Impact of Value-Driven Healthcare Strategies for Biosimilar Adoption: The Singapore Story.

BACKGROUND: Healthcare sustainability is a global challenge. Various value-driven healthcare strategies have been implemented by Singapore's national health technology assessment (HTA) agency, the Agency for Care Effectiveness (ACE). Considering the high and growing expenditure on biologics, strategies have been implemented to drive the use of biosimilars. As Singapore has reached the 5-year mark since the subsidy listing of the first monoclonal antibody biosimilar infliximab, this review aimed to evaluate the impact of these strategies on the changes in adoption rates, utilisation, spending and cost savings for biosimilars in the public healthcare sector. METHODS: A retrospective cross-sectional study was conducted using aggregated drug utilisation data from all public healthcare institutions. Five monoclonal antibodies with biosimilars, namely infliximab, adalimumab, trastuzumab, rituximab and bevacizumab, were included in this study. The outcomes evaluated were the monthly trends for utilisation volume, proportion attributed to biosimilar use, and drug spending up to December 2022. The simulated cost savings associated with biosimilar adoption were also reported. RESULTS: After subsidy implementation, an upward trend in biosimilar use and proportion attributed to biosimilar adoption was observed, while spending reduced substantially. The adoption rate of most biosimilars reached more than 95% within 1 year of listing. Drugs with more than one approved biosimilar brand at the time of subsidy listing reported substantial price reductions of over 80%. Overall, spending for the five monoclonal antibodies have significantly reduced after biosimilar subsidy listing, with an estimated cumulative cost savings of $136 million over 5 years. CONCLUSION: Value-driven healthcare strategies implemented in Singapore's public healthcare institutions have contributed to high adoption rates of biosimilars and have improved affordable access through lower treatment costs. This in turn has led to significant cost savings to the healthcare system.

Post-Traumatic Carotid Artery Dissection Begins at the Skull Base: A Case Report.

Cervical artery dissection is a rare complication of head and neck trauma. Though it is an infrequent cause of ischaemic stroke, it is more common among the young with cerebral ischaemia. The usual location of carotid dissection is just beyond the carotid bulb. We report a case of post-traumatic internal carotid dissection that began at the base of the skull after blunt head trauma from a road traffic accident. The patient is a 25-year-old right-handed lady who, 2 days after the accident, developed dysphasia and right-sided limb weakness. She had no significant past medical history. Magnetic resonance imaging (MRI) showed acute ischaemic stroke in the internal watershed regions of the left cerebral hemisphere. MR angiogram revealed focal near-occlusion of the left internal carotid artery at the base of the skull just prior to its entry into the petrous temporal bone. There were no skull fractures. She progressed despite anticoagulation. The location of the site of dissection at the base of the skull is likely due to stresses on the carotid intima at this point during flexion-extension-rotation that occurs during head injury, as this is where the internal carotid artery is tethered to the skull. Rapid recognition of symptoms of cerebral ischaemia among patients with blunt head trauma is needed to allow prompt investigation and institution of relevant therapies.

The free sartorius flap: clinical cases and anatomical study.

The thigh is a rich source of tissue for free flap harvest. The anterolateral thigh and gracilis flaps are most commonly used. The sartorius flap is an easily harvested flap that can be raised with the leg in the anatomically extended position without rotation. The cutaneous landmarks are readily identified and so the relevant perforators can be quickly found. Pedicle dissection is quick and easy, allowing the flap to be raised in a short time. We report our experience of using this flap both as a free muscle-only flap and as a free fasciocutaneous perforator flap for soft-tissue reconstruction in the lower limb. An anatomical study was also carried out to examine the vascular anatomy of the sartorius muscle flap and the cutaneous perforator flap. Twenty limbs from soft fixed adult cadavers were dissected and the position, length, diameter and cutaneous extension of all segmental pedicles, from the anterior superior iliac spine (ASIS) to the medial femoral condyle, were measured. Fourteen out of 20 (70%) sartorius muscles had at least one musculocutaneous perforator and, of these muscles, 13 (93%) had at least one musculocutaneous perforator that was found at 20±3cm from the ASIS. The free sartorius flap is a useful addition to flap choice from the thigh and carries a predictable cutaneous perforator in the majority of cases, allowing a fasciocutaneous perforator flap to be quickly and reliably raised with minimal donor-site morbidity.

Scrotal reconstruction with a free greater omental flap: A case report.

We report a case of Fournier's gangrene, where we used the greater omentum as a free flap for scrotal reconstruction and outline the advantages over previously described methods. The greater omentum was harvested using a standard open technique. The deep inferior epigastric vessels were passed through the inguinal canal into the scrotal area as recipient vessels. The detached greater omental flap was prefabricated into a three-dimensional sac prior to inset and microvascular anastomoses. The flap was then covered by skin graft. The reconstruction had shown good early results with complete survival of the flap, as well as good functional and esthetic outcome at six months. The greater omentum can therefore be used as a free flap for scrotal reconstruction. It allows easy prefabrication and flap inset. The deep inferior epigastric vessels are also suitable recipient vessels.

Anatomical repair of zone 1 flexor tendon injuries.

BACKGROUND: Repair and rehabilitation of the flexor digitorum profundus tendon in zone I may be demanding. The aim of the authors' study was to assess a new technique for reinsertion of the distal flexor digitorum profundus tendon. METHODS: The authors' series consisted of 18 patients who required primary (n = 10) or secondary (n = 8) repair of the flexor digitorum profundus tendon in zone I. A half-Bruner incision was extended into the distal volar skin to expose the insertion site. Two drill holes were made through the base of the distal phalanx obliquely from the insertion of the profundus tendon in a dorsolateral direction. A modified Kessler suture was passed through the tendon and then through these holes and tied anteriorly, providing transosseous, internal fixation. Range of movement was assessed according to Moiemen's categories. RESULTS: Fourteen patients had excellent or good results, two patients had fair results, and one patient had a poor result. One patient failed to complete physiotherapy and was lost to follow-up. No tendon rupture was documented during a mean follow-up period of 8 months. CONCLUSIONS: The authors' technique anchors the flexor digitorum profundus tendon or the graft in an anatomical position on the distal phalanx, without the need for external sutures or additional incisions. Furthermore, this is accomplished with minimal morbidity to the surrounding highly specialized tissue. The authors' results compare favorably with those of other techniques in the literature.

Sentinel lymph node biopsy for malignant melanoma as day surgery.

UNLABELLED: Sentinel lymph node biopsy for malignant melanoma has been performed as day surgery at our hospital since August 2002. The aim of this retrospective study was to assess its feasibility compared to the inpatient procedure. METHODS: A telephone survey and review of medical records was carried out for patients who had daycase, nonhead and neck sentinel lymph node biopsy for malignant melanoma over an 18-month period. A similar matched number of inpatients were reviewed, comparing waiting times, prolonged hospital stay, complication rates and overall satisfaction. RESULTS: There were no significant differences between the two groups in terms of time from diagnosis to surgery, prolonged hospital stay and complication rates. However, in terms of overall satisfaction, 86.3% of daycase patients preferred their mode of admission whereas 52.9% of inpatients preferred their mode of admission (P=0.0003). CONCLUSIONS: Sentinel lymph node biopsy (nonhead and neck) for malignant melanoma as day surgery is feasible and confers greater patient satisfaction, increased availability of inpatient beds and cost savings without compromising patient care.

Current use of antibiotic prophylaxis in breast surgery: a nationwide survey.

There is currently no consensus regarding the use of antibiotic prophylaxis in breast surgery. This postal survey aimed to establish the current practice in perioperative antibiotic use for breast surgery in the United Kingdom. Questionnaires were sent to 406 breast surgeons, enquiring about antibiotic use for common breast procedures. A total of 266 completed questionnaires were returned (65.5%). Over 80% of surgeons who performed breast augmentations, myocutaneous flap reconstructions and implant reconstructions used antibiotic prophylaxis. Up to 33% used antibiotic prophylaxis for wide local excisions (WLEs), mastectomies and axillary surgery for breast cancer, while 62% and 45% used antibiotics for breast reductions and duct excisions, respectively. The most common antibiotic used was co-amoxiclav. The variation in practice regarding antibiotic prophylaxis in breast surgery reflects the lack of reliable evidence for its efficacy. Further randomised controlled trials are required, taking into consideration specific risk factors affecting postoperative infection rate for breast surgery.

Induction of advanced glycation end products and alterations of the tensile properties of articular cartilage.

OBJECTIVE: To determine whether increasing advanced glycation end products (AGEs) in bovine articular cartilage to levels present in aged human cartilage modulates the tensile biomechanical properties of the tissue. METHODS: Adult bovine articular cartilage samples were incubated in a buffer solution with ribose to induce the formation of AGEs or in a control solution. Portions of cartilage samples were assayed for biochemical indices of AGEs and tested to assess their tensile biomechanical properties, including stiffness, strength, and elongation at failure. RESULTS: Ribose treatment of cartilage induced increases in tissue fluorescence, absorbance, and pentosidine content (P < 0.001 for each comparison) by amounts similar to those that occur during aging in humans. Ribose treatment of cartilage also induced an increase in dynamic modulus (60% increase) and strength (35% increase), and a decrease (25% decrease) in strain (P < 0.001 for each comparison). CONCLUSION: The concomitant increase in AGEs and alteration of tensile properties of cartilage after ribose treatment suggest that aging-associated changes in AGEs have functional consequences for this tissue. The AGE-associated increases in strength and stiffness of cartilage may be beneficial by counteracting the decreases in these properties that are associated with degeneration. Conversely, the AGE-associated decrease in failure length, or increase in brittleness, together with increased stiffness may predispose cartilage to increased stress concentration, fracture, and aging-associated biomechanical dysfunction.