Economic evaluations of interventions against influenza at workplaces: systematic review.

BACKGROUND: The burden of influenza is mostly felt by employees and employers because of increased absenteeism rates, loss of productivity and associated direct costs. Even though interventions against influenza among working adults are effective, patronage and compliance to these measures especially vaccination are low compared to other risk groups. AIMS: This study was aimed to assess evidence of economic evaluations of interventions against influenza virus infection among workers or in the workplace setting. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline for systematic reviews was followed. Three databases, PubMed, Web of Science and EconLit, were searched using keywords to identify relevant articles from inception till 25 October 2020. Original peer-reviewed papers that conducted economic evaluations of influenza interventions using cost-benefit, cost-effectiveness or cost-utility analysis methods focused on working-age adults or work settings were eligible for inclusion. Two independent teams of co-authors extracted and synthesized data from identified studies. RESULTS: Twenty-four articles were included: 21 were cost-benefit analyses and 3 examined cost-effectiveness analyses. Two papers also presented additional cost-utility analysis. Most of the studies were pharmaceutical interventions (n = 23) primarily focused on vaccination programs while one study was a non-pharmaceutical intervention examining the benefit of paid sick leave. All but two studies reported that interventions against influenza virus infection at the workplace were cost-saving and cost-effective regardless of the analytic approach. CONCLUSIONS: Further cost-effectiveness research in non-pharmaceutical interventions against influenza in workplace settings is warranted. There is a need to develop standardized methods for reporting economic evaluation methods to ensure comparability and applicability of future research findings.

Association Between Fruit and Vegetable Consumption and Sleep Quantity in Pregnant Women.

Introduction To determine the association of fruit and vegetable consumption with overall sleep duration among pregnant women. Methods Data from the 2011 and 2012 Behavioral Risk Factors Surveillance System (BRFSS) were used. All women (n = 2951) of childbearing age (18-44 years) who were pregnant and responded to all fruit and vegetable consumption and sleep duration questions were included. Covariates included age, race, education level, exercise, and marital status. Data were analyzed using linear and ordinal logistic regression. Results Total daily fruit and vegetable consumption was not associated with sleep duration among pregnant women, controlling for confounders [ß = -0.03, (-0.07, 0.00)]. Orange and green vegetable consumption were both inversely associated with sleep duration [ß = -0.19, (-0.38, -0.01) and ß = -0.20, (-0.33, -0.08) respectively]. Ordinal logistic regression found that the odds of meeting or exceeding sleep time recommendations increased slightly with each unit increase in total fruit and vegetable consumption [OR = 1.05 (1.003, 1.092)] and for every unit increase in fruit consumption [OR = 1.12 (1.038, 1.208)]. Women who exercised within the past 30 days reported approximately 20 min of additional sleep compared to those who did not [ß = 0.32 (0.16, 0.49)]. Age, employment status, and marital status were also independently associated with sleep duration. Discussion Sleep duration in pregnant women was associated with exercise and other demographic factors, but only mildly associated with fruit and vegetable consumption. Future research should investigate the effects of additional factors including sleep quality, gestational age, family status and other medications as potential confounders.

A randomized trial of varenicline (Chantix) for the treatment of spinocerebellar ataxia type 3.

OBJECTIVE: The objective of this double-blind, placebo-controlled, randomized study was to evaluate the efficacy of varenicline (Chantix), a partial agonist at α4ß2 neuronal nicotinic acetylcholine receptors used for smoking cessation, in patients with spinocerebellar ataxia (SCA) 3. METHODS: Patients with genetically confirmed SCA3 were randomly assigned to receive either varenicline (4 weeks for titration and 4 weeks at a dose of 1 mg twice daily) or placebo. Outcome measures included changes in the Scale for the Rating and Assessment of Ataxia (SARA) scores at endpoint (8 weeks) compared with baseline, a timed 25-foot walk and 9-hole peg test, measurements of mood and anxiety, and adverse events. RESULTS: Twenty patients with SCA3 (mean age = 51 ± 10.98 years; mean disease duration = 14 ± 9.82 years; mean SARA score = 16.13 ± 4.67) were enrolled in the study, and data on 18 patients were analyzed in period I. The most common side effect associated with varenicline was nausea. Improvements were noted in the SARA subsections for gait (p = 0.04), stance (p = 0.03), rapid alternating movements (p = 0.003), and timed 25-foot walk (p = 0.05) and Beck Depression Inventory scores (p = 0.03) in patients taking varenicline compared with those taking placebo at endpoint, with a trend toward improvement in the SARA total score (p = 0.06) in the varenicline group. CONCLUSIONS: In this controlled study, varenicline significantly improved axial symptoms and rapid alternating movements in patients with SCA3 as measured by SARA subscores and was fairly well tolerated. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that varenicline improved the axial functions of gait, stance, and timed 25-foot walk but did not improve appendicular function, except for rapid alternating movements, in adult patients with genetically confirmed SCA3.

Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology.

BACKGROUND: This evidence-based guideline is an update of the 2005 American Academy of Neurology practice parameter on the treatment of essential tremor (ET). METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 2004 and April 2010. RESULTS AND RECOMMENDATIONS: Conclusions and recommendations for the use of propranolol, primidone (Level A, established as effective); alprazolam, atenolol, gabapentin (monotherapy), sotalol, topiramate (Level B, probably effective); nadolol, nimodipine, clonazepam, botulinum toxin A, deep brain stimulation, thalamotomy (Level C, possibly effective); and gamma knife thalamotomy (Level U, insufficient evidence) are unchanged from the previous guideline. Changes to conclusions and recommendations from the previous guideline include the following: 1) levetiracetam and 3,4-diaminopyridine probably do not reduce limb tremor in ET and should not be considered (Level B); 2) flunarizine possibly has no effect in treating limb tremor in ET and may not be considered (Level C); and 3) there is insufficient evidence to support or refute the use of pregabalin, zonisamide, or clozapine as treatment for ET (Level U).

Practice Parameter: treatment of nonmotor symptoms of Parkinson disease: report of the Quality Standards Subcommittee of the American Academy of Neurology.

OBJECTIVE: Nonmotor symptoms (sleep dysfunction, sensory symptoms, autonomic dysfunction, mood disorders, and cognitive abnormalities) in Parkinson disease (PD) are a major cause of morbidity, yet are often underrecognized. This evidence-based practice parameter evaluates treatment options for the nonmotor symptoms of PD. Articles pertaining to cognitive and mood dysfunction in PD, as well as treatment of sialorrhea with botulinum toxin, were previously reviewed as part of American Academy of Neurology practice parameters and were not included here. METHODS: A literature search of MEDLINE, EMBASE, and Science Citation Index was performed to identify clinical trials in patients with nonmotor symptoms of PD published between 1966 and August 2008. Articles were classified according to a 4-tiered level of evidence scheme and recommendations were based on the level of evidence. RESULTS AND RECOMMENDATIONS: Sildenafil citrate (50 mg) may be considered to treat erectile dysfunction in patients with Parkinson disease (PD) (Level C). Macrogol (polyethylene glycol) may be considered to treat constipation in patients with PD (Level C). The use of levodopa/carbidopa probably decreases the frequency of spontaneous nighttime leg movements, and should be considered to treat periodic limb movements of sleep in patients with PD (Level B). There is insufficient evidence to support or refute specific treatments for urinary incontinence, orthostatic hypotension, and anxiety (Level U). Future research should include concerted and interdisciplinary efforts toward finding treatments for nonmotor symptoms of PD.

Treatment of imbalance with varenicline Chantix(R): report of a patient with fragile X tremor/ataxia syndrome.

We describe the case of a man with Fragile X tremor/ataxia syndrome, whose ataxia and imbalance improved with the use of varenicline (Chantix) and reverted to baseline 10 days after varenicline was discontinued. Varenicline was started as part of a smoking cessation program.

Social Security Disability Insurance (SSDI) in Parkinson's disease.

OBJECTIVE: Parkinson's disease (PD) causes significant economic burden for patients and caregivers. Social Security Disability Insurance (SSDI) provides insurance to workers in the United States who have been gainfully employed, but who are no longer able to work due to a medical condition. We performed a descriptive pilot study that examined PD patients' experience with SSDI. METHODS: PD patients who were diagnosed with PD prior to age 60 and were followed at an academic movement disorders center were consecutively invited to participate in a survey concerning their employment history and experience with SSDI. RESULTS: All 68 invited patients participated in the study (mean age 58 years, mean disease duration 9.5 years). Eighty-two percent of patients felt that they were too disabled to work full time at a mean of 3.4 years after PD diagnosis. Patients applied for SSDI at a mean of 5 years after diagnosis, and two-thirds of PD patients who applied for SSDI obtained it on their first attempt. The primary debilitating symptom that subjectively contributed to work disability was fatigue (49% of patients). Patients who successfully acquired SSDI had extensive documentation of physician visits, and the aid of a disability lawyer. CONCLUSIONS: Patients felt they were too disabled to work full time at a mean of 3.4 years after diagnosis. Those who applied for SSDI did so at a mean of 5 years after diagnosis. Patients who obtained SSDI awards had extensive documentation of medical records or the help of a disability lawyer.

Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology.

BACKGROUND: Essential tremor (ET) is one of the most common tremor disorders in adults and is characterized by kinetic and postural tremor. To develop this practice parameter, the authors reviewed available evidence regarding initiation of pharmacologic and surgical therapies, duration of their effect, their relative benefits and risks, and the strength of evidence supporting their use. METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 1966 and August 2004. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. RESULTS AND CONCLUSIONS: Propranolol and primidone reduce limb tremor (Level A). Alprazolam, atenolol, gabapentin (monotherapy), sotalol, and topiramate are probably effective in reducing limb tremor (Level B). Limited studies suggest that propranolol reduces head tremor (Level B). Clonazepam, clozapine, nadolol, and nimodipine possibly reduce limb tremor (Level C). Botulinum toxin A may reduce hand tremor but is associated with dose-dependent hand weakness (Level C). Botulinum toxin A may reduce head tremor (Level C) and voice tremor (Level C), but breathiness, hoarseness, and swallowing difficulties may occur in the treatment of voice tremor. Chronic deep brain stimulation (DBS) (Level C) and thalamotomy (Level C) are highly efficacious in reducing tremor. Each procedure carries a small risk of major complications. Some adverse events from DBS may resolve with time or with adjustment of stimulator settings. There is insufficient evidence regarding the surgical treatment of head and voice tremor and the use of gamma knife thalamotomy (Level U). Additional prospective, double-blind, placebo-controlled trials are needed to better determine the efficacy and side effects of pharmacologic and surgical treatments of ET.

Heart failure in Parkinson's disease: analysis of the United States medicare current beneficiary survey.

OBJECTIVE: We sought to examine the prevalence of heart failure in elderly PD versus non-PD patients using a national sample of Medicare beneficiaries in the United States. SCOPE: The prevalence of heart failure in elderly PD patients was 2.27 times that of non-PD patients (19.4% versus 8.7%, 95% CI = 1.43-3.60, p 0.0005), and remained twice as high after excluding patients with stroke and possible vascular parkinsonism. CONCLUSIONS: In this cross-sectional study of a national Medicare database, heart failure occurred twice as frequently in elderly PD patients as in non-PD patients. Prospective studies are warranted to verify these findings.

Quantification of elastic recoil after balloon angioplasty in the iliac arteries.

PURPOSE: Elastic recoil of the arterial wall has been shown to be responsible for a significant loss of luminal area after balloon angioplasty in the coronary arteries, but it has not been well studied in the peripheral arteries. Because elastic recoil depends on the presence of elastin in the arterial wall, and the amount of elastin varies by artery and proximity to the aorta, the importance of this response to angioplasty may be different in peripheral arteries. The purpose of this study is to document the degree of elastic recoil in the iliac arteries, and analyze variables that might influence the results. MATERIALS AND METHODS: A series of 19 patients with 25 iliac artery stenoses underwent balloon angioplasty followed by placement of a Palmaz stent with the same-sized angioplasty balloon. The minimum luminal diameter of the lesion was measured before treatment, immediately after balloon angioplasty, and again after stent placement. The arterial diameter after stent placement was defined as the diameter of the inflated balloon. The degree of recoil was correlated with nine variables: patient age and sex, lesion location and length, lesion severity (as percent stenosis), the balloon:artery ratio, and three factors related to lesion morphology--complex versus simple, eccentric versus concentric, and calcified versus noncalcified. RESULTS: Elastic recoil averaged 36% +/- 11% and ranged from 19% to 54% in this series of patients. The only variable that significantly influenced the degree of elastic recoil was the balloon:artery ratio (P =.039), which was directly related. CONCLUSION: Elastic recoil is a significant limitation of balloon angioplasty in the iliac arteries. This study illustrates the importance of techniques that limit recoil, such as vascular stents, in angioplasty of the iliac arteries.

The relationship of clinical and academic productivity in a university hospital radiology department.

OBJECTIVE: The purpose of this study was to evaluate the relationship between clinical and academic productivity over a 2-year period in a university hospital radiology department. MATERIALS AND METHODS: Clinical productivity, as determined by the number of total professional relative value units generated, was compared with academic productivity, which was determined by the number of published peer-reviewed articles, published non-peer-reviewed articles, published abstracts, and presentations delivered by each full-time clinical faculty member. The relationships of age, academic rank, administrative position, and division within the department were also assessed for their effect on relative value units and academic productivity. RESULTS: We found a significant inverse relationship between relative value units and the number of published peer-reviewed articles, published abstracts, and presentations. Age, academic rank, and administrative responsibilities had no effect on the number of relative value units. Faculty in the neuroradiology and cardiovascular-interventional radiology divisions generated more relative value units than did other faculty members. CONCLUSION: Faculty members with higher levels of clinical productivity showed significantly lower levels of academic productivity. This finding is consistent with the idea that increases in the clinical workload may diminish research output.

Tacrolimus-FK506 induced immunosuppression in gnotobiotic piglets.

Tacrolimus (FK506), an inhibitor of calcineurin, is an immunosuppressive agent used in clinical trials of transplant patients. Although FK506 targets Ca(2+)-mediated T-cell signaling, phenotype(s) of the specific target cells and the corresponding cytokine pathways are not well known. In this study, the impact of FK506 on number and characteristic of T-cells in selected lymphoid tissues of gnotobiotic (GB) piglets was determined. FK506-treated GB piglets were compared with untreated GB and conventional piglets. The T-helper, cytotoxic, natural killer, double-positive, and activated T-cell populations were analyzed in suspensions of mononuclear cells isolated from thymus, mesenteric lymph nodes and peripheral blood. In vitro secretion of interleukin-8 and interferon-gamma in concanavalin A-stimulated lymphoid cell-cultures was measured by ELISA. Daily intramuscular treatment of GB piglets with 1mg/kg of FK506 from birth for 4 weeks resulted in lowered (P<0.05) in vitro secretion of interferon-gamma and interleukin-8. Moreover, depletions of MNC in systemic and mucosa-associated lymphoid tissues were observed in piglets treated with FK506. The depletions of mononuclear cells and low levels of interferon-gamma and interleukin-8 in piglets treated with FK506 were accompanied by lower proportion of CD3+, CD2+CD4+ and CD2+CD8+ T-cell phenotypes in peripheral blood but not in thymus and mesenteric lymph nodes. These results indicate that FK506-treatment causes immunosuppression in GB piglet, and this effect could be exploited further to study opportunistic pathogens in pig model.

Accuracy and safety of carbon dioxide inferior vena cavography.

PURPOSE: The purpose of this study was to assess the accuracy of carbon dioxide compared to iodinated contrast material for determining inferior vena cava (IVC) diameter prior to filter placement, and to assess the safety of CO2 when used for this purpose. PATIENTS AND METHODS: Consecutive patients undergoing inferior vena cavography prior to filter placement were prospectively evaluated with use of both CO2 and iodinated contrast material. The diameter of the IVC was measured and compared in the same four locations in each patient for both agents. The diameter was corrected for magnification and pin-cushion distortion. The ability of CO2 to correctly classify IVC diameter as < or =28 mm or >28 mm, based on the IVC diameter with iodinated contrast material, was determined. A consensus panel assessed renal vein visualization with CO2 and iodinated contrast material. Blood pressure and arterial oxygen saturation were measured immediately before and after CO2 injection. RESULTS: Among 30 patients, there was no significant difference in the measured diameter of the IVC with CO2 versus iodinated contrast material after correction for magnification and pin-cushion distortion. One of 30 patients (3.3%) in this study was misclassified as having an IVC < or =28 mm with CO2 when, in fact, the IVC diameter was >28 mm based on iodinated contrast material. This could be clinically significant for certain IVC filters. Forty-seven percent of renal veins identified on contrast venography were identified by CO2 vena cavography. There was no significant difference in the blood pressure or oxygen saturation values measured before and after CO2 injection. However, one patient with pulmonary artery hypertension did experience transient, symptomatic hypotension after CO2 injection. CONCLUSIONS: In most patients, CO2 vena cavography accurately evaluated IVC diameter prior to filter placement. In 3.3% of patients, the discrepancy in measurements between CO2 and iodinated contrast material could be clinically significant, depending on the type of filter placed. CO2 was less accurate than iodinated contrast material in identifying renal veins. Although CO2 vena cavography is safe in the majority of patients, it should be used with caution in patients with pulmonary hypertension.

Intravascular ultrasound as an alternative to positive-contrast vena cavography prior to filter placement.

PURPOSE: In a nonconsecutive series of patients, intravascular ultrasound (IVUS) was investigated for safety and efficacy as an alternative to positive-contrast vena cavography for evaluating the inferior vena cava (IVC) prior to filter placement. MATERIALS AND METHODS: In a 6.5-year period, 30 patients (15 women, 15 men) ranging in age from 22 to 98 years old (mean, 56 years) underwent vena cava filter placement without conventional positive-contrast vena cavography, after IVUS evaluation of the IVC with use of a 6.2-F, 12.5- or 20-MHz monorail catheter system. The rationale for using IVUS included contraindications to iodinated contrast material in 14 patients with renal insufficiency and in four patients with previous life-threatening anaphylactoid reaction to iodinated contrast material; limitations to radiation exposure in four pregnant patients; and inability to otherwise image the IVC of eight morbidly obese patients who exceeded the weight limits of available angiographic equipment. IVUS completely replaced positive-contrast vena cavography, although not fluoroscopy in the four pregnant patients and in the 18 patients with contrast material contraindications. In two of the eight obese patients, IVUS was the only imaging modality. RESULTS: In all 30 patients, IVUS successfully determined the patency of the filter delivery route veins and the vena cava, the absence of thrombus, the location of renal veins, the absence of anatomical variants, and the vena cava diameter at the desired filter deployment level. Successful filter placement was confirmed in all 30 patients either with plain film alone (n = 12), IVUS alone (n = 3), computed tomography alone (n = 1), external ultrasound alone (n = 1), IVUS and another imaging modality (n = 10), or by combinations of other imaging modalities (n = 3). There were no complications. CONCLUSIONS: IVUS is a safe and effective alternative to conventional positive-contrast vena cavography for imaging the IVC prior to filter placement in patients with contraindications to iodinated contrast material or ionizing radiation.

Carbon dioxide as a contrast agent to guide vascular interventional procedures.

OBJECTIVE: The purpose of this study was to assess the value and limitations of carbon dioxide (CO2) as a contrast agent to guide vascular interventional procedures. SUBJECTS AND METHODS: Twenty-two adults underwent 26 vascular interventional procedures (21 arterial, five venous). We aimed to use only CO2 if possible because these patients had renal insufficiency (n = 21; mean creatinine level, 2.8 mg/dl) or were allergic to contrast material (n = 1). Arterial procedures performed included renal angioplasty or stent (n = 6), iliac angioplasty or stent (n = 5), infrainguinal angioplasty (n = 5), arterial bypass graft angioplasty (n = 3), and thrombolysis (n = 2). Venous procedures included transjugular intrahepatic portosystemic shunt recanalization (n = 3), angioplasty of the venous anastomosis of a thigh dialysis graft (n = 1), and angioplasty of the inferior vena cava (n = 1). RESULTS: Twenty-five of the 26 procedures were successfully performed. Of the 26 procedures, eight required no iodinated contrast material and 11 required less than or equal to 20 ml of contrast material. CO2 proved to be inadequate for the remaining seven procedures. Iliac artery angioplasty or stent placement required an average of 9 ml of iodinated contrast material; infrainguinal angioplasty required an average of 22 ml of iodinated contrast material. CONCLUSION: CO2 can be successfully used as a contrast agent in a variety of vascular interventional procedures. Such procedures can usually be performed in the iliac and infrainguinal arteries using minimal supplemental iodinated contrast material. However, CO2 failed to provide satisfactory guidance in half of the intraabdominal procedures in our study.

Improved axon diameter and myelin sheath thickness in facial nerve cable grafts wrapped in temporoparietal fascial flaps.

Injury to the facial nerve in the temporal bone presents a challenge to the recovery of nerve function, in that the fallopian canal in which it lies is poorly vascularized. This study was designed to determine if wrapping an intratemporal facial nerve defect repaired with a cable graft with a well-vascularized temporoparietal fascial (TPF) flap would improve facial nerve regeneration. To evaluate this question, a defect was created in the intratemporal left facial nerve of 10 rabbits. All nerves were repaired using cable grafts. In 5 animals, the nerve graft was wrapped with temporoparietal fascia, whereas in the other 5 rabbits it was not. Three additional animals underwent exposure only. The contralateral nerve served as a control in all animals. Quantitative analysis of the nerve graft 12 weeks after repair revealed greater recovery of original fiber diameter and myelin sheath thickness in TPF flap-wrapped repairs. Histological evidence of improved neural regeneration and functional nerve recovery was also seen in the repairs where the TPF flap was utilized. Nerve conduction and electromyographic studies of the cable-grafted nerve at 6 and 12 weeks were equivocal, however.

Profiles of healing and nonhealing Cryptosporidium parvum infection in C57BL/6 mice with functional B and T lymphocytes: the extent of gamma interferon modulation determines the outcome of infection.

This study describes healing and nonhealing models of Cryptosporidium parvum infection with adult mice that have functional T and B lymphocytes. In our nonhealing model, mice on a C57BL/6 background which have a targeted disruption in the gamma interferon (IFN-gamma) gene (GKO mice) are utilized. C. parvum-infected GKO mice shed extremely high levels of oocysts and displayed overwhelming infection of the entire small intestine. The majority of these mice succumbed within 2 to 3 weeks due to severe acute infection and profound mucosal destruction. In our healing murine model, C57BL/6J mice treated with a single injection of the neutralizing anti-IFN-gamma monoclonal antibody XMG 1.2 prior to infection were used. These mice developed two peaks of oocyst shedding but were ultimately free of parasites on day 30 of infection. Again, the small intestine was the primary site of infection. Mesenteric lymph node (MLN) cells isolated from C. parvum-infected nonhealing GKO mice proliferated and secreted interleukin 2 (IL-2) but not IFN-gamma or IL-4 in response to ex vivo restimulation with intact C. parvum sporozoites or a C. parvum sporozoite antigen preparation. In contrast, parasite-specific MLN cells isolated from healing C57BL/6J mice secreted IL-2 and IFN-gamma but not IL-4. These results suggest that IFN-gamma, either directly or indirectly, is important for resistance to and resolution of cryptosporidiosis. Moreover, these models now allow the analysis of parasite-specific cell-mediated and humoral mucosal immune responses to determine what constitutes protective immunity to C. parvum.

Pressure sores in the acute trauma patient: incidence and causes.

OBJECTIVES: The purpose of this review was to determine the incidence of pressure sores in acute trauma patients and to identify the causes. DESIGN AND MATERIALS AND METHODS: This study is a retrospective chart review of all acute trauma patients admitted to Harborview Medical Center between January of 1991 and December of 1993 who were discharged with an ICD-9 diagnosis of acute pressure sore. RESULTS: A total of 7,492 trauma patients were admitted. Thirty-two patients developed 44 pressure sores for an incidence of 0.4%. All of the patients were severely injured (mean Injury Severity Score, 21). Eighteen (41%) of the pressure sores developed as a result of unrelieved positional pressure. Thirteen (30%) of the pressure sores were equipment induced. CONCLUSION: Our incidence of pressure sores in acute trauma victims is very low and occurs in those most seriously injured. The majority of the wounds are due to unrelieved pressure from body positioning or equipment failure.

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy.

PURPOSE: To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents. MATERIALS AND METHODS: Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy. RESULTS: Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months). CONCLUSION: Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.