Evaluating the Preferences and Willingness-to-Pay for Oral Antidiabetic Drugs Among Patients with Type 2 Diabetes Mellitus in China: A Discrete Choice Experiment

PURPOSE

To quantify the preferences for an oral antidiabetic drug (OAD) among patients with type 2 diabetes mellitus (T2DM) in China.

METHODS

A discrete choice experiment (DCE) with hypothetical OAD profiles was performed among patients with T2DM recruited from both online and offline sources. Each patient completed 12 DCE choice tasks. The attributes, elicited through mixed methods, include blood glucose level decrease, blood glucose level stability, frequency of medication, gastrointestinal side effects, dose adjustment and out-of-pocket expense. The conditional logit regression model was used to analyze the data. Patients' willingness-to-pay (WTP) was also calculated. Subgroup analyses based on patient characteristics were also conducted.

RESULTS

A total of 741 respondents were included in the analysis sample, covering 456 respondents online and 285 offline. The result showed that all attributes and levels were statistically significant, except one level "dose adjustment required for patients with hepatic or renal insufficiency" in the attribute of dose adjustment. WTP results showed that patients were willing to pay 12.06 and 23.20 yuan, respectively to reduce the frequency of medication from "once per day" and "three times per day" to "once every 2 weeks", respectively. Subgroup analyses showed that the frequency of medication (once versus two to three times per day) had the largest impact and influenced most coefficient estimates.

CONCLUSION

The results suggest that Chinese patients with T2DM prioritized better efficacy, less frequency of medication, lower gastrointestinal side effects, no dose adjustment required for patients with hepatic or renal insufficiency, and less out-of-pocket expense of OAD treatment.

Characteristics of health-state utilities used in cost-effectiveness analyses: a systematic review of published studies in Asia

INTRODUCTION

Cost-utility analysis (CUA) is the preferred form of economic evaluation in many countries. As one of the key data inputs in cost-utility models, health state utility (HSU) has a crucial impact on CUA results. In the past decades, health technology assessment has been expanding rapidly in Asia, yet research examining the methodology and process used to generate cost-effectiveness evidence is scarce. The aim of this study was to examine the reporting of the characteristics of HSU data used in CUAs in Asia and how the characteristics have changed over time.

METHODS

A systematic literature search was performed to identify published CUA studies targeting Asian populations. Information was extracted for both the general characteristics of selected studies and the characteristics of reported HSU data. For each HSU value identified, we extracted data for four key characteristics, including 1) estimation method; 2) source of health-related quality of life (HRQoL) data; 3) source of preference data; and 4) sample size. The percentage of nonreporting was calculated and compared over two time periods (1990-2010 vs 2011-2020).

RESULTS

A total of 789 studies were included and 4,052 HSUs were identified. Of these HSUs, 3,351 (82.7%) were from published literature and 656 (16.2%) were from unpublished empirical data. Overall, the characteristics of HSU data were not reported in more than 80% of the studies. Of HSUs whose characteristics were reported, most of them were estimated using the EQ-5D (55.7%), Asian HRQoL data (91.9%), and Asian health preferences (87.7%); 45.7% of the HSUs was estimated with a sample of 100 or more individuals. All four characteristics showed improvements after 2010.

CONCLUSION

Over the past two decades, there has been a significant increase in CUA studies targeting Asian populations. However, HSU's characteristics were not reported in most of the CUA studies, making it difficult to evaluate the quality and appropriateness of the HSUs used in those cost-effectiveness studies.

Estimating a social value set for EQ-5D-5L in Sweden

BACKGROUND

The study aims to elicit a value set based on the EQ-VT for the EQ-5D-5L that can be used to support decision-making in Sweden.

METHODS

Participants were recruited from the general population based on age, sex and urban/rural area quota sampling from five regions across Sweden. In total, 785 interviews were conducted from February 2020 to April 2021 using the EQVT 2.1 protocol, and both composite time trade-off (c-TTO) and discrete choice experiments (DCE) were used to elicit health preferences. A variety of models have been tested for the c-TTO data (generalized least square, Tobit, heteroskedastic models) and DCE data (conditional logit model), as well as the combined c-TTO and DCE data (hybrid modelling). Model selection was based on theoretical considerations, logical consistency of the parameter estimates, and significance of the parameters (p = 0.05). Model goodness-of-fit was assessed by AIC and BIC, and prediction accuracy was assessed in terms of mean absolute error. The predictions for the EQ-5D-5L health states between models were compared using scatterplots.

RESULTS

The preferred model for generating the value set was the heteroskedastic model based on the c-TTO data, with the health utilities ranging from -0.31 for the worst (55,555) to 1 for the best (11111) EQ-5D-5L states.

CONCLUSION

This is the first c-TTO-based social value set for the EQ-5D-5L in Sweden. It can be used to support the health utility estimation in economic evaluations for reimbursement decision making in Sweden.

Cost-effectiveness of brentuximab vedotin for relapsed or refractory systemic anaplastic large-cell lymphoma in China

OBJECTIVES

Systemic anaplastic large-cell lymphoma (sALCL) is a rare hematological malignancy with poor prognosis, which is associated with a significant economic burden. This study aimed to evaluate the cost-effectiveness of brentuximab vedotin (BV) in comparison to conventional chemotherapy in patients with relapsed/refractory sALCL, from a Chinese healthcare perspective.

METHODS

A partitioned survival model with three health states (progression-free survival, post-progression survival, and death) was adapted to compare BV against chemotherapy. Comparator represented a basket of commonly used chemotherapies in China. Two cohorts in each arm were estimated, representing patients receiving no transplant and autologous stem cell transplant (ASCT) after BV or chemotherapy. Clinical data was obtained from the pivotal phase-II trial (NCT00866047) for BV and also from the literature for a comparator. Resource use items covered drug acquisition and administration; concomitant medications; ASCT; treatment of adverse events; and long-term follow-up. Cost parameters were based on Chinese sources. Outcomes were measured in quality-adjusted life-years (QALYs). Both costs and effects were discounted at 5% according to Chinese guidelines. The impact of uncertainty was evaluated using deterministic and probabilistic sensitivity analyses.

RESULTS

The incremental cost-effectiveness ratio (ICER) for BV vs. chemotherapy was $9,610 (¥62,084) per QALY in the base case. The main model driver was superior progression-free and overall survival benefits of BV. The ICERs were relatively robust in the majority of sensitivity analyses, ranging around ±10% of the base case. Under the conventional decision thresholds (1-3 times of Chinese per capita GDP), the probability of BV being cost-effective ranged from 56 to 100%. Limitations of the study included the lack of comparative data from the trial and the small and heterogeneous sample due to its disease nature.

CONCLUSIONS

BV may be a cost-effective treatment vs. chemotherapy in treating relapsed or refractory systemic anaplastic large-cell lymphoma in China.

Comparison of the EQ-5D-5L and the EQ-5D-3L using individual patient data from the REFORM trial

Background: This study compares the 5-level version of the EQ-5D (5L) with the 3-level version EQ-5D (3L) in older adults using individual patient data from the REFORM (REducing Falls with Orthoses and a Multifaceted podiatry intervention) trial. Methods: EQ-5D-5L and EQ-5D-3L were administered to men and women (n=151) over the age of 65 years alongside the REFORM trial. The two versions of the EQ-5D were assessed in terms of feasibility, level of consistency, ceiling effect and discriminatory power. We also undertook a comparison of the performance of different EQ-5D-3L and EQ-5D-5L value sets. Results: The proportion of participants that returned a complete questionnaire was higher for the 5L (96.7%) than for the 3L (92.7%). Missing values among dimensions were on average 1.59% (5L) and 1.45% (3L). The ceiling effect was reduced from 18.2% (3L) to 6% (5L). On average the proportion of inconsistent responses between both descriptive systems was 3.25%. Redistribution from 3L to 5L showed valid results for the majority of consistent level combinations, with slight inconsistency in the case of Anxiety/Depression. For the 5L, 67 unique health states were observed for the 5L compared to 27 for the 3L. The absolute informatively improved with the new classification system (5.48 for 5L versus 3.91 for 3L) and relative discriminatory power improved slightly on average (0.90 for 5L versus 0.84 for 3L). The mean difference between the EQ-5D-5L and EQ-5D-3L values was 0.091 (range -0.345 to 0.505); whilst the mean difference between the EQ-5D-5L and the crosswalk values was 0.082 (range -0.035 to 0.293). Conclusion: In the REFORM clinical trial involving an elderly population, our study supported the feasibility and convergent validity of both EQ-5D-3L and EQ-5D-5L. Results suggest that the 5L improves the ceiling effect and discriminatory power. The EQ-5D-5L scores were significantly higher than both EQ-5D-3L and crosswalk.

Mortality Prediction of the CHA2DS2-VASc Score, the HAS-BLED Score, and Their Combination in Anticoagulated Patients with Atrial Fibrillation

Background and Objectives: Atrial fibrillation (AF) is associated with increased mortality, predictors of which are poorly characterized. We investigated the predictive power of the commonly used CHA₂DS₂-VASc score (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65–75 years, sex category [female]), the HAS-BLED score (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly [age ≥ 65 years], drugs/alcohol concomitantly), and their combination for mortality in AF patients. Methods: The PREvention oF thromboembolic events—European Registry in Atrial Fibrillation (PREFER in AF) was a prospective registry including AF patients across seven European countries. We used logistic regression to analyze the relationship between the CHA₂DS₂-VASc and HAS-BLED scores and outcomes, including mortality, at one year. We evaluated the performance of logistic regression models by discrimination measures (C-index and DeLong test) and calibration measures (Hosmer and Lemeshow goodness-of-fit and integrated discrimination improvement (IDI), with bootstrap techniques for internal validation. Results: In 5209 AF patients with complete information on both scores, average one-year mortality was 3.1%. We found strong gradients between stroke/systemic embolic events (SSE), major bleeding and—specifically—mortality for both CHA₂DS₂-VASc and HAS-BLED scores, with a similar C-statistic for event prediction. The predictive power of the models with both scores combined, removing overlapping components, was significantly enhanced (p < 0.01) compared to models including either CHA₂DS₂-VASc or HAS-BLED alone: for mortality, C-statistic: 0.740, compared to 0.707 for CHA₂DS₂-VASc or 0.646 for HAS-BLED alone. IDI analyses supported the significant improvement for the combined score model compared to separate score models for all outcomes. Conclusions: Both the CHA₂DS₂-VASc and the HAS-BLED scores predict mortality similarly in patients with AF, and a combination of their components increases prediction significantly. Such combination may be useful for investigational and—possibly—also clinical purposes.

Deep Vein Thrombosis in Europe-Health-Related Quality of Life and Mortality

Objectives:

Deep vein thrombosis (DVT) is a major health-care burden in Europe, but exact estimates are lacking. This study reports results from the PREFER venous thromboembolism (VTE) study concerning health-related quality of life (HrQoL) and mortality of patients with DVT.

Methods:

PREFER VTE was a prospective, observational study, conducted in 7 European countries, designed to provide data concerning treatment patterns, resource utilization, mortality, and QoL. First-time or recurrent patients with DVT were followed at 1, 3, 6, and 12 months. Health-related QoL—as measured by the EuroQoL 5-Dimension 5-Level instrument ( EQ-5D-5L)—was analyzed using Tobit regression with repeated measures, assessing the impact of baseline characteristics stratified by cancer activity. Mortality was analyzed using logistic regression.

Results:

At baseline, patients with DVT had a 0.14 lower EQ-5D-5L index score (0.72 for total sample) compared to the reference UK population (0.85). The EQ-5D-5L index score improved from baseline to 12 months in patients with active cancer (from 0.70 to 0.79) and those without (0.72-0.87); 7.3% died within a year, a 5.2% excess mortality compared to the age- and gender-adfjusted general population. The 12-month mortality rate of DVT varied between 2.9% in the pooled data from Germany, Switzerland, or Austria and 15.4% in Italy. Furthermore, the mortality rate differed between patients with active cancer and those without (42.9% vs 4.7%).

Conclusions:

Deep vein thrombosis is associated with a substantial burden of illness in terms of HrQoL at baseline, which following treatment normalizes after 12 months and has a significant mortality rate. In addition, active cancer has a significant impact on mortality and the HrQoL of patients with DVT.

Measurement Properties of Commonly Used Generic Preference-Based Measures in East and South-East Asia: A Systematic Review

OBJECTIVES

Our aim was to systematically review published evidence on the construct validity, test-retest reliability and responsiveness of generic preference-based measures (PBMs) used in East and South-East Asia.

METHODS

This systematic review was guided by the COSMIN guideline. A literature search on the MEDLINE, EMBASE, PsycINFO and PubMed databases up to August 2019 was conducted for measurement properties validation papers of the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), Health Utilities Index (HUI), Quality of Well-Being (QWB), 15-Dimensional (15D) and Assessment of Quality of Life (AQOL) in East and South-East Asian countries. Included papers were disaggregated into individual studies whose results and quality of design were rated separately. The population-specific measurement properties (construct validity, test-retest reliability and responsiveness) of each PBM were assessed separately using relevant studies. The overall methodological quality of the studies used in each of the assessments was also rated.

RESULTS

A total of 79 papers containing 1504 studies were included in this systematic review. The methodological quality was 'very good' or 'adequate' for the majority of the construct validity studies (99%) and responsiveness studies (61%), but for only a small portion of the test-retest reliability studies (23%). EQ-5D was most widely assessed and was found to have 'sufficient' construct validity and responsiveness in many populations, while the SF-6D and EuroQol-Visual Analog Scale (EQ-VAS) exhibited 'inconsistent' construct validity in some populations. Scarce evidence was available on HUI and QWB, but current evidence supported the use of HUI.

CONCLUSIONS

This systematic review provides a summary of the quality of existing generic PBMs in Asian populations. The current evidence supports the use of EQ-5D as the preferred choice when a generic PBM is needed, and continuous testing of all PBMs in the region.

Pulmonary embolism in Europe - Burden of illness in relationship to healthcare resource utilization and return to work

OBJECTIVES

Pulmonary embolism (PE) is associated with a substantial economic burden. However evidence from patients in Europe is scarce. The aim of this study was to report the impacts of PE on healthcare resource utilization (HCRU) and return to work using the PREFER in VTE registry.

METHODS

The PREFER in VTE registry was a prospective, observational, multicenter study in seven European countries, aiming to provide data concerning treatment patterns, HCRU, mortality, quality of life and work-loss. Patients with a first-time or recurrent PE were included and followed up at 1, 3, 6 and 12 months. Treatment patterns, re-hospitalization rates, length of hospital stays (LOS), and ambulatory/office visits, as well as proportion of patients returning to work, were assessed. Subgroups by country and with/without active cancer were examined separately. Zero-inflated negative binomial and Cox regression were applied to investigate the relationship between baseline characteristics and LOS and return to work, respectively.

RESULTS

Amongst 1399 patients with PE, 53.2% were male and the average age was 62.3 ± 17.1 years old. Overall, patients were treated with combinations of heparin, vitamin K antagonists (VKA) and the non-VKA oral anticoagulants (NOACs) (50.0% treated with the combination of heparin with VKA). Patients with active cancer were primarily treated with heparin (84.9%). NOACs were used more frequently in DACH (Germany, Austria and Switzerland) and France (55.2% and 32.6%) compared to Italy and Spain (4.5% and 6.1%). The VTE-related re-hospitalization rate within 12 months and the average LOS varied substantially between countries, from 26.2% in UK to 12.3% in France, and from 12.9 days in Italy to 3.9 days in France. PE patients were often co-managed by general practitioners in France and DACH (>84%), and less frequently in other countries (<47%). The regression results confirmed the country variation of HCRU. Of the employed patients (n = 385), 60% returned to work at 1 month but 27.8% had not after one year. PE patients with DVT were more likely to return to work. Active cancer was a significant predictor for not returning to work, as well as smoking history.

CONCLUSIONS

Medical treatment of PE differed between patients with active cancer and patients without active cancer. VTE-related resource utilization differed markedly between countries. While the reported 'not return to work' was high for patients with PE, this may at least in part reflect the presence of co-morbidities such as cancer.

Cost-effectiveness analysis of exenatide once-weekly versus dulaglutide, liraglutide, and lixisenatide for the treatment of type 2 diabetes mellitus: an analysis from the UK NHS perspective

OBJECTIVE

To assess the cost-effectiveness of exenatide 2 mg once-weekly (EQW) compared to dulaglutide 1.5 mg QW, liraglutide 1.2 mg and 1.8 mg once-daily (QD), and lixisenatide 20 μg QD for the treatment of adult patients with type 2 diabetes mellitus (T2DM) not adequately controlled on metformin.

METHODS

The Cardiff Diabetes Model was applied to evaluate cost-effectiveness, with treatment effects sourced from a network meta-analysis. Quality-adjusted life years (QALYs) were calculated with health-state utilities applied to T2DM-related complications, weight changes, hypoglycemia, and nausea. Costs (GBP £) included drug treatment, T2DM-related complications, severe hypoglycemia, nausea, and treatment discontinuation due to adverse events. A 40-year time horizon was used.

RESULTS

In all base-case comparisons, EQW was associated with a QALY gain per patient; 0.046 vs dulaglutide 1.5 mg; 0.102 vs liraglutide 1.2 mg; 0.043 vs liraglutide 1.8 mg; and 0.074 vs lixisenatide 20 μg. Cost per patient was lower for EQW than for liraglutide 1.8 mg (-£2,085); therefore, EQW dominated liraglutide 1.8 mg. The cost difference per patient between EQW and dulaglutide 1.5 mg, EQW and liraglutide 1.2 mg, and EQW and lixisenatide 20 μg was £27, £103, and £738, respectively. Cost per QALY gained with EQW vs dulaglutide 1.5 mg, EQW vs liraglutide 1.2 mg, and EQW vs lixisenatide 20 μg was £596, £1,004, and £10,002, respectively. In the probabilistic sensitivity analysis, the probability that EQW is cost-effective ranged from 76-99%.

CONCLUSION

Results suggest that exenatide 2 mg once-weekly is cost-effective over a lifetime horizon compared to dulaglutide 1.5 mg QW, liraglutide 1.2 mg QD, liraglutide 1.8 mg QD, and lixisenatide 20 μg QD for the treatment of T2DM in adults not adequately controlled on metformin alone.

The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults

BACKGROUND

Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults.

DESIGN

A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years.

SETTING

Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation.

PARTICIPANTS

Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck.

INTERVENTIONS

The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups.

MAIN OUTCOME MEASURES

The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected.

RESULTS

The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses.

CONCLUSIONS

Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50850043.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.

VenUS IV (Venous leg Ulcer Study IV) - compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model

BACKGROUND

Compression is an effective and recommended treatment for venous leg ulcers. Although the four-layer bandage (4LB) is regarded as the gold standard compression system, it is recognised that the amount of compression delivered might be compromised by poor application technique. Also the bulky nature of the bandages might reduce ankle or leg mobility and make the wearing of shoes difficult. Two-layer compression hosiery systems are now available for the treatment of venous leg ulcers. Two-layer hosiery (HH) may be advantageous, as it has reduced bulk, which might enhance ankle or leg mobility and patient adherence. Some patients can also remove and reapply two-layer hosiery, which may encourage self-management and could reduce costs. However, little robust evidence exists about the effectiveness of two-layer hosiery for ulcer healing and no previous trials have compared two-layer hosiery delivering 'high' compression with the 4LB.

OBJECTIVES

Part I To compare the clinical effectiveness and cost-effectiveness of HH and 4LB in terms of time to complete healing of venous leg ulcers. Part II To synthesise the relative effectiveness evidence (for ulcer healing) of high-compression treatments for venous leg ulcers using a mixed-treatment comparison (MTC). Part III To construct a decision-analytic model to assess the cost-effectiveness of high-compression treatments for venous leg ulcers.

DESIGN

Part I A multicentred, pragmatic, two-arm, parallel, open randomised controlled trial (RCT) with an economic evaluation. Part II MTC using all relevant RCT data - including Venous leg Ulcer Study IV (VenUS IV). Part III A decision-analytic Markov model.

SETTINGS

Part I Community nurse teams or services, general practitioner practices, leg ulcer clinics, tissue viability clinics or services and wound clinics within England and Northern Ireland.

PARTICIPANTS

Part I Patients aged ≥ 18 years with a venous leg ulcer, who were willing and able to tolerate high compression.

INTERVENTIONS

Part I Participants in the intervention group received HH. The control group received the 4LB, which was applied according to standard practice. Both treatments are designed to deliver 40 mmHg of compression at the ankle. Part II and III All relevant high-compression treatments including HH, the 4LB and the two-layer bandage (2LB).

MAIN OUTCOME MEASURES

Part I The primary outcome measure was time to healing of the reference ulcer (blinded assessment). Part II Time to ulcer healing. Part III Quality-adjusted life-years (QALYs) and costs.

RESULTS

Part I A total of 457 participants were recruited. There was no evidence of a difference in time to healing of the reference ulcer between groups in an adjusted analysis [hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.79 to 1.25; p = 0.96]. Time to ulcer recurrence was significantly shorter in the 4LB group (HR = 0.56, 95% CI 0.33 to 0.94; p = 0.026). In terms of cost-effectiveness, using QALYs as the measure of benefit, HH had a > 95% probability of being the most cost-effective treatment based on the within-trial analysis. Part II The MTC suggests that the 2LB has the highest probability of ulcer healing compared with other high-compression treatments. However, this evidence is categorised as low to very low quality. Part III Results suggested that the 2LB had the highest probability of being the most cost-effective high-compression treatment for venous leg ulcers.

CONCLUSIONS

Trial data from VenUS IV found no evidence of a difference in venous ulcer healing between HH and the 4LB. HH may reduce ulcer recurrence rates compared with the 4LB and be a cost-effective treatment. When all available high-compression treatments were considered, the 2LB had the highest probability of being clinically effective and cost-effective. However, the underpinning evidence was sparse and more research is needed. Further research should thus focus on establishing, in a high-quality trial, the effectiveness of this compression system in particular.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49373072.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 57. See the NIHR Journals Library website for further project information.

Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial

IMPORTANCE

The need for surgery for the majority of patients with displaced proximal humeral fractures is unclear, but its use is increasing.

OBJECTIVE

To evaluate the clinical effectiveness of surgical vs nonsurgical treatment for adults with displaced fractures of the proximal humerus involving the surgical neck.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic, multicenter, parallel-group, randomized clinical trial, the Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) trial, recruited 250 patients aged 16 years or older (mean age, 66 years [range, 24-92 years]; 192 [77%] were female; and 249 [99.6%] were white) who presented at the orthopedic departments of 32 acute UK National Health Service hospitals between September 2008 and April 2011 within 3 weeks after sustaining a displaced fracture of the proximal humerus involving the surgical neck. Patients were followed up for 2 years (up to April 2013) and 215 had complete follow-up data. The data for 231 patients (114 in surgical group and 117 in nonsurgical group) were included in the primary analysis.

INTERVENTIONS

Fracture fixation or humeral head replacement were performed by surgeons experienced in these techniques. Nonsurgical treatment was sling immobilization. Standardized outpatient and community-based rehabilitation was provided to both groups.

MAIN OUTCOMES AND MEASURES

Primary outcome was the Oxford Shoulder Score (range, 0-48; higher scores indicate better outcomes) assessed during a 2-year period, with assessment and data collection at 6, 12, and 24 months. Sample size was based on a minimal clinically important difference of 5 points for the Oxford Shoulder Score. Secondary outcomes were the Short-Form 12 (SF-12), complications, subsequent therapy, and mortality.

RESULTS

There was no significant mean treatment group difference in the Oxford Shoulder Score averaged over 2 years (39.07 points for the surgical group vs 38.32 points for the nonsurgical group; difference of 0.75 points [95% CI, -1.33 to 2.84 points]; P = .48) or at individual time points. There were also no significant between-group differences over 2 years in the mean SF-12 physical component score (surgical group: 1.77 points higher [95% CI, -0.84 to 4.39 points]; P = .18); the mean SF-12 mental component score (surgical group: 1.28 points lower [95% CI, -3.80 to 1.23 points]; P = .32); complications related to surgery or shoulder fracture (30 patients in surgical group vs 23 patients in nonsurgical group; P = .28), requiring secondary surgery to the shoulder (11 patients in both groups), and increased or new shoulder-related therapy (7 patients vs 4 patients, respectively; P = .58); and mortality (9 patients vs 5 patients; P = .27). Ten medical complications (2 cardiovascular events, 2 respiratory events, 2 gastrointestinal events, and 4 others) occurred in the surgical group during the postoperative hospital stay.

CONCLUSIONS AND RELEVANCE

Among patients with displaced proximal humeral fractures involving the surgical neck, there was no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years following fracture occurrence. These results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus.

TRIAL REGISTRATION

isrctn.com Identifier: ISRCTN50850043.

Network meta-analysis of (individual patient) time to event data alongside (aggregate) count data

BACKGROUND

Network meta-analysis methods extend the standard pair-wise framework to allow simultaneous comparison of multiple interventions in a single statistical model. Despite published work on network meta-analysis mainly focussing on the synthesis of aggregate data, methods have been developed that allow the use of individual patient-level data specifically when outcomes are dichotomous or continuous. This paper focuses on the synthesis of individual patient-level and summary time to event data, motivated by a real data example looking at the effectiveness of high compression treatments on the healing of venous leg ulcers.

METHODS

This paper introduces a novel network meta-analysis modelling approach that allows individual patient-level (time to event with censoring) and summary-level data (event count for a given follow-up time) to be synthesised jointly by assuming an underlying, common, distribution of time to healing. Alternative model assumptions were tested within the motivating example. Model fit and adequacy measures were used to compare and select models.

RESULTS

Due to the availability of individual patient-level data in our example we were able to use a Weibull distribution to describe time to healing; otherwise, we would have been limited to specifying a uniparametric distribution. Absolute effectiveness estimates were more sensitive than relative effectiveness estimates to a range of alternative specifications for the model.

CONCLUSIONS

The synthesis of time to event data considering individual patient-level data provides modelling flexibility, and can be particularly important when absolute effectiveness estimates, and not just relative effect estimates, are of interest.

Comparative responsiveness and minimal change of the Knee Quality of Life 26-item (KQoL-26) questionnaire

OBJECTIVES

To assess the responsiveness of the KQoL-26 and demonstrate minimal change for this instrument in two different samples of patients with suspected internal derangement of the knee.

METHODS

Data were collected from two surveys conducted alongside a clinical trial: the arthroscopy sample and the general practitioner (GP) sample. The effect size (ES) was used to assess responsiveness. Anchor-based minimal change included minimal clinical important difference (MCID) and receiver operator characteristic curves; standardized error of measurement and minimal detectable change (MDC) was employed for distribution-based approaches. The KQoL-26 results are compared with those for the Lysholm Knee Score, EQ-5D and SF-36.

RESULTS

The arthroscopy sample consisted of 121 participants and the GP sample of 218 participants at baseline. The largest ES was found for the KQoL-26 emotional functioning scale in both samples. The results were in favour of the condition-specific instrument. The MCID for KQoL-26 physical functioning, activities limitations and emotional functioning scales were 3, 15 and 18, respectively, in the arthroscopy sample; they were 11, 16 and 24 in the GP sample. The MDC 95 % was estimated as 18, 28 and 34, and 15, 24 and 30 in each sample, respectively.

CONCLUSIONS

The KQoL-26 emotional functional scale was the most responsive of all scales. It is recommended that an instrument such as the KQoL-26 that includes emotional functioning should be included rather than the Lysholm in future clinical trials of patients with suspected internal derangement of the knee.

Randomized controlled trial of a lay-facilitated angina management programme

AIMS

This article reports a randomized controlled trial of lay-facilitated angina management (registered trial acronym: LAMP).

BACKGROUND

Previously, a nurse-facilitated angina programme was shown to reduce angina while increasing physical activity, however most people with angina do not receive a cardiac rehabilitation or self-management programme. Lay people are increasingly being trained to facilitate self-management programmes.

DESIGN

A randomized controlled trial comparing a lay-facilitated angina management programme with routine care from an angina nurse specialist.

METHODS

Participants with new stable angina were randomized to the angina management programme (intervention: 70 participants) or advice from an angina nurse specialist (control: 72 participants). Primary outcome was angina frequency at 6 months; secondary outcomes at 3 and 6 months included: risk factors, physical functioning, anxiety, depression, angina misconceptions and cost utility. Follow-up was complete in March 2009. Analysis was by intention-to-treat; blind to group allocation.

RESULTS

There was no important difference in angina frequency at 6 months. Secondary outcomes, assessed by either linear or logistic regression models, demonstrated important differences favouring the intervention group, at 3 months for: Anxiety, angina misconceptions and for exercise report; and at 6 months for: anxiety; depression; and angina misconceptions. The intervention was considered cost-effective.

CONCLUSION

The angina management programme produced some superior benefits when compared to advice from a specialist nurse.

Mapping for economic evaluation

INTRODUCTION/BACKGROUND

Mapping provides a statistical algorithm that allows the estimation of utilities and consequently calculation of QALYs in clinical studies where preference-based measures are not implemented.

SOURCES OF DATA

Reviews of the mapping literature were utilized.

AREAS OF AGREEMENT

Mapping requires similar populations between the estimation and study data sets, with a high degree of overlap between the target and base measures being desirable. The National Institute for Health and Clinical Excellence recognizes mapping as a method to provide utility information. Areas of controversy Issues surrounding mapping include the descriptive system of the measure, the appropriate econometric method and model specification.

GROWING POINTS

There is a need for further research into the issue of over-prediction for severe health states and uncertainty around the estimated utility scores.

AREAS TIMELY FOR DEVELOPING RESEARCH

Mapping continues to be an important area of research for economic evaluation, in particular validation of mapping functions.

Yoga for chronic low back pain: a randomized trial

BACKGROUND

Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain.

OBJECTIVE

To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain.

DESIGN

Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604)

SETTING

13 non-National Health Service premises in the United Kingdom.

PATIENTS

313 adults with chronic or recurrent low back pain.

INTERVENTION

Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months.

MEASUREMENTS

Scores on the Roland-Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes).

RESULTS

93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain.

LIMITATION

There were missing data for the primary outcome (yoga group, n = 21; usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes.

CONCLUSION

Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care.

PRIMARY FUNDING SOURCE

Arthritis Research UK.

Use of weekly, low dose, high frequency ultrasound for hard to heal venous leg ulcers: the VenUS III randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness of weekly delivery of low dose, high frequency therapeutic ultrasound in conjunction with standard care for hard to heal venous leg ulcers.

DESIGN

Multicentre, pragmatic, two arm randomised controlled trial.

SETTING

Community and district nurse led services, community leg ulcer clinics, and hospital outpatient leg ulcer clinics in 12 urban and rural settings (11 in the United Kingdom and one in the Republic of Ireland).

PARTICIPANTS

337 patients with at least one venous leg ulcer of >6 months' duration or >5 cm(2) area and an ankle brachial pressure index of ≥ 0.8.

INTERVENTIONS

Weekly administration of low dose, high frequency ultrasound therapy (0.5 W/cm(2), 1 MHz, pulsed pattern of 1:4) for up to 12 weeks plus standard care compared with standard care alone.

MAIN OUTCOME MEASURES

Primary outcome was time to healing of the largest eligible leg ulcer. Secondary outcomes were proportion of patients healed by 12 months, percentage and absolute change in ulcer size, proportion of time participants were ulcer-free, health related quality of life, and adverse events.

RESULTS

The two groups showed no significant difference in the time to healing of the reference leg ulcer (log rank test, P=0.61). After adjustment for baseline ulcer area, baseline ulcer duration, use of compression bandaging, and study centre, there was still no evidence of a difference in time to healing (hazard ratio 0.99 (95% confidence interval 0.70 to 1.40), P=0.97). The median time to healing of the reference leg ulcer was inestimable. There was no significant difference between groups in the proportion of participants with all ulcers healed by 12 months (72/168 in ultrasound group v 78/169 in standard care group, P=0.39 for Fisher's exact test) nor in the change in ulcer size at four weeks by treatment group (model estimate 0.05 (95% CI -0.09 to 0.19)). There was no difference in time to complete healing of all ulcers (log rank test, P=0.61), with median time to healing of 328 days (95% CI 235 to inestimable) with standard care and 365 days (224 days to inestimable) with ultrasound. There was no evidence of a difference in rates of recurrence of healed ulcers (17/31 with ultrasound v 14/31 with standard care, P=0.68 for Fisher's exact test). There was no difference between the two groups in health related quality of life, both for the physical component score (model estimate 0.69 (-1.79 to 3.08)) and the mental component score (model estimate -0.93 (-3.30 to 1.44)), but there were significantly more adverse events in the ultrasound group (model estimate 0.30 (0.01 to 0.60)). There was a significant relation between time to ulcer healing and baseline ulcer area (hazard ratio 0.64 (0.55 to 0.75)) and baseline ulcer duration (hazard ratio 0.59 (0.50 to 0.71)), with larger and older ulcers taking longer to heal. In addition, those centres with high recruitment rates had the highest healing rates.

CONCLUSIONS

Low dose, high frequency ultrasound administered weekly for 12 weeks during dressing changes in addition to standard care did not increase ulcer healing rates, affect quality of life, or reduce ulcer recurrence. Trial registration ISRCTN21175670 and National Research Register N0484162339.

The effect of health state selection on the valuation of EQ-5D

BACKGROUND

Many aspects of valuation

STUDY DESIGN

s are poorly understood, and the size and composition of health states used in valuation studies vary widely. Our aims were to investigate the impact of the selection of a subset of EQ-5D health states in generating a set of visual analog scale (VAS)-based values. Our aims were to investigate the optimal number of health states, the sample size required per health state, and which combinations of health states are required to establish a EQ-5D VAS value set.

METHODS

Data were drawn from a United Kingdom (UK) general population postal survey in which all health states defined by EQ-5D were evaluated using VAS. We used a simulation approach to address each question, and the performance of each estimation model was assessed by the average value of the mean absolute errors.

RESULTS

Despite the constraint of the small sample size in the study dataset, the results suggest that the optimal number of states for a valuation study is 32, 100 observations per health state were sufficient, and multiple subsets of health states were feasible.

CONCLUSIONS

Selecting health states not included in the "Measurement and Valuation of Health" dataset in valuation studies is quite specifically encouraged. However, it remains prudent to ensure that the selection of health states covers as wide a range of severity as possible. Setting the number of observations per health state to 150 might allow for correction of any errors in data collection or processing. The extent to which the results of this study based on VAS valuation data can be safely generalized to the design of time tradeoff valuation studies remains an open question.

Protocol for the ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial: a pragmatic multi-centre randomised controlled trial of surgical versus non-surgical treatment for proximal fracture of the humerus in adults

BACKGROUND

Proximal humeral fractures, which occur mainly in older adults, account for approximately 4 to 5% of all fractures. Approximately 40% of these fractures are displaced fractures involving the surgical neck. Management of this group of fractures is often challenging and the outcome is frequently unsatisfactory. In particular it is not clear whether surgery gives better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform this decision.

METHODS/DESIGN

We aim to undertake a pragmatic UK-based multi-centre randomised controlled trial evaluating the effectiveness and cost-effectiveness of surgical versus standard non-surgical treatment for adults with an acute closed displaced fracture of the proximal humerus with involvement of the surgical neck. The choice of surgical intervention is left to the surgeon, who must use techniques that they are fully experienced with. This will avoid 'learning curve' problems. We will promote good standards of non-surgical care, similarly insisting on care-provider competence, and emphasize the need for comparable provision of rehabilitation for both groups of patients.We aim to recruit 250 patients from a minimum of 18 NHS trauma centres throughout the UK. These patients will be followed-up for 2 years. The primary outcome is the Oxford Shoulder Score, which will be collected via questionnaires completed by the trial participants at 6, 12 and 24 months. This is a 12-item condition-specific questionnaire providing a total score based on the person's subjective assessment of pain and activities of daily living impairment. We will also collect data for other outcomes, including general health measures and complications, and for an economic evaluation. Additionally, we plan a systematic collection of reasons for non-inclusion of eligible patients who were not recruited into the trial, and their baseline characteristics, treatment preferences and intended treatment.

DISCUSSION

This article presents the protocol for a multi-centre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50850043.

A pragmatic multi-centred randomised controlled trial of yoga for chronic low back pain: trial protocol

A systematic review revealed three small randomised controlled trials of yoga for low back pain, all of which showed effects on back pain that favoured the yoga group. To build on these studies a larger trial, with longer term follow-up, and a number of different yoga teachers delivering the intervention is required. This study protocol describes the details of a randomised controlled trial (RCT) to determine the effectiveness and cost-effectiveness of Yoga for chronic Low Back Pain, which is funded by Arthritis Research Campaign (arc) and is being conducted by the University of York. 262 patients will be recruited from GP practices in 5 centres in England. Patients will be randomised to receive usual care or 12 weekly classes of yoga. A yoga programme will be devised that can be delivered by yoga teachers of the two main national yoga organisations in the UK (British Wheel of Yoga and Iyengar Yoga Association (UK)).

Trial registration: Current controlled trials registry ISRCTN81079604 (date registered 30/03/2007).

South Korean time trade-off values for EQ-5D health states: modeling with observed values for 101 health states

OBJECTIVES

This study establishes the South Korean population-based preference weights for EQ-5D based on values elicited from a representative national sample using the time trade-off (TTO) method.

METHODS

The data for this paper came from a South Korean EQ-5D valuation study where 1307 representative respondents were invited to participate and a total of 101 health states defined by the EQ-5D descriptive system were directly valued. Both aggregate and individual level modeling were conducted to generate values for all 243 health states defined by EQ-5D. Various regression techniques and model specifications were also examined in order to produce the best fit model. Final model selection was based on minimizing the difference between the observed and estimated value for each health state.

RESULTS

The N3 model yielded the best fit for the observed TTO value at the aggregate level. It had a mean absolute error of 0.029 and only 15 predictions out of 101 had errors exceeding 0.05 in absolute magnitude.

CONCLUSIONS

The study successfully establishes South Korean population-based preference weights for the EQ-5D. The value set derived here is based on a representative population sample, limiting the interpolation space and possessing better model performance. Thus, this EQ-5D value set should be given preference for use with the South Korean population.

Converting the SF-12 into the EQ-5D: an empirical comparison of methodologies

BACKGROUND

For cost-utility analysis, analysts need a measure that summarizes health-status utilities in a single index of health-related quality of life (HR-QOL). It is common to find in clinical studies that only an HR-QOL profile measure such as the SF-36 is included, but not the summary HR-QOL index. Therefore, the economist's usual practice is to reprocess the profile data into a single index format. Several 'after-market' tools are available to convert the SF-36 or SF-12 into a single form with or without utility-weighting metric property. However, there has been no consensus with regard to a regression method that should be recommended for such a mapping task.

OBJECTIVE

To report on the performance of different regression methods that have previously been applied to the conversion of SF-12 data in the analysis of a single common dataset. The mapping between the SF-12 and EQ-5D is the focus.

METHODS

The data were adopted from the Medical Expenditure Panel Survey 2003 where 19 678 adults completed both EQ-5D and SF-12 questionnaires. Four econometric techniques, namely ordinary least squares (OLS), censored least absolute deviation, multinomial logit model and two-part model regressions were investigated together with two main types of model specifications: item-based and summary score-based. The performance of each examined model was judged by various criteria, including its estimated mean, the size of mean absolute error and the number of errors.

RESULTS

Among four compared econometric techniques, OLS regression was the most accurate model in estimating the group mean. Models with item-based model specification performed better than those with summary score-based regardless of the chosen econometric technique. Nevertheless, the accuracy of OLS deteriorates in older and less healthy subgroups. The results also suggested that the two-part model, which addresses the heterogeneity issue, performs better in these vulnerable subgroups.

CONCLUSIONS

None of the mapping methods included in the current study are suitable for estimating at the individual level. The methodology exemplified here has wider applicability and might just as readily be applied to other members of the SF family or indeed to other profile measures of HR-QOL. However, it is recommended that a preference-based, single index measure of HR-QOL should be included in the clinical studies for the purpose of economic evaluation.

Hispanic valuation of the EQ-5D health states: a social value set for Latin Americans

OBJECTIVES

Cost-effectiveness analysis has been recommended by national health agencies worldwide. In the United Kingdom, the National Institute of Health and Clinical Excellence supports the use of generic health-related quality of life instruments such as EuroQol EQ-5D when quality-adjusted life-years are used to measure health benefits. Despite the urgent need for appropriate methodologies to improve the use of scarce resources in Latin American countries, little is known about how health is valued.

METHODS

A national population survey was conducted in the United States in 2002, based on a sample of 1603 non-Hispanic nonblacks and 1115 Hispanics. Participants provided time trade-off utilities for a subset of 42 EQ-5D health states. Hispanic respondents were grouped according to their language preferences (Spanish or English). Mean utilities were compared for each health state. A random-effects model was used to determine whether real population differences exist after adjusting for sociodemographic characteristics. A population value set for all 243 EQ-5D health states was developed using only the data from Spanish-speaking Hispanics.

RESULTS

Mean valuations differed slightly between non-Hispanic nonblacks and English-speaking Hispanics. Spanish-speaking Hispanics, however, tended to give higher valuations than non-Hispanic nonblacks (P < 0.05) corresponding to an average of 0.034 point. A regression model was developed for Spanish-speaking Hispanics with a mean absolute error of 0.031. Values estimated using this model show marked differences when compared with corresponding values estimated using the UK (N3) and US (D1) models.

CONCLUSION

The availability of a Hispanic model for EQ-5D valuations represents a significant new option for decision-makers, providing a set of social preference weights for use in Latin American countries that presently lack their own domestic value set.

A traumatic macular hole secondary to a high-energy Nd:YAG laser

A case is reported of a traumatic macular hole caused by a high-energy Nd:YAG laser. The initial ocular examination revealed an explosive, crater-shaped, full-thickness macular hole surrounded by local edema and detachment. By the 12th day after the injury, the hole had shrunk progressively and was covered by a thin fibrin-like membrane. A thick epiretinal membrane covered the injured area 1 month after the injury. Nine months after the injury, the macular hole closed spontaneously with a partially detached epiretinal membrane. This case demonstrates one of the natural healing processes of a traumatic macular hole. Although the hole finally closed, the patient did not regain his vision because of the severe damage to the photoreceptors, retinal pigment epithelium, and choroid.

Endogenous Klebsiella pneumoniae endophthalmitis associated with prostate abscess: case report

A young alcoholic and heavy smoker was admitted because of Klebsiella pneumoniae bacteremia. The abdominal and pelvic computed tomography with enhancement revealed an abscess in the right prostate. He experienced blurred vision of his left eye on the third day during admission. Initial ocular examination revealed mild reaction in the anterior chamber and vitreous as well as multiple Roth's spots in the retina. The administration of empirical antibiotics including cefazolin and gentamicin intravenously was changed to ceftriaxone and amikacin after ophthalmologic consultation. After parenteral antibiotics for 3 weeks, the systemic condition was controlled, and the vision remained stable. During the past decades, many cases of endogenous Klebsiella pneumoniae endophthalmitis associated with liver abscess were reported in Taiwan. However, documented reports of this condition associated with a prostate abscess are rare. This case, classified as posterior focal endogenous endophthalmitis, had good prognosis under appropriate antibiotic treatment. Early diagnosis and prompt therapy are important for control of sepsis and restoration of vision.

Evaluation of peribulbar anesthesia in encircling scleral buckle surgery and its postoperative pain course

BACKGROUND

Retrobulbar anesthesia is considered effective in ocular surgery but it can give rise to serious complications. We used peribulbar anesthesia with sub-Tenon's irrigation to perform encircling scleral buckling for retinal detachment, as it could reduce the complications caused by retrobulbar anesthesia. We also recorded the course of pain for 72 hours after surgery.

METHODS

Thirty patients who were diagnosed with rhegmatogenous retinal detachment were treated with an encircling scleral buckle. The surgery was performed with peribulbar anesthesia with occasional sub-Tenon's irrigation. We evaluated the patient's pain with a visual analogue scale after surgery at 30 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours.

RESULTS

In 24 cases (80%), the anesthesia was complete with the peribulbar block. Only 6 patients (20%) needed sub-Tenon's irrigation and four of them felt no pain after augmentation. Although all the surgical procedures proceeded without problem, two of the patients felt pain and were uncomfortable during the surgery. No serious complications occurred. The course of pain peaked 6 hours after surgery when 26 patients (86.7%) felt pain and 12 patients (40%) were uncomfortable (pain score > or = 5). Forty-eight hours after surgery, 9 patients (30%) still felt pain but no one felt uncomfortable.

CONCLUSION

Peribulbar anesthesia can be used safely in encircling scleral buckling for retinal detachment. The postoperative pain is maximal 6 hours after surgery and becomes mild (pain score < or = 4) after 48 hours.