Minimally invasive surgery for suspected early-stage ovarian cancer; a cost-effectiveness study.

OBJECTIVE: While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses. DESIGN: Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management. METHODS: The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings. MAIN OUTCOME MEASURES: The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs). RESULTS: MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses. CONCLUSION: MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses. TWEETABLE ABSTRACT: MIS is a cost-effective management strategy for women with suspicious ovarian masses.

Multivariable analysis of association of beta-blocker use and survival in advanced ovarian cancer.

OBJECTIVE: In this study, we sought to evaluate the relationship between survival and beta blocker use in both the primary and interval debulking setting while adjusting for frequently co-administered medications. METHODS: We performed a retrospective cohort study reviewing charts of women who underwent primary or interval cytoreduction for stage IIIC and IV epithelial ovarian cancer. The exposure of interest was beta-blocker use identified at the time of cytoreduction. The outcomes of interest were PFS and OS. We collected demographic/prognostic variables and information about use of aspirin, metformin, and statins. We used the Kaplan-Meier method and Cox proportional hazards models in survival analyses. RESULTS: 534 women who underwent surgery for stage IIIC or IV ovarian cancer were included in the study. The median age at diagnosis was 64 and 84.8% of women had serous carcinoma. We identified 105 women (19.7%) on a beta-blocker of whom 94 (90%) were on a cardioselective beta-blocker. Additionally, 24 women (4.5%) were on metformin, 91 (17%) on aspirin, and 128 (24%) on a statin. In univariable analysis, beta-blocker users had a median overall survival of 29 months vs 35 months among non-users (hazard ratio HR = 1.52, p = 0.007). After adjustment for important demographic, clinical, and histopathologic factors, as well as use of other common medications, beta-blocker use remain associated with an increased hazard of death (adjusted HR 1.57, p = 0.006). CONCLUSION: In this retrospective study, we found that patients identified as being on a beta-blocker at the time of surgery had worse overall survival and greater risk of death when compared to those patients not on betablockers. Importantly, 90% of patients on beta-blockers were identified as being on a cardioselective beta-blocker.

Hospital volume and cesarean delivery among low-risk women in a nationwide sample.

OBJECTIVE: We sought to determine if hospital delivery volume was associated with a patient's risk for cesarean delivery in low-risk women. STUDY DESIGN: This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal-Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient's odds for cesarean delivery. RESULTS: The range of cesarean delivery rates was 2.4-51.2% among low-risk patients, and the median was 16.5% (IQR 12.8-20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient's odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188). CONCLUSION: Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

The immune regulation in familial Mediterranean fever (FMF).

In order to investigate a possible immune regulation imbalance in familial Mediterranean fever (FMF), the T-cell subsets and interleukin (IL)-1 and -2 production were examined in 39 patients (32 consecutive; 7 previous) and 14 controls. Results in the FMF group indicated no change in total T-cells and B-cells. The number of supp T-cells and helper cells were significantly decreased, as compared to the controls (14 +/- 5.2, 19 +/- 4.6 vs. 31 +/- 4.6, 41 +/- 5.3, respectively), and the NK cells were significantly increased (16 +/- 4.8, 36 +/- 2.1). Peripheral blood monocytes from the patients with FMF produced higher amounts of IL-1 and lower amounts of IL-2 than those from the control subjects. The latter results were enhanced when the FMF group was subdivided on the basis of pretreatment with colchicine and presence of amyloidosis. This study, although preliminary, indicates an immune regulation imbalance in FMF patients. Further research is necessary to understand the interrelation of amyloidosis and colchicine treatment.

Bibliography: handling considerations for cancer chemotherapeutic agents.

Since the introduction of antineoplastic agents in the 1940s, there have been reports of the effects of these agents on workers who have had prolonged contact with them. The Regional Oncology Drug Information Center (RODIC) at Memorial Sloan-Kettering Cancer Center receives numerous inquiries nationwide regarding our policies and procedures for handling antineoplastic agents. In August 1987, RODIC conducted a computerized literature search on the handling of antineoplastic agents and the risks to hospital employees, coming in contact with these agents. We used the MEDLINE system from 1966 to the present, limiting the search to English-language articles. This article provides a comprehensive bibliography on the handling of antineoplastic agents.

Detection and prevention of deep venous thrombosis.

Deep venous thrombosis (DVT) is a significant problem in the postoperative course of high-risk patients. Risk factors that further predispose patients to DVT include obesity, age over 40 years, smoking, dehydration, and a prior history of thromboembolism. Diagnosis of DVT by physical examination and medical history is difficult; objective diagnostic techniques are often required. Considerable emphasis has been placed on the cost-effectiveness of implementing prophylactic measures in patients who are at high risk for developing DVT. Physical maneuvers attempt to reduce stasis and enhance venous return and pharmacologic approaches alter blood coagulability. The drug therapy used in preventing DVT consists of dextran, low-dose heparin, a combination of low-dose heparin and dihydroergotamine, and warfarin. Effective prophylactic regimens differ according to the type of patients at risk. Prophylactic therapy should be tailored according to the patient's disease and degree of risk.

The immune system response to Campylobacter infection.

Campylobacter may be one of the most common causes of bacterial gastroenteritis (GE) in children. It has recently been suggested that it is one of the bacterial pathogens most likely to infect immune-compromised children, and it may facilitate colonization of enteric pathogens. The immune system response was studied in 12 children with Campylobacter fetus subspecies jejuni (CBJ) infections. Serum concentrations of IgA, IgM, and IgG were analyzed using a Beckman auto-analyzer. Sera specific Ab to CBJ were tested with CBJ specific enzyme-linked immunosorbent assay (ELISA). Mitogen stimulation of lymphocytes was performed to three lectins: Con A, PWM, and PHA. The lymphocyte blast transformation to Campylobacter was studied using the Campylobacter antigen. T-cell subsets were studied using the monoclonal antibodies Leu 2, 3, and 4 (Becton Dickinson). Chemotaxis was measured in modified Boyden chambers; chemotactic stimulants were the Formyl Met Leu Phe, Campylobacter antigen virion, and E. coli 0111 B. Immunoglobulins were normal in nine cases and abnormal in two children previously diagnosed as agammaglobulinemic and one diagnosed as hypoagammaglobulinemic. Specific serum Ab level was significantly higher in the CBJ group, except in the agammaglobulinemic group. Stimulation indices to mitogens and monoclonal subset were in the normal range. The blastogenic transformation to CBJ Ag was decreased compared to normal lectins, and positive and high compared to controls. The chemotactic activity to campylobacter Ag was decreased in comparison to other stimulants. Most CBJ infections are self-limiting due to a normal immune response and collaboration of all cellular limbs. When, however, the immune response is disturbed, we may find a prolonged and complicated course of CBJ.