open donor nephrectomy (OpenDN). Nonetheless, costs are less favorable for LapDN than for OpenDN. We compared LapDN and OpenDN with cost-utility analysis. METHODS: A decision analysis modeling approach was performed: utilities derived using time trade-off and quality-adjusted life year (QALY) techniques; probabilities derived from a systematic review of the literature. All costs were included from a societal perspective using actual cost data from OpenDN and LapDN patients performed contemporaneously between July 1, 2000 and December 31, 2000. Costs of lost employment were estimated using mean provincial annual earnings. Incremental cost-effectiveness ratio (ICER) was calculated with "best-case" and "worst-case" scenarios for confidence intervals; sensitivity analyses were used to assess robustness. RESULTS: LapDN costs are higher ($10,317.40 vs. $9,853.70), while quality of life (QOL) is superior (0.7683 vs. 0.7062). The ICER from a societal perspective was C$7,471.11/QALY. If all donor nephrectomies nationally were performed laparoscopically, there would be an additional annual cost of C$665,240 with a societal gain of 24.84 QALYs. CONCLUSIONS: LapDN offers improved QOL at marginally higher cost. A societal ICER of $7,471.11/QALY compares favorably to many accepted health-care interventions. By potentially increasing organ donor rates, LapDN may be cost saving by decreasing the number of patients on dialysis.