Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial.

OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

[Social and psychological motives of frequency of calls for emergency care in advanced age].

The purpose of this investigation relates to the problem encountered by the elderly population. There is a current increase of the number of elderly people and the share of the elderly population in many countries of the world. Living on their own, people of advanced age create specific problems, both medically and socially. The current investigation presents the data showing their high and "ultrahigh" appliance for the emergency, which not always is a reflection of the level of a disease. Request for the emergency of this social category of the population is ten times higher than in other age groups. As a result, it causes unnecessary economical expenses and requires a correction of social programs.

Prevention of venous thromboembolism in Wales: results of a survey among general surgeons.

OBJECTIVE: To examine the current attitudes towards the prevention of venous thromboembolism among a cohort of surgeons. DESIGN: A postal survey, comprising a questionnaire covering various aspects of venous thromboembolism prophylaxis was sent to all (n=84) consultant general surgeons in Wales. RESULTS: Replies were received from 57 surgeons (68%), all of whom routinely used prophylaxis, the most frequent modalities used being heparin (100%) and graded compression stockings (79%). A combination of physical and pharmacological methods was used by over 89% of surgeons, with 60% starting prophylaxis more than two hours before operation. All surgeons continued prophylaxis after surgery, 53% until patients were mobile, 45% until they were discharged, and one surgeon continued prophylaxis for seven days after discharge. The thrombosis risk factors considered most important by surgeons when deciding about prophylaxis were (i) a previous history of venous thromboembolism, (ii) hypercoagulability, and (iii) malignancy. CONCLUSIONS: This study confirms that Welsh surgeons conform to standard methods, but also highlights some uncertainties that are present in current surgical practice. Those who responded all routinely used prophylaxis, the timing of which was variable. The main risk factors identified when considering prophylaxis were previous history of deep vein thrombosis/pulmonary embolism, hypercoagulability, and the presence of malignancy. Suggestions for future practice are made.

Obesity predisposes to increased drainage following axillary node clearance: a prospective audit.

BACKGROUND: Whilst sentinel node biopsy is being evaluated for optimising treatment of the axilla, axillary dissection remains the gold standard. Seroma formation, a common sequel to axillary dissection, has been shown to be associated with an increased incidence of wound infection, delayed healing, and lymphoedema. This study was conducted to evaluate the possible contributory role of obesity in axillary drainage following lymphatic dissection. PATIENTS AND METHODS: This study comprised a prospective review of all patients undergoing axillary dissection in conjunction with mastectomy or wide local excision. The total in-patient axillary drainage and the average daily drainage was correlated with various clinical parameters, including obesity, type of surgery, level of axillary dissection and nodal involvement. The body mass index (BMI) was used as a measure of obesity. RESULTS: During a 6-month period, axillary dissection was performed in 79 women. Nineteen patients were excluded. Patey mastectomy was performed on 33 (55%) and the remaining had breast conservation. The amount or duration of axillary drainage did not correlate with the type of operation, tumour histology, level of axillary dissection or the nodal status. Higher BMI correlated with increased mean daily axillary drainage and total volume drained, whilst in hospital. (Spearman correlation coefficient 0.42; P < 0.01). CONCLUSION: Obesity predisposes to increased axillary drainage following nodal clearance.

Management of the impalpable testis: a six year review together with a national experience.

The management of undescended testes remains variable, and the use of laparoscopy for localisation is controversial. This study reviews the need for laparoscopy and also assesses the current practice among a cohort of surgeons.A retrospective review of all patients undergoing orchidopexy was performed, together with a postal survey of all members of the Welsh Surgical Society. Of the 139 orchidopexies performed, the testis was deemed impalpable in 39 (28%) cases. All patients were treated with groin exploration, and only in two (5%) patients was the testis not located. From the survey, replies were received from 90 (81%) surgeons, of whom 65 (72%) were still performing orchidopexy. Forty eight (74%) surgeons performed orchidopexy between the age of 2 and 3, and only 32 (36%) performed preoperative investigations. The follow up period was variable with the majority of patients seen at six weeks. Laparoscopy for the impalpable testis is not initially warranted. An inguinal exploration is regarded as the definitive investigation. This has the advantage of providing the diagnosis and treatment in the majority of cases.

Pancolitis associated with docetaxel: a rare cause of megacolon.

The toxic effects of chemotherapy have been noted to cause a range of acute necrotizing colonic inflammatory disorders but until recently these have not been associated with docetaxel chemotherapy. Here we report a case of pancolitis presenting as megacolon following the administration of docetaxel for recurrent breast cancer.

Combined wide excision and mastopexy/reduction mammoplasty for inframammary hidradenitis: a novel and effective approach.

Hidradenitis suppurativa is a rare chronic skin condition involving the apocrine glandular zones, which are found predominantly in the axilla and inguinoperineal regions, but have been described at other sites, including the inframammary fold. Treatment requires complex surgical intervention with wide excision of involved tissue. Inframammary hidradenitis tends to affect young women and can prove resistant even to this radical form of surgery, which often results in marked scarring and breast deformity. We therefore decided to adopt a novel approach by incorporating the wide excision of inframammary skin currently necessary in a reduction mastopexy procedure. This enables primary closure with ptosis correction and should improve cosmesis. The reduction in the depth of the inframammary fold also makes hygiene easier in the long term. During a 6-year period, five patients (mean age 27 years) have been treated by this method. All patients had long-standing hidradenitis (mean 12 years), and had been treated with several courses of antibiotics. A modified Wise pattern reduction incision was used with a minimum amount of breast tissue being removed. In each case histology was consistent with hidradenitis. All wounds healed well and to date there have been no inframammary recurrences. The success of this operation in curing inframammary hidradenitis has had a dramatic affect on the lives of these young women and underlines the need for this rare condition to be treated in a specialist centre.

Angiosarcoma of the breast following radiation therapy.

Breast carcinoma is increasingly treated by conservation therapy. This includes wide local excision and axilliary node clearance followed by radiotherapy to the remaining breast. Therapeutic irradiation may be complicated by several problems, including the development of other malignant tumours. We report a case of angiosarcoma occurring following such treatment and present a review of the literature.

Prospective randomized controlled trial comparing Lichtenstein with modified Bassini repair of inguinal hernia.

We present a prospective randomized study of 80 patients with inguinal hernia who underwent either a modified Bassini repair (n = 38) or a Lichtenstein mesh repair (n = 42). Treatment groups were matched for age, side of hernia, type of hernia and ASA grade. There was no difference in the time taken to perform the two operations: the mean time taken to perform Lichtenstein repair was 26.8 min (range 12 to 49), Bassini repair taking a mean of 27.5 min (range 9 to 51), P = 0.76. There was, however, a difference between the operating times with respect to the type of hernia present, direct hernias being the fastest to repair. Pain scores were assessed by a visual analogue scale, and there was significantly less pain in the Lichtenstein group, P = 0.028. Despite this, there was no difference between the analgesic requirements of the two groups, P = 0.073. In order to assess rehabilitation, lengths of time not working and not driving were assessed. There was no difference in either measurement, P = 0.335 and 0.467 respectively. Patients were followed up a mean of 7 weeks post-operatively (range 1 to 13 weeks). There was no significant difference between the two procedures with regard to post-operative urinary complications, wound infection or other complications. All measurements except the time taken to perform the operation were independent of the surgeon involved. The accuracy of the clinical diagnosis was also assessed, and found to be moderate, with 63% of diagnoses being correct.

Chronic groin pain in an athlete: an unusual presentation.

Persistent disabling groin pain in an active sportsman is a frustrating diagnostic and management problem for both the athlete and physician. After clinical examination and investigation there remains a group of patients who have unexplained groin pain, and may undergo lengthy periods of conservative management with numerous radiological investigations. Here we highlight such a case.

Depletion of a Drosophila homolog of yeast Sup35p disrupts spindle assembly, chromosome segregation, and cytokinesis during male meiosis.

In the course of a genetic screen for male-sterile mutations in Drosophila affecting chromosome segregation during the meiotic divisions in spermatocytes, we identified the mutation dsup35(63D). Examination of mutant testes showed that chromosome misbehavior was a consequence of major disruptions in meiotic spindle assembly. These perturbations included problems in aster formation, separation, and migration around the nuclear envelope; aberrations in spindle organization and integrity; and disappearance of the ana/telophase central spindle, which in turn disrupts cytokinesis. The dsup35(63D) mutation is caused by a P element insertion that affects, specifically in the testis, the expression of a gene (dsup35) encoding the Drosophila homolog of the yeast Sup35p and Xenopus eRF3 proteins. These proteins are involved in the termination of polypeptide synthesis on ribosomes, but previous studies have suggested that Sup35p and closely related proteins of the same family also interact directly with microtubules. An affinity-purified antibody directed against the product of the dsup35 gene was prepared; interestingly, this antibody specifically labels primary spermatocytes in one or two discrete foci of unknown structure within the nucleoplasm. We discuss how depletion of the dsup35 gene product in spermatocytes might lead to the global disruptions in meiotic spindle assembly seen in mutant spermatocytes.

Cooperative interactions between the central spindle and the contractile ring during Drosophila cytokinesis.

We analyzed male meiosis in mutants of the chickadee (chic) locus, a Drosophila melanogaster gene that encodes profilin, a low molecular weight actin-binding protein that modulates F-actin polymerization. These mutants are severely defective in meiotic cytokinesis. During ana-telophase of both meiotic divisions, they exhibit a central spindle less dense than wild type; certain chic allelic combinations cause almost complete disappearance of the central spindle. Moreover, chic mutant spermatocytes fail to form an actomyosin contractile ring. To further investigate the relationships between the central spindle and the contractile ring, we examined meiosis in the cytokinesis-defective mutants KLP3A and diaphanous and in testes treated with cytochalasin B. In all cases, we found that the central spindle and the contractile ring in meiotic ana-telophases were simultaneously absent. Together, these results suggest a cooperative interaction between elements of the actin-based contractile ring and the central spindle microtubules: When one of these structures is disrupted, the proper assembly of the other is also affected. In addition to effects on the central spindle and the cytokinetic apparatus, we observed another consequence of chic mutations: A large fraction of chic spermatocytes exhibit abnormal positioning and delayed migration of asters to the cell poles. A similar phenotype was seen in testes treated with cytochalasin B and has been noted previously in mutants at the twinstar locus, a gene that encodes a Drosophila member of the cofilin/ADF family of actin-severing proteins. These observations all indicate that proper actin assembly is necessary for centrosome separation and migration.

The Drosophila kinesin-like protein KLP3A is a midbody component required for central spindle assembly and initiation of cytokinesis.

We describe here a new member of the kinesin superfamily in Drosophila, KLP3A (Kinesin-Like-Protein-at-3A). The KLP3A protein localizes to the equator of the central spindle during late anaphase and telophase of male meiosis. Mutations in the KLP3A gene disrupt the interdigitation of microtubules in spermatocyte central spindles. Despite this defect, anaphase B spindle elongation is not obviously aberrant. However, cytokinesis frequently fails after both meiotic divisions in mutant testes. Together, these findings strongly suggest that the KLP3A presumptive motor protein is a critical component in the establishment or stabilization of the central spindle. Furthermore, these results imply that the central spindle is the source of signals that initiate the cleavage furrow in higher cells.