Cost-Effectiveness Analysis: Selective Use of Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer.

BACKGROUND: Locally advanced rectal cancer has high cure rates with trimodal therapy. Studies sparing neoadjuvant chemoradiation in selected patients show comparable outcomes. OBJECTIVE: This study aimed to determine the cost-effectiveness of selective use of neoadjuvant chemoradiation in this population. DESIGN: A cost-effectiveness analysis model compared selective and blanket use chemoradiation for locally advanced rectal cancer. SETTINGS: Literature review, expert consensus, and a prospective database populated the model. Health care utilization costs were based on information from the Centers for Medicare and Medicaid Services. PATIENTS: Adult patients with stage II and III rectal cancer were selected. MAIN OUTCOMES MEASURES: Primary outcomes were cost, effectiveness in quality-adjusted disease-free life years, net monetary benefit, and incremental cost-effectiveness ratios in dollars per quality-adjusted disease-free life years. Base-case 5-year disease-free survival for both strategies was 65%. One-way sensitivity analysis found the probability of 5-year disease-free survival for selective ranged between 40% and 65%. Probabilistic sensitivity analysis assessed second-order variability. RESULTS: Base-case 5-year disease-free survival demonstrated selective use is dominant with lower cost and higher quality-adjusted disease-free life years. For selective use, cost is $153,176, effectiveness is 2.71 quality-adjusted life years, and net monetary benefit is -$17,564 and for blanket use cost is $176,362, effectiveness is 2.64 quality-adjusted life years, and net monetary benefit is -$44,217. One-way sensitivity analysis shows selective use is dominant for disease-free survival above 61.25% and is preferred for disease-free survival above 53.7%. Probabilistic sensitivity analysis shows selective use is optimal in 88% of the iterations for a population of 10,000 patients. LIMITATIONS: Model was based on data from the literature, prospective database, and expert consensus. CONCLUSION: In a population of patients with locally advanced rectal cancer with base-case disease-free survival of 65%, selective use of neoadjuvant chemoradiation is the superior strategy as long as disease-free survival in this group remains above 53%. See Video Abstract at http://links.lww.com/DCR/C199. ANLISIS DE COSTOEFECTIVIDAD USO SELECTIVO DE QUIMIORRADIACIN NEOADYUVANTE EN CNCER DE RECTO LOCALMENTE AVANZADO: ANTECEDENTES:El cáncer de recto localmente avanzado tiene altas tasas de curación con la terapia trimodal. Los estudios que evitan la quimiorradiación neoadyuvante en pacientes seleccionados muestran resultados comparables.OBJETIVO:Determinar la relación costo-efectividad del uso selectivo de quimiorradiación neoadyuvante en esta población.DISEÑO:Un modelo de análisis de costo-efectividad comparó la quimiorradiación selectiva y de uso general para el cáncer de recto localmente avanzado.AJUSTES:Revisión de literatura, consenso de expertos y una base de datos prospectiva poblaron el modelo. Los costos de utilización de la atención médica se basaron en los Centros de Servicios de Medicare y Medicaid.PACIENTES:Se seleccionaron pacientes adultos con cáncer de recto en estadio II y III.PRINCIPALES MEDIDAS DE RESULTADOS:Los resultados primarios fueron el costo, efectividad en años de vida sin enfermedad ajustados por calidad, el beneficio monetario neto y la relación costo-efectividad incremental en $/años de vida sin enfermedad ajustados por calidad. La supervivencia libre de enfermedad a 5 años del caso base para ambas estrategias fue del 65%. El análisis de sensibilidad unidireccional varió la probabilidad de supervivencia libre de enfermedad a 5 años para uso selectivo entre 40%-65%. El análisis de sensibilidad probabilístico evaluó la variabilidad de segundo orden.RESULTADOS:El caso base de 5 años de supervivencia libre de enfermedad demostró que el uso selectivo es dominante con menor costo y años de vida libre de enfermedad ajustados de mayor calidad. El costo, la efectividad y el beneficio monetario neto para el uso selectivo y general fueron ($153 176; 2,71 QALY; -$17 564) y ($176 362; 2,64 QALY; -$44 217). El análisis de sensibilidad unidireccional demostró que el uso selectivo es dominante para la supervivencia sin enfermedad por encima del 61,25% y se prefiere para la supervivencia sin enfermedad por encima del 53,7%. El análisis de sensibilidad probabilístico demostró que el uso selectivo es óptimo en el 88% de las iteraciones para una población de 10 000 pacientes.LIMITACIONES:Modelo basado en datos de literatura, base de datos prospectiva y consenso de expertos.CONCLUSIÓN:En una población de pacientes con cáncer de recto localmente avanzado con caso base de supervivencia libre de enfermedad del 65%, el uso selectivo de quimiorradiación neoadyuvante para el cáncer de recto localmente avanzado es la estrategia superior, siempre y cuando la supervivencia libre de enfermedad en este grupo se mantenga por encima del 53%. Consulte Video Resumen en http://links.lww.com/DCR/C199. (Traducción-Dr. Fidel Ruiz Healy).

Geographic information system protocol for mapping areas targeted for mosquito control in North Carolina.

Geographic information systems (GIS) can be used to map mosquito larval and adult habitats and human populations at risk for mosquito exposure and possible arbovirus transmission. Along with traditional methods of surveillance-based targeted mosquito control, GIS can help simplify and target efforts during routine surveillance and post-disaster (e.g., hurricane-related flooding) to protect emergency workers and public health. A practical method for prioritizing areas for emergency mosquito control has been developed and is described here. North Carolina (NC) One Map was used to identify state-level data layers of interest based on human population distribution and mosquito habitat in Brunswick, Columbus, Onslow, and Robeson Counties in eastern NC. Relevant data layers were included to create mosquito control treatment areas for targeted control and an 18-step protocol for map development is discussed. This protocol is expected to help state, territorial, tribal, and/or local public health officials and associated mosquito control programs efficiently create treatment area maps to improve strategic planning in advance of a disaster. This protocol may be applied to any NC county and beyond, thereby increasing local disaster preparedness.

Predictors and Consequences of Unplanned Conversion to Open During Robotic Colectomy: An ACS-NSQIP Database Analysis.

Robotic-assisted surgery has become a desired modality for performing colectomy; however, unplanned conversion to an open procedure may be associated with worse outcomes. The purpose of this study is to examine predictors and consequences of unplanned conversion to open in a large, high fidelity data set. A retrospective analysis of 11 061 robotic colectomies was conducted using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2017 database. Predictors of conversion and the effect of conversion on outcomes were analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of conversion and morbidity/mortality. Overall, 10 372 (93.8%) patients underwent successful robotic colectomy, and 689 (6.2%) had an unplanned conversion. Predictors of conversion included age ≥ 65 years, male gender, obesity, functional status not independent, American Society of Anesthesia (ASA) classification IV-V, non-oncologic indication, emergency case, smoking, recent weight loss, bleeding disorder, and preoperative organ space infection. Conversion is an independent risk factor for mortality, overall morbidity, cardiac morbidity, pulmonary morbidity, renal morbidity, venous thromboembolism morbidity, wound morbidity, sepsis, bleeding, readmission, return to the operating room, and extended length of stay (LOS). Unplanned conversion to open during robotic colectomy is an independent predictor of morbidity and mortality.

Endoscopic dacryocystorhinostomy as an option for symptomatic epiphora in isolated monocanalicular obstruction.

Epiphora from monocanalicular obstruction is commonly treated with canaliculoplasty, with or without dacryocystorhinostomy, or with conjunctivodacryocystorhinostomy with Jones tube placement. We describe two patients with epiphora due to isolated monocanalicular obstruction without concurrent nasolacrimal duct obstruction who underwent endoscopic dacryocystorhinostomy; both cases had previously failed canaliculoplasty, and both reported significant improvement in epiphora postoperatively. We hypothesize this is due to decreased resistance through the lacrimal drainage system allowing for increased flow through the patent canaliculus and shortened lacrimal apparatus. In patients presenting with epiphora secondary to isolated monocanalicular obstruction, endoscopic dacryocystorhinostomy may be considered in the absence of nasolacrimal duct obstruction before proceeding to conjunctivodacryocystorhinostomy and Jones tube placement.

Foreign-Body Granulomata Caused by Injected Permanent Filler Masquerading as Cutaneous Sarcoidosis.

Foreign-body granuloma formation following filler injections is most commonly seen with permanent fillers; these reactions can occur years following the injections and often require either an intralesional steroid injection or surgical excision. The authors present a case of a 75-year-old woman with a history of systemic sarcoidosis previously treated with numerous immunosuppressive medications who was examined for bilateral infraorbital nodules and swelling that were unresponsive to treatment. She underwent a bilateral anterior orbitotomy through a transconjunctival approach with mass excision. The histologic analysis was consistent with foreign-body granulomata juxtaposed to implantable material, specifically ArteFill, which was injected many years prior. There were no separate noncaseating granulomas to suggest sarcoidosis as the underlying etiology. It is important to consider prior filler injections in patients with sarcoidosis who present with subcutaneous nodules as this changes management and may prevent the need for more aggressive immunosuppressive treatment.

High density penetrating electrode arrays for autonomic nerves.

Electrode arrays for recording and stimulation in the central nervous system have enabled numerous advances in basic science and therapeutic strategies. In particular, micro-fabricated arrays with precision size and spacing offer the benefit of accessing single neurons and permit mapping of neuronal function. Similar advances are envisioned toward understanding the autonomic nervous system and developing therapies based on its modulation, but appropriate electrode arrays are lacking. Here, we present for the first time, a multi-channel electrode array suitable for penetration of peripheral nerves having diameters as small as 0.1mm, and demonstrate performance in vivo. These arrays have the potential to access multiple discrete nerve fibers in small nerves. We fabricated and characterized five-channel arrays and obtained preliminary recordings of activity when penetrating rat carotid sinus nerve. The electrodes were constructed using hybrid microfabrication processes. The individual electrode shafts are as small as 0.01mm in diameter and at its tip each has a defined site that is addressable via a standard electronic connector. In addition to acute in vivo results, we evaluate the device by electrochemical impedance spectroscopy. Having established the fabrication method, our next steps are to incorporate the arrays into an implantable configuration for chronic studies, and here we further describe concepts for such a device.

Improved Magnetic Resonance Imaging Utilization for Children with Musculoskeletal Infection.

BACKGROUND: Magnetic resonance imaging (MRI) with sedation is an important resource used to evaluate children with musculoskeletal infection. This study assesses the impact of multidisciplinary guidelines and continuous process improvement on MRI utilization at a tertiary pediatric medical center. METHODS: A multidisciplinary team developed a guideline for MRI with sedation, and it was implemented at our institution. Scan duration, anatomic regions imaged, sequences performed, timing of surgical intervention, length of hospital stay, and readmissions for these children were compared with these measures among a cohort of similar children who had been treated prior to guideline implementation. Comparative data were gathered for the subsequent cohort to determine any impact of the continued process improvement program on MRI utilization. Statistical comparison was performed to determine significant differences between groups. RESULTS: Children evaluated prior to the guideline implementation had 9.0 MRI sequences per scan, an MRI scan duration of 111.6 minutes, and a hospital stay of 7.5 days. In comparison, children in the initial MRI guideline cohort had 7.5 sequences per scan, a scan duration of 76.1 minutes, and a hospital stay of 5.4 days. Children in the subsequent guideline cohort had 6.5 sequences per scan, a scan duration of 56.3 minutes, and a hospital stay of 5.0 days. The rate of immediate surgical procedure under continued anesthesia was 16.7% prior to the guideline, 50.5% among children in the initial guideline cohort, and 64% among children in the subsequent guideline cohort. Differences between cohorts were significant (p < 0.0001). In aggregate, 264 hours of MRI scan time and 809 hospital bed-days were conserved for more than thirty months. CONCLUSIONS: This initiative promoted improvement in diagnostic efficiency, therapeutic consistency, and patient safety for children with musculoskeletal infection. CLINICAL RELEVANCE: The findings of this study illustrate the beneficial impact of interdisciplinary coordination of care on clinical outcomes for children with musculoskeletal infection. Tangible improvements occurred for both length of stay and resource utilization.

The high dose response and functional capability of the DT-702/Pd lithium fluoride thermoluminescent dosimeter.

The United States Navy monitors the dose its radiation workers receive using the DT-702/PD thermoluminescent dosimeter, which consists of the Harshaw 8840 holder and the four-element Harshaw 8841 card. There were two main objectives of this research. In the first objective, the dosimeters were exposed to 100 Gy using electron and x-ray beams and found to respond approximately 30-40% lower than the delivered dose. No significant effect on the under-response was found when dose rate, radiation type, dosimeter position on the phantom, and dosimeter material were varied or when the card was irradiated while enclosed in its holder. Since the current naval policy is to remove from occupational use any thermoluminescent dosimeter with an accumulated deep dose equivalent of 0.05 Sv or greater, the functionality of the dosimeter was also investigated at deep dose equivalents of 0.05, 0.15, and 0.25 Sv using 60Co and 137Cs sources as the second main objective. All dosimeters were annealed following exposure and then exposed to 5.0 mSv from a 90Sr source. In all cases, the dosimeters responded within 3% of the delivered dose, indicating that the dosimeters remained functional as defined by naval dosimetry requirements. However, the anneal time required to clear the thermoluminescent dosimeter's reading was found to increase approximately as the cube root with the delivered dose.

Optical planar waveguide for cell counting.

Low cost counting of cells has medical applications in screening, military medicine, disaster medicine, and rural healthcare. In this report, we present a shallow, buried, planar waveguide fabricated by potassium ion exchange in glass that enables low-cost and rapid counting of metal-tagged objects that lie in the evanescent field of the waveguide. Laser light transmitted through the waveguide was attenuated proportionately to the presence of metal-coated microstructures fabricated from photoresist. This technology enables the low-cost enumeration of cells from blood, urine, or other biofluids.

Micromagnetic-microfluidic blood cleansing device.

Sepsis is a lethal disease caused by a systemic microbial infection that spreads via the bloodstream to overwhelm the body's defenses. Current therapeutic approaches are often suboptimal, in part, because they do not fully eliminate the pathogen, and hence the source of deadly toxins. Here we describe an extracorporeal blood cleansing device to selectively remove pathogens from contaminated blood and thereby enhance the patient's response to antibiotic therapy. Immunomagnetic microbeads were modified to create magnetic opsonins that were used to cleanse flowing human whole blood of Candida albicans fungi, a leading cause of sepsis-related deaths. The micromagnetic-microfluidic blood cleansing device generates magnetic field gradients across vertically stacked channels to enable continuous and high throughput separation of fungi from flowing whole blood. A multiplexed version of the device containing four parallel channels achieved over 80% clearance of fungi from contaminated blood at a flow rate of 20 mL/h in a single pass, a rate 1000 times faster than a previously described prototype micromagnetic-microfluidic cell separation system. These results provide the first proof-of-principle that a multiplexed micromagnetic-microfluidic separation system can be used to cleanse pathogens from flowing human blood at a rate and separation efficiency that is relevant for clinical applications.