Toe Pressure and Toe Brachial Index are Predictive of Cardiovascular Mortality, Overall Mortality, and Amputation Free Survival in Patients with Peripheral Artery Disease.

OBJECTIVE/BACKGROUND: Peripheral haemodynamic parameters are used to assess the presence and severity of peripheral artery disease (PAD). The prognostic value of ankle brachial index (ABI) has been thoroughly delineated. Nonetheless, the relative usefulness of ankle pressure (AP), ABI, toe pressure (TP), and toe brachial index (TBI) in assessing patient outcome has not been investigated in a concurrent study setting. This study aimed to resolve the association of all four non-invasive haemodynamic parameters in clinically symptomatic patients with PAD with cardiovascular mortality, overall mortality, and amputation free survival (AFS). METHODS: In total, 732 symptomatic patients with PAD admitted to the Department of Vascular Surgery for conventional angiography at Turku University Hospital, Turku, Finland, between January 2009 and August 2011 were reviewed retrospectively. Demographic factors, cardiovascular mortality, all-cause mortality, and above foot level amputations were obtained and assessed in relation to AP, ABI, TP, and TBI by means of Kaplan-Meier life tables and a multivariate Cox regression model. RESULTS: The haemodynamic parameter that was associated with poor 36 month general outcome was TP < 30 mmHg. Univariate Cox regression analysis of stratified values showed that TP and TBI associated significantly with mortality. In multivariate analysis both TP and TBI were associated with a significant risk of death. For TP < 30 mmHg and TBI < 0.25 the risk of cardiovascular mortality was hazard ratio [HR] 2.84, 95% confidence interval [CI] 1.75-4.61 [p<.001]; HR 3.68, 95% CI 1.48-9.19 [p=.050], respectively; all-cause mortality (HR 2.05, 95% CI 1.44-2.92 [p<.001]; HR 2.53, 95% CI 1.35-4.74 [p=.040], respectively); and amputation or death (HR 2.13, 95% CI 1.52-2.98 [p<.001]; HR 2.46, 95% CI 1.38-4.40 [p=.050], respectively)... CONCLUSION: Among non-invasive haemodynamic measurements and pressure indices both TP and TBI appear to be associated with cardiovascular and overall mortality and AFS for patients with PAD presenting symptoms of the disease.

A European perspective on costs and cost effectiveness of ophthalmic combinations in the treatment of open-angle glaucoma.

PURPOSE: Efficacy, safety, and cost implications are important considerations when choosing an ophthalmic treatment. Fixed-combination glaucoma medications containing brimonidine 0.2% and timolol 0.5%, or dorzolamide 2% and timolol 0.5%, were compared with brimonidine 0.2% and dorzolamide 2% that were used as adjunctive therapy to timolol 0.5%. METHODS: A literature review was conducted to determine the outcome parameters of intraocular pressure reduction and tolerability after 3 months of use of brimonidine or dorzolamide, each together with timolol as a fixed-combination or in concomitant therapy. Modelled cost-minimization and cost-effectiveness analyses were performed to investigate the economic consequences of ophthalmic therapy with brimonidine, dorzolamide, and timolol from a societal perspective. RESULTS: The literature review found that brimonidine and dorzolamide used as fixed combinations with timolol as well as in adjunctive therapy to timolol were equally effective and safe. Furthermore, in the European countries studied, the fixed combination of brimonidine/timolol represented a less costly option when compared to the fixed combination of dorzolamide/timolol evaluated over both a 3-month and a 12-month horizon. CONCLUSIONS: Brimonidine used as a fixed-combination therapy with timolol provided better cost value than dorzolamide/timolol in all the countries studied. For most countries, the fixed combination of brimonidine and timolol also provided better cost value than adjunctive therapy with brimonidine, which was more cost effective than adjunctive therapy with dorzolamide.

A cost-effectiveness analysis of fixed-combination therapies in patients with open-angle glaucoma: a European perspective.

OBJECTIVE: To compare the efficacy and cost implications of the use of the intraocular pressure-lowering prostaglandin analogues bimatoprost, travoprost, and latanoprost as fixed-combination therapies with timolol, a beta-adrenergic receptor antagonist. METHODS: A decision analytic cost-effectiveness model was constructed. Since no head-to-head studies comparing the three treatment options exist, the analysis was based on an indirect comparison. Hence, the model was based on efficacy data from five randomized, controlled, clinical studies. The studies were comparable with respect to study design, time horizon, patient population and type of end point presented. The measure of effectiveness was the percentage reduction of the intraocular pressure level from baseline. The cost evaluated was the cost of medication and clinical visits to the ophthalmologist. All drug costs were market prices inclusive of value-added tax, and visit costs were priced using official physician fees. Cost-effectiveness analyses were carried out in five European countries: Spain, Italy, United Kingdom, Norway and Sweden. The time horizon for the analyses was 3 months. RESULTS: The analysis showed that fixed-combination bimatoprost/timolol was more effective and less costly than fixed-combination travoprost/timolol and fixed-combination latanoprost/timolol in three out of the five countries analyzed. In two countries, bimatoprost/timolol was less costly than latanoprost/timolol, and cost the same as travoprost/timolol. CONCLUSIONS: This cost-effectiveness analysis showed that the fixed combination of bimatoprost 0.03%/timolol 0.5% administered once daily was a cost-effective treatment option for patients with primary open-angle glaucoma. This study was limited by available clinical data: without a head-to-head trial, indirect comparisons were necessary. In the United Kingdom, Sweden, Norway, Italy, and Spain, from a health service viewpoint, bimatoprost/timolol was a slightly more effective as well as less costly treatment strategy when compared to both travoprost/timolol and latanoprost/timolol.

Inside Nepal: expanding contraceptive choice.

PIP: More than 80% of the population of Nepal are more than 2 hours from a health care facility. Almost 40% of women want to use contraception now or in the future, but cannot or will not be able to because they do not have access to contraception. Physicians and assistants in mobile units have provided family planning, particularly voluntary sterilization, to Nepalese living in remote areas during drier seasons. In 1988, the Ministry of Heath began to provide voluntary sterilization services at permanent facilities all year round. People in some districts still receive family planning services via mobile services. The contraceptive prevalence rate in 1991 was 25% and 81% of contraceptive acceptors depended on female or male sterilization. The Association for Voluntary Sterilization (AVSC) is helping the Ministry of Health improve its quality control systems, expand access to services, and ameliorate clinical and counseling training. AVSC has learned that clients are more apt to be happy with contraceptive services if they have a range of choices. Thus, it is helping family planning practitioners expand the contraceptive mix for both women and men in Nepal. Research indicates a significant demand for methods other than sterilization. For example, 9% of women want to use injectables, but just 2% use injectables. AVSC is introducing Norplant and expanding access to IUDs and injectables. This expansion, improved quality assurance, and training of providers should greatly increase the contraceptive prevalence rate. Both USAID and the UN Population Fund are funding AVSC's activities in Nepal.^ieng

Turbulent times for Pakistan: U.S. government halts funding.

PIP: Only 12% of married women in Pakistan use contraception. Yet amid political disputes and US allegations of terrorist activities, the US has decided to end its foreign assistance to the country. Both the family planning program of the government of Pakistan and operations of nongovernmental organizations (NGO) will be severely crippled by this US action. Many family planning providers will have to cut services. The Association for Voluntary Surgical Contraception (AVSC) has been working with 6 NGOs and 2 private hospitals at 11 sites since 1985 to focus upon the delivery of high-quality family planning services. Although these sites constitute only 3.5% of all voluntary sterilization sites in the country, they perform more than 15% of male and female surgical sterilization procedures. All remaining procedures are carried out at 300 government sites throughout the country. The AVSC will fund these Pakistani NGOs for a period of 6 months with funds provided by individual contributors. Over that time, the organizations will search for alternative funding and, if necessary, undergo a gradual shutdown of operations.^ieng

Congenital absence of the radius.

We review the experience in treating congenital absence of the radius at Shriners Hospital in Shreveport. The prognosis for hand function in patients treated nonoperatively is poor to fair, while a minority of patients have good function after operative treatment.

The early clinical presentation of synovial sarcoma.

While synovial sarcoma most commonly presents as a painless mass, occasionally the cancer emerges in a misleading manner resulting in an unfavorable delay or error in diagnosis. A review of the litrature reveals 4 such occult patterns: pretumor phase characterized only by pain or tenderness; the acute inflammatory lesion presenting as a "hot" arthritis or bursitis; the chronic contracture; the post traumatic tumor. These conditions, especially when otherwise unaccounted for, are indications for biopsy. Four avoidable pitfalls in biopsy management also emerged from the review.

Dislocation of the elbow: a retrospective study of 115 patients.

Of the 115 elbow dislocations treated at two New Orleans hospitals between 1959 and 1969, 78% were posterior. Sixty-one percent of the patients were 21 years of age or younger, and the male-female ratio was 1.7:1.0. The most common associated injuries were fractures of the medial condyle or epicondyle. All uncomplicated dislocations were treated by closed reduction and plaster immobilization. Of the 35 cases complicated by medial condylar or epicondylar fractures, 29 required open reduction and internal fixation. Results were excellent or good in 91% of the cases. The three patients (2.6%) with poor results all had mental impairment. This study suggests a generally favorable prognosis for these injuries.