Clinical Results and Quality of Life after Nonelective Cardiac Surgery in Octogenarians.

BACKGROUND: We analyzed the short-term and mid-term outcomes as well as the health-related quality of life (HRQOL) of octogenarians undergoing elective and urgent cardiac surgery. PATIENTS AND METHODS: We retrospectively identified 688 consecutive octogenarians who underwent cardiac surgery at our center between January 2012 and December 2019. A propensity score matching was performed which resulted in the formation of 80 matched pairs. The patients were interviewed and the Short Form-36 survey was used to assess the HRQOL of survivors. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model. RESULTS: The median age of the matched cohort was 82 years (p = 0.937), among whom, 38.8% of patients were female (p = 0.196). The median EuroSCORE II of the matched cohort was 19.4% (10.1-39.1%). The duration of postoperative mechanical ventilation was found to be independently associated with in-hospital mortality (odds ratio: 1.01 [95% confidence interval: 1.0-1.02], p = 0.038). The survival rates at 1, 2, and 5 years was 75.0, 72.0, and 46.0%, respectively. There was no difference in the total survival between the groups (p = 0.080). The physical health summary score was 41 (30-51) for the elective patients and 42 (35-49) for the nonelective octogenarians (p = 0.581). The median mental health summary scores were 56 (48-60) and 58 (52-60), respectively (p = 0.351). CONCLUSION: Cardiac surgery can be performed in octogenarians with good results and survivors enjoy a good quality of life; however, the indication for surgery or especially for escalation of therapy should always be made prudently, reserved, and in consideration of patient expectations.

Cost-Effectiveness of Erenumab for the Preventive Treatment of Migraine in Patients with Prior Treatment Failures in Sweden.

BACKGROUND: Migraine is a common neurological disease that disproportionately affects females and has a peak incidence during productive years, resulting in significant burden. OBJECTIVE: The aim of the study was to determine the cost effectiveness of erenumab for the preventive treatment of migraine. METHODS: A hybrid decision-tree plus Markov model was developed to evaluate the cost effectiveness of erenumab as a migraine treatment compared with best supportive care only for patients experiencing at least 4 monthly migraine days for whom at least two prior preventive treatments had failed. Clinical efficacy data were based on results from four randomized controlled trials of erenumab against placebo. The primary outcomes were costs, migraine days, and quality-adjusted life-years (QALYs). An incremental cost-effectiveness ratio (ICER) was estimated as the cost per QALY gained. The cost per migraine day avoided was also estimated, as were disaggregated direct and indirect costs. The analysis was conducted from Swedish societal and healthcare system perspectives based on total migraine, chronic migraine and episodic migraine populations, using a discount rate of 3% applied to both costs and health benefits and using year 2019 values. RESULTS: In the base-case deterministic analyses, erenumab treatment resulted in ICERs of Swedish krona (SEK) 34,696 (€3310) and SEK301,565 (€28,769) per QALY gained in the total migraine and episodic migraine populations, respectively. Erenumab was dominant in the chronic migraine population. In the total migraine population, the use of erenumab resulted in a net benefit to society of SEK81,739 (€7773) per patient, assuming a willingness-to-pay threshold of SEK300,000 (€28,528) per QALY. CONCLUSIONS: Our analysis suggests that erenumab is a cost-effective treatment for migraine with a willingness-to-pay threshold of SEK300,000 per QALY.

Cost evaluation of gadoxetic acid-enhanced magnetic resonance imaging in the diagnosis of colorectal-cancer metastasis in the liver: Results from the VALUE Trial.

OBJECTIVES: To assess the costs of diagnostic workup and surgery of three strategies for patients with colorectal cancer liver-metastases (CRCLM): gadoxetic-acid-enhanced MRI (Gd-EOB-DTPA-MRI), MRI with extracellular contrast-media (ECCM-MRI) or contrast-enhanced MDCT (CE-MDCT). METHODS: The within-trial cost evaluation was modelled as a decision-tree to calculate the cost of diagnosis and surgery. The model used clinical outcomes and resource utilization data from a prospective randomized multicentre study. Analyses were performed for the 354-patient safety population from eight participating countries. RESULTS: The diagnostic workup cost using Gd-EOB-DTPA-MRI upfront resulted in savings compared to ECCM-MRI in all countries except Thailand (difference <2 %). Compared to CE-MDCT, initial imaging with Gd-EOB-DTPA-MRI was less costly in all countries except Korea and Spain (differences 4 and 8 %, respectively). Significantly more patients in the Gd-EOB-DTPA-MRI group were eligible for surgery (39.3 % (48/122) vs. 31.0 % (36/116) and 26.7 % (31/116) for ECCM-MRI and CE-MDCT, respectively), allowing more patients to undergo potentially curative surgery, but resulting in higher treatment costs for the strategy starting with Gd-EOB-DTPA-MRI. CONCLUSIONS: The benefits of Gd-EOB-DTPA-MRI due to less additional imaging and similar diagnostic workup costs in the three groups suggest that Gd-EOB-DTPA-MRI should be the preferred initial imaging procedure to evaluate hepatic resectability in patients with CRCLM. KEY POINTS: • Diagnostic imaging cost to evaluate resectability was similar among the groups • Cost for imaging was rather small compared to the cost of surgery • Significantly more patients in the Gd-EOB-DTPA-MRI arm were eligible for surgery • Gd-EOB-DTPA-MRI is recommended for evaluating hepatic resectability in patients with CRCLM.

Cost of Dementia and Its Correlation With Dependence.

OBJECTIVE: To estimate the cost of dementia care and its relation to dependence. METHOD: Disease severity and health care resource utilization was retrieved from the Swedish National Study on Aging and Care. Informal care was assessed with the Resource Utilization in Dementia instrument. A path model investigates the relationship between annual cost of care and dependence, cognitive ability, functioning, neuropsychiatric symptoms, and comorbidities. RESULTS: Average annual cost among patients diagnosed with dementia was €43,259, primarily incurred by accommodation. Resource use, that is, institutional care, community care, and accommodation, and corresponding costs increased significantly by increasing dependency. Path analysis showed that cognitive ability, functioning, and neuropsychiatric symptoms were significantly correlated with dependence, which in turn had a strong impact on annual cost. DISCUSSION: This study confirms that cost of dementia care increases with dependence and that the impact of other disease indicators is mainly mediated by dependence.

Intergenerational transmission of gambling: links between young adult and perceived grandparent gambling attitudes and behavior.

This study examined associations between the gambling attitudes and behavior of 213 young adults and their perceptions of the gambling attitudes and behavior of their closest grandparent. Regression analyses showed that young adult gambling attitudes mediated the relations between perceived grandparent gambling attitudes and behavior and young adult gambling behavior. Grandparent-grandchild relationship quality experienced while growing up did not moderate the relations between young adult and perceived grandparent gambling attitudes and behavior. Men experienced gambling at a younger age and reported more positive gambling attitudes, more frequent gambling activity, higher levels of gambling pathology, and higher levels of gambling affinity than women. Implications of results and suggestions for future research are discussed.

Cost-effectiveness of etanercept treatment in early active rheumatoid arthritis followed by dose adjustment.

OBJECTIVES: To explore the cost-effectiveness of early biologic treatment, followed by dose-reduction in the case of remission, of active rheumatoid arthritis (RA), compared with standard treatment with methotrexate (MTX) in Sweden. METHODS: Effectiveness (function, disease activity, erosions) in early RA for both alternatives was taken from a clinical trial comparing etanercept (ETA) combined with MTX to MTX alone. Patients discontinuing treatment can switch to another or their first biologic treatment. For patients in remission (Disease Activity Score [DAS28] < 2.6), ETA is reduced to half the dose. Return to full dose occurs when DAS28 reaches ≥ 3.2 again. Costs and utilities by level of functional capacity from an observational study are used. The model is analyzed as a micro-simulation and results are presented from the societal perspective for Sweden, for 10 years; costs (€2008) and effects are discounted at 3 percent. Sensitivity analysis was performed for the perspective, the time horizon, switching, and dose-reduction. RESULTS: The main analysis conservatively assumes 50 percent switching at discontinuation. The cost per quality-adjusted life-year (QALY) gained with early ETA/MTX treatment is €13,500 (societal perspective, incremental cost of €15,500 and incremental QALYs of 1.15). With 75 percent switching, the cost per QALY gained was €10,400. Over 20 years, the cost per QALY gained was €8,200. Results were further sensitive to the time patients remained on half dose and the perspective. CONCLUSIONS AND POLICY IMPLICATIONS: This study combines clinical trial and clinical practice data to explore cost-effective treatment scenarios in early RA, including the use of biologics. Our results indicate that a situation where a considerable proportion of patients achieve remission, dose-adjustments will increase the cost-effectiveness of treatment.

Gastrointestinal tolerability and patterns of switching in patients treated for primary osteoporosis: the Swedish Adherence Register Analysis (SARA).

The objective of this study was to describe and analyze the gastrointestinal tolerability and medication switching in patients receiving treatment for primary osteoporosis in Sweden. The study was based on all patients starting therapy with alendronate, risedronate, strontium ranelate, and raloxifene in Sweden between 2005 and 2009. The primary outcome measure was start of treatment with a gastroprotective agent, and the secondary outcome was hospitalization for a gastrointestinal adverse event (GIAE). Switching was analyzed while patients were on treatment. The crude incidence of gastroprotective treatment during the first 6 months after initiation of osteoporosis therapy was 5.14%, 5.93%, 4.25%, and 2.86% for patients prescribed alendronate, risedronate, strontium ranelate, and raloxifene, respectively. Patients prescribed raloxifene had a significantly lower risk of filling a prescription for a gastroprotective agent compared with alendronate. There was no significant difference in the risk of hospitalization for GIAEs. Less than 3% switched therapy while on treatment. Patients prescribed risedronate, strontium ranelate, and raloxifene had a significantly higher risk of switching compared with patients taking alendronate. In conclusion, no significant difference in the incidence of GIAEs was found between patients prescribed alendronate, risedronate, and strontium ranelate. Individuals prescribed raloxifene had a significantly lower risk of GIAEs compared with patients prescribed alendronate. No significant difference was found in the frequency of hospitalization for GIAEs. Switching between osteoporosis medications and drug classes was uncommon. Prescribers should consider the real-world gastrointestinal safety of osteoporosis drugs when choosing between treatment options to potentially improve medication adherence and consequently effectiveness.

Sensory responsiveness as a predictor of social severity in children with high functioning autism spectrum disorders.

This study examines the relationship between sensory responsiveness and social severity in children with high functioning autism spectrum disorders (HFASD; N = 36) and age-matched controls (N = 26) between 6 and 10 years old. Significant relationships were found between social responsiveness scale scores and each of the six sensory profile sensory system scores for children with HFASD and controls. Multivariate regression analyses revealed atypical scores from multisensory responsiveness, and responsiveness of the proximal senses of oral sensory/olfactory and touch as the strongest predictors of greater social impairment in the participants. Findings suggest that the relationship between sensory responsiveness and other autistic traits is more important than previously recognized and addressing sensory modulation issues in children with HFASD may be more critical than previously understood.

Los predictores de "insight" con respecto a la enfermedad mental entre los pacientes psicóticos y no psicóticos

El propósito de este estudio fue 1) Crear un índice de "insight" en relación con la enfermedad mental 2) Examinar los predictores de "insight" entre una muestra regional representativa compuesta por 418 pacientes. El "insight" se definió mediante un índice basado en tres cuestiones. Además de estas cuestiones fue tenida en cuenta la estimación hecha por el entrevistador utilizando así mismo un índice. Un buen "insight" o uno "moderado" estaba asociado con una edad joven, estado civil de casado o bien de "conviviente", la existencia de confidente íntimo, el diagnóstico de un trastorno afectivo, de uno ansioso o bien de un trastorno de adaptación, así como de dependencias al alcohol o a otras drogas, baja gravedad de la enfermedad, baja edad del primer tratamiento, alta validación del tratamiento y pocas admisiones durante el periodo de estudio. Utilizando el análisis discriminante se consiguió una clasificación grupal correcta en el 44 por ciento del total de pacientes. El índice parece ser una medida rápida y aceptable que puede encontrar aplicación como método para medir los diferentes niveles de "insight" (AU)

Predictores de la percepción de la enfermedad mental entre pacientes psicóticos y no psicóticos

Los objetivos de este estudio eran 1°) elaborar un índice para una mejor percepción de la enfermedad mental y 2°) examinar los predictores para lograr dicha percepción dentro de una muestra regionalmente representativa de 418 pacientes. La percepción se evaluó por medio de un índice basado en tres preguntas. De forma adicional a las preguntas, la estimación del entrevistador sobre la percepción de los pacientes también se tuvo en cuenta para el índice. Una buena percepción y una percepción moderada se asociaron con edad temprana, estado civil casado/cohabitando, existencia de una relación de confianza íntima, diagnóstico de trastorno de estado de ánimo, ansiedad o trastorno de adaptación y dependencias del alcohol y/o de drogas, levedad de la enfermedad, salud física y mental autovalorada como mala, edad temprana en el primer tratamiento, alta valoración del tratamiento, y pocos ingresos hospitalarios durante el periodo de estudio. Por medio de un análisis discriminante se alcanzó una clasificación correcta de grupo en el 44 per cent del número total de pacientes. Se halló que el índice suponía una herramienta rápida y aceptable que podía encontrar aplicación como método de ponderación de estos niveles de percepción de la enfermedad mental (AU)

Quality of life and other characteristics of Viennese mental health care users.

BACKGROUND: The purposes of this study are (1) to characterise patients with different treatment experiences, (2) to evaluate differences in quality of life (QoL) among patients with different treatment experiences, (3) to evaluate changes in QoL following community resettlement, and (4) to find predictors of overall life satisfaction (OLS). METHODS: Treatment experiences are defined according to service use as follows: (a) user of in- and outpatient services (overall users), (b) user of inpatient (inpatients) or (c) outpatient facilities only (outpatients). Demographic and clinical data of 425 psychiatric patients are analysed cross-sectionally in relation to their treatment experiences. QoL of former inpatients is followed up after hospital discharge. RESULTS: Long-term 'overall users' have a significantly higher QoL than long-term 'outpatients' or 'inpatients'. QoL of former inpatients increases after discharge. Predictors of higher OLS are high income, high subjective social functioning (SFQ), good self-rated health, satisfactory QoL domains as well as being single or cohabiting, diagnosis of schizophrenia, 'outpatients', and 'overall users'. Together they explain 63% of the variance in patients' subjective OLS. CONCLUSION: QoL is independent of illness severity. Deinstitutionalisation improves QoL and OLS is mainly predicted by subjective variables.