The cost-effectiveness of transcatheter aortic valve implantation: exploring the Italian National Health System perspective and different patient risk groups.

OBJECTIVES: To assess the cost-effectiveness (CE) of transcatheter aortic valve implantation (TAVI) in Italy, considering patient groups with different surgical risk. METHODS: A Markov model with a 1-month cycle length, comprising eight different health states, defined by the New York Heart Association functional classes (NYHA I-IV), with and without stroke plus death, was used to estimate the CE of TAVI for intermediate-, high-risk and inoperable patients considering surgical aortic valve replacement or medical treatment as comparators according to the patient group. The Italian National Health System perspective and 15-year time horizon were considered. In the base-case analysis, effectiveness data were retrieved from published efficacy data and total direct costs (euros) were estimated from national tariffs. A scenario analysis considering a micro-costing approach to estimate procedural costs was also considered. The incremental cost-effectiveness ratio (ICER) was expressed both in terms of costs per life years gained (LYG) and costs per quality adjusted life years (QALY). All outcomes and costs were discounted at 3% per annum. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess robustness of results. RESULTS: Over a 15-year time horizon, the higher acquisition costs for TAVI were partially offset in all risk groups because of its effectiveness and safety profile. ICERs were €8338/QALY, €11,209/QALY and €10,133/QALY, respectively, for intermediate-, high-risk and inoperable patients. ICER values were slightly higher in the scenario analysis. PSA suggested consistency of results. CONCLUSIONS: TAVI would be considered cost-effective at frequently cited willingness-to-pay thresholds; further studies could clarify the CE of TAVI in real-life scenarios.

Therapeutic strategy of late cerebral radionecrosis. A retrospective study of 21 cases.

AIM: Late cerebral radiation necrosis (LCR) is a serious complication of radiation treatment for brain tumors. This study investigates the diagnosis and management of patients with late clinical and neuroradiological cerebral radionecrosis after primary removal of brain neoplasm. The authors discuss the clinical features and long-term outcome of 21 patients with late cerebral radionecrosis and emphasize the importance of surgical and medical therapy. METHODS: Twenty-one patients with brain tumor treated by surgical resection or brain biopsy alone after radiotherapy during follow-up developed radionecrosis. The magnetic resonance imaging (MRI), surgical and clinical findings of these patients with radionecrosis are reviewed. RESULTS: MRI showed radionecrosis in 21 patients, 9 of which had undergone craniotomy for lesion removal. CONCLUSION: Late radionecrosis is infrequent following radiation therapy and may simulate tumor recurrence on MRI scans. From the authors' experience it is evident that, once begun, radiation treatment of neoplastic lesions can lead to complications such as late cerebral radionecrosis which often require surgical treatment. As correct diagnosis is necessary for appropriate treatment, a fair balance needs to be struck when considering ionizing radiation, medical therapy, surgery and diagnostic imaging.

Reduction of blood coagulation and monocyte-platelet interaction following the use of a minimal extracorporeal circulation system (Synergy) in coronary artery bypass grafting (CABG).

Cardiovascular surgery with cardiopulmonary bypass (CPB) induces activation of blood coagulation and systemic inflammation involved in post-operative complications. Our study evaluated the impact of the minimal extracorporeal circulation (mini-CPB) system (Synergy, Sorin Group) on these functional aspects. Twenty patients were randomly assigned to standard CPB (n = 10) or to Synergy (n = 10). Platelet expression of PAC-1, and monocyte/granulocyte-platelet conjugates were evaluated by flow cytometry. A leukocyte-platelet adhesion index was calculated after cell number normalization. ELISAs were performed to measure IL-6 and TNF-alpha, thrombin-antithrombin III complexes (TAT), prothrombin fragments (F1+2), beta-thromboglobulin (beta-TG) and sP-selectin (sCD62P). Blood samples were drawn at the time of anesthesia (T1), at the end of CPB (T2), and at 4 (T3) and 24 hours (T4) after weaning from CPB. All patients were similar for clinical characteristics. When compared to standard CPB, the Synergy showed lower levels of the monocyte-platelet adhesion index at T2 (0.023 +/- 0.005 vs 0.063 +/- 0.013, P = 0.0092) and T4 (0.031 +/- 0.003 vs 0.055 +/- 0.005, P = 0.0017), TAT complexes at T2 (27.175 +/- 5.967 vs 86.592 +/- 5.415, P = 0.0005) and T3 (26.977 +/- 2.468 vs 45.146 +/- 4.365, P = 0.0041), F1+2 fragments at T2 (2.222 +/- 0.226 vs 4.249 +/- 0.292, P = 0.0009), and sP-selectin at T3 (115.17 +/- 19.623 vs 169.554 +/- 19.709, P = 0.0703) and T4 (108.542 +/- 6.429 vs 140.799 +/- 14.771, P = 0.0833). In summary, the Synergy exhibited a lower post-operative activation of blood coagulation, together with a reduced interaction between circulating monocytes and platelets.

Aggressive eosinophilic granuloma of the parietal bone. An immunohystochemical study of Ki-67 expression.

Solitary eosinophilic granuloma (EG) of the skull is a rare lesion, the natural history of which is still to be defined. We report a case of a 26-year-old female who presented with progressive headache and nausea accompanied by a painful firm mass in her left parietal region, which grew very rapidly during the last two weeks before admission. Computed tomography scan showed an osteolytic lesion, which on magnetic resonance imaging appeared hyperintense on both T1- and T2-weighted images, with marked and heterogeneous enhancement after gadolinium administration. Total surgical excision of the lesion was performed and histopathological diagnosis was compatible with eosinophilic granuloma. Immuno-histochemical study of Ki-67 antigen expression was also performed with a labelling index of 10%. In a review of the pertinent literature, we found one case report showing a Ki-67 labelling index of 6.2% in a patient harboring EG of the occipital bone. These two relatively high percentages of proliferative activity suggest a role of local Langerhans'cell proliferation, along with that of inflammatory response, in the aggressive clinical course and rapid expansion observed in some rare cases of solitary eosinophilic granuloma.

Lymphoplasmacyte rich meningioma. A case report and review of the literature.

A peculiar type of meningioma with conspicious plasma-cell components is described. In accordance with the World Health Organization's Histological Typing of Tumours of the Central Nervous System, this rare clinical entity is recently designed as lymphoplasmacyte rich (LPR) meningioma. This type of meningioma is usually accompanied by prominent peripheral blood abnormalities, anemia and/or policlonal gammophaty, that disappear after surgical removal of the tumor. Actually, the origin (neoplastic or inflammatory) of this tumor is unclear; its biological behavior and clinical course are anomalous so it is considered closer to intracranial inflammatory masses rather than typical meningioma. In this paper, a new case of intracranial LPR meningioma occurring in a woman, is reported and a review the literature is made.

Bilateral chronic subdural hematoma associated with meningioma. Case report and review of the literature.

Gross intracranial hemorrhage associated with brain tumor has been reported to range from 3.6-10%. Brain metastases and malignant glioma are the most frequent underlying pathologies. Intracranial hemorrhage related to meningioma is a rare condition. Subarachnoid hemorrhage, acute subdural hematoma, intratumoral and intraparenchymal hematomas are the most common forms of bleeding associated with meningioma. By contrast, chronic subdural hematoma (cSDH) and intraventricular hemorrhage are seen less frequently. The authors report a very rare case of left fronto-parietal convexity meningioma associated with bilateral cSDH in a patient with history of recent minor head trauma and review the literature on hemorrhage associated with meningiomas.

Is the low tri-iodothyronine state a crucial factor in determining the outcome of coronary artery bypass patients? Evidence from a clinical pilot study.

The cardiovascular system is an important target for thyroid hormones. The present study evaluates the changes affecting thyroid hormone metabolism during and 6 days after coronary artery bypass and their relationship with the post-operative outcome of the patients. Thirty-three patients were enrolled in the study; their thyroid hormone profiles were determined at 13 sampling points during surgery and for 6 days afterwards. Serum total tri-iodothyronine (T3) and free T3 (FT3) concentrations decreased significantly after surgery (P<0.001) and they remained significantly low until the end of the study. Free thyroxine (FT4) and T4 declined significantly immediately after surgery (P<0.05 for FT4, P<0.001 for T4) but they returned to baseline values (24 h and 96 h post-surgery respectively). Serum reverse T3 increased remarkably 36 h after surgery (P<0.001) and remained significantly higher than the baseline value throughout the study. A relevant finding was that the days of post-operative hospitalization (10+/-3 days, means+/-S.D.) was inversely correlated with the slope of the recovery of T3 concentration (P<0.001) or with the area under the plasma curves of T3 (P=0.024, time range 72-144 h) and the FT3/FT4 ratio (P=0.037, time range 72-144 h) during the post-operative period. Our data suggest a prolonged reduction of T4 to T3 conversion in patients undergoing cardiac surgery and indicate that the recovery period is the most critical in the evaluation of a possibly successful approach for T3 substitutive therapy.

Paravertebral retropleuric microsurgery approach to the treatment of thoracic disc herniation. Personal experience and consideration of unsatisfactory results.

AIM: The authors report their experience on the paravertebral retropleuric microsurgery approach to the treatment of thoracic disc herniation. The paper describes both the approach and its result and it further expands on the reason behind the few cases of unsatisfactory results. METHODS: Twenty-three patients were operated upon for thoracic disc herniation between 1994 and 2000. The paravertebral retropleuric microsurgery approach was used in each. RESULTS: The results were very satisfactory in 20 cases, with all symptoms completely disappearing. In only 3 cases we had unsatisfactory results. CONCLUSION: We think that the postero-lateral retropleuric approach is a correct method for the treatment of thoracic disc herniation because it did not cause any significant bone intervention.

Neurocysticercosis. Case report.

In the present review we report a case of a 53-year-old woman affected with a cyst solitary cerebral hemispheric lesion causing acute generalized seizure. Clinical and neuroradiologic diagnosis of cystic astrocytoma was performed and the patient was operated. Microscopic analysis of the surgical specimen led to a diagnosis of parasitic infection, consistent with neurocysticercosis (NCC). NCC is the most frequent parasitosis of the central nervous system (CNS) in the world. The infective agent is taenia solium larvae. It is endemic in Latin America, Africa and some Asiatic countries, such as India. In Europe, many cases have been reported in Portugal, Spain, Poland and Romania. In Italy NCC is a rare disease. In recent years no cases have been described, but with high rate of immigration from endemic areas (Africa and East Europe) this parasitosis will be found in our country too, particularly affecting communities where hygienic conditions are poor. In conclusion we briefly analyze the relationship between pathogenesis of this parasitosis and its clinical symptoms.

Encapsulated intracerebral hematoma: a case report and review of the literature.

A case of encapsulated intracerebral hematoma is described in the light of the relevant literature. The etiopathogenesis, diagnostic problems and treatment of this rare entity are also discussed.

[Posttraumatic syringomyelia. A report of an atypical case]. / Siringomielia post-traumatica. Descrizione di un caso atipico.

An atypical case of post-traumatic syringomyelia is reported. Clinical presentation, electrophysiological and MR findings, as well as therapeutic efforts adopted for this case are discussed in the light of pertinent literature.

Soft cervical disc herniation. An analysis of 187 cases.

METHODS: During the period from January 1986 to December 1994, 187 consecutive patients (102 males and 85 females, between the ages of 24 and 63 years) with soft disc herniations of the cervical spine were operated on by anterior approach. RESULTS: One hundred and twenty-seven (67.9%) patients presented pure radicular syndrome, 17 (9.1%) with pure medullary syndrome, and 43 (23%) with myeloradiculopathy. Disc herniation was at the C3/4 level in 8 (4.3%) cases, at the C4/5 level in 17 (9.1%) cases, at the C5/6 level in 101 (54%) cases, and at the C6/7 level in 87 (46.6%) cases. In 18 (30%) patients suffering from myelopathy (with or without radiculopathy) an area of high MR signal intensity was observed within the cervical cord on T2-weighted images; such area corresponded at the level of cord compression by the herniated disc and was not demonstrated on T1-weighted images. All patients underwent microdiscectomy without bone grafting. Complete or almost complete relief of preoperative symptomatology was observed in 95.6% of patients with radiculopathy and in 83.3% of those with myelopathy.

Atypical pleomorphic xanthoastrocytoma.

A 65-year-old man experienced an ictal episode. CT revealed a left capsulo-thalamic mass, and SPET showed hypoperfusion of the left cerebral emisphere. The lesion was subtotally removed, and postoperative radiotherapy was given. Pathological examination demonstrated an "atypical" pleomorphic xanthoastrocytoma. The patient died of massive regrowth of the tumor 22 months after surgery. This case is discussed in light of the pertinent literature.

Myeloradicular damage in traumatic cervical disc herniation.

BACKGROUND: The literature on pure traumatic disc herniation is now voluminous but diversity of opinion exists regarding frequency, pathogenesis and management of this type of lesion. As a further contribution to the solution of the question it is thus justified to report our series of cervical traumatic disc herniation. METHODS: During the period from January 1986 to December 1994, 41 patients (25 males and 16 females, between the ages of 24 and 51 years) with traumatic cervical disc herniations were operated on by anterior approach. Twenty-six (63.4%) patients presented with radicular syndrome, 3 (7.3%) with medullary symptoms and signs, and 12 (29.3%) with myeloradiculopathy. Disc herniation was at the C3/4 level in 4 (9.7%) cases, at the C4/5 level in 7 (17.1%) cases, at the C5/6 level in 24 (58.5%) cases, and at the C6/7 level in 8 (19.5%) cases. In 6 (40%) patients suffering from myelopathy (with or without radiculopathy) an area of high MR signal intensity was observed within the cervical cord on T2-weighted images; such area corresponded at the level of cord compression by disc and was not demonstrated on T1-weighted images. All patients underwent discectomy without bone grafting. RESULTS: Among patients with radiculopathy, 27 (71%) experienced complete relief of preoperative symptomatology, and 11 (29%) minor pain and/or neurological deficits without interference with work activities. The myelopathy completely disappeared in 11 (73.3%) cases whereas remained unchanged in 3 (20%); 1 patient with myelopathy experienced amelioration of preoperative specific symptoms and signs. CONCLUSIONS: The results of surgery for cervical radiculopathy due to traumatic disc herniation are satisfactory since 92 to 100% of the patients postoperatively regain prior activities, an observation we have confirmed with our own series. The results in cases of myelopathy are less satisfactory: although approximately 73% of our patients with myelopathy reported total relief of preoperative symptomatology, published reports indicate that a significant postoperative improvement is seen in 33 to 56% of patients.

Intracranial epidermoid and dermoid cysts. Results of microneurosurgery.

The authors present their series of intracranial epidermoid and dermoid cysts. Clinical, radiological and anatomopathological features of these tumors are analyzed. Appropriate surgical treatment and results are discussed in light of the pertinent literature.

[The microsurgical treatment of the carpal tunnel syndrome]. / Trattamento microchirurgico della sindrome del tunnel carpale.

Between 1988 and 1994, 101 patients with carpal tunnel syndrome underwent microsurgical treatment. In 69 (68.3%) patients, simple incision of the transverse carpal ligament was performed. The remaining 32 (31.7%) patients also required neurolysis: external neurolysis in 17 (16.8%) patients, both external and internal neurolysis in 15 (14.9%) patients. There were no intra- and postoperative complications. After surgery, preoperative symptoms completely disappeared in 98 (97.1%) patients and improved in 3 (2.9%).

Pleomorphic xanthoastrocytoma: clinical, imaging and pathological features of four cases.

Four cases of pleomorphic xanthoastrocytoma (PXA) were collected from among 688 glioma patients who underwent operation at the Institute of Neurosurgery, University of Naples "Federico II" between January 1973 and December 1994. Three were females and one male, ranging in age from 10 months to 65 years. Three tumors were superficial in location, appearing as a meningo-cerebral mass in the temporo-parietal region. In one case, the tumor was situated deep within the brain (capsulo-thalamic region), without contact with leptomeninges. Three patients had experienced epileptic seizures, whereas one patient presented with an ictal episode. Tumor excision was grossly total in two cases, and subtotal in the remaining two. In three cases, histological examination demonstrated a "typical" PXA; conversely one tumor (subtotal excised) was an "atypical" PXA. The two patients with incomplete surgical resection were postoperatively treated with fractionated brain radiation therapy. Of the two patients who had grossly total removals, one showed tumor recurrence 6 years after surgery, and underwent operation (the recurrent neoplasm did not exhibit malignant transformation); the second patient was free of tumor at 14 months following craniotomy. Of the two patients who had undergone subtotal removals, one died because of massive regrowth of the lesion 22 months after surgery, whereas the second patient was asymptomatic at 1 year follow up.