A socioeconomic analysis of surgical treatment of migraine headaches.

BACKGROUND: This study is meant to compare the direct and indirect cost of migraine headache care before and after migraine surgery and to evaluate any postoperative changes in patient participation in daily activities. METHODS: Eighty-nine patients enrolled in a migraine surgery clinical trial completed the Migraine-Specific Quality-of-Life Questionnaire, the Migraine Disability Assessment questionnaire, and a financial cost report preoperatively and 5 years postoperatively. RESULTS: Mean follow-up was 63.0 months (range, 56.9 to 72.6 months). Migraine medication expenses were reduced by a median of $1997.26 annually. Median cost reduction for alternative treatment expenses was $450 annually. Patients had a median of three fewer annual primary care visits for the migraine headache treatment, resulting in a median cost reduction of $320 annually. Patients missed a median of 8.5 fewer days of work or childcare annually postoperatively, with a median regained income of $1525. The median total cost spent on migraine headache treatment was $5820 per year preoperatively, declining to $900 per year postoperatively. Total median cost reduction was $3949.70 per year postoperatively. The mean surgical cost was $8378. Significant improvements were demonstrated in all aspects of the Migraine-Specific Quality-of-Life Questionnaire and the Migraine Disability Assessment questionnaire. CONCLUSIONS: Surgical deactivation of migraine trigger sites has proven to be effective for the treatment of severe migraine headache. This study illustrates that the surgical treatment is a cost-effective modality, reducing direct and indirect costs. Patients may also expect improvements in the performance of and increased participation in activities of daily living. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of desmopressin for unremitting epistaxis following septorhinoplasty and turbinectomy.

BACKGROUND: Cauterization, nasal packing, and topical and/or injection of intranasal vasoconstrictors have been the mainstay of treatment for epistaxis following outpatient nasal surgery. In this study, the authors report the clinical outcomes in a cohort of patients with postoperative epistaxis managed with a single dose of intravenous desmopressin. METHODS: A retrospective chart review of 268 consecutive nasal operations (rhinoplasty, septoplasty, and/or turbinectomy for cosmetic and/or functional purposes) was conducted. Information on demographics, perioperative blood pressure, postoperative management, and effectiveness of the measures used was assessed. The primary outcome variable was cessation of bleeding. RESULTS: Nine patients were identified who experienced excessive postoperative bleeding following discharge from the surgical facility. Each patient received 0.3 µg/kg of intravenous desmopressin over 30 minutes under the supervision of the local emergency room physician with verbal instructions from the treating plastic surgeon. After administration of desmopressin, bleeding either stopped completely (eight patients) or slowed down significantly to allow discharge (one patient). No significant adverse side effects of desmopressin were observed. No patient was known to be taking medication negatively affecting coagulation perioperatively. Preoperatively, two patients were documented to have von Willebrand disease and thus received desmopressin preoperatively. Average blood pressure was 116/71 mmHg intraoperatively (range, 109 to 126/66 to 83 mmHg) and 118/74 mmHg postoperatively (range, 105 to 129/65 to 85 mmHg). CONCLUSION: Unremitting postoperative epistaxis following outpatient nasal surgery can be successfully controlled by a protocol using intravenous desmopressin without the need for alternative maneuvers.

Safety and early outcomes using a corticosteroid-avoidance immunosuppression protocol in pediatric heart transplant recipients.

BACKGROUND: Long-term oral corticosteroids have been a mainstay of maintenance immunosuppression in pediatric heart transplantation. In this study, we report early clinical outcomes in a cohort of pediatric heart transplant recipients managed using a steroid-avoidance protocol. METHODS: Of the 70 patients who underwent heart transplantation during the study period, 55 eligible recipients, including 49 non-sensitized and 6 sensitized (all 55 with negative crossmatch) patients, entered a steroid-avoidance immunosuppression protocol consisting of thymoglobin induction followed by a 2-drug, tacrolimus-based, corticosteroid-free regimen. The primary outcome variable was freedom from moderate rejection (International Society for Heart and Lung Transplantation [ISHLT] Grade 2R/3A or antibody-mediated rejection). RESULTS: The median age at transplant was 7.1 years (range 2 weeks to 22 years) and median follow-up was 19 months (range 2 to 46 months). Fifty patients survived to discharge after transplantation. Of these patients, 2 (4%) were discharged on steroids and 8 (16%) started on maintenance steroids at follow-up. Rejection was diagnosed in 8 patients (Grade 2R cellular rejection in 3 and antibody-mediated rejection in 5). Freedom from rejection was 92% at 6 months (95% confidence interval [CI] 80% to 97%) and 87% at 1 year (CI 73% to 94%). Post-transplant survival was 91% at 6 months (CI 79% to 96%) and 88% at 12 and 24 months (CI 75% to 95%). There was 1 death due to rejection (antibody-mediated) 8 months after transplantation. CONCLUSIONS: An immunosuppression protocol consisting of induction followed by corticosteroid avoidance appears to achieve acceptable rejection rates during the first year post-transplant in pediatric heart transplant recipients.