A motivation-focused weight loss maintenance program is an effective alternative to a skill-based approach

Objective

Maintaining weight loss is a major challenge in obesity treatment. Individuals often indicate that waning motivation prompts cessation of effective weight management behaviors. Therefore, a novel weight loss maintenance program that specifically targets motivational factors was evaluated.

Design

Overweight women (N=338; 19% African American) with urinary incontinence were randomized to lifestyle obesity treatment or control and followed for 18 months. All participants in lifestyle (N=226) received the same initial six-month group behavioral obesity treatment and were then randomized to 1) a novel motivation-focused maintenance program (N=113) or 2) a standard skill-based maintenance approach (N=113).

Main Outcome Measure

Weight assessed at baseline, 6, and 18 months.

Results

Both treatment groups (motivation-focused and skill-based) achieved comparable 18-month weight losses (−5.48% for motivation-focused vs −5.55% in skill-based, p=0.98), and both groups lost significantly more than controls (−1.51%; p=.0012 in motivation-focused and .0021 in skill-based).

Conclusions

A motivation-focused maintenance program offers an alternative, effective approach to weight maintenance expanding available evidence-based interventions beyond traditional skill-based programs.

Pelvic floor disorders and quality of life in women with self-reported irritable bowel syndrome

BACKGROUND

Quality of life among women with irritable bowel syndrome may be affected by pelvic floor disorders.

AIM

To assess the association of self-reported irritable bowel syndrome with urinary incontinence, pelvic organ prolapse, sexual function and quality of life.

METHODS

We analysed data from the Reproductive Risks for Incontinence Study at Kaiser Permanente, a random population-based study of 2109 racially diverse women (mean age = 56). Multivariate analyses assessed the association of irritable bowel syndrome with pelvic floor disorders and quality of life.

RESULTS

The prevalence of irritable bowel syndrome was 9.7% (n = 204). Women with irritable bowel had higher adjusted odds of reporting symptomatic pelvic organ prolapse (OR 2.4; 95% CI, 1.4-4.1) and urinary urgency (OR 1.4; 95% CI, 1.0-1.9); greater bother from pelvic organ prolapse (OR 4.3; 95% CI, 1.5-11.9) and faecal incontinence (OR 2.0; 95% CI, 1.3-3.2); greater lifestyle impact from urinary incontinence (OR 2.2; 95% CI, 1.3-3.8); and worse quality of life (P < 0.01). Women with irritable bowel reported more inability to relax and enjoy sexual activity (OR 1.8; 95% CI, 1.3-2.6) and lower ratings for sexual satisfaction (OR 1.8; 95% CI, 1.3-2.5), but no difference in sexual frequency, interest or ability to have an orgasm.

CONCLUSIONS

Women with irritable bowel are more likely to report symptomatic pelvic organ prolapse and sexual dysfunction, and report lower quality of life.

Effects of urinary incontinence, comorbidity and race on quality of life outcomes in women

PURPOSE

We investigated the effects of comorbidity and urinary incontinence on both generic and incontinence specific quality of life outcome measures, and investigated whether the association between urinary incontinence and quality of life varies by race.

MATERIALS AND METHODS

Study participants were 2,109 women 40 to 69 years old randomly selected from an urban health maintenance organization and interviewed in person for a study of risk factors for urinary incontinence. The sample was racially diverse consisting of 48% white, 18% black, 17% Hispanic and 16% Asian-American women. In addition to incontinence, reproductive and medical history questionnaires, all participants completed the Medical Outcomes Study Short Form 36, a measure of health related quality of life. All participants with daily and weekly incontinence (29%) completed the Incontinence Impact Questionnaire, an incontinence specific quality of life measure. The health maintenance organization's inpatient and outpatient electronic databases were used to calculate a Charlson comorbidity index score for each participant. ANCOVA was used to produce a model adjusting for sociodemographic variables, comorbidity and incontinence frequency. The same model was run for each of 4 racial groupings to examine differences by race/ethnicity.

RESULTS

Urinary incontinence is significantly associated with a decreased quality of life and those with more frequent incontinence have significantly lower quality of life scores. In our model the Charlson score, an objective measure of comorbidity based on hospital and physician records, also has a significant negative impact on quality of life. When comorbidity is controlled, incontinence frequency continues to have a significant negative association with quality of life except among the sickest women. For women with the greatest extent of comorbidity, incontinence frequency is not significantly associated with negative quality of life outcomes. We did not find clear patterns of variation by race.

CONCLUSIONS

Urinary incontinence and comorbidity each have an independent and significant role in reducing quality of life outcomes for all but the sickest women.

Urinary incontinence and pelvic floor dysfunction in Asian-American women

OBJECTIVE

The objective of the study was to describe the prevalence, risk factors, and impact of urinary incontinence and other pelvic floor disorders among Asian-American women.

STUDY DESIGN

This was a population-based cohort study of older women randomly selected from age and race strata.

RESULTS

Weekly urinary incontinence was reported by 65 of 345 Asian women (18%), with stress and urge incontinence being approximately equally common. In multivariate analysis, higher body mass index (greater than 25 kg/m2) was associated with both stress incontinence (odds ratio 4.90, 95% confidence interval 1.76 to 13.68) and urge incontinence (odds ratio 2.49, 95% confidence interval 1.01 to 6.16) in Asians. Hysterectomy was a significant risk factor for stress incontinence (odds ratio 2.79, 95% confidence interval 1.03 to 7.54). Only 34% of Asian women with weekly urinary incontinence reported ever having sought treatment. Pelvic floor exercises were the most common form of treatment, being used by 29% of Asian women with weekly incontinence. Asians were less likely then white women to report anal incontinence (21% versus 29%, P = .007), although this difference became nonsignificant after adjusting for differences in risk factors.

CONCLUSION

Asian women share some risk factors for stress and urge urinary incontinence with white women. Urinary incontinence is associated with anal incontinence among Asian women.

Does weight loss improve incontinence in moderately obese women?

The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (+/-SD) baseline BMI of 38.3 (+/-10.1) kg/m2 and 13 (+/-10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (+/-6.2) kg/ m2 (P < 0.03). Among women achieving a weight loss of > or = 5%, 6/6 had > or = 50% reduction in incontinence frequency compared to 1 in 4 women with < 5% weight loss (P < 0.03). Incontinence episodes decreased to 8 (+/-10) per week following weight reduction (P < 0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.

Cost of pelvic organ prolapse surgery in the United States

OBJECTIVE

To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.

METHODS

We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.

RESULTS

In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.

CONCLUSION

The annual direct costs of operations for pelvic organ prolapse are substantial.

Annual direct cost of urinary incontinence

OBJECTIVE

To estimate the annual direct cost of urinary incontinence in 1995 US dollars.

METHODS

Epidemiologically based models using diagnostic and treatment algorithms from published clinical practice guidelines and current disease prevalence data were used to estimate direct costs of urinary incontinence. Prevalence and event probability estimates were obtained from literature sources, national data sets, small surveys, and expert opinion. Average national Medicare reimbursement was used to estimate costs, which were determined separately by gender, age group, and type of incontinence. Sensitivity analyses were performed on all variables.

RESULTS

The annual direct cost of urinary incontinence in the United States (in 1995 dollars) was estimated as $16.3 billion, including $12.4 billion (76%) for women and $3.8 billion (24%) for men. Costs for community-dwelling women ($8.6 billion, 69% of costs for women) were greater than for institutionalized women ($3.8 billion, 31%). Costs for women over 65 years of age were more than twice the costs for those under 65 years ($7.6 and $3.6 billion, respectively). The largest cost category was routine care (70% of costs for women), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and evaluations (1%). Costs were most sensitive to changes in incontinence prevalence, routine care costs, and institutionalization rates and costs.

CONCLUSION

Urinary incontinence is a very costly condition, with annual expenditures similar to other chronic diseases in women.

Measuring cost-effectiveness of surgical procedures

Our review of CEA of surgical procedures suggests that much of the existing cost analysis literature does not adhere to basic recommended analytic guidelines. However, those authors who specifically planned to perform a CEA analysis met all or nearly all of the methodologic principles (Table 1). Investigators who conduct CEA are strongly encouraged to use the many outstanding methodologic reviews for CEA. An example of threshold analysis was presented by Gray et al in their CEA of laparoscopy versus laparotomy for the treatment of ectopic pregnancy. They calculated that cost per successful treatment would be equal between the two strategies at an initial failure rate of 32% for laparoscopy (compared with their baseline value of 19%). This type of analysis is helpful, in addition to sensitivity analyses, to identify the value of a variable that results in an equal outcome. In the only cost-utility analysis performed on gynecologic surgery, Sculpher studied the trade-offs between a less invasive, less costly procedure (transcervical resection of the endometrium) with a more invasive, more costly, and more effective procedure (abdominal hysterectomy) to treat menorrhagia. Hysterectomy resulted in an incremental cost of 1,500 British pounds per QALY during 2 years of follow-up. This is much less than the range of $30,000 to $100,000 that represents a currently acceptable C/E ratio. Grover et al evaluated the cost-effectiveness of performing a concurrent hysterectomy in women undergoing bilateral salpingo-oophorectomy. They observed that in 45-year-old women, the additional concurrent procedure dominated the alternative strategy of bilateral salpingo-oophorectomy, being both less expensive and increasing average life expectancy. The concurrent hysterectomy strategy also dominated for women aged 55, but both with less cost-savings and gains in life expectancy compared with 45-year-old women. Selecting an appropriate time frame for the analysis is difficult and may dramatically affect the results of the analysis. The time frame should be long enough to measure all clinically relevant costs and benefits. For example, Kung et al compared the cost per cure of stress urinary incontinence of laparoscopic and open Burch procedures. The probability of cure after each procedure was estimated from a retrospective cohort of 62 women with a mean follow-up of 1.2 years for the laparoscopic Burch strategy and 2.7 years in the open Burch strategy. The authors found that the laparoscopic Burch dominated, with lower costs and a higher cure rate. However, the analysis would be more informative with much longer follow-up, because most women who undergo an incontinence procedure have a life expectancy far greater than 1 to 2 years. Ramsey et al performed an economic analysis to assess the long-term costs of behavioral therapy, pharmacotherapy, and surgical therapy used for stress urinary incontinence. They found that in the short-term, behavioral and pharmacotherapy were less costly. However, if life expectancy was equal to or greater than 3.5 years, surgical therapy was least costly. In many articles that evaluate the cost of managing ectopic pregnancy, only short-term costs of the procedures and follow-up visits are considered. Mol et al considered a longer time frame and also included the costs of infertility management based on the future probability of conception correlated with the different management strategies. Selection of an effectiveness measure after surgical intervention is often difficult and controversial. For benign disease, life years or QALYs will be minimally affected by a reasonably safe intervention. In the short-term, utility may be negatively affected by surgery and recovery. In longer-term analyses, these effects will be diluted by time and be negligible. Intermediate measures such as days of hospitalization averted or lives saved are often more appropriate for gynecologic interventions than are longer-term outcomes such as lif

Urge incontinence: the patient's perspective

Urge incontinence has a profound effect on the day-to-day lives of women. The purpose of this study was to identify specific aspects of functioning and well-being affected by urge incontinence or mixed incontinence with a primary urge component. We conducted six focus groups of 65 racially and age diverse, community-dwelling women with urge incontinence. Transcripts of the focus groups were quantitatively analyzed for word use frequency with QSR NUD*IST software. Demographics, symptomatology, and the impact of incontinence on daily activities and feelings were assessed by questionnaire. Participants in the focus groups were on average 62 years of age; 52% were nonwhite, and 26% had a high school or less education. In the three identified broad domains, 52% of domain-related words were associated with feelings, 40% with activities, and 8% with relationships. Frequently identified references were bathroom availability (24%), loss of control (14%), anxiety (11%), and sleep disturbance (10%). Women under the age of 70 compared with older women more commonly identified feeling unattractive and low self-esteem (12% versus 2%, p < 0.007) and adverse effects on dating and sexual activity (45% versus 0%, p < 0.02). The effect of incontinence on quality of life correlated with frequency, nocturia, and pad use (Kendall's tau beta 0.02-0.32, p < 0.05). Urge incontinence affects many quality of life issues and contributes to limitation of activities, loss of control, and negative self-perception. Focus groups of diverse women with urge incontinence symptomatology are useful in understanding these effects.

Preoperative staging of cervical carcinoma: phased array coil fast spin-echo versus body coil spin-echo T2-weighted MR imaging

OBJECTIVE

This study was performed to compare the diagnostic efficacy of MR imaging in the preoperative evaluation of invasive cervical cancer using the pelvic phased array coil in combination with fast spin-echo T2-weighted imaging and the body coil in combination with conventional spin-echo T2-weighted imaging.

MATERIALS AND METHODS

Ninety-four women (22-68 years old) with invasive cervical cancer underwent MR imaging (at 1.5 T) using a body coil conventional spin-echo protocol (n = 62) or a phased array coil fast spin-echo protocol (n = 32). Imaging preceded surgery by no more than 5 weeks. MR images were evaluated for tumor size, local stage, and nodal metastasis using surgical pathology as the standard of reference.

RESULTS

Overall staging accuracy for the body coil conventional spin-echo protocol (89%) was not significantly different from that of the phased array coil fast spin-echo protocol (91%). Both techniques also achieved similar accuracy in diagnosing parametrial invasion (95% versus 94%) and lymph node metastases (85% versus 91%) and in tumor sizing (correlation coefficient, .93 versus .94).

CONCLUSION

In the preoperative staging of cervical carcinoma by MR imaging, both the newer (phased array coil fast spin-echo protocol) and the older (body coil conventional spin-echo protocol) techniques achieved similarly high accuracies in local staging, assessment of parametrial invasion, and evaluation of tumor size. Decreased imaging time and increased image resolution are advantages of the newer technique, although in our series they did not increase staging accuracy.

Comparison of diagnostic studies in the pretreatment evaluation of stage Ib carcinoma of the cervix

The results of our study highlight the need for change in the pretreatment workup of clinical stage Ib cervical cancer. The routine use of excretory urography, barium enema, cystoscopy,and sigmoidoscopy is not justified. MR evaluation is recommended in patients with lesions larger than 2 cm (the group with the greatest increase in predictive value). Although CT scanning is not recommended for the evaluation of parametrial invasion, both CT scanning and MR imaging provide similar positive and negative posttest probabilities for the evaluation of nodal disease.

Invasive cervical carcinoma: role of MR imaging in pretreatment work-up--cost minimization and diagnostic efficacy analysis

PURPOSE

To examine the cost and efficacy of diagnostic work-up in patients with invasive cervical cancer.

MATERIALS AND METHODS

In 246 patients with invasive cervical cancer, all diagnostic tests performed before treatment were recorded. Patients were divided into two groups: those who underwent magnetic resonance (MR) imaging as the initial study (n = 105) and those who did not (n = 141). A list of 1995 Medicare global payments was used to measure cost. Bayesian analysis (likelihood ratios derived from a literature search) was performed for bladder, rectal, parameterial, and nodal involvement in stage Ib disease.

RESULTS

Significantly fewer procedures and fewer invasive studies were performed in the MR imaging group. Net cost savings for the MR imaging group was $401 for all patients and $449 for patients with stage Ib disease. For stage Ib disease, the 0% pretest probability of bladder or rectal invasion does not justify the routine use of barium enema examination, cystoscopy, or proctoscopy. The increase in predictive values for parameterial and nodal disease was highest for MR imaging when tumor size was at least 2 cm.

CONCLUSION

Guidelines for the pretreatment work-up of clinical stage Ib cervical cancer need revision. MR imaging should be used as an adjunct to clinical evaluation.

Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging

OBJECTIVE

To assess the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of invasive cervical cancer.

METHODS

Seventy-nine women with untreated cervical cancer underwent pre-treatment MRI (n = 71) and/or CT (n = 37) within 4 weeks of surgical evaluation. Twenty-nine women had both MRI and CT. Images were evaluated for tumor detection, size, stromal invasion, local extension, and nodal metastases.

RESULTS

Tumor size was evaluated accurately by MRI, with a correlation coefficient of 0.93. Magnetic resonance estimates of tumor size were within 0.5 cm of the surgical sample in 64 of 69 women (93%). Magnetic resonance was 88% accurate evaluating the presence of stromal invasion and 78% accurate for depth of stromal invasion. Computed tomography could not evaluate tumor size or stromal invasion because it could not distinguish cancer from the surrounding normal cervical tissue. In evaluating stage of disease, MRI had an accuracy of 90%, compared with 65% for CT (P < .005). Magnetic resonance imaging was more accurate than CT (94 versus 76%, P < .005) in assessing parametrial invasion. Both modalities were comparable in evaluating lymph node metastases (86% each). In determining operative candidates (stage I and minimal IIA), MRI was 94% accurate, compared with 76% for CT (P < .005).

CONCLUSION

Compared with CT, MRI offered significantly improved evaluation of tumor size, stromal invasion, and local and regional extent of disease in pre-treatment imaging for cervical cancer.

Therapeutic donor insemination: a prospective randomized trial of fresh versus frozen sperm

OBJECTIVE

We evaluated the efficacy of fresh versus frozen sperm in therapeutic donor insemination.

STUDY DESIGN

Fifty-seven women underwent 72 courses of treatment (a maximum of six therapeutic donor insemination cycles--three fresh and three frozen) totaling 198 cycles. Each woman served as her own control and was prospectively randomized to receive a single, timed insemination of either fresh or frozen sperm.

RESULTS

Fecundity was 20.6% for fresh sperm cycles and 9.4% for frozen (p less than 0.03, by chi 2 analysis). Fresh cervical cap insemination fecundity was 20.3%; frozen was 7.8% (p less than 0.03, by chi 2 analysis). Fresh intrauterine insemination fecundity was 21.2%; frozen was 15.8% (p = 0.63, by chi 2 analysis). Fresh 3-month life-table pregnancy rates were 48% +/- 10%; frozen rates were 22% +/- 8% (p = 0.05 by Breslow analysis). Survival analysis with fixed covariates showed a positive association with the use of fresh sperm (p = 0.04).

CONCLUSION

Cycle fecundity was significantly greater with fresh sperm in women undergoing cervical cap insemination or intrauterine insemination and in women undergoing only cervical cap insemination. These results have important implications for contemporary management of patients undergoing therapeutic donor insemination with frozen sperm.

Comparison of CO2 laser laparoscopy with laparotomy for treatment of endometriomata

OBJECTIVE

To assess the effectiveness of laparoscopy versus laparotomy in the treatment of endometriomata.

DESIGN

Controlled study using data prospectively tabulated.

SETTING

Treatment performed by senior author in a referral reproductive endocrinology and surgery private practice.

PATIENTS

One hundred infertile women were diagnosed with endometriomata.

INTERVENTION

Forty-eight women were treated with CO2 laser laparoscopy (laparoscopy group) and 52 women were treated with CO2 laser or nonlaser laparotomy (laparotomy group).

MAIN OUTCOME MEASURE

The hypothesis that laparoscopy group pregnancy rates (PRs) would be equal to or greater than laparotomy group was formulated before data analysis but after data tabulation.

RESULTS

The 1 and 3-year life table estimated cumulative PRs +/- SE were 0.30 +/- 0.07 and 0.52 +/- 0.09 for laparoscopy group and 0.23 +/- 0.06 and 0.46 +/- 0.09 for laparotomy group (Breslow P = 0.48). Monthly fecundity over 3 years was 2.4% for laparoscopy group and 2.0% for laparotomy group.

CONCLUSIONS

Laparoscopy with CO2 laser can be a safe and effective modality for treating endometriomata.

Failure of intrauterine insemination in a refractory infertility population

Intrauterine insemination by itself for multiple and/or severe infertility factors had no benefit over cervical cap with whole ejaculate or coitus in this study. The PRs for IUI and cervical cap with whole ejaculate or coitus were similar and low, suggesting that IUI by itself has limited, if any, utility in enhancing PRs in this type of infertility population. Couples attempting IUI should be advised about the low probability of achieving pregnancy. Ovulation stimulation and/or heterologous donor insemination, IVF, or gamete intrafallopian transfer may be beneficial therapeutic options.

Analgesia after cesarean delivery: patient evaluations and costs of five opioid techniques

The study was designed to compare five opioid analgesic regimens administered after cesarean delivery in a routine hospital setting with respect to patients' perceptions of their pain relief and the impact of analgesic technique on recovery and hospital costs. After cesarean delivery, 684 patients received one of the following: epidural morphine, alone (EM,n = 128), or with fentanyl (EM + F,n = 245); subarachnoid morphine (n = 48); intramuscular meperidine (n = 165), or patient-controlled analgesia using meperidine (PCA, n = 98). On the first three postoperative days (Days 1-3; day of operation is Day 1) patients were surveyed regarding their impressions of their analgesia, the incidence of side effects, times to resume normal activities and satisfaction with their technique. Information regarding drug interventions and costs was obtained from anesthetic records and nursing charts. Patients receiving intramuscular and PCA opioids reported significantly more severe pain during the first 16 hours than those receiving intraspinal opioids (p less than 0.05); differences were minimal for the remainder of Day 1. Among the intraspinal groups, analgesia was best overall with EM; specifically, fentanyl did not decrease early postoperative pain. Analgesia with PCA and intramuscular opioids was similar during the first 16 hours; however, PCA patients felt they had less pain thereafter. Side effects were common in all intraspinal groups and were least frequent with PCA (p less than 0.05 versus all intraspinal groups). Times to sit, walk and drink were similar in all patients except those receiving intramuscular opioids after general anesthesia, who experienced a several-hour delay. Other aspects of recovery did not differ among the groups. Satisfaction parallelled pain relief and was better with intraspinal than with systemic opioids. Costs were greatest with PCA, although differences were small (less than 1%) relative to total hospital charges.

Improved prediction of postovulatory day using temperature recording, endometrial biopsy, and serum progesterone

The use of basal body temperature (BBT) recording and a single progesterone (P) level at the time of the endometrial biopsy in the late luteal phase improved our ability to predict the onset of the next menstrual period (NMP) and determine the postovulatory day (POD) in 124 regularly menstruating infertile women. We determined BBT shift using a microcomputer program, analyzed P levels by radioimmunoassay, and evaluated endometrial biopsies both prospectively (blinded) and retrospectively (with knowledge of the other variables). Serum P levels were within the normal range for the luteal phase and prospective and retrospective histological diagnoses closely agreed (82% within 2 days). The best correlation with the NMP was the BBT shift (r = 0.493) followed by P (r = 0.426) and prospective histologic dating (r = 0.390). Multiple regression analysis confirmed that use of all of the variables markedly improved the ability to estimate the POD (R2 = 0.51).

Laparoscopic CO2 laser vaporization of endometriosis compared with traditional treatments

This study reports on 108 infertile patients with endometriosis diagnosed at laparoscopy. Sixty-four patients had endometriosis and adhesions vaporized with a CO2 laser (LAS) and were prospectively compared with a control group (CON) of 44 patients who had laparoscopy. The 6- and 12-month estimated cumulative pregnancy rates for LAS were 0.32 +/- 0.07 and 0.55 +/- 0.09 respectively, and for CON 0.17 +/- 0.06 and 0.43 +/- 0.09 (Breslow P = 0.10). Monthly fecundity rates were 6.7% in LAS and 4.5% in CON. Survival analysis with fixed covariates showed that pregnancy rates were increased in patients with adhesions (P = 0.002) and other pelvic disease (P = 0.0001). Pregnancy rates were reduced by age (P = 0.02), previous adhesiolysis (P = 0.0000) and post-laparoscopy medical treatment (P = 0.0002). Our findings indicate that CO2 laser laparoscopy vaporization of endometriosis can be a safe, effective, and possibly improved modality for treating endometriosis.

Cost-effectiveness of splenectomy versus intravenous gamma globulin in treatment of chronic immune thrombocytopenic purpura in childhood

Infusions of intravenous gamma-globulin (IVGG) are an effective, nontoxic therapy for chronic idiopathic thrombocytopenic purpura (ITP) that would be more widely accepted if the therapeutic agent were not so expensive. The costs and outcomes of managing such children with splenectomy and IVGG were modeled with Markov processes. Children unresponsive to one treatment were considered to have received the alternative. The model accounted for spontaneous remissions, therapeutic responses, traumatic events, episodes of sepsis, and operative deaths. For a 10-year-old child with chronic ITP, the strategy of initial treatment with splenectomy had associated costs of $17,000 and a 97.9% ten-year survival rate, whereas the strategy of initial treatment with IVGG had associated costs of $21,000 but a 98.6% survival rate. Each additional life saved by employing the IVGG strategy cost $540,000, or $8,000 per year for a life expectancy of 70 years. Sensitivity analyses demonstrated that for older children the IVGG strategy continued to result in improved survival rates but was more costly than the splenectomy strategy. For younger children, the IVGG strategy dominated, with improved survival rates and lower costs.