Single-center nonrandomized clinical trial to assess the safety and efficacy of irreversible electroporation (IRE) ablation of liver tumors in humans: Short to mid-term results.

INTRODUCTION: A single-center nonrandomized clinical trial was performed to assess the safety and efficacy of IRE ablation of liver tumors in humans. METHODS: 38 malignant liver tumors on 30 patients were treated with IRE between September 2011 and September 2014. Treatment was with curative intent, and the diagnoses were colorectal cancer with liver metastases (CRLM) (n = 23), hepatocellular carcinoma (HCC) (n = 8) and other metastasis (n = 7). Patients were selected when surgery, radiofrequency ablation (RFA) or microwave ablation (MWA) was not an option, and when they met inclusion criteria (tumor size < 3 cm, 1-2 tumors). Patients were followed-up at 1 and 6 months with a contrast-enhanced computed tomography (CE-CT), and contrast-enhanced ultrasound (CE-US) at 3 months. RESULTS: Ablation success was defined as no evidence of residual tumor in the ablated area as confirmed by CE-CT and CE-US. At 3 months ablation success was 78.9%, and 65.8% at 6 months. There was no statistically significant difference between tumor volume (<5 cm3 vs >5 cm3, p = 0.518), and between diagnosis (CRLM vs HCC, p = 0.084) in terms of local recurrence. Complications were classified according to the standardized grading system of Society of Interventional Radiology (SIR). A minor complication occurred in six patients (20%), one patient (3.3%) suffered from a major complication (bile duct dilatation and stricture of the portal vein and bile duct). No mortalities occurred at 30 days. CONCLUSIONS: IRE appears to be a safe treatment modality for a selected group of patients with liver tumors and offers high local tumor control at 3 and 6 months.

Is positron emission tomography using 18F-fluorodeoxyglucose and 11C-acetate valuable in diagnosing indeterminate pancreatic masses?

BACKGROUND: It can be impossible to differentiate a mass forming chronic pancreatitis from adenocarcinoma of the pancreas using standard anatomical imaging. Positron emission tomography using 2-[18F] fluoro-2deoxy-D-glucose (18FDG-PET) and 1-[11C]-acetate (11C-acetate-PET) are methods taking advantage of the metabolic differences between benign and malignant tissues. AIMS: To determine the diagnostic accuracy of 18FDG-PET and 11C-acetate-PET in indeterminate pancreatic masses. METHODS: Twenty patients with an indeterminate mass of the head of the pancreas were prospectively studied. All patients underwent 18FDG-PET and eighteen of them 11C-acetate-PET. Scans were evaluated qualitatively and quantitatively; the later by using regional standardised uptake value (SUV). Final diagnosis was established using histopathologic evaluation of resected specimen or biopsy. RESULTS: Adenocarcinoma was diagnosed in twelve patients and chronic pancreatitis in eight. Qualitative evaluation of 18FDG-PET imaging revealed three false negative and one false-positive results. The sensitivity, specificity, and diagnostic accuracy were 75 %, 88 %, and 80 %, respectively. The cut-off SUV to differentiate malignant from benign disease was 3,5 demonstrating a sensitivity of 91.7 % and a specificity of 75 %. CONCLUSION: 18FDG-PET imaging could not confirm or exclude malignancy in indeterminate masses of the head of the pancreas with high sensitivity and diagnostic accuracy. 11C-acetate-PET provided no additional diagnostic benefits.

Microbial translocation and inflammatory response in patients with acute peritonitis.

BACKGROUND: In peritonitis, increased production of cytokines and changes in the splanchnic cellular immune system may cause translocation of bacteria and endotoxins. The aims of this study were to assess the frequency of translocation and relate translocation to the immune response in patients with acute peritonitis. METHODS: Patients with local (LP, n=20) or general peritonitis (GP, n=15) were compared with controls (C, n=12). Blood was obtained preoperatively for cultures, and analyses of endotoxin and cytokines (tumour necrosis factor-alpha, interleukins 6 and 10). Mesenteric lymph nodes (MLNs) were excised for culturing and immunohistochemistry using antibodies CD4, CD8 and CD68. RESULTS: Positive blood and MLN cultures were not obtained in controls. DNA typing proved bacterial translocation in one patient with local and one patient with general peritonitis. Thus translocation was proven to occur in 6% of patients with peritonitis. Endotoxaemia was predominantly found in the GP group. Cytokines increased during peritonitis and more so in patients with GP than in those with LP. More CD8 and CD68 cells were found in MLNs from LP patients than in C patients and more CD4 and CD8 cells in LP patients than in GP patients. There was no significant difference in this regard between the GP and C groups. CONCLUSIONS: Bacterial translocation occurs during acute peritonitis but seems to be fairly infrequent. Peritonitis causes significant inflammatory cellular reactions.

Musculoskeletal pain in Europe: its impact and a comparison of population and medical perceptions of treatment in eight European countries.

OBJECTIVES: To describe the impact of musculoskeletal pain (MP); to compare management of MP by the population and by primary care physicians; and to identify misconceptions about treatment. METHODS: 5803 people with MP and 1483 primary care physicians, randomly selected, in eight European countries were interviewed by telephone. A structured questionnaire was used to ask about usual management of MP and perceived benefits and risks of treatment. Current health status (SF-12) was also assessed. RESULTS: From primary care physicians' perceptions, MP appears to be well managed. All presenting patients are offered some form of treatment, 90% or more doctors are trying to improve patients' quality of life, and most are aware and concerned about the risks of treatment with NSAIDs. From a population perspective, up to 27% of people with pain do not seek medical help and of those who do, several wait months/years before seeing a doctor. 55% or fewer patients who have seen a doctor are currently receiving prescription treatment for their pain. Communication between doctors and patients is poor; few patients are given information about their condition; and many have misconceptions about treatment. CONCLUSIONS: Management of MP is similar across eight European countries, but there is discordance between physician and patient perspectives of care. Some people with pain have never sought medical help despite being in constant/daily pain. Those who do seek help receive little written information or explanation and many have misperceptions about the benefits and risks of treatment that limit their ability to actively participate in decisions about their care.

Long-term results of antireflux surgery indicate the need for a randomized clinical trial.

BACKGROUND: Well conducted, comparative trials of laparoscopic versus open antireflux surgery with an adequate patient enrollment are few and they do not demonstrate obvious advantages for the laparoscopic approach except for a marginal gain in shorter hospital stay. The aim of this study was to compare the effectiveness of laparoscopic and open procedures. METHODS: Two unselected groups of 230 patients were identified through a register of all inpatient public care in Sweden. Outcomes of laparoscopic and open antireflux surgery were compared using a disease-specific questionnaire 4 years after operation. RESULTS: Failure and dissatisfaction were significantly more common in the laparoscopy group than among patients having conventional open surgery. Treatment failure rates were 29.0 and 14.6 per cent respectively (P = 0.004). Dissatisfaction rates were 15.0 and 7.0 per cent respectively (P = 0.005). There was no other questionnaire item for which the proportion of failures differed significantly between the two groups. CONCLUSION: This study does not support the presumption that laparoscopic antireflux surgery is to be preferred to the open procedure. It is strongly recommended that a randomized controlled trial be conducted.

Laparoscopic antireflux surgery in routine hospital care.

BACKGROUND: The frequency of antireflux surgery has tripled since laparoscopic techniques were introduced. In Sweden, laparoscopic antireflux surgery is often done at local hospitals with a very low annual number of patients. Many surgeons. who may have limited experience with conventional antireflux surgery, have started to perform laparoscopic antireflux procedures, in spite of the well-known fact that there is a long learning curve for laparoscopic antireflux surgery. METHODS: A random sample of 225 of 660 patients operated on at high-volume and all 220 patients from low-volume hospitals were identified through a nation-wide register. Outcome 4 years after laparoscopic antireflux surgery was studied using a disease-specific questionnaire. RESULTS: Treatment failures were more common in the high-volume group than among patients operated on at low-volume hospitals, 29.0% and 19.7%, respectively. In the high volume group, medication (specifically to relieve heartburn or acid regurgitation) was taken at least once a week and revisional surgery was found in 19.5% and 6.0%, respectively. Corresponding results in the low-volume group were 11.1% and 2.9%, respectively. None of these differences was statistically significant at the overall 0.05 level. CONCLUSION: A failure rate of almost 30% at 4 years' follow-up for patients operated on at relatively high-volume hospitals was disappointing, despite the fact that these results are population-based. Hospitals are encouraged to provide accounts of their results in an effort to identify the reasons for treatment failures, and for the public to have access to more objective information on different therapeutic options.

Economic burden of NSAID-induced gastropathy in Sweden.

BACKGROUND: Gastrointestinal side effects carry a significant cost related to the use of NSAID medications. METHODS: The economic burden of NSAID-induced gastric side effects is estimated using the cost-of-illness methodology. Costs are calculated using both a prevalence (top-down) approach and an incidence (bottom-up) approach. RESULTS: Using the top-down approach, the total cost in 1998 of NSAID-induced ulcers was MSEK 329-586, direct costs accounting for 76%-83%. The bottom-up approach gives an estimate of MSEK 320, of which MSEK 290 was direct cost. About one-quarter of total costs for ulcer disease can be attributed to the use of NSAIDs. CONCLUSIONS: Gastrointestinal side effects carry a significant cost from the use of NSAIDs, costs that are as important as the price of NSAIDs. This should be considered when choice of drug and prophylaxis is being made.

The Swedish Council on Technology Assessment in Health Care (SBU) systematic overview of chemotherapy effects in some major tumour types--summary and conclusions.

This report by The Swedish Council on Technology Assessment in Health Care (SBU) reviews, classifies, and grades the scientific literature on cancer chemotherapy in some major tumour types, describes the practice of chemotherapy in Sweden, compares practice with scientific knowledge, and analyses the costs and cost-effectiveness of chemotherapy. The report is intended primarily for decision-makers at various levels, both practitioners and administrators. It is also of interest for the medical profession. The extensive body of scientific literature was reviewed according to strict criteria that reflected the scientific weight of the literature. Sixteen experts representing different disciplines (oncology, surgery, internal medicine, health economy and quality of life research) participated in the literature review. Each section was discussed within the project group and was reviewed by at least one, but usually two international researchers. Additional input was provided by national experts representing different scientific disciplines. For the final evaluation to be as close to the objective truth as possible, a concerted effort was made to guarantee objectivity and thorough assessment of current knowledge about the effects of chemotherapy on the selected cancers. The tumour types selected for this assessment include firstly those types where three investigations had shown an increased use of chemotherapy in Sweden during the latest decade. These were non-small cell lung cancer (NSCLC), gastric cancer, pancreatic cancer, colorectal cancer and urinary bladder cancer. Secondly, the two tumour types comprising the greatest number of patients treated with chemotherapy in Sweden, breast cancer and haematological malignancies, were included. Among the haematological malignancies, the most prevalent ones, acute myeloid leukaemia (AML), chronic lymphocytic leukaemia (CLL), Hodgkin's disease (HD), aggressive non-Hodgkin's lymphoma (NHL) of the large B-cell type and indolent NHL of follicular type were evaluated. These constitute about 75%, of all haematological malignancies. Thirdly, ovarian cancer was included since chemotherapy has been extensively used and since, at the time of the planning of this overview, a group of very expensive drugs, the taxanes, had preliminarily shown promising results. A wealth of scientific literature has been published on cancer therapy. The review presented in this report is limited to scientific studies judged to be important for evaluating chemotherapy efficacy. Assessments of the content and quality of these studies, and a critical summary of the results in all stages of the selected tumours, have never before been attempted in this way. However, similar comprehensive overviews of certain stages of the tumours have previously been made. These overviews were also critically evaluated. Totally 1,496 studies involving 558,743 patients were reviewed. The survey of practice of chemotherapy use involved all departments of surgery, urology, gynaecology, internal medicine including haematologic units, pulmonary medicine and general and gynaecologic oncology at 16 hospitals in two health care regions in Sweden, covering 39% of the Swedish population. During the 4 weeks of the survey, all patients with the diagnoses concerned who received chemotherapy were registered. The study included 1,590 patients. The working group's general conclusions are summarised in the following points: The literature on the effects of chemotherapy is extensive. Chemotherapy has a well-documented role in the curative and palliative treatment of patients with several types of cancer. The use of chemotherapy is of utmost importance for the possibility of cure in certain tumour types. In other tumours, chemotherapy increases the possibility of cure when added to local and regional treatments, particularly surgery. In the instances of no possibility of cure, chemotherapy may to a variable extent improve both patient survival and well-being. In Sweden chemotherapy is largely used in accordance with that documented in the scientific literature. The extent of both over- and under-treatment seems to be limited but cannot be excluded at the individual patient level. The literature-based knowledge is scientifically of lower quality in the most chemotherapy sensitive tumours than in tumours showing more limited sensitivity. In the more sensitive tumours, positive effects on a symptomatic stage and survival were seen several decades ago. In those days, clinical treatment studies did not fulfil the current high quality requirements. Small life-prolonging effects of chemotherapy are sometimes very well documented in large, high quality scientific studies. Some of these s

Turn structures in CGRP C-terminal analogues promote stable arrangements of key residue side chains.

The 37-amino acid calcitonin gene-related peptide (CGRP) is a potent endogenous vasodilator thought to be implicated in the genesis of migraine attack. CGRP antagonists may thus have therapeutic value for the treatment of migraine. The CGRP C-terminally derived peptide [D(31),P(34),F(35)]CGRP(27-37)-NH(2) was recently identified as a high-affinity hCGRP(1) receptor selective antagonist. Reasonable CGRP(1) affinity has also been demonstrated for several related analogues, including [D(31),A(34),F(35)]CGRP(27-37)-NH(2). In the study presented here, conformational and structural features in CGRP(27-37)-NH(2) analogues that are important for hCGRP(1) receptor binding were explored. Structure-activity studies carried out on [D(31),P(34),F(35)]CGRP(27-37)-NH(2) resulted in [D(31),P(34),F(35)]CGRP(30-37)-NH(2), the shortest reported CGRP C-terminal peptide analogue exhibiting reasonable hCGRP(1) receptor affinity (K(i) = 29.6 nM). Further removal of T(30) from the peptide's N-terminus greatly reduced receptor affinity from the nanomolar to micromolar range. Additional residues deemed critical for hCGRP(1) receptor binding were identified from an alanine scan of [A(34),F(35)]CGRP(28-37)-NH(2) and included V(32) and F(37). Replacement of the C-terminal amide in this same peptide with a carboxyl, furthermore, resulted in a greater than 50-fold reduction in hCGRP(1) affinity, thus suggesting a direct role for the amide moiety in receptor binding. The conformational properties of two classes of CGRP(27-37)-NH(2) peptides, [D(31),X(34),F(35)]CGRP(27-37)-NH(2) (X is A or P), were examined by NMR spectroscopy and molecular modeling. A beta-turn centered on P(29) was a notable feature consistently observed among active peptides in both series. This turn led to exposure of the critical T(30) residue to the surrounding environment. Peptides in the A(34) series were additionally characterized by a stable C-terminal helical turn that resulted in the three important residues (T(30), V(32), and F(37)) adopting consistent interspatial positions with respect to one another. Peptides in the P(34) series were comparatively more flexible at the C-terminus, although a large proportion of the [D(31),P(34),F(35)]CGRP(27-37)-NH(2) calculated conformers contained a gamma-turn centered on P(34). These results collectively suggest that turn structures at both the C-terminus and N-terminus of CGRP(27-37)-NH(2) analogues may help to appropriately orient critical residues (T(30), V(32), and F(37)) for hCGRP(1) receptor binding.

The mesenteric hemodynamic response to circulatory shock: an overview.

The mesenteric hemodynamic response to circulatory shock is characteristic and profound; this vasoconstrictive response disproportionately affects both the mesenteric organs and the organism as a whole. Vasoconstriction of post-capillary mesenteric venules and veins, mediated largely by the alpha-adrenergic receptors of the sympathetic nervous system, can effect an "autotransfusion" of up to 30% of the total circulating blood volume, supporting cardiac filling pressures ("preload"), and thereby sustaining cardiac output at virtually no cost in nutrient flow to the mesenteric organs. Under conditions of decreased cardiac output caused by cardiogenic or hypovolemic shock, selective vasoconstriction of the afferent mesenteric arterioles serves to sustain total systemic vascular resistance ("afterload"), thereby maintaining systemic arterial pressure and sustaining the perfusion of non-mesenteric organs at the expense of mesenteric organ perfusion (Cannon's "flight or fight" response). This markedly disproportionate response of the mesenteric resistance vessels is largely independent of the sympathetic nervous system and variably related to vasopressin, but mediated primarily by the renin-angiotensin axis. The extreme of this response can lead to gastric stress erosions, nonocclusive mesenteric ischemia, ischemic colitis, ischemic hepatitis, ischemic cholecystitis, and/or ischemic pancreatitis. Septic shock can produce decreased or increased mesenteric perfusion, but is characterized by an increased oxygen consumption that exceeds the capacity of mesenteric oxygen delivery, resulting in net ischemia and consequent tissue injury. Mesenteric organ injury from ischemia/reperfusion due to any form of shock can lead to a triggering of systemic inflammatory response syndrome, and ultimately to multiple organ dysfunction syndrome. The mesenteric vasculature is therefore a major target and a primary determinant of the systemic response to circulatory shock.

Intramucosal pH and pCO(2) do not strictly correlate with intestinal energy metabolism in experimental peritonitis.

This study aimed to investigate tissue hypoxia on the cellular level in sepsis. Eighteen pigs weighing 18-27 kg were studied. Intramucosal-arterial PCO(2) gradient (PCO(2)-gap) and intramucosal pH (pH(i)) were calculated using tonometry. A blind loop of the small intestine was constructed for repeated tissue biopsies to measure intestinal energy-related metabolites and lactate concentration. Six animals served as controls. In 12 animals, faecal peritonitis was induced. Six of these animals were studied without further interventions, while the others were resuscitated with dextran to maintain cardiac index at baseline level. Untreated peritonitis caused an increase in PCO(2)-gap and a drop in pH(i). The intestinal energy metabolism was not disturbed until the end of the experimental period, with a decreased energy charge value and a moderately increased lactate concentration. In peritonitis-dextran animals, PCO(2)-gap and pH(i) remained at baseline level and the energy metabolism was not disturbed. We conclude that in peritonitis, PCO(2)-gap - like pH(i) - can be influenced by other factors than strictly anaerobic tissue metabolism.

Antireflux surgery in Sweden, 1987-1997: a decade of change.

BACKGROUND: The aim of this study was to analyse whether new therapeutic options--the introduction of proton-pump inhibitors (PPI) in 1989 and the laparoscopic technique in 1992--altered the surgical treatment of gastro-oesophageal reflux disease (GORD) in Sweden. METHODS: Data obtained from the Centre for Epidemiology (EpC) on patients undergoing surgery for GORD from 1987 to 1997 was analysed, and the information was validated with a questionnaire to all surgical departments. RESULTS: The questionnaire gave a response rate of 94%, and the figures corresponded well with those obtained from the EpC. In 1987, 456 antireflux procedures were performed. Ten years later this figure had increased to 1303. This approximately threefold increase started before the introduction of PPI and was even more pronounced during the following few years. The development of laparoscopic antireflux surgery did not alter this increase. In 1997, 76% of the procedures were performed laparoscopically. The fundoplication rate rose from 5.5 to 12.7 procedures/100,000 inhabitants. The rates varied greatly among different counties; 7 of 23 still had a fundoplication rate of less than 10 in 1997. The median number of procedures per hospital in 1997 was 10. Only two departments accomplished more than 50 antireflux procedures. CONCLUSION: Within 5 years the laparoscopic technique replaced the open procedure as the method of choice. However, the increase in the frequency of antireflux surgery was apparent even before the introduction of laparoscopy.

Bacterial translocation in experimental shock is dependent on the strains in the intestinal flora.

BACKGROUND: Enteric microorganisms are responsible for a significant proportion of post-surgical infections. Intestinal mucosal injury may permit translocation of bacteria and endotoxin. This study investigates translocation in peritonitis and ischemia/reperfusion by inoculating different bacterial species into the small intestine. METHODS: Twenty-five pigs were monitored hemodynamically and divided into three groups: controls (C), ischemia/reperfusion (I/R), and peritonitis (P). Intramucosal pH (pHi) was calculated tonometrically. A perfusion tube was positioned in the ileum for inoculation of the bacterial strains. In a first study period a non-pathogenic bacterium was used, whereas Escherichia coli strains with known ability to translocate were used in a second. Blood and mesenteric lymph nodes (MLNs) were obtained for bacterial culture and endotoxin analyses. RESULTS: Mesenteric arterial blood flow and pHi decreased in groups I/R and P. Endotoxin levels increased in these groups in period 1, whereas in period 2 an increase over time was only observed in group P. No bacterial translocation to blood or MLNs occurred in period 1. In period 2 bacteria translocated to MLNs in all animals, including controls. Translocation to central and/or mesenteric venous blood was found in all groups, but mainly in I/R and P. The incidence of mucosal injury was similar in the two periods. CONCLUSIONS: Since positive blood and MLN samples were only found in period 2, we conclude that translocation of bacteria seems to be more dependent on the presence of translocating strains in the intestinal bacterial flora than on the mucosal insult.

[Guidelines for management of patients with acute pancreatitis]. / Riktlinjer för handläggning av patienter med akut pankreatit.

During recent years new concepts and methods have been introduced in the management of acute pancreatitis. Severity and risk of complications show wide variation. Outcome is also dependent on the physician's experience and on his local resources. In this light the Swedish Society of Upper Abdominal Surgery has elaborated national guidelines for management. Attention is paid to diagnosis, severity assessment and etiology. Furthermore, guidelines are offered for treatment of mild and severe pancreatitis, as well as for the management of pseudocysts. The role of multidisciplinary intensive care specialist teams in the management of severe disease is emphasized. The guidelines are supported by the Swedish Society of Gastroenterology, the Swedish Society of Gastroenterology, the Swedish Society of Anesthesiology and Intensive Care and by experts from other Nordic countries.

Selective inhibitors of COX-2--are they safe for the stomach?

NSAIDs are widely used and beneficial for patients with inflammatory pain. However, NSAIDs cause significant adverse upper gastrointestinal effects, including increased mortality from serious ulcer complications. NSAIDs exert their anti-inflammatory effects by inhibiting the activity of the COX enzyme, which was recently shown to exist in two isoforms, a constitutive COX-1 and an inducible COX-2. The latter isoform is induced in inflammation, while the former is responsible for prostaglandin effects on platelet function and gastric mucosal defense. Two specific COX-2 inhibitors have recently been introduced into the market. The available data from clinical trials indicate that these new drugs have anti-inflammatory and analgesic effects similar to those of conventional NSAIDs, but reduced rates of adverse upper gastroduodenal effects, which are similar to those observed with placebo. This difference in rates of adverse effects might imply improved safety for patients requiring anti-inflammatory treatment. It has, however, to be kept in mind that specific COX-2 inhibitors lack cardiovascular protective effects. Considering the high consumption rate of NSAIDs to achieve pain relief in arthritis and other musculo-sceletal diseases, the reduced risk of gastrointestinal ulcers and ulcer complications may have a positive impact on population health and health economy.

Immune cell distribution in gut-associated lymphoid tissue and synthesis of IL-6 in experimental porcine peritonitis.

This study aimed to evaluate the possibility to detect early changes in gut-associated lymphoid tissue related to an inflammatory response. Anaesthetised pigs were subjected to faecal peritonitis (n = 9) or to a sham procedure (n = 8). Blood from the vena cava and the superior mesenteric vein was repeatedly sampled, and the levels of interleukin-6 (IL-6) were analysed. Biopsies of the small intestine and mesenteric lymph nodes (MLNs), harvested at 300 min, were incubated with monoclonal antibodies specific for CD2 (T lymphocytes), IgM (B lymphocytes) and CD11a/CD18 (leucocyte adhesion molecule). The number of positive (+) cells was scored. During peritonitis, IL-6 increased significantly. Compared to controls, the number of CD2+ cells decreased, IgM+ cells tended to increase and CD11a/CD18+ cells increased in the mucosa during peritonitis. In MLNs, the number of cells positive for all studied markers increased during peritonitis. We conclude that peritonitis causes an inflammatory response in the gut reflected by changes in the distribution of immune cells in gut-associated lymphoid tissue and release of IL-6 to venous blood.

The Swedish ACCES model: predicting the health economic impact of celecoxib in patients with osteoarthritis or rheumatoid arthritis.

The Arthritis Cost Consequence Evaluation System (ACCES) pharmacoeconomic model was used to evaluate the economic and health impact of the recent introduction of celecoxib for treatment of osteoarthritis (OA) and rheumatoid arthritis (RA) in Sweden. The model demonstrates that use of celecoxib can be expected to reduce the incidence of gastrointestinal adverse events, resource utilization and treatment costs. In a cost-effectiveness analysis, celecoxib demonstrated economic dominance (i.e. improved health at reduced cost) compared with the currently available alternatives for OA, and demonstrated economic dominance against a clinically relevant base-case scenario for RA. In sensitivity analyses, the results were shown to be relatively robust; celecoxib demonstrated economic dominance or favourable cost-effectiveness ratios in all analyses. Based on these data, it can be concluded that the use of celecoxib in Sweden will provide societal benefits by improving health care at reduced cost for patients with OA and RA.