[Analysis on clinical efficacy, safety and economy of Shaobei injection and elastic band ligation in the treatment of grade II or III hemorrhoids].

Objective: Currently, various treatments such as hemorrhoidectomy, ligation and sclerotherapy injection can be applied in grade II or III hemorrhoids. This study aims to compare the clinical efficacy, safety and economy between Shaobei injection and elastic band ligation in treating patients with grade II or grade III hemorrhoids. Methods: A retrospective cohort study was used. Clinical data of 60 patients with grade II or grade III hemorrhoids at Department of Anorectal Surgery of the Sixth Affiliated Hospital, Sun Yat-sen University between January 2019 and October 2019 were collected. Patients were divided into two groups according to surgical methods. Patients in the Shaobei group received Shaobei injection (n=28), and those in the ligation group received elastic band ligation (n=32). Inclusion criteria: (1) diagnosis of grade II or III hemorrhoid; (2) application of Shaobei injection or elastic band ligation; (3) age between 18-75 years old. Exclusion criteria: (1) comorbidity with anal fissure, anal fistula, anal sinusitis or other perianal diseases; (2) patients with mental disorder or poor compliance; (3) incomplete clinical or follow-up data. Recurrent rate, postoperative pain, anal edema, anal distension, total cost of hospitalization, length of hospitalization, and postoperative life quality EQ-5D-3L score were compared between the two groups at postoperative 6-month. Results: No significant difference was observed in the baseline data (including Nystrom hemorrhoid symptom score) between the two groups (all P>0.05), except gender ratio [male proportion: Shaobei 75% (21/28) vs. ligation 37.5%(12/32), χ(2)=8.485, P=0.004]. No significant difference in recurrent rate was found between the two groups [14.3% (4/28) vs. 9.4% (3/32), χ(2)=0.035, P=0.851]. Compared to the ligation group, Shaobei group showed less pain at postoperative day 1 [VAS median (range): 2 (1-6) vs. 3 (1-7), Z=2.814, P=0.005] and postoperative day 7 [VAS median (range): 0 (0-2) vs. 1 (0-4), Z=3.149, P=0.002]; lower anal edema ratio at postoperative day 1 [10.7% (3/28) vs. 34.4% (11/32), Z=4.673, P=0.037]; lower anal distension ratio at postoperative day 1 [7.1% (2/28) vs. 28.1% (9/32), Z=4.391, P=0.048]; less hospitalization cost [(6343.5±1444.1) yuan vs. (10 587.1± 1719.0) yuan, t=12.515, P<0.001] and shorter postoperative hospital stay [median (range): 1 (1-5) days vs. 3 (1-6) days, Z=5.879, P<0.001]. The EQ-5D-3L scores of two groups were significantly improved six months after treatment [Shaobei group: (0.90±0.16) vs. (0.73±0.14); ligation group: (0.91±0.13) vs. (0.74±0.10); both P<0.001], while there was no statistically significant difference between the two groups (t=0.130, P=0.897). No complications such as massive hemorrhage, infection, iatrogenic anal fistula, rectal stricture and local induration occurred after the injection. Conclusions: Shaobei injection is effective and safe in treating grade II or III hemorrhoids. Compared with elastic band ligation, it can reduce morbidity of complications and hospitalization expenses.

Trigger Finger Treatment: Identifying Predictors of Nonadherence and Cost.

BACKGROUND: Evidence-based practices in medicine are linked with a higher quality of care and lower health care cost. For trigger finger, identifying patient factors associated with nonadherence to evidence-based practices will aid physicians in treatment decisions. The objectives were to (1) determine patient factors associated with treatment nonadherence, (2) examine the success rates of steroid injections, and (3) evaluate the economic consequences of nonadherence to treatment recommendations. METHODS: The authors used data from the Clinformatics DataMart database from 2010 to 2017 to conduct a population-based analysis of patients with single-digit trigger finger. The authors calculated rates of steroid injection success and examined associations between injection success and patient factors using chi-square tests. In addition, the authors analyzed differences in the cost to the insurer, the cost to the patient, and total cost. RESULTS: A total of 29,722 patients were included in this analysis. Injection success rates were similar for diabetic (72 percent) and nondiabetic patients (73 percent), women (73 percent), and men (73 percent). Nonetheless, diabetics (OR, 1.4; 95 percent CI, 1.4 to 1.5; p < 0.001) and women (OR, 1.2; 95 percent CI, 1.1 to 1.2; p < 0.001) were significantly more likely to receive nonadherent treatment. In total, $23 million (U.S. dollars) were spent on nonadherent trigger finger care. CONCLUSIONS: Diabetics and women have increased odds of having surgery without a prior steroid injection, despite similar success rates of steroid injections compared to nondiabetics and men. Because performing surgical release before any steroid injections may represent a higher cost treatment option, providers should provide steroid injections before surgery for all patients regardless of diabetes status or sex to minimize overtreatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A single-arm open-label clinical trial of autologous epidermal cell transplantation for stable vitiligo: A 30-month follow-up.

BACKGROUND: Recently, we introduced intralesional injection of autologous epidermal cells as a safe and feasible approach for transplantation in patients with stable vitiligo. This approach resulted in less pain during and after the procedure, no scarring or cobblestone formation at the recipient site, and was more feasible to perform on curved surfaces such as joints, lips, eyelids, ears, and face. OBJECTIVE: In this study, we aimed to investigate the long-term efficacy and safety of this transplantation technique. METHODS: In this open-label and single-arm clinical trial, we enrolled 300 patients with stable vitiligo. We obtained a partial thickness normo-pigmented skin specimen from the patients' thigh-buttock junction with an area of one tenth to one third of the recipient site area. The epidermal cell suspension was prepared by processing the autologous skin specimen. We injected the cell suspension into 1060 vitiligo patches in 300 patients. Patients did not use any adjuvant phototherapy during the study. An experienced dermatologist and patients respectively defined the repigmentation score and self-assessment score at regular follow-up visits for up to 30 months after treatment. The scores represented the repigmentation percentage as follows: 0 (0), I (1%-24%), II (25%-49%), III (50%-74%), and IV (75%-100%). RESULTS: The mean repigmentation score at 3 months post-transplantation was 1.12±0.73. A significant upward trend existed in the mean repigmentation score until 9 months after cell transplantation, when the mean repigmentation score reached to 1.98±1.20. At 9 months after treatment, repigmentation of >50% was obtained in 32.2% of treated patches. Acquired repigmentation remained stable in 79.3% of treated patches during the follow-up period. The number of received cells per cm2 positively influenced the repigmentation score. Patches located on face, neck and trunk showed significantly higher response to the treatment. CONCLUSION: The results of our study demonstrated efficacy and safety of autologus epidermal cell transplantation on repigmentation of vitiligo patches. The achieved repigmentation was stable in the majority of treated patches during the follow-up period.

Cost of Immediate Surgery Versus Non-operative Treatment for Trigger Finger in Diabetic Patients.

PURPOSE: As health care costs continue to rise, providers must increasingly identify and implement cost-effective practice measures without sacrificing quality of care. Corticosteroid injections are an established treatment for trigger finger; however, numerous clinical trials have documented the limited efficacy of these injections in the diabetic population. Furthermore, the most cost-effective treatment strategy for diabetic trigger finger has not been determined. The purpose of this study was to perform a decision analysis to identify the least costly strategy for effective treatment of diabetic trigger finger using existing evidence in the literature. METHODS: Four treatment strategies for diabetic trigger finger were identified: (1) 1 steroid injection followed by surgical release, (2) 2 steroid injections followed by surgical release, (3) immediate surgical release in the operating room, and (4) immediate surgical release in the clinic. A literature review was conducted to determine success rates of the different treatment strategies. Costing analysis was performed using our institutional reimbursement from Medicare. One-way sensitivity and threshold analysis was utilized to determine the least costly treatment strategy. RESULTS: The least costly treatment strategy was immediate surgical release in the clinic. In patients with insulin-dependent diabetes mellitus, this strategy results in a 32% and a 39% cost reduction when compared with treatment with 1 or 2 corticosteroid injections, respectively. For 1 or 2 corticosteroid injections to be the most cost-effective strategy, injection failure rates would need to be less than 36% and 34%, respectively. The overall cost of care for immediate surgical release in the clinic was $642. CONCLUSIONS: Diabetic trigger finger is a common problem faced by hand surgeons, with a variety of acceptable treatment algorithms. Management of diabetic trigger finger with immediate surgical release in the clinic is the most cost-effective treatment strategy, assuming a corticosteroid injection failure rate of at least 34%. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision III.

Comparison of tolerance and cost-effectiveness of two nasal anesthesia techniques for transnasal flexible laryngoscopy.

OBJECTIVE: (1) Compare tolerance of aerosolized spray versus syringe administration of topical anesthesia for transnasal flexible laryngoscopy (TFL), (2) analyze cost-effectiveness of both techniques. STUDY DESIGN: Prospective, blinded, randomized trial. SETTING: Tertiary academic laryngology practice. METHODS: One hundred and eight patients underwent TFL over 3 months. Patients were randomized to receive equivalent dose 1:1 neosynephrine/4% plain lidocaine mixture via aerosolized spray ("spray") or application with 1-cc syringe ("syringe"). Patients and physicians independently rated comfort of TFL on 5-point scale (1 = not at all comfortable to 5 = very comfortable). Data were collected on patient and endoscopist experience with TFL and reasons for poor tolerance of laryngoscopy. Cost analyses of disposable spray tips and syringes were calculated. RESULTS: Both patients and physicians reported very high tolerance of TFL. Patient tolerance appears to be similar between spray- versus syringe-administered anesthesia, although study limitations preclude definitive analysis. Poor tolerance of laryngoscopy was reported in 6.5% with comparable distribution between anesthetic delivery methods. There was no impact of patient prior experience with TFL, and there was no difference between anesthetic methods for TFL performed by resident, fellow, or attending. The difference between costs of the disposable spray tip versus syringe was $1.32 per unit. CONCLUSIONS: Use of a 1-cc syringe is an effective method to provide topical nasal anesthesia for TFL and saves $1.32 per unit compared to disposable spray tips. In our practice, transition to syringe-administered nasal anesthesia is projected to save $1300 per 1000 patients, or an anticipated $1000 per year per physician, with excellent patient tolerance of TFL.

Efficacy and safety of collagenase Clostridium histolyticum injection for Dupuytren contracture: report of 40 cases.

BACKGROUND: Dupuytren's disease (DD) is a fibroproliferative pathology that affects the palmar aponeurosis causing the development of nodules and collagen cords and the progressive flexion of the fingers. The standard procedure is surgical fasciectomy, followed by high recurrence rates. Collagenase Clostridium histolyticum (CCH) injection represents an innovative noninvasive approach to the treatment of DD. This prospective study was designed to examine the efficacy and safety of CCH injection performed in the outpatient, using local anesthesia. MATERIALS AND METHODS: Forty patients [32 metacarpophalangeal (MP), 8 proximal interphalangeal (PIP)] with Dupuytren's contracture of at least 20° for MP joint and any degree for PIP joint were included. The mean age was 66. All joints were treated with a single vial of collagenase injection and manual breaking of the cord 24 h after. All adverse effects (AEs) were monitored. Patients were checked 7, 30, 90, and 180 days after the injection. Primary endpoint was a reduction in digit contracture within 0°-5° of normal extension. Secondary endpoints were the improvement of range of motion, the evaluation of AEs incidence, and cost-effectiveness of collagenase treatment. RESULTS: About 67.5 % of patients obtained a clinical success. At 6 months, a further 7.5% attained the same result. The mean contracture of treated joints was 5.3º for MP and 6.8° for PIP joints. Twenty-three patients had one or more mild-to-moderate side effects. CONCLUSIONS: The use of collagenase appears to be an effective and safe method for the treatment of Dupuytren's contracture. Therapeutic success was achieved in a significant percentage of patients. The incidence of side effects was higher, but they were local reactions of short duration. The use of a single collagenase vial in patients treated in day surgery appears more cost-effective than surgery.

Topical and intralesional treatment of nonmelanoma skin cancer: efficacy and cost comparisons.

BACKGROUND: Topical chemotherapy, topical immunomodulators, or intralesional chemotherapy may be used to treat nonmelanoma skin cancer (NMSC). OBJECTIVES: To review the cost and efficacy of topical and intralesional therapies for NMSC. METHODS: Literature search assessing the efficacy of NMSC treatment with topical imiquimod, topical 5-fluorouracil (5FU) intralesional 5FU, methotrexate, bleomycin, and interferon (IFN). Single-lesion case reports were excluded. Aggregate cure rates and the estimated cost of treatment (including excision and repair of recurrent lesions) for a sample 1-cm lesion on an extremity were calculated. RESULTS: Cure rates ranged from 65% to 100% for topical imiquimod and 61% to 92% for 5FU. For intralesional agents, cure rates varied considerably according to medication used and NMSC subtype treated. Keratoacanthomas had high cure rates with intralesional agents: 98% for 5FU, 91% for methotrexate, 100% for bleomycin, 100% for IFN alpha (α)-2, 83% for IFN α-2a, and 100% for IFN α-2b. Estimated costs (excluding medication cost) ranged from $205 (intralesional methotrexate for keratoacanthoma) to $1,174 (IFN α-2a for superficial basal cell carcinoma). CONCLUSION: Nonsurgical management of NMSC remains a viable and relatively cost effective treatment option in select cases. Providers should consider the relative efficacy and cost of each medication when using nonsurgical modalities.

Inyección intratumoral del adenoma prostático: criterios bioeconómicos evaluables en el paciente que presenta una hiperplasia prostática con indicación quirúrgica / Intratumoral injection of prostatic adenoma: evaluative bioeconomical criteria in the patient suffering prostatic hyperplasia with surgical indication

Se realiza el análisis bioeconómico de los resultados obtenidos en el tratamiento de la hiperplasia prostática a 100 pacientes, y se destaca el ahorro de más de $41 000.00 en el período 1983-1984, así como la ausencia de mortalidad y la escasa morbilidad atribuible a este método de tratamiento, aplicado a los pacientes con retención aguda de orina y con alto riesgo quirúrgico. Se informa que con esta experiencia se quiere alentar a nuestros colegas a pensar en las enormes posibilidades que puede brindar este método de tratamiento, el cual no es nuevo en el arsenal terapéutico. Se destacan las perspectivas que ofrece en un futuro no lejano, la aplicación de conjunto de esta forma de tratamiento y el ultrasonido prostático