Leiomyoma presenting as an anterior vaginal mass.

Leiomyoma, otherwise known as a fibroid, is commonly encountered in the uterus. Vaginal leiomyomas are extremely rare with a relative paucity of cases reported in the literature. Due to the rarity of the disease and complexity of the vaginal anatomy, definitive diagnosis and treatment are challenging. The diagnosis is often only made postoperatively after resection of the mass. They usually arise from the anterior vaginal wall and women may present with dyspareunia, lower abdominal pain, vaginal bleeding or dysuria. Imaging with a transvaginal ultrasound scan and MRI can confirm the vaginal origin of the mass. Surgical excision is the treatment of choice. The diagnosis is confirmed following histological assessment. The authors present the case of a woman in her late 40s presenting to the gynaecology department with an anterior vaginal mass. Further investigation with a non-contrast MRI was suggestive of a vaginal leiomyoma. She underwent surgical excision. Histopathological features were in keeping with the diagnosis of a hydropic leiomyoma. A high index of clinical suspicion is required to establish the diagnosis as it can be mistaken for a cystocele, Skene duct abscess or Bartholin gland cyst. Although it is a benign entity, local recurrence following incomplete resection and sarcomatous changes have been reported.

The direct medical cost of cardiovascular diseases, hypertension, diabetes, cancer, pregnancy and female infertility in a large HMO in Israel.

OBJECTIVES: The aim of this study was to assess the direct medical cost of treating major chronic illnesses in Maccabi Healthcare Services, a 1.8 million member health maintenance organization in Israel. METHODS: Direct medical costs were calculated for each member in 2006. We used multiple linear regression models to evaluate the overall costs of chronic conditions (cardiovascular diseases, diabetes mellitus, hypertension, female infertility treatments, and cancer), pregnancy and treatments for female infertility. RESULTS: According to the study model, hypertension was associated with the largest direct medical costs in both sexes. Cardiovascular diseases accounted for 9.5% of the total direct medical costs in men, but only 5.9% in women. Diabetes mellitus accounted for 3.5% of the total medical costs both in men and women and is comparable to the total pregnancy-related costs in women. CONCLUSIONS: The findings indicate that hypertension, diabetes mellitus and female infertility treatments impose a considerable economic burden on public healthcare services in Israel which is comparable with the costs of cancer and cardiovascular diseases.

Impact of new medical technologies on health expenditures in Israel 2000-07.

OBJECTIVES: The aim of this study was to estimate the impact of new medical technologies on public healthcare expenditures in Israel over the period 2000-07. METHODS: For each year, government estimates for the costs of new technologies recommended as high-priority for public funding were summarized. The ratio of projected costs of these technologies to total public healthcare expenditures was calculated and compared with actual governmental budget allocations for new technologies. RESULTS: Funding all new high-priority medical technologies would have increased healthcare expenditures by 2.1 percent per year. Government allocations for new technologies raised expenditures by 1.0 percent per year. CONCLUSIONS: New medical technologies significantly increase healthcare expenditures in Israel. Budgetary constraints have reduced their actual impact by 52 percent. This study indicates the need for an annual addition of 2 percent to public healthcare budget for funding new high-priority technologies.

The direct medical cost of diabetes in Israel.

Diabetes mellitus is an important chronic disease with a growing prevalence that absorbs an ever increasing investment of resources. This population-based study evaluated the direct medical costs of diabetes mellitus in an HMO setting. We evaluated both the total cost of diabetic patients and their added cost in comparison to other HMO members (diabetes-related costs). Data were obtained for the years 1999-2001 in a cohort of 24,632 diabetic patients followed up for 3 years drawn from the computerized medical administrative database of a large HMO in Israel, insuring around 25% of the population. The mean direct cost of the medical treatment of a diabetic patient rose 29% from US $2,017 in 1999 to $2,601 in 2001 (in 2001 terms) in comparison to a 19.7% rise (from $1,246 to $1,492). Hospitalizations, medication, and physician visits account for 39%, 29%, and 21% of the total diabetic patient costs, respectively. Dialysis, insulin intake, impaired creatinine, and elevated HbA1c were associated with increased expenditures. According to our results, the total national medical cost of diabetes alone in 2001 was $317 million and that of diabetic patients was $564 million, 6.9% and 12.4% of the total Israeli HMO budget, respectively. The study presents the use of a population-based computerized database to comprehensively assess the economic burden of disease and the potential savings from prevention. The study data suggest a rise in the cost of diabetes which has implications for prevention and treatment policies.

Cost-utility analysis of hepatitis A prevention among health-care workers in Israel.

This study was conducted to evaluate the efficiency of different strategies of preventing hepatitis A (HA) among physicians, nurses, and paramedical staff by means of cost-effectiveness analysis. The strategies compared were passive immunization during a hepatitis A outbreak, systematic mass vaccination of all workers, and screening for antibodies to HA virus followed by vaccination of nonimmune employees. To predict the prevented number of HA cases, an epidemiological model was incorporated based on our previous nationwide study on clinical HA cases, seroepidemiological survey, and other scientific medical literature. Under the model assumptions, the lowest cost per prevented HA case ($6240) was achieved by screening prior vaccination among 18- to 39-year-old physicians and paramedical workers, and highest ($61,858) by mass vaccination of nurses over age 39 years. Because the price per prevented case may show that mass vaccination is highly cost-effective, especially among 18- to 39-year-old physicians and paramedical workers ($6399 and $8196, respectively), the cost per gained quality-adjusted life-year seems less attractive ($56,532 and $61,350, respectively). This cost per saved quality-adjusted life-year is similar to many other medical interventions but is markedly higher than other primary prevention vaccines, which are mostly associated with a negative ratio. In view of the conducted study, and taking $60,000 as a limit cost per saved quality-adjusted life-year, we propose selective vaccination for physicians and for paramedical workers. Mass vaccination should be offered to all health care workers, aside from nurses 40+ years of age, once the active HA vaccine price is reduced to $23.

Obligaciones de la profesión médica hacia el canceroso

Tomado del Quart, Bull., City of New York, Dept. of Health, 56, dic. 1943