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OBJECTIVES: To conduct a cost-utility analysis comparing drug strategies involving octreotide, lanreotide, pasireotide, and pegvisomant for the treatment of patients with acromegaly who have failed surgery, from a Brazilian public payer perspective. METHODS: A probabilistic cohort Markov model was developed. One-year cycles were employed. The patients started at 45 years of age and were followed lifelong. Costs, efficacy, and quality of life parameters were retrieved from the literature. A discount rate (5%) was applied to both costs and efficacy. The results were reported as costs per quality-adjusted life year (QALY), and incremental cost-effectiveness ratios (ICERs) were calculated when applicable. Scenario analyses considered alternative dosages, discount rate, tax exemption, and continued use of treatment despite lack of response. Value of information (VOI) analysis was conducted to explore uncertainty and to estimate the costs to be spent in future research. RESULTS: Only lanreotide showed an ICER reasonable for having its use considered in clinical practice (R$ 112,138/US$ 28,389 per QALY compared to no treatment). Scenario analyses corroborated the base-case result. VOI analysis showed that much uncertainty surrounds the parameters, and future clinical research should cost less than R$ 43,230,000/US$ 10,944,304 per year. VOI also showed that almost all uncertainty that precludes an optimal strategy choice involves quality of life. CONCLUSIONS: With current information, the only strategy that can be considered cost-effective in Brazil is lanreotide treatment. No second-line treatment is recommended. Significant uncertainty of parameters impairs optimal decision-making, and this conclusion can be generalized to other countries. Future research should focus on acquiring utility data.
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Acromegalia/tratamento farmacológico , Acromegalia/economia , Antineoplásicos , Análise Custo-Benefício , Hormônios , Hormônio do Crescimento Humano/análogos & derivados , Octreotida , Avaliação de Resultados em Cuidados de Saúde , Peptídeos Cíclicos , Somatostatina/análogos & derivados , Antineoplásicos/economia , Antineoplásicos/farmacologia , Brasil , Hormônios/economia , Hormônios/farmacologia , Hormônio do Crescimento Humano/economia , Hormônio do Crescimento Humano/farmacologia , Humanos , Programas Nacionais de Saúde , Octreotida/economia , Octreotida/farmacologia , Avaliação de Resultados em Cuidados de Saúde/economia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Peptídeos Cíclicos/economia , Peptídeos Cíclicos/farmacologia , Somatostatina/economia , Somatostatina/farmacologiaRESUMO
Objective: To evaluate optical vs immersion ultrasound biometry to measure ocular axial length (the distance between the anterior surface of the cornea and the fovea). Design and Methodology: The axial length of the eye is usually measured by A-scan ultrasonography or optical coherence biometry. Optical biometry is the gold standard, but cannot be used for patients with dense cataracts, when immersion ultrasound biometry is utilized. Both optical and immersion ultrasound biometry were performed on patients scheduled to undergo cataract surgery between November 2017 and November 2018. Statistical difference was determined using a two tailed t-test. Results: There was no statistical difference between mean axial length measured using optical biometry (23.83 mm ± 1.34) vs immersion ultrasound biometry (23.80 mm ± 1.30); t(46)= -0.05, p=0.96. Conclusion: Accurate axial length measurement is essential for reliable intraocular lens power calculation, minimizing refractive error following cataract surgery. The cost of optical coherence biometry equipment is prohibitive and this technology is not readily available in the public hospital eye clinics. There was no statistical difference in axial length measured using optical biometry and immersion ultrasound. This suggests that in low resource settings, immersion biometry can be utilized without compromising surgical outcome.
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Humanos , Catarata , Trinidad e Tobago , Comprimento Axial do Olho , Imagem ÓpticaRESUMO
OBJECTIVES: To assess blood usage for elective surgery in a developing country as a first step towards developing a maximum surgical blood-ordering schedule (MSBOS). BACKGROUND: Cross-match:transfusion (C/T) ratio, transfusion index (Ti ) and transfusion ratio (T%) are standard indices of efficient blood usage for elective surgical procedures. The MSBOS assigns surgical procedures to Group and Cross Match (GXM) and Group and Save (G&S) categories. Non-use probability (NUP) is the percentage of blood that is requested but not used. Trinidad and Tobago (TTO) has a transfusion service that predominantly uses family replacement (F/R) donors. MATERIALS/METHODS: C/T ratio, Ti , T% and NUP were retrospectively calculated for 304 elective surgical procedures performed at a tertiary medical institution in TTO between 1st January and 15th May 2013. RESULTS: For 17 types of surgical procedure, C/T ratio was <2·5 for 10, T% ≥ 30 for 10 and Ti ≥ 0·5 for 12, suggesting efficiency, significant blood use and a requirement for GXM for most operations. However, the majority of these procedures qualify for G&S when performed under conditions that guarantee ready access to blood in an emergency. A substantial proportion of issued blood was returned unused to the blood bank, giving an NUP of 39·7%. CONCLUSION: NUP was the most sensitive measure of efficiency. C/T ratio, T% and Ti must be interpreted in the context of the blood donation system. An internationally accepted value of NUP that equates to efficient blood use should be adopted.
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Segurança do Sangue , Transfusão de Sangue , Atenção à Saúde , Procedimentos Cirúrgicos Eletivos , Humanos , Trinidad e TobagoRESUMO
Introduction: Glaucoma is the leading cause of blindness in the Caribbean, accounting for 28.4% in Barbados and 32% in Trinidad and Tobago (T&T). In T&T, 28% of glaucoma patients miss clinic appointments and 40% are non-compliant with eye drops. There is a role for surgery in preventing glaucoma blindness. However, the complications of mitomycin C trabeculectomy (MMCT) have deterred local ophthalmologists and patients from selecting this option. The Moorfields Safer Surgery System (MSSS) allows simple modification of surgical technique which can be implemented to improve surgical outcomes. Purpose: To demonstrate the safety and efficacy of the MSSS in the Caribbean. Methods: Thirty-three consecutive MMCT procedures were performed by a single surgeon using the MSSS. Patients were of African descent, 16 male and 8 female. Median age was 56 years (range 34-79 years). Mean pre-operative intraocular pressure (IOP) 23.2 mmHg. In 38%, best-corrected visual acuity (BCVA) was ≤3/60 in at least one eye. Results. IOP was ≤21 mmHg in 92.6% of patients at 1 year and in 87.5% at 5 years. Removal of scleral releasable suture(s) was required in 85%, 5-fluorouracil injection(s) in 85% and bleb needling in 36%. The most common complication was early bleb leak (52%). 91% had excellent or satisfactory bleb morphology. No patient developed endophthalmitis. 73% had equal or better BCVA in the operated eye. Conclusion: Glaucoma in the African Caribbean population is an aggressive disease which affects young adults. Late presentation and non-adherence to topical treatment favour surgical intervention. This study provides evidence that knowledge and skills transfer of the MSSS to the Caribbean is possible. Surgical success and complication rates comparable to best published international data can be achieved.
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Trinidad e Tobago , Barbados , Glaucoma , Oftalmopatias , Região do CaribeRESUMO
Brown trout (Salmo trutta) broodstock from a single population were separated prior to spawning andexposed to two different holding environments: a raceway system and a tank system. Eggs were stripped from females and 13 measures of egg qualitywere collected, analysed individually, combined by principle components analysis into an integrated egg quality score which was validated against egg survival.The multivariate egg quality score (PC1) differed for fish held in the tank and raceway systems. Egg survival, chorion breaking strength and chorion Se concentrations were higher in eggs produced by broodstock held in the tank system compared to those in the raceway system. In contrast, chorion concentrations of P and K were higher in eggs from fish held in the raceway system. The results suggest that brown trout broodstock reared in tank systems produced higher quality eggs compared to trout reared in raceways. Finally, this study also indicates that multivariate statistical analysis can be used to determine egg quality from multiple egg parameters.(AU)
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Animais , Salmonidae/anatomia & histologia , Salmonidae/embriologia , Salmonidae/fisiologia , PesqueirosRESUMO
Brown trout (Salmo trutta) broodstock from a single population were separated prior to spawning andexposed to two different holding environments: a raceway system and a tank system. Eggs were stripped from females and 13 measures of egg qualitywere collected, analysed individually, combined by principle components analysis into an integrated egg quality score which was validated against egg survival.The multivariate egg quality score (PC1) differed for fish held in the tank and raceway systems. Egg survival, chorion breaking strength and chorion Se concentrations were higher in eggs produced by broodstock held in the tank system compared to those in the raceway system. In contrast, chorion concentrations of P and K were higher in eggs from fish held in the raceway system. The results suggest that brown trout broodstock reared in tank systems produced higher quality eggs compared to trout reared in raceways. Finally, this study also indicates that multivariate statistical analysis can be used to determine egg quality from multiple egg parameters.
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Animais , Salmonidae/anatomia & histologia , Salmonidae/embriologia , Salmonidae/fisiologia , PesqueirosRESUMO
AIM: To determine the sensitivity and specificity of the Reichert™ Tono-Pen AVIA® when used by novice medical students in an ethnically diverse population in Trinidad. SUBJECTS AND METHOD: Participants were residents of Trinidad between the ages of 20 and 90 years attending the Ophthalmology Clinic at the Eric Williams Medical Sciences Complex (EWMSC). Intraocular pressure (IOP) was measured using the Goldmann applanation tonometer (the gold standard) for ophthalmology clinic patients as part of their routine care. Intraocular pressure measurements were then taken using the Tono-Pen. RESULTS: One hundred persons participated, consisting of Indo-Trinidadians (55%), Afro-Trinidadians (36%), Mixed (8%) and 1% of Caucasian descent. Fourteen per cent reported a diagnosis of glaucoma, with 70.6% of these being of African descent. One hundred and ninety-eight readings of IOP were taken. At a cut-off point of 21 mmHg, there were nine true positives, four false positives, seven false negatives and 178 true negatives. The sensitivity and specificity were found to be 56.3% (95% CI 33.2, 76.9) and 97.8% (95% CI 94.5, 99.1), respectively. The positive predictive value was calculated as 69.2% (95% CI 42.4, 87.3) while the negative predictive value was 96.2% (95% CI 92.4, 98.2). The prevalence of elevated IOP in this population was 8.1% (95% CI 4.8, 13.0). The likelihood ratio of a positive result was calculated to be 25.6 (95% CI 8.6, 73.9). CONCLUSION: The high specificity and negative predictive value suggests that the Tono-Pen can be used with minimal training, and can prove beneficial at the primary care level in the exclusion of increased IOP in an ethnically diverse high-risk Caribbean population.
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BACKGROUND: Vascular smooth muscle cells (VSMCs) migration is a critical process during human uterine spiral artery (SpA) remodeling and a successful pregnancy. Extravillous trophoblast cells (EVT) interact with VSMC and enhance their migration, however, the mechanisms by which EVT remodel SpA remain to be fully elucidated. We hypothesize that exosomes released from EVT promote VSMC migration. METHODS: JEG-3 and HTR-8/SVneo cell lines were used as models for EVT. Cells were cultured at 37°C and humidified under an atmosphere of 5% CO2-balanced N2 to obtain 8% O2. Cell-conditioned media were collected, and exosomes (exo-JEG-3 and exo- HTR-8/SVneo) isolated by differential and buoyant density centrifugation. The effects of exo-EVT on VSMC migration were established using a real-time, live-cell imaging system (Incucyte™). Exosomal proteins where identified by mass spectrometry and submitted to bioinformatic pathway analysis (Ingenuity software). RESULTS: HTR-8/SVneo cells were significantly more (~30%) invasive than JEG-3 cells. HTR-8/SVneo cells released 2.6-fold more exosomes (6.39 × 10(8) ± 2.5 × 10(8) particles/10(6) cells) compared to JEG-3 (2.86 × 10(8) ± 0.78 × 10(8) particles/10(6) cells). VSMC migration was significantly increased in the presence of exo-JEG-3 and exo-HTR-8/SVneo compared to control (-exosomes) (21.83 ± 0.49 h and 15.57 ± 0.32, respectively, vs. control 25.09 ± 0.58 h, p < 0.05). Sonication completely abolished the effect of exosomes on VSMC migration. Finally, mass spectrometry analysis identified unique exosomal proteins for each EVT cell line-derived exosomes. CONCLUSION: The data obtained in this study are consistent with the hypothesis that the release, content, and bioactivity of exosomes derived from EVT-like cell lines is cell origin-dependent and differentially regulates VSMC migration. Thus, an EVT exosomal signaling pathway may contribute to SpA remodeling by promoting the migration of VSMC out of the vessel walls.
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INTRODUCTION: In developed countries, preterm birth is the major cause of perinatal morbidity, mortality and the most important public health problem in the obstetric field. In the past decades, an increasing trend has been observed regardless of the great efforts focussed on the improvement of our understanding of the physiopathological mechanisms behind preterm labour (PTL) and the improvement in the use of tocolytic drugs. AREAS COVERED: In this review, the authors focus on some points of the physiopathology of labour in order to understand the rationality behind the different management approaches developed for the PTL syndrome. EXPERT OPINION: There is a need to develop new tools for the treatment of patients with PTL. Research focussed on improving tocolysis, the physiology of labour and pathological processes involved in PTL would afford new approaches for the treatment of PTL, allowing clinicians to provide integrative solutions for this multifactorial disease. Recently, the prophylactic use of progesterone pessary and cerclage in women with high risk of premature labour has been reported to reduce the incidence of premature births and improve neonatal outcomes. These results highlight the importance of prediction models in order to establish preventative strategies early in pregnancy.
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Trabalho de Parto Prematuro/prevenção & controle , Trabalho de Parto Prematuro/fisiopatologia , Tocólise/métodos , Tocolíticos/farmacologia , Tocolíticos/uso terapêutico , Animais , Ensaios Clínicos Fase III como Assunto , Feminino , Humanos , GravidezRESUMO
Five case histories are presented. Waldenstrom's macroglobulinaemia caused bilateral central retinal vein occlusion, proptosis was the presenting feature of retro-orbital plasmacytoma in relapsed multiple myeloma, a red painful eye was due to neovascular glaucoma in primary polycythaemia, bilateral VIth nerve palsy caused convergent squint and diplopia in meningeal relapse of acute lymphoblastic leukaemia and lymphoma of the eyelid caused complete ptosis. Interdisciplinary management is described. Ophthalmological lesions in haematological disease should be promptly recognized and managed. Collaboration between ophthalmology and haematology departments may be effective for palliative management.