Bayesian heterogeneity in a meta-analysis with two studies and binary data.

The meta-analysis of two trials is valuable in many practical situations, such as studies of rare and/or orphan diseases focussed on a single intervention. In this context, additional concerns, like small sample size and/or heterogeneity in the results obtained, might make standard frequentist and Bayesian techniques inappropriate. In a meta-analysis, moreover, the presence of between-sample heterogeneity adds model uncertainty, which must be taken into consideration when drawing inferences. We suggest that the most appropriate way to measure this heterogeneity is by clustering the samples and then determining the posterior probability of the cluster models. The meta-inference is obtained as a mixture of all the meta-inferences for the cluster models, where the mixing distribution is the posterior model probability. We present a simple two-component form of Bayesian model averaging that is unaffected by characteristics such as small study size or zero-cell counts, and which is capable of incorporating uncertainties into the estimation process. Illustrative examples are given and analysed, using real sparse binomial data.

Task-based measures of sensitivity to physical activity predict daily life pain and mood among people living with back pain.

BACKGROUND: Clinical interventions aim to improve the daily life experiences of patients. However, past research has highlighted important discrepancies between commonly used assessments (e.g. retrospective questionnaires) and patients' daily life experiences of pain. These gaps may contribute to flawed clinical decision-making and ineffective care. Recent work suggests that real-time, task-based clinical assessments may help reduce these discrepancies by adding predictive value in explaining daily life pain experiences. This study aimed to investigate these relationships by evaluating whether task-based measures of sensitivity to physical activity (SPA) predict daily life pain and mood, beyond traditional pain-related questionnaires. METHODS: Adults with back pain (<6-month onset) answered pain-related questionnaires and completed a standardized lifting task. SPA-Pain, SPA-Sensory and SPA-Mood were, respectively, assessed as task-evoked changes in pain intensity, pressure pain threshold (back, hands), situational catastrophizing. Over the next 9 days, daily life pain and mood were assessed using smartphone-based ecological momentary assessment (EMA-Pain and EMA-Mood, respectively) with stratified random sampling. Data analyses estimated fixed effects (b) using multilevel linear modelling with random intercepts. RESULTS: Median EMA completion per participant was 66.67% (n = 67 participants). After controlling for covariates, SPA-Pain was associated with EMA-Pain (b = 0.235, p = 0.002) and SPA-Psych approached significance with EMA-Mood (b = -0.159, p = 0.052). CONCLUSIONS: Task-based assessment of SPA helps explain daily life pain and mood among adults with back pain, beyond traditional questionnaires. Adding task-based assessment of SPA may achieve a more complete picture of pain and mood in daily life, offering clinicians better guidance when prescribing activity-based interventions that are designed to modify daily life behaviour, such as graded activity. SIGNIFICANCE: This study found that, among people with back pain, task-based measures of sensitivity to physical activity contribute additional predictive value for daily life pain and mood beyond self-report questionnaires. Findings suggest that real-time, task-based measures may help mitigate some of the shortcomings that are commonly associated with retrospective questionnaires.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review.

BACKGROUND: Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area. METHODS: This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines. RESULTS: A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence. CONCLUSIONS: This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Does vitamin C supplementation improve rotator cuff healing? A preliminary study.

PURPOSE: One of the complications after rotator cuff repair is a tendon non-healing. It has already been posited in the literature that vitamin C (VC) promotes tendon healing through its antioxidant properties and its role as a cofactor in collagen synthesis. The aim of this study was to evaluate the effect of postoperative VC supplementation on the tendon healing following repair. METHODS: This randomized monocentric prospective study included 98 patients who underwent arthroscopic rotator cuff repair in 1-year period and follow-up ultrasound 6 months postoperatively. The cohort was divided into two groups: the VC+ group (500 mg/day PO for 45 days postoperatively) and the VC- group (no supplementation). The evaluation criterion was tendon healing at 6 months postoperatively according to the Sugaya ultrasound classification. Preoperative and postoperative clinical evaluations were based on active mobilities, the Constant score and the subjective shoulder value. RESULTS: There was no difference in term of postoperative outcomes between the two groups. At an average follow-up of 6.3 months, the non-healing rate in the overall population was 17%. This rate was higher in VC- compared to VC+, respectively, 23% vs. 11%), p = 0.2. CONCLUSION: This study showed a trend to improve tendon healing after rotator cuff repair with VC supplementation. However, a prospective study with a larger patient population should be conducted to confirm this finding.

Comparison of whole-cell versus acellular pertussis vaccine effectiveness in school clusters of pertussis, France, 2013.

OBJECTIVES AND METHOD: We conducted a prospective study in 2013 to compare the whole-cell versus acellular pertussis vaccines effectiveness and duration of protection, following the occurrence of pertussis clusters. RESULTS: During seven school outbreaks, we identified 102 clinical pertussis cases, including 10 cases biologically confirmed by Bordetella pertussis specific PCR, among a cohort of 305 children in 2nd to 6th grade. The risk of pertussis when vaccinated with an acellular vaccine alone was 1.6 (RR=1.6; 95% CI=1.1-2.5) times higher than when vaccinated with a whole-cell vaccine or using a combined schedule. CONCLUSIONS: The limited duration of protection conferred by the acellular vaccine reinforces the 2013 introduction of the pertussis booster at six years old.

Ultra-fast prompt gamma detection in single proton counting regime for range monitoring in particle therapy.

In order to fully exploit the ballistic potential of particle therapy, we propose an online range monitoring concept based on time-of-flight (TOF)-resolved prompt gamma (PG) detection in a single proton counting regime. In a proof of principle experiment, different types of monolithic scintillating gamma detectors are read in time coincidence with a diamond-based beam hodoscope, in order to build TOF spectra of PG generated in a target presenting an air cavity of variable thickness. Since the measurement was carried out at low beam currents (< 1 proton/bunch) it was possible to reach excellent coincidence time resolutions, of the order of 100 ps (σ). Our goal is to detect possible deviations of the proton range with respect to treatment planning within a few intense irradiation spots at the beginning of the session and then carry on the treatment at standard beam currents. The measurements were limited to 10 mm proton range shift. A Monte Carlo simulation study reproducing the experiment has shown that a 3 mm shift can be detected at 2σ by a single detector of ∼1.4 × 10-3 absolute detection efficiency within a single irradiation spot (∼108 protons) and an optimised experimental set-up.

Influence of vitamin C on the incidence of CRPS-I after subacromial shoulder surgery.

PURPOSE: The primary aim of this study was to determine whether postoperative administration of vitamin C (VC) is associated with reduced risk of complex regional pain syndrome type I (CRPS-I) after subacromial shoulder surgery (SaSS). The secondary objective of the study was to identify risk factor for the development of CRPS-I after SaSS. MATERIALS AND METHODS: A retrospective cohort study was performed to evaluate 542 patients undergoing SaSS from January 2015 to December 2016. The cohort was divided into two groups based on VC administration [Group I (no VC) and Group II (500 mg/day oral VC for 50 days postoperatively)]. The relationship between VC administration and development of CRPS-I was assessed. Demographics, preoperative clinical parameters, and operative variables were evaluated to determine their effect on the incidence of CRPS-I. RESULTS: A total of 267 patients (Group II) undergoing SaSS received VC, and 266 patients (Group I) did not. The incidence of CRPS-I was significantly different between two groups (36(13%) vs 18(7%), p = 0.009). Multivariable regression, however, demonstrated that VC reduced the risk of CRPS-I after SaSS by > 50% (aOR = 0.49; 95% CI 0.27-0.91). Patients undergoing open surgery (aOR = 2.19; 95% CI 1.2-4.0) were more likely to develop CRPS-I postoperatively. Higher preoperative Constant score (aOR = 0.94; 95% CI 0.91-0.98) was associated with lower risk for CRPS-I development. CONCLUSIONS: The present study found that VC administered prophylactically for 50 days postoperatively is effective in preventing CRPS-I development after SaSS. CRPS-I is a common complication following SaSS, especially in the setting of an open approach. The authors recommend preventive management with VC and arthroscopic approaches when possible for SaSS. LEVEL OF EVIDENCE III: Retrospective comparative study.

Origen intraorbitario de las arterias etmoidales: estudio anatómico / Intraorbital origin of the ethmoidal arteries: anatomical study

RESUMEN Introducción: Ramas de la arteria oftálmica contribuyen a la irrigación de diversos territorios de la fosa nasal y de los senos paranasales. Objetivo: El objetivo de nuestro estudio es describir las arterias etmoidales desde su origen intraorbitario, y su relación con las estructuras musculares y nerviosas. Material y Método: Se realizó un estudio anatómico endoscópico en 20 fosas nasales y órbitas de diez cadáveres. Resultados: La disección del plano muscular permitió definir dos espacios de entrada a la órbita. Un primer espacio entre el músculo recto inferior y músculo recto medial (área 1) y otro entre el músculo recto medial y músculo oblicuo superior (área 2). En el área 1, la arteria oftálmica discurrió superior al nervio óptico en el 90%. La arteria etmoidal anterior se observó en todos los casos inferior al músculo oblicuo superior. En el área 2, la arteria etmoidal posterior, se localizó en todos los casos superior al músculo oblicuo superior. No se identificó la arteria etmoidal media en ningún caso. El origen de la arteria supraorbitaria se identificó entre las dos arterias etmoidales. Conclusión: La comprensión anatómica del origen intraorbitario de la arteria oftálmica permite el abordaje de determinada patología intraorbitaria compleja a través de la pared medial de la órbita.

ABSTRACT Introduction: Branches of the ophthalmic artery contribute to the irrigation of various territories of the nasal cavity and paranasal sinuses. Aim: The aim of our study is to describe the intraorbital course of the ethmoidal arteries and their relationship with the muscular and nervous structures. Material and method: We performed twenty nasal cavities and orbital dissections in ten adults cadaveric heads. Results: The dissection of the muscular orbital wall allowed defining two surgical orbital corridors, between the inferior rectus and the medial rectus muscles (area 1) and between the medial rectus and the superior oblique muscles (area 2). In area 1, the ophthalmic artery crosses over the optic nerve in 90% of the cases. The anterior ethmoidal artery was observed inferior to the superior oblique muscle. In area 2, the posterior ethmoidal artery was located superior to the superior oblique muscle in all cavities. No middle ethmoidal artery was identified. The origin of the supraorbital artery was found between the two ethmoidal arteries. Conclusions: The anatomical understanding of the intraorbital origin of the arteries of the ophthalmic artery allows perform two surgical approaches through the media orbital wall.

Somatosensory-guided tool use modifies arm representation for action.

Tool-use changes both peripersonal space and body representations, with several effects being nowadays termed tool embodiment. Since somatosensation was typically accompanied by vision in most previous tool use studies, whether somatosensation alone is sufficient for tool embodiment remains unknown. Here we address this question via a task assessing arm length representation at an implicit level. Namely, we compared movement's kinematics in blindfolded healthy participants when grasping an object before and after tool-use. Results showed longer latencies and smaller peaks in the arm transport component after tool-use, consistent with an increased length of arm representation. No changes were found in the hand grip component and correlations revealed similar kinematic signatures in naturally long-armed participants. Kinematics changes did not interact with target object position, further corroborating the finding that somatosensory-guided tool use may increase the represented size of the participants' arm. Control experiments ruled out alternative interpretations based upon altered hand position sense. In addition, our findings indicate that tool-use effects are specific for the implicit level of arm representation, as no effect was observed on the explicit estimate of the forearm length. These findings demonstrate for the first time that somatosensation is sufficient for incorporating a tool that has never been seen, nor used before.

BOARD-INVITED REVIEW: Quantifying water use in ruminant production.

The depletion of water resources, in terms of both quantity and quality, has become a major concern both locally and globally. Ruminants, in particular, are under increased public scrutiny due to their relatively high water use per unit of meat or milk produced. Estimating the water footprint of livestock production is a relatively new field of research for which methods are still evolving. This review describes the approaches used to quantify water use in ruminant production systems as well as the methodological and conceptual issues associated with each approach. Water use estimates for the main products from ruminant production systems are also presented, along with possible management strategies to reduce water use. In the past, quantifying water withdrawal in ruminant production focused on the water demand for drinking or operational purposes. Recently, the recognition of water as a scarce resource has led to the development of several methodologies including water footprint assessment, life cycle assessment, and livestock water productivity to assess water use and its environmental impacts. These methods differ with respect to their target outcome (efficiency or environmental impacts), geographic focus (local or global), description of water sources (green, blue, and gray), handling of water quality concerns, the interpretation of environmental impacts, and the metric by which results are communicated (volumetric units or impact equivalents). Ruminant production is a complex activity where animals are often reared at different sites using a range of resources over their lifetime. Additional water use occurs during slaughter, product processing, and packaging. Estimating water use at the various stages of meat and milk production and communicating those estimates will help producers and other stakeholders identify hotspots and implement strategies to improve water use efficiency. Improvements in ruminant productivity (i.e., BW and milk production) and reproductive efficiency can also reduce the water footprint per unit product. However, given that feed production makes up the majority of water use by ruminants, research and development efforts should focus on this area. More research and clarity are needed to examine the validity of assumptions and possible trade-offs between ruminants' water use and other sustainability indicators.

Integrated genome and transcriptome sequencing identifies a noncoding mutation in the genome replication factor DONSON as the cause of microcephaly-micromelia syndrome.

While next-generation sequencing has accelerated the discovery of human disease genes, progress has been largely limited to the "low hanging fruit" of mutations with obvious exonic coding or canonical splice site impact. In contrast, the lack of high-throughput, unbiased approaches for functional assessment of most noncoding variants has bottlenecked gene discovery. We report the integration of transcriptome sequencing (RNA-seq), which surveys all mRNAs to reveal functional impacts of variants at the transcription level, into the gene discovery framework for a unique human disease, microcephaly-micromelia syndrome (MMS). MMS is an autosomal recessive condition described thus far in only a single First Nations population and causes intrauterine growth restriction, severe microcephaly, craniofacial anomalies, skeletal dysplasia, and neonatal lethality. Linkage analysis of affected families, including a very large pedigree, identified a single locus on Chromosome 21 linked to the disease (LOD > 9). Comprehensive genome sequencing did not reveal any pathogenic coding or canonical splicing mutations within the linkage region but identified several nonconserved noncoding variants. RNA-seq analysis detected aberrant splicing in DONSON due to one of these noncoding variants, showing a causative role for DONSON disruption in MMS. We show that DONSON is expressed in progenitor cells of embryonic human brain and other proliferating tissues, is co-expressed with components of the DNA replication machinery, and that Donson is essential for early embryonic development in mice as well, suggesting an essential conserved role for DONSON in the cell cycle. Our results demonstrate the utility of integrating transcriptomics into the study of human genetic disease when DNA sequencing alone is not sufficient to reveal the underlying pathogenic mutation.

Measures of trainee performance in advanced endoscopy: A systematic review.

INTRODUCTION: The diversity, technical skills required, and risk inherent to advanced endoscopy techniques all contribute to complex training curricula and steep learning curves. Since trainees develop endoscopy skills at different rates, there has been a shift towards competency-based training and certification. Validated endoscopy performance measures for trainees are, therefore, necessary. The aim of this systematic review was to describe and critically assess the existing evidence regarding measures of performance for trainees in advanced endoscopy. METHODS: A systematic review of the literature from January 1980 to January 2016 was carried out using the MEDLINE, EMBASE, CENTRAL, and ISI Web of knowledge databases. MeSH terms related to 'advanced endoscopy' and 'performance' were applied to a highly sensitive search strategy. The main outcomes were face, content, and construct validity, as well as reliability. RESULTS: The literature search yielded 1,662 studies and 77 met the inclusion criteria after abstract and full-text review (endoscopic retrograde cholangiopancreatography (ERCP)=23, endoscopic ultrasound (EUS)=30, colonoscopic polypectomy (CP)=11, balloon-assisted enteroscopy (BAE)=7, luminal stenting=3, radiofrequency ablation (RFA)=2, and endoscopic muscosal resection (EMR)=1). Good validity and reliability were found for measurement tools of overall performance in ERCP, EUS and CP, with applications for both patient-based and simulator training models. A number of specific technical skills were also shown to be valid measures of performance. These include: selective biliary cannulation, sphincterotomy, biliary stent placement, stone extraction and procedure time for ERCP; pancreatic solid mass T-staging, EUS-guided fine needle aspiration (EUS-FNA) procedure time, number of EUS-FNA passes and puncture precision for EUS; procedure time and en bloc resection rate for CP; retrograde fluoroscopy time for BAE; and mean number of endoscopy sessions required to achieve complete eradication of intestinal metaplasia (CIEM) for RFA. The evidence for EMR and luminal stenting is of insufficient quality to make recommendations. CONCLUSIONS: We have identified multiple valid and readily available performance measures for advanced endoscopy trainees for ERCP, EUS, CP, BAE and RFA procedures. These tools should be considered in advanced endoscopy training programs wishing to move away from apprenticeship-based training and towards competency-based learning with the help of patient-based and simulator tools.

Changes in Pain Sensitivity and Pain Modulation During Oral Opioid Treatment: The Impact of Negative Affect.

OBJECTIVE: Opioids are frequently prescribed for chronic low back pain (CLBP), but there are broad individual differences in the benefits and risks of opioid therapy, including the development opioid-induced hyperalgesia. This study examined quantitative sensory testing (QST) data among a group of CLBP patients undergoing sustained oral opioid treatment. We investigated whether individual differences in psychological characteristics were related to opioid-induced changes in pain perception and pain modulation. DESIGN: The six-month, open-label trial evaluated patients with low to high levels of negative affect (e.g., symptoms of distress, depression and anxiety); participants underwent QST at baseline (prior to initiating treatment) and during oral opioid treatment. SETTING: A chronic pain management center. PATIENTS: The 31 study participants had chronic discogenic back pain, with a pain intensity rating >3/10. Participants were divided into groups with high vs. low levels of Negative Affect (NA). RESULTS: In the previously-published manuscript describing the clinical outcomes of the trial, high NA patients achieved only about half of the analgesic effect observed in the low NA group (Wasan AD, Michna E, Edwards RR, et al. Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology 2015;123:861-72). The QST findings reported here suggested that tolerance to experimental (cold pressor) pain and conditioned pain modulation tended to decrease in the high NA group over the course of opioid treatment, while temporal summation of mechanical pain declined in the low NA group. CONCLUSIONS: These results reveal that while the low NA group seemed to exhibit a generally adaptive, analgesic pattern of changes during opioid management, the high NA group showed a pattern more consistent with opioid-induced hyperalgesic processes. A greater susceptibility to hyperalgesia-promoting changes in pain modulation among patients with high levels of distress may contribute to a lower degree of benefit from opioid treatment in high NA patients.

Bayesian robustness in meta-analysis for studies with zero responses.

Statistical meta-analysis is mostly carried out with the help of the random effect normal model, including the case of discrete random variables. We argue that the normal approximation is not always able to adequately capture the underlying uncertainty of the original discrete data. Furthermore, when we examine the influence of the prior distributions considered, in the presence of rare events, the results from this approximation can be very poor. In order to assess the robustness of the quantities of interest in meta-analysis with respect to the choice of priors, this paper proposes an alternative Bayesian model for binomial random variables with several zero responses. Particular attention is paid to the coherence between the prior distributions of the study model parameters and the meta-parameter. Thus, our method introduces a simple way to examine the sensitivity of these quantities to the structure dependence selected for study. For illustrative purposes, an example with real data is analysed, using the proposed Bayesian meta-analysis model for binomial sparse data. Copyright © 2016 John Wiley & Sons, Ltd.

Does catastrophic thinking enhance oesophageal pain sensitivity? An experimental investigation.

BACKGROUND: Gastro-oesophageal reflux disease (GORD) is a major health problem that is frequently accompanied by debilitating oesophageal pain symptoms. OBJECTIVES: The first objective of the study was to examine the association between catastrophizing and oesophageal pain sensitivity. The second objective was to examine whether catastrophizing was associated with the magnitude of acid-induced oesophageal sensitization. METHODS: Twenty-five healthy volunteers (median age: 24.0 years; range: 22-31) were recruited and were asked to complete the Pain Catastrophizing Scale (PCS). During two subsequent study visits, mechanical, thermal, and electrical pain sensitivity in the oesophagus was assessed before and after inducing oesophageal sensitization using a 30-min intraluminal oesophageal acid perfusion procedure. RESULTS: Analyses were conducted based on data averaged across the two study visits. At baseline, catastrophizing was significantly associated with mechanical (r = -0.42, p < 0.05) and electrical (r = -0.60, p < 0.01) pain thresholds. After acid perfusion, catastrophizing was also significantly associated with mechanical (r = -0.58, p < 0.01) and electrical (r = -0.50, p < 0.05) pain thresholds. Catastrophizing was not significantly associated with thermal pain thresholds. Subsequent analyses revealed that catastrophizing was not significantly associated with the magnitude of acid-induced oesophageal sensitization. CONCLUSION: Taken together, findings from the present study suggest that catastrophic thinking exerts an influence on oesophageal pain sensitivity, but not necessarily on the magnitude of acid-induced oesophageal sensitization. WHAT DOES THIS STUDY ADD?: Catastrophizing is associated with heightened pain sensitivity in the oesophagus. This was substantiated by assessing responses to noxious stimulation of the oesophagus using an experimental paradigm mimicking features and symptoms experienced by patients with gastro-oesophageal reflux disease (GORD).

Cost-effectiveness of daclatasvir plus sofosbuvir-based regimen for treatment of hepatitis C virus genotype 3 infection in Canada.

OBJECTIVE: New regimens for the treatment of chronic hepatitis C virus (HCV) genotype 3 have demonstrated substantial improvement in sustained virologic response (SVR) compared with existing therapies, but are considerably more expensive. The objective of this study was to evaluate the cost-effectiveness of two novel all-oral, interferon-free regimens for the treatment of patients with HCV genotype 3: daclatasvir plus sofosbuvir (DCV + SOF) and sofosbuvir plus ribavirin (SOF + RBV), from a Canadian health-system perspective. METHODS: A decision analytic Markov model was developed to compare the effect of various treatment strategies on the natural history of the disease and their associated costs in treatment-naïve and treatment-experienced patients. Patients were initially distributed across fibrosis stages F0-F4, and may incur disease progression through fibrosis stages and on to end-stage liver disease complications and death; or may achieve SVR. Clinical efficacy, health-related quality-of-life, costs, and transition probabilities were based on published literature. Probabilistic sensitivity analysis was performed to assess parameter uncertainty associated with the analysis. RESULTS: In treatment-naive patients, the expected quality-adjusted life years (QALYs) for interferon-free regimens were higher for DCV + SOF (12.37) and SOF + RBV (12.48) compared to that of pINF + RBV (11.71) over a lifetime horizon, applying their clinical trial treatment durations. The expected costs were higher for DCV + SOF ($170,371) and SOF + RBV ($194,776) vs pINF + RBV regimen ($90,905). Compared to pINF + RBV, the incremental cost-effectiveness ratios (ICER) were $120,671 and $135,398 per QALYs for DCV + SOF and SOF + RBV, respectively. In treatment-experienced patients, DCV + SOF regimen dominated the SOF + RBV regimen. Probabilistic sensitivity analysis indicated a 100% probability that a DCV + SOF regimen was cost saving in treatment-experienced patients. CONCLUSION: Daclatasvir plus sofosbuvir is a safe and effective option for the treatment of chronic HCV genotype 3 patients. This regimen could be considered a cost-effective option following a first-line treatment of peg-interferon/ribavirin treatment experienced patients with HCV genotype-3 infection.

Sospecha clínica y tratamiento quirúrgico de los mucoceles esfenoidales / Diagnosis and surgical treatment of sphenoid mucoceles

Introducción: Los mucoceles son formaciones benignas de lento crecimiento que pueden aparecer en cualquier seno paranasal, representando el seno esfenoidal menos del 10%. Objetivo: Presentamos nuestra experiencia de mucoceles en el seno esfenoidal. Material y método: Se obtuvieron los datos a partir de nuestra base de datos que recoge prospectivamente los casos de tumores de cabeza y cuello. Entre enero 1989 y enero 2013 se registraron 58 mucoceles en 54 pacientes, de los cuales 4 (7%) eran de seno esfenoidal. Tres pacientes eran mujeres y uno varón, con edades comprendidas entre 42 y 61 años. Todas las lesiones fueron estudiadas con endoscopia nasal, tomo-grafía computarizada y resonancia magnética. Resultados: Tres pacientes presentaron un antecedente quirúrgico de seno paranasal. El síntoma más frecuente fue la cefalea (3 pacientes de 4). Dos pacientes presentaron diplopia y uno pérdida progresiva de agudeza visual, requiriendo manejo quirúrgico urgente. Todos fueron tratados con esfenoidotomía por abordaje endoscópico endonasal. Fueron dados de alta a las 48 h posteriores con antibioticoterapia. Ninguno presentó recidiva. Conclusión: Los mucoceles esfenoidales representan menos del 10% de los mucoceles nasosinusales. La pérdida de agudeza visual requiere un rápido diagnóstico y manejo terapéutico quirúrgico urgente. El tratamiento de elección es la marsupialización.

Introduction: Sinus mucoceles are benign cysts that may appear in any sinus, but only 1%-10% occur in the sphenoid sinus. Aim: We describe the cases of sphenoid sinus mucoceles seen at our centre over the last 25 years. Material and method: In a prospective review of all mucoceles diagnosed between 1989 and 2013, we identified 58 mucocels in 54 patients. Four of the 58 (7%) were sphenoid mucoceles. There were three female patients and one male, and ages ranged from 42 to 61 years. We performed an endoscopy, CT and MR in all patients to confirm diagnosis. Results: Three patients had had endoscopic endonasal surgery in the past. The presenting symptoms were headache in 3 patients, diplopia in two, and visual loss, causing blindness, in one. The patient with amaurosis requiered urgent surgery. All four patients underwent sphenoidotomy with marsupialisation by the endonasal endoscopic approach. They were discharged 48 hours later on oral antibiotics. No recurrences have been observed to date. Conclusions: Sphenoid mucocele is a rare disease, requiring prompt treatment in cases of amaurosis. Good results can be achieved with endonasal endoscopic marsupialisation.