Major cost savings associated with biologic dose reduction in patients with inflammatory arthritis.

The purpose of this study was to explore whether patients with Inflammatory Arthritis (IA) (Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS)) would remain in remission following a reduction in biologic dosing frequency and to calculate the cost savings associated with dose reduction. This prospective non-blinded non-randomised study commenced in 2010. Patients with Inflammatory Arthritis being treated with a biologic agent were screened for disease activity. A cohort of those in remission according to standardized disease activity indices (DAS28 < 2.6, BASDAI < 4) was offered a reduction in dosing frequency of two commonly used biologic therapies (etanercept 50 mg once per fortnight instead of weekly, adalimumab 40 mg once per month instead of fortnightly). Patients were assessed for disease activity at 3, 6, 12, 18 and 24 months following reduction in dosing frequency. Cost saving was calculated. 79 patients with inflammatory arthritis in remission were recruited. 57% had rheumatoid arthritis (n = 45), 13% psoriatic arthritis (n = 10) and 30% ankylosing spondylitis (n = 24). 57% (n = 45) were taking etanercept and 43% (n = 34) adalimumab. The percentage of patients in remission at 24 months was 56% (n = 44). This resulted in an actual saving to the state of approximately 600,000 euro over two years. This study demonstrates the reduction in biologic dosing frequency is feasible in Inflammatory Arthritis. There was a considerable cost saving at two years. The potential for major cost savings in biologic usage should be pursued further.

The Snodgrass repair: is stenting always necessary?

To evaluate the need for stenting in Snodgrass hypospadias repairs. Sixty-five boys underwent hypospadias repairs between April 1996 and July 2001. A variety of techniques were employed. Snodgrass repair was performed in 39 patients, MAGPI in 18, Glanular approximation procedures in 4, Mathieu procedures in 3 and one Duckett Onlay-flap. Seventeen patients, all Snodgrass repairs, had placement of a urethral stent for one week postoperatively. Follow-up at six weeks and one year or when toilet-trained was carried out on all patients. A Fisher's exact test was performed analysing the difference in outcome of the distal Snodgrass repairs depending on the presence or absence of a urethral stent. The patient age at the time of surgery ranged from 8-115 months, with a median of 21 months. Postoperative complications included 1 stent migration, 1 urethral diverticulum and 4 fistulas. Also in one patient part of the ventral skin flap on one side sloughed away, this was debrided and allowed to close by secondary intention. The fistula rate in the entire group is 6%, with an incidence of 10.5% in patients undergoing Snodgrass repair. In the cases having Snodgrass repair for meatal position other than mid- or proximal shaft there was no statistical difference in the incidence of fistula whether or not a stent was used. The long-term follow-up of the entire group indicates that 5 patients developed meatal narrowing, 3 in stented Snodgrass repairs, one patient who had a MAGPI and one GAP patient. Otherwise the long-term outcome of the surgery has been excellent for the entire group. We believe that stenting can be abandoned in distal repairs without compromising patient outcomes.

Hypospadias associated undescended testis in a Spigelian hernia.

BACKGROUND: First described in 1764, Spigelian hernias are rare. The patient profile is of an overweight, 50-year-old with associated respiratory disease. However we report the case of a four-month-old, with an associated hypospadias and cryptorchidism, where the testis was lying in a spigelian hernia. AIMS: To highlight this unusual presentation of cryptorchidism. CONCLUSION: Embryological development is a complex event that relies on the sequencing of hormonal surges for anatomical development. In this case report we postulate that the findings are secondary to hormonal disruption.

Urological complications of pancreatic transplantation.

PURPOSE: Pancreas transplantation is increasingly being used in the treatment of type I insulin-dependent diabetes mellitus. Because bladder drainage of the exocrine pancreatic secretion is the procedure of choice, urological complications are frequent. As the number of these procedures increases the urologist will have an extended role in the management of the postoperative complications, the majority of which are urological. MATERIALS AND METHODS: The literature from 1985 on the complications related to pancreas transplants was reviewed. RESULTS: Approximately 50 to 60% of bladder drained pancreas transplant recipients will have a urological complication postoperatively. CONCLUSIONS: The increasing application of bladder drained pancreas transplantation in the treatment of type I insulin-dependent diabetes mellitus necessitates that the clinical urologist is familiar with the management of complications related to this procedure.

The introduction of laparoscopic cholecystectomy--audit of transition period with late follow-up.

The operative treatment of 356 consecutive patients with gallstone related disease who presented in the thirty months following the introduction of laparoscopic cholecystectomy was reviewed. A standard questionnaire, with emphasis on total hospital stay (including convalescence), late postoperative morbidity and time to return to work/full activity was sent to all patients. Two hundred and ninety-eight patients responded (83%). The median duration of follow-up was 19 months, (range 6-36 months). Patients who underwent laparoscopic cholecystectomy spent significantly less time in hospital post-operatively (median 3 days, interquartile range 2-4) than either those who required conversion to open cholecystectomy (median 7.5 days, interquartile range 5.5-10) or those who had planned open cholecystectomy (median 9.5 days, interquartile range 5-13), (p < 0.001, Kruskal-Wallis). Planned gall bladder extraction through the umbilical port site was associated with a significantly higher probability of wound infection compared with extraction through the epigastric port site (chi 2 = 4.977, P < 0.05). The median time to return to work/full activity was significantly shorter after laparoscopic cholecystectomy (median 21 days, interquartile range 14-42), than after open cholecystectomy (median 42 days, interquartile range 21-60) or following conversion to open cholecystectomy (median 56 days, interquartile range 35-60). We conclude that laparoscopic cholecystectomy requires a significantly shorter hospitalisation than open cholecystectomy and facilitates early return to work/full activity.

A randomized comparison of patient-controlled versus standard analgesic requirements in patients undergoing cholecystectomy.

In the current study, 55 patients undergoing elective cholecystectomy were randomly allocated to receive postoperative analgesia (morphine sulfate) administered through either patient-controlled intravenous (PCA) or standard intramuscular (IM) routes. There were no significant differences in length of hospitalization or required dose of morphine sulfate. Patients randomized to PCA reported significantly improved subjective relief from pain and a smaller percentage of time in pain during each of the first two postoperative days. In addition, they reported less sedation and less interference with both postoperative breathing and pulmonary recovery than patients who received IM morphine. Theoretically, PCA regimens can deliver narcotic analgesia at a higher and more varied rate (with fewer side effects) compared with standard IM narcotic delivery, which is more limited by considerations of clinical doses. In PCA dosing, patients should experience less time in pain and sedation. The results of the current study support this premise.

The responses of superior laryngeal nerve afferent fibres to laryngeal airway CO2 concentration in the anaesthetized cat.

In anaesthetized cats, the isolated, in situ, larynx was subjected to a simulated respiratory cycle and the responses of fifty-six superior laryngeal nerve (SLN) afferent fibres to respiration-related stimuli were examined during changes in the fractional CO2 concentration of the laryngeal airway (Faw, CO2). Sensory SLN fibres which displayed low rates of discharge when the larynx was unventilated (quiescent fibres) and which responded to negative laryngeal airway pressure were excited by elevations in Faw, CO2 whereas quiescent fibres responsive to positive laryngeal pressure were inhibited by the same procedure. We propose that changes in airway CO2 levels may play a role in maintaining upper airway patency, especially during sleep.

Analysis of fatty acid methyl esters with high accuracy and reliability. VI. Rapid analysis by split injection capillary gas-liquid chromatography.

Of the several facets of technique that must be addressed to allow the generation of highly accurate results by gas chromatographic analysis of fatty acid methyl esters, that of split injection to capillary columns has long been a major problem. A practical solution of this problem is now proposed. Three factors were found to be of major importance in achieving highly accurate results viz. avoidance of needle discrimination when injecting, very rapid vaporisation of the sample and complete homogenisation of the sample with the carrier gas stream. High speed of injection was found to be a highly effective means of avoiding needle discrimination. Rapid vaporisation of the sample was achieved by the use of relatively dilute solutions of analyte in the solvent, the smallest sample size commensurate with obtaining a chromatogram that could be accurately quantitated and, particularly, by the use of injector temperatures considerably higher than those generally adopted. Good mixing of the vaporized sample with the carrier gas was achieved with a number of injector insert designs, but, with improvement of design, it was found possible to achieve linear splitting over a wide range of operating conditions. The most controversial recommendation is to use very high injection temperatures, but it has been shown that the commonly held view that this may cause pyrolysis of fatty acid methyl esters is not true, even when the esters are highly unsaturated.

The influence of dose frequency and agent toxicity on the cost of parenteral antibiotic therapy.

The influence of the number of daily doses on the overall cost of antibiotic therapy is examined in a general surgery patient population. Patients receiving a single first-generation cephalosporin are compared with patients receiving two or three antibiotics (including an aminoglycoside) in terms of (1) the cost of the drug and the supplies, (2) time required for nursing and pharmacy personnel to prepare and administer the doses, and (3) the influence of agent toxicity (renal function) on physician-ordered laboratory tests. On the whole, combination therapy including an aminoglycoside was four times as expensive as single-agent (first-generation cephalosporin) therapy. If future studies demonstrate that single-agent antibiotic therapy is as effective as traditional combination therapy for specific infectious diseases, the influence of the number of daily doses of drug and agent toxicity may support the cost-effective use of the newer agents.

Experiences with conversion of jejunoileal bypass to gastric bypass: its use for maintenance of weight loss.

Jejunoileal bypass for morbid obesity has been associated with a variety of long-term adverse sequelae, including excess diarrhea, electrolyte imbalance, kidney dysfunction, liver abnormalities, and polyarthropathy. Takedown of the bypass without providing a means of maintenance of weight reduction will lead to recurrence of morbid obesity. We studied 32 patients who underwent conversion of jejunoileal bypass to gastric bypass either in one procedure (27 patients) or more than one procedure (five patients). There were no operative deaths, but significant morbidity. Nevertheless, the conversion has maintained weight reduction and reversed the adverse effects of the small-bowel bypass. We concluded that conversion of the jejunoileal bypass to the gastric bypass, particularly with a Roux-en-Y anastomosis, in a single procedure is relatively safe, simple, and effective.