Economic evaluation of robot-assisted hysterectomy: a cost-minimisation analysis.

OBJECTIVE: The aim of this study was to carry out an economic evaluation of robot-assisted hysterectomy compared with the current standard of care in Ireland. DESIGN: Cost-minimisation analysis of robot-assisted hysterectomy compared with a combination of traditional open and conventional laparoscopic surgery. SETTING: The publicly funded healthcare system in Ireland. POPULATION: The target population was women requiring hysterectomy that could be completed using robot-assisted surgery. METHODS: A simulation-based economic evaluation model including data derived from a systematic review and local databases was used to estimate surgical costs. MAIN OUTCOME MEASURES: Incremental cost of robot-assisted surgery compared to current routine care. RESULTS: The incremental cost of robot-assisted hysterectomy is an estimated €3291 (95% confidence interval €2509-€4183) more than the existing mix of open and traditional laparoscopic surgery. The additional cost of robot-assisted surgery is primarily driven by the increased cost of surgical equipment, the robot, maintenance of the robot, and the cost of theatre staff due to longer operative times. The only significant factor reducing the cost of surgery is a shorter hospital stay relative to open surgery. CONCLUSIONS: Robot-assisted hysterectomy is more costly than the current mix of open and traditional laparoscopic surgery. Without longer-term or functional outcome data, the additional expense associated with robot-assisted hysterectomy may not be justified in a budget-constrained health system.

T-cell response to staphylococcal enterotoxin B is reduced among heart failure patients on ventricular device support.

Infections are the major complication among patients on left ventricular device (LVAD) support. One mechanism that may explain the elevated incidence of infection is a deficiency in cellular immunity after LVAD placement. To test this hypothesis, we evaluated the in vitro T-cell-proliferative and cytokine response following challenge with staphylococcal enterotoxin B in 14 LVAD and 6 non-LVAD stable outpatients awaiting heart transplantation. Clinical outcome was followed for 12 months. Clinical outcome was poorer (P < .05) for LVAD vs non-LVAD patients. T-cell-proliferative response was lower (P = .002) for LVAD vs non-LVAD patients. Th1 cytokine expression was lower (P < .05) and Th2 cytokine expression was higher (P < .05) for LVAD vs non-LVAD patients. We conclude that LVAD recipients are hyporesponsive to superantigen challenge, indicating a depressed cellular immunity that may contribute to their increased susceptibility to infections.

To induce or not to induce: do patients at greatest risk for fatal rejection benefit from cytolytic induction therapy?

BACKGROUND: Induction immunosuppression utilizing lymphocytolytic agents in the early peri-operative period has a number of theoretical and practical advantages and disadvantages. However, the efficacy of cytolytic agents as induction therapy remains unproven. METHODS: To assess the current impact of induction therapy in heart transplantation, we queried a multi-institutional database regarding the frequency of use, type of agent, duration of therapy and outcomes of 6,553 patients transplanted from 1990 to 2001. A study group of 5,897 patients were identified who survived the first 48 hours post-transplant and received either no induction therapy (n = 4,161) or induction with OKT3 or anti-thymocyte preparations (n = 1,736). RESULTS: By multivariate analysis, risk factors for rejection death were identified and then applied to a model of overall mortality. Among patients with a 1-year risk of rejection death at >5%, induction therapy provided a survival advantage, but survival with induction was decreased when the risk of rejection death was <2%. Specific patient sub-sets that received a survival benefit in the current era with induction included younger patients of black race with >/=4 HLA mismatches and long-term (>6 months) support on a ventricular assist device (VAD). CONCLUSIONS: Use and application of induction therapy continues to be controversial in heart transplantation. At present, this approach appears to be beneficial in selected patients who are at high risk for rejection death, but likely detrimental in patients who are at low risk for rejection death. Those with a combination of longer term VAD support, of black ethnicity, and having extensive HLA mismatching are most likely to benefit from cytolytic induction therapy.

Influenza vaccination does not promote cellular or humoral activation among heart transplant recipients.

BACKGROUND: The impact of influenza vaccination on in vitro parameters of cellular and humoral immunity, anti-viral titers, and clinical outcome was evaluated among cardiac transplant recipients. METHODS: Blood was collected from 29 patients before and 3-4 weeks after influenza vaccination and tested for phenotypic changes in lymphoid subpopulations and generation of antibodies against the allograft and vaccine. RESULTS: Vaccination did not change the percentage of lymphoid subpopulations and did not induce generation of anti-HLA alloantibodies. Anti-vaccine response was detected in 12 of 29 patients and did not correlate with rejection history, length of graft survival, or immunosuppressive therapy. Vaccination did not change the frequency of rejection. Flu-like symptoms were reported in one patient but not confirmed microbiologically. CONCLUSION: Despite the small number of patients in the study, influenza vaccination did not induce undesirable side effects, such as graft rejection or allo-sensitization. Generation of a positive anti-vaccine response was lower among the transplant recipients than healthy volunteers (41% vs. 80%). Clinical efficacy of the vaccine among the responders was not evaluated.

Incidence and treatment of cancer in transplant recipients.

Solid organ transplantation has been an accepted mode of therapy for the treatment of end-stage organ diseases for many years. Recipients' survival, however, has been hindered by organ rejection and the comorbid diseases that develop as a result of immunosuppresive therapy. In particular, organ transplant recipients have an increased risk of developing cancer de novo after transplantation. Prevalence ranges from 4 to 18% with an average incidence of 6%. Data submitted to the Cincinnati transplant tumor registry have revealed that cancers prevalent in the general population exhibited no increase in rate and may even show a slight decline in the transplant population. Length of survival after transplantation is associated with the likelihood of having cancer; the longer the recipient survives, the greater the chance. The actuarial risk among 124 cardiac transplant recipients was 2.7 +/- 1.9% at 1 year and 25.6 +/- 11% at 5 years. This article will review the current literature on the incidence and treatment of cancer in solid organ transplant recipients.

Stress and coping among parents of children awaiting cardiac transplantation.

Psychosocial support during the waiting period for pediatric transplant recipients and their families is vital. This study describes the stress levels and coping techniques among parents of children awaiting cardiac transplant. Twenty-six parents of 18 children demonstrated a range of stress with 77% scoring at a moderate stress level. They perceived transplantation neutrally and used a similar number of coping mechanisms as did a normative group of adults. Use of coping mechanisms significantly decreased over the 3-month study period. A moderate correlation between a negative perception of transplantation and parental stress was found. Parents of girls viewed transplant more negatively than did boys' parents. This study provides a beginning for assisting families during the waiting period.

Myelodysplasia and acute myeloid leukaemia following adjuvant chemotherapy for breast cancer using mitoxantrone and methotrexate with or without mitomycin.

BACKGROUND: Secondary acute myeloid leukaemia/myelodysplasia (t-AML, t-MDS) may occur following adjuvant chemotherapy for breast cancer and has been most frequently associated with alkylating agents. This complication is now being associated with an expanding list of chemotherapeutic agents including topoisomerase II poisons. Mitoxantrone is an agent with potential to cause t-AML and t-MDS and which is being used increasingly in the treatment of breast cancer. PATIENTS AND METHODS: Fifty-nine patients who received mitoxantrone as part of adjuvant chemotherapy for breast cancer between 1986 and 1992 were studied to determine the incidence of t-AML and t-MDS. RESULTS: With a median follow-up of 72 months, 2 cases of t-AML and 1 of t-MDS have occurred. CONCLUSIONS: This 5% incidence of t-AML and t-MDS is high and likely related to mitoxantrone. Whereas this agent is effective and has acceptable toxicity in advanced disease, its incorporation into adjuvant treatment regimens cannot be recommended based on this experience.