Economics of Malignant Gliomas: A Critical Review.

PURPOSE: Approximately 18,500 persons are diagnosed with malignant glioma in the United States annually. Few studies have investigated the comprehensive economic costs. We reviewed the literature to examine costs to patients with malignant glioma and their families, payers, and society. METHODS: A total of 18 fully extracted studies were included. Data were collected on direct and indirect costs, and cost estimates were converted to US dollars using the conversion rate calculated from the study's publication date, and updated to 2011 values after adjustment for inflation. A standardized data abstraction form was used. Data were extracted by one reviewer and checked by another. RESULTS: Before approval of effective chemotherapeutic agents for malignant gliomas, estimated total direct medical costs in the United States for surgery and radiation therapy per patient ranged from $50,600 to $92,700. The addition of temozolomide (TMZ) and bevacizumab to glioblastoma treatment regimens has resulted in increased overall costs for glioma care. Although health care costs are now less front-loaded, they have increased over the course of illness. Analysis using a willingness-to-pay threshold of $50,000 per quality-adjusted life-year suggests that the benefits of TMZ fall on the edge of acceptable therapies. Furthermore, indirect medical costs, such as productivity losses, are not trivial. CONCLUSION: With increased chemotherapy use for malignant glioma, the paradigm for treatment and associated out-of-pocket and total medical costs continue to evolve. Larger out-of-pocket costs may influence the choice of chemotherapeutic agents, the economic implications of which should be evaluated prospectively.

2015 Oman Heart Association guidelines for the management of hypertension : practical recommendations from the Oman Heart Association (OHA).

Hypertension (HTN) is a major independent risk factor for the development of stroke, coronary artery disease (CAD), peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD). HTN is a growing public health problem in Oman, almost certainly the most prevalent modifiable risk factor for cardiovascular disease (CVD). The risk of CVD in patients with HTN can be greatly reduced with lifestyle modifications and effective antihypertensive therapy. Randomized trials have shown that blood pressure (BP) lowering produces rapid reductions in CV risk. Several studies have shown that the majority of the hypertensive patients remain uncontrolled. It is well established that the observed poor control of the disease is not only related to poor adherence to medications, but also to limited awareness and adherence to evidence-based management of hypertension among physicians. Several guidelines for the management of patients with hypertension have been published. However, the aim of this document is to provide the busy physicians in Oman with more concise and direct approach towards implementing these guidelines into clinical practice.

Mechanical Prosthetic Valves and Pregnancy: A therapeutic dilemma of anticoagulation.

Choosing the best anticoagulant therapy for a pregnant patient with a mechanical prosthetic valve is controversial and the published international guidelines contain no clear-cut consensus on the best approach. This is due to the fact that there is presently no anticoagulant which can reliably decrease thromboembolic events while avoiding damage to the fetus. Current treatments include either continuing oral warfarin or substituting warfarin for subcutaneous unfractionated heparin or low-molecular-weight heparin (LMWH) in the first trimester (6-12 weeks) or at any point throughout the pregnancy. However, LMWH, while widely-prescribed, requires close monitoring of the blood anti-factor Xa levels. Unfortunately, facilities for such monitoring are not universally available, such as within hospitals in developing countries. This review evaluates the leading international guidelines concerning anticoagulant therapy in pregnant patients with mechanical prosthetic valves as well as proposing a simplified guideline which may be more relevant to hospitals in this region.

2014 Oman Heart Association protocol for the management of acute atrial fibrillation.

Although atrial fibrillation (AF) is the most common cardiac arrhythmia, there is variation in practice with regard to the management of acute AF among the hospitals and even within the same hospital in Oman. This variation likely reflects a lack of high-quality evidence. Standard guidelines and textbooks do not offer clear evidence-based direction for physicians to guide the management of acute AF. Particularly controversial is the issue of using rhythm control or rate control. This stimulated Oman Heart Association (OHA) to issue a simplified protocol for the management of acute AF to be applied by the entire cardiac caregivers all over the country. The priorities for acute management of AF include stabilizing the patient's hemodynamic status, symptom control, treatment of the underlying and precipitating cause, and more importantly protecting the brain.

Clinical Pathways for Non-ST Elevation Acute Coronary Syndrome in Oman: An Oman Heart Association Protocol for Hospital Quality Improvement Initiative.

In 2012, Oman Heart Association (OHA) published its own guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction, the aim was not to be comprehensive but rather simplified and practical in order to reduce the gap between the long comprehensive guidelines and our actual practice. However, we still feel that the busy registrars and residents need simpler and direct clinical pathways or protocol to be used in the emergency departments, coronary care units and in the wards. Clinical pathways are now one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes in acute care.

The chain of survival for ST-segment elevation myocardial infarction: insights into the Middle East.

Although coronary heart disease is the leading cause of morbidity and mortality in the Middle East (ME), not much is known about patients with ST-segment elevation myocardial infarction (STEMI) from this region. The STEMI Chain of Survival can be used to target regional improvements in patient care. We tried to adopt a modified chain of survival for STEMI to highlight the challenges and difficulties and the possible solutions to improve the STEMI care in the Middle East based on the few data available.

2012 Oman Heart Association simplified guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction.

Although current practice guidelines provide an evidence-based approach to the management of acute coronary syndromes, application of the evidence by individual physicians has been suboptimal. This gap between comprehensive guidelines and actual practice stimulated Oman Heart Association to issue a simplified series for the management of the common cardiac abnormalities to be applied by the entire cardiac caregivers all over the country. This simplified approach for the management of non-ST-elevation acute coronary syndrome provides a practical and systematic means to implement evidence-based medicine into clinical practice.

Coronary perforation and covered stents: an update and review.

Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventional cardiology. Coronary perforations are classified as type I (extraluminal crater), II (myocardial or pericardial blushing), and III (contrast streaming or cavity spilling). Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardial drainage. However, type III perforations can be managed with covered stents without need for surgical intervention.

Acute coronary syndrome in pregnant women.

The purpose of this article is to review the available information on the pathophysiology, diagnosis, treatment and prognosis of acute coronary syndromes (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) during all stages of pregnancy. We searched the English-language literature indexed in MEDLINE, Scopus and EBSCO host research databases from 1980 through to August 2010 using the indexing terms 'pregnancy', 'ante-,peri-, and postpartum', 'acute coronary syndrome', 'myocardial infarction', 'STEMI' and 'NSTEMI'. Symptomatic coronary artery disease is still infrequent in women of childbearing age, but the recent increase in its prevalence in pregnancy has been attributed to the modern trend of childbearing in older years because many young working women are postponing having children. Although rare, acute pregnancy-related MI is a devastating event that may claim the life of a mother and her fetus. The incidence of MI is estimated at 0.6-1 per 10,000 pregnancies. The case fatality rate has been reported to be 5-37%. Owing to the rarity of the event, information related to MI in pregnancy is derived from case reports and, therefore, is subject to considerable reporting bias. Treatment needs to be prompt and urgent because of the very high mortality rate. Current guidelines for the diagnosis and treatment of MI should be expanded to include pregnancy-related MI. Screening and management of cardiovascular risk factors should be achieved before pregnancy.