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Second-look endoscopy for bleeding peptic ulcer disease: a decision-effectiveness and cost-effectiveness analysis
(Wolters Kluwer, 2012) Imperiale, Thomas F.; Kong, Nan; Medicine, School of Medicine
Background: Second-look endoscopy after initial therapeutic endoscopy for bleeding peptic ulcer disease may decrease the risk of rebleeding; however, it is not recommended routinely. Understanding conditions under which second-look endoscopy is beneficial might be useful for clinical decision making.
Methods: Using a decision model, literature-based probabilities, and Medicare reimbursement costs, we compared routine second-look endoscopy with no second-look endoscopy. We measured rebleeding, need for surgery, hospital mortality, and costs, and calculated the cost to avoid each outcome, expressed as the number needed to treat, along with the cost per outcome prevented.
Results: In the base case, routine second-look endoscopy reduced rebleeding from 16% to 10% (needed to treat=16) but had no effect on other outcomes. The cost to prevent 1 case of rebleeding was nearly $13,000. Threshold analysis revealed a rebleeding threshold of 31% to neutralize the cost difference between routine second-look endoscopy and no routine second-look endoscopy. If routine second-look endoscopy was 100% effective in preventing rebleeding, then the rebleeding threshold for cost neutrality would be 17.5%. When rebleeding risks after the index endoscopy and second-look endoscopy were simultaneously considered, the cost per bleed prevented ranged from a cost savings of $165 when the respective risks were 25% and 5%, to a cost of nearly $33,000 when the risks were 20% and 15%.
Conclusions: The results suggest that routine second-look endoscopy is not indicated after therapeutic endoscopy for bleeding peptic ulcer disease. However, if rebleeding risk is 31% or greater, then routine second-look endoscopy reduces this risk at no additional cost.
Comparison of Seven Liver Allocation Models with Respect to Lives Saved Among Patients on the Liver Transplant Waiting List
(Wiley, 2012) Magder, Laurence S.; Regev, Arie; Mindikoglu, Ayse L.; Medicine, School of Medicine
The patients with end-stage liver disease (ESLD) on the liver transplant waiting list are prioritized for transplant based on the model for end-stage liver disease (MELD) score. We developed and used an innovative approach to compare MELD to six proposed alternatives with respect to waiting list mortality. Our analysis was based on United Network for Organ Sharing data of patients with ESLD on the waiting list between January 2006 and June 2009. We compared six allocation models to MELD. Two models were based on reweighting the variables used by MELD: an "updated" MELD, and ReFit MELD. Four models also included serum sodium: MESO, MeldNa, UKELD, and ReFit MELDNa. We estimated that UKELD and the updated MELD would result in significantly fewer lives saved. There were no significant differences between the other models. Our new approach can supplement standard methods to provide insight into the relative performance of liver allocation models in reducing waiting list mortality. Our analysis suggests that UKELD and the updated MELD score would not be optimal for reducing waiting list mortality in the United States.
Functions of Thymic Stromal Lymphopoietin in Immunity and Disease
(Springer, 2012) Zhang, Yanlu; Zhou, Baohua; Pediatrics, School of Medicine
Thymic stromal lymphopoietin (TSLP) is an interleukin 7-like cytokine expressed mainly by epithelial cells. Current studies provide compelling evidence that TSLP is capable of activating dendritic cells to promote T helper (Th) 2 immune responses. TSLP has also been shown to directly promote Th2 differentiation of naïve CD4(+) T cell and activate natural killer T cells, basophils and other innate immune cells at the initial stage of inflammation. In addition, TSLP affects B cell maturation and activation and can also influence regulatory T (Treg) cell differentiation and development. TSLP-induced Th2 responses are associated with the pathogenesis of allergic inflammatory diseases, including atopic dermatitis, asthma, and rhinitis. Based on recent findings in humans and mouse models, TSLP might also be involved in the pathogenesis of inflammatory bowel disease and progression of cancer. In this review, we will summarize our current understanding of the biology of TSLP and highlight the important issues for future investigations.
Dental Abnormalities in Congenital Ichthyoses: Case Report and Review of the Literature
(2024-07-26) Maarouf, Sarah; Clark, Marie; Chen, Anthony; Haggstrom, Anita
We describe a 1-day old female with features of keratitis-ichthyosis-deafness (KID) syndrome and natal teeth. Genetic analysis confirmed GJB2 263C and A88V de novo pathogenic variants consistent with KID syndrome. Natal teeth were promptly extracted to avoid the risk of aspiration. This review describes subsets of ichthyoses that have been reported in association with dental anomalies, highlighting the need for early dental referral and importance of long-term follow-up.
Impact of efavirenz on intestinal metabolism and transport: insights from an interaction study with ezetimibe in healthy volunteers
(Wiley, 2012) Oswald, S.; Meyer zu Schwabedissen, H. E.; Nassif, A.; Modess, C.; Desta, Z.; Ogburn, E. T.; Mostertz, J.; Keiser, M.; Jia, J.; Hubeny, A.; Ulrich, A.; Runge, D.; Marinova, M.; Lütjohann, D.; Kroemer, H. K.; Siegmund, W.; Medicine, School of Medicine
Hypercholesterolemia frequently occurs in patients treated with efavirenz who cannot be treated adequately with statins because of drug interactions. These patients may benefit from cholesterol-lowering therapy with ezetimibe. This study determined the influence of single-dose and multiple-dose efavirenz (400 mg/day for 9 days) on the pharmacokinetics and sterol-lowering of ezetimibe (10 mg) in 12 healthy subjects. In addition, the influence of efavirenz on genome-wide intestinal expression and in vitro function of ABCB1, ABCC2, UGT1A1, and OATP1B1 was studied. Efavirenz (multiple dose) had no influence on the pharmacokinetics and lipid-lowering functions of ezetimibe. Intestinal expression of enzymes and transporters (e.g., ABCB1, ABCC2, and UGT1A1) was not affected by chronic efavirenz. Efavirenz (single dose) slightly increased ezetimibe absorption and markedly decreased exposure to ezetimibe-glucuronide (single dose and multiple dose), which may be explained by inhibition of UGT1A1 and ABCB1 (in vitro data). Ezetimibe had no effect on the disposition of efavirenz. Consequently, ezetimibe may be a safe and efficient therapeutic option in patients with HIV infection.