Effectiveness Of Various Treatment Options Research Articles

On the economics of post-traumatic stress disorder among first responders in Canada

There is an increasing awareness of the tragic consequences of post-traumatic stress disorder (PTSD) among first responders in Canada. There is also an increasing awareness of the lack of understanding about the economic and social costs of PTSD in Canada. This article aims to briefly review the current evidence on the prevalence rates of PTSD, the economic costs associated with PTSD, and the costs and efficacy of various treatment strategies, to provide a framework for future research on the economic analysis of PTSD. Estimates suggest that as many as 2.5 million adult Canadians and 70,000 Canadian first responders have suffered from PTSD in their lifetimes. While we could not find any evidence on the economic cost of PTSD specifically, a recent estimate suggests that mental illness in the Canadian labour force results in productivity losses of $21 billion each year. Research from Australia suggests that expanded mental health care may improve the benefits of treatment over traditional care, and more cost-effectively. Given the methodological challenges in the existing studies and the paucity of evidence on Canada, more Canadian studies on prevalence, on the economic and social costs of PTSD, and on the costs and effectiveness of various treatment options are encouraged.

Simulation of metastatic progression using a computer model including chemotherapy and radiation therapy

IntroductionDespite considerable research efforts, the process of metastasis formation is still a subject of intense discussion, and even established models differ considerably in basic details and in the conclusions drawn from them. Mathematical and computational models add a new perspective to the research as they can quantitatively investigate the processes of metastasis and the effects of treatment. However, existing models look at only one treatment option at a time. MethodsWe enhanced a previously developed computer model (called CaTSiT) that enables quantitative comparison of different metastasis formation models with clinical and experimental data, to include the effects of chemotherapy, external beam radiation, radioimmunotherapy and radioembolization. CaTSiT is based on a discrete event simulation procedure. The growth of the primary tumor and its metastases is modeled by a piecewise-defined growth function that describes the growth behavior of the primary tumor and metastases during various time intervals. The piecewise-defined growth function is composed of analytical functions describing the growth behavior of the tumor based on characteristics of the tumor, such as dormancy, or the effects of various therapies. The spreading of malignant cells into the blood is modeled by intravasation events, which are generated according to a rate function. Further events in the model describe the behavior of the released malignant cells until the formation of a new metastasis. The model is published under the GNU General Public License version 3. ResultsTo demonstrate the application of the computer model, a case of a patient with a hepatocellular carcinoma and multiple metastases in the liver was simulated. Besides the untreated case, different treatments were simulated at two time points: one directly after diagnosis of the primary tumor and the other several months later. Except for early applied radioimmunotherapy, no treatment strategy was able to eliminate all metastases. These results emphasize the importance of early diagnosis and of proceeding with treatment even if no clinically detectable metastases are present at the time of diagnosis of the primary tumor. ConclusionCaTSiT could be a valuable tool for quantitative investigation of the process of tumor growth and metastasis formation, including the effects of various treatment options.

Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research: Implementing the patient-driven research paradigm to aid decision making in stroke care

Stroke is common and costly, annually depriving the lives and well-being of 800,000 Americans. Despite demonstrated efficacy in clinical trials, questions remain about the safety and clinical effectiveness of various treatment options given patient characteristics, conditions, preferences, and their desired outcomes. The Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) is a Patient-Centered Outcomes Research Institute-sponsored project designed to help patients, physicians, and other stakeholders make informed decisions regarding stroke care and improve outcomes through patient-centered comparative effectiveness research. The primary outcomes identified and prioritized by stroke patients are "home time" (time spent alive and outside a hospital) and major adverse cardiovascular events. With inputs from stroke patients themselves, a series of comparative safety and effectiveness analyses will be performed across 3 prioritized therapeutic areas identified as important by stroke survivors: oral anticoagulants, statin therapy, and antidepressants. We obtained data from Get With the Guidelines-Stroke linked with Medicare claims and follow-up telephone interviews. Our combined retrospective and prospective research strategy allows the evaluation of the safety and effectiveness of various treatment options and patient-centered longitudinal outcomes. To ensure the rapid translation of findings into clinical practice, results will be disseminated to stroke survivors, caregivers, and health care providers through traditional and social media, including an online decision aid tool. PROSPER is a patient-centered outcome research study guided by patients, caregivers, and the broader health care community. By addressing knowledge gaps in treatment uncertainties through comparative effectiveness research, PROSPER has the potential to improve decision making in stroke care and patient outcomes reflecting individual patient preferences, needs, and values.

Additional Evidence for the Long-Term Benefits of Pulmonary Rehabilitation.

Pulmonary rehabilitation programs document outcomes to prepare for program certification, to demonstrate the value of the program to upper management, and to provide feedback to pulmonary rehabilitation staff regarding the efficacy of the program. The overall goal of this study was to evaluate the feasibility of using non-research-generated clinical data to report long-term outcomes following a pulmonary rehabilitation program. Using a longitudinal descriptive design, all subjects who completed pulmonary rehabilitation at one community-based pulmonary rehabilitation program in the San Francisco Bay Area were asked to complete a 6-month and subsequent yearly questionnaires. Adherence to pulmonary rehabilitation techniques was described for 7 y following pulmonary rehabilitation participation, health-care utilization from 1 y before pulmonary rehabilitation was compared with subsequent years, and health-care utilization was compared between those who participated in ongoing regular exercise after pulmonary rehabilitation and those who did not exercise. More than 70% of subjects who completed the questionnaire reported adherence to pulmonary rehabilitation techniques, including exercise for at least 7 y following pulmonary rehabilitation. Health-care utilization declined after pulmonary rehabilitation. Subjects who did not exercise regularly required significantly more health care than those who exercised regularly (P < .05). This study demonstrated the ability of one pulmonary rehabilitation program to accurately monitor extended long-term follow-up after pulmonary rehabilitation. Implementing this long-term monitoring methodology consistently in pulmonary rehabilitation programs could contribute to evaluation of the comparative effectiveness of various treatment options.

Advanced clinical trials for China.

Clinical trials are the primary means through which new drugs and devices are developed for use in patients. Through a series of studies that aim to demonstrate safety, activity, benefit, and effectiveness, clinical trials provide a rigorous scientific methodology for evaluating questions in clinical medicine and advancing new treatments to the marketplace. Clinical trials are also essential to directly compare the effectiveness of various treatment options and to assess the cost and cost effectiveness of new treatments. Clinical trials also provide a context and infrastructure that enables investigators to prospectively collect biospecimens that can be used to answer important questions about the benefits and harms of therapies in subgroups of patients as well as to develop new prognostic and predictive tests.

Aloe vera gel and thyroid hormone cream may improve wound healing in Wistar rats

Therapeutic effects of various treatment options in wound healing have been one of the most controversial issues in surgical science. The present study was carried out to examine and compare the effects of Aloe vera gel, thyroid hormone cream and silver sulfadiazine cream onsutured incisions in Wistar rats. In a randomized controlled trial, thirty-six Wistar male rats, 250 to 300 g, received surgical incisions followed by topical application of Aloe vera gel, thyroid hormone cream and silver sulfadiazine 1%. To assess the efficacy of each treatment technique, a histological approach was used to evaluate the mean number of fibroblasts, macrophages, neutrophils, blood vessel sections and thickness of the regenerating epithelium and dermis on days 4, 7 and 14. Re-epithelialization and angiogenesis were significantly improved in Aloe vera gel group compared with the other treatments while thyroid hormone cream had positive effects on day 4 (P≤0.05). Topical administration of Aloe vera gel is recommended as the treatment of choice for surgical incisions.

Which dressing do donor site wounds need?: study protocol for a randomized controlled trial

BackgroundDonor site wounds after split-skin grafting are rather 'standard' wounds. At present, lots of dressings and topical agents for donor site wounds are commercially available. This causes large variation in the local care of these wounds, while the optimum 'standard' dressing for local wound care is unclear. This protocol describes a trial in which we investigate the effectiveness of various treatment options for these donor site wounds.MethodsA 14-center, six-armed randomized clinical trial is being carried out in the Netherlands. An a-priori power analysis and an anticipated dropout rate of 15% indicates that 50 patients per group are necessary, totaling 300 patients, to be able to detect a 25% quicker mean time to complete wound healing. Randomization has been computerized to ensure allocation concealment. Adult patients who need a split-skin grafting operation for any reason, leaving a donor site wound of at least 10 cm2 are included and receive one of the following dressings: hydrocolloid, alginate, film, hydrofiber, silicone dressing, or paraffin gauze. No combinations of products from other intervention groups in this trial are allowed. Optimum application and changes of these dressings are pursued according to the protocol as supplied by the dressing manufacturers. Primary outcomes are days to complete wound healing and pain (using a Visual Analogue Scale). Secondary outcomes are adverse effects, scarring, patient satisfaction, and costs. Outcome assessors unaware of the treatment allocation will assess whether or not an outcome has occurred. Results will be analyzed according to the intention to treat principle. The first patient was randomized October 1, 2009.DiscussionThis study will provide comprehensive data on the effectiveness of different treatment options for donor site wounds. The dressing(s) that will prevail in effectiveness, satisfaction and costs will be promoted among clinicians dealing with such patients. Thus, we aim to contribute a well-designed trial, relevant to all clinicians involved in the care for donor site wounds, which will help enhance uniformity and quality of care for these patients.Trial registrationhttp://www.trialregister.nl, NTR1849. Date registered: June 9, 2009

A Pseudo-Rigid-Body Model of the Human Spine to Predict Implant-Induced Changes on Motion

Injury, instrumentation, or surgery may change the functional biomechanics of the spine. Adverse changes at one level may affect the adjacent levels. Modeling these changes can increase the understanding of adjacent-level effects and may help in the creation of devices that minimize adverse outcomes. The current modeling techniques (e.g., animal models, in vitro testing, and finite element analysis) used to analyze these effects are costly and are not readily accessible to the clinician. It is proposed that the pseudo-rigid-body model(PRBM) may be used to accurately predict adjacent level effects in a quick and cost effective manner that may lend itself to a clinically relevant tool for identifying the adjacent-level effects of various treatment options for patients with complex surgical indications. A PRBM of the lumbar spine (lower back) was developed using a compliant mechanism analysis approach. The global moment-rotation response, relative motion, and local moment-rotation response of a cadaveric specimen were determined through experimental testing under three conditions: intact, fused, and implanted with a prototype total disc replacement. The spine was modeled using the PRBM and compared with the values obtained through in-vitro testing for the three cases. The PRBM accurately predicted the moment-rotation response of the entire specimen. Additionally, the PRBM predicted changes in relative motion patterns of the specimen. The resulting models show particular promise in evaluating various procedures and implants in a clinical setting and in the early stage design process.

Is Radical Oncosurgery Justified for the Treatment of Primary Malignant Fibrous Histiocytoma of the Urinary Bladder? Report of Two Cases and Analyses of Disease-Specific Survival Rates Based on a Review of the Literature

Disease-specific survival (DSS) rates were evaluated in 20 patients with primary malignant fibrous histiocytoma (MFH) of the bladder. The most common pathologic finding was the pleomorphic subtype of MFH (55%) with a mean tumor size of 6.8 cm. 10 patients underwent surgery without and 6 patients with adjuvant therapy. Local and systemic rates of progression were 30 and 60% after surgery only compared with 16.7 and 50% after surgery with adjuvant therapy. Although none of the patients showed metastatic dissemination at the time of diagnosis, overall 1- and 2-year DSS rates of only 47.8 and 31.9% were observed. Hence, after the onset of clinical symptoms, the disease runs a very aggressive course regardless of the therapeutic options employed. Although distant dissemination seems to be rare at the time of diagnosis, the prognostic outcome is dismal. The rarity and inconsistency of the currently available case reports on MFH of the bladder hampers the development of therapeutic guidelines. Advanced studies enrolling a larger number of patients with appropriate clinical and pathological data are needed to compare the beneficial effects of various treatment options.

Tabaksverslaving: de impact van gezondheidsvoorlichting en hulpverlening op de totale populatie rokers

Tobacco addiction: The impact of health education and clinical treatment on the total population of smokers Health education and clinical treatment are two different approaches to tobacco control. This paper reviews the literature with respect to the effectiveness and population impact of both approaches. Health education has the strongest population impact through mass media campaigns that stimulate quit attempts among smokers. Both why-to-quit and how-to-quit campaigns can be effective. Clinical treatment through either pharmacotherapy or behavioural therapy is highly efficacious on the individual level, especially if they are provided to smokers in tandem. However, they play a marginal role in reaching population targets. This paper further explores how the population reach of efficacious treatment can be improved. An important avenue is to try to change smokers' perceptions of treatment. It is concluded that smokers need to be educated on the availability and effectiveness of various treatment options. Moreover, misperceptions about the role of willpower and motivation need to be addressed. Another route is through the health care sector. Physicians have a crucial role to play, but this role has not yet been fully realized. It is argued that clinical treatment of tobacco addiction is crucial in a comprehensive tobacco control policy, because it offers smokers who cannot quit on their own, much needed support. While mass media anti-tobacco campaigns and further regulation of tobacco use augment quitting activity in population, they marginalize smokers in more deprived socio-economic groups, further increasing the social gradient in smoking prevalence. The government has a moral obligation to invest more money in providing effective treatment pro-actively to lower SES smokers.

The Impact of Subthalamic Deep Brain Stimulation on Nigral Neuroprotection—Myth or Reality?

In the present review article we summarize available clinical and preclinical evidence, if modulation of the subthalamic nucleus (STN) could be a target for neuroprotection in Parkinson's disease (PD). Chronic deep brain stimulation (DBS) of the STN has emerged as a powerful therapeutic alternative for the treatment of PD, ensuring stable symptom control for up to five years despite the progressive nature PD. Comparative review of literature in PuBMed available up to December 2008. The assessment of neuroprotection has been proven difficult in the clinical situation, as medical or surgical therapeutic options that improve PD symptoms could be erroneously considered to be neuroprotective because of the difficulty of differentiating between symptomatic effects and potential neuromodulative disease-related effects of various treatment options applied in PD. The methodological limitations of clinical trials underline the importance of putative neuroprotective compounds to be tested in clinically driven preclinical studies. Thus, animal models, mimicking progressive nigrostriatal cell death, are indispensable to further advance the important issue of neuroprotection or neuromodulation following DBS. Clear clinical evidence for STN-DBS-related neuroprotection in PD is missing. However, numerous preclinical studies show (and are discussed) that silencing of the STN via lesion or DBS may exert neuromodulative effects on nigral dopamine neurons.

Cost-effectiveness Considerations of Cardiovascular Therapeutics

As medical knowledge advances, potential new tests and treatments are usually evaluated in randomised clinical trials and may then be adopted into clinical practice. Some are adopted because they are more effective than what went before, improving quality and/or quantity of life, others because they can achieve a similar clinical outcome at a lower cost. Comparing the costs and effects of various treatment options in the management of cardiac conditions is a fundamental process towards achieving the best outcomes for our own patients and our whole population with available resources. We all make daily decisions about treatment choices for our patients that no doubt take these issues into account, at least in a qualitative way, but formal quantitative methods are now well developed and will become increasingly important as we try to do the most good for the most people using our departmental, state and national health budgets.

Maternal and Perinatal Outcome of Massive Postpartum Hemorrage: A Review of 33 Cases

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

Motion – Laparoscopic Nissen Fundoplication Is More Cost-Effective than Oral PPI Administration: Arguments against the Motion

Discussion of the cost effectiveness of medical and surgical treatments of gastroesophageal reflux disease (GERD) is plagued by a number of logical fallacies. Several of these defects in reasoning are reviewed. For example, it is inappropriate to compare the costs of therapies unless they are equally effective. The relative cost effectiveness of various treatment options is difficult to determine because monetary expenditures and gains in health status cannot easily be measured in commensurate units. Not everything can be translated into incremental cost effectiveness ratios. Two decision analyses from European investigators seemed to show that Nissen fundoplication was more cost effective than long term acid-suppression therapy, but they failed to consider the costs of surgical complications and failures. The most comprehensive decision analysis, employing a Markov chain model, found that the two treatment options were roughly equivalent, at least during the first seven years of follow-up. Decision analyses often do not reflect actual practice patterns and cannot provide solutions to problems that cannot be solved by appropriate medical reasoning. Moreover, results that are reported by specialized surgical centres probably cannot be duplicated by less experienced surgeons. The increasing incidence of esophageal adenocarcinoma has been erroneously attributed to the use of potent acid-suppressant medications, but the actual cause has been shown to be the decreased prevalence of Helicobacter pylori. There are no significant differences in the incidence of this tumour after medical or surgical therapy of GERD. It is unlikely, however, that arguments will convince proponents of one treatment or another to change their opinions.

Decision Analysis in Head and Neck Cancer

To the Editor .—I would like to commend CPT Vic Velanovich, MC, USA, on his recently published article, Choice of Treatment for Stage I Floor-of-Mouth Cancer. 1 The use of decision analysis in the field of head and neck cancer is both appropriate and overdue. Dr Velanovich has modeled the clinical situation clearly and accurately. He has drawn from 22 articles to obtain his rates for cure, recurrence, morbidity, and mortality following treatment. Those who would argue with the results of his study should question the database from which the author draws his rates and not the process of decision analysis. The author has identified an area of needed research—quality of life following treatment for head and neck cancer. The effects of various treatment options on the quality of life for the patient with head and neck cancer is sorely lacking. Fundamental research in quality of life will allow more