P-750 The cost-effectiveness of transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility

Study question

Is transvaginal hydrolaparoscopy (THL) cost-effective compared to hysterosalpingography (HSG) in the work-up for subfertility in a population at low-risk for tubal pathology?

Summary answer

THL is cost-effective compared to HSG in a preselected group of women at low-risk of tubal pathology.

What is known already

Tubal pathology is a common cause of subfertility and tubal patency testing plays an important part in the work-up of the subfertile couple and the subsequent counseling for fertility treatment. THL is an out-patient procedure. After access through the pouch of Douglas, the tubes and pelvic cavity are directly observed using hydroflotation, whereas HSG is a radiographic evaluation of the uterine cavity and patency of the tubes with injection of contrast medium in the uterine cavity. Both methods are safe and feasible for subfertile women at low-risk of tubal pathology.

Study design, size, duration

We performed an economic analysis as part of a randomized controlled trial comparing THL and HSG in the work-up for subfertility. Women were eligible if they had an indication for evaluation of tubal patency. Primary outcome was a conception leading to live birth in 24 months. We randomly assigned 300 subfertile women to THL or HSG between May 2013 and October 2016.

Participants/materials, setting, methods

This study was performed in four Dutch teaching hospitals. The economic evaluation was performed from a health care perspective. Costs were either derived from literature or calculated. The mean costs and outcomes for each treatment group were compared. Costs were combined with effectiveness by calculating ICER, and bootstrap resampling was performed. We generated a cost-effectiveness plane and cost-effectiveness acceptability curves.

Main results and the role of chance

After 24 months of follow-up there was a 3% difference in live birth rate in favour of the THL group (58.5% in the THL group versus 55.4% in the HSG group (83/142 versus 82/148 difference 3.0% (95% CI: -8.3 – 14.4)). Multiple pregnancy and miscarriage rate were low and did not differ between groups. Ectopic pregnancy occurred in two women in the HSG group and not in the THL group. The mean cost was lower in the THL group, compared to the HSG group (THL group 4,927 EUR versus 5,197 EUR in the HSG group, difference -270 EUR). Although the costs of the diagnostic procedure itself were higher in the THL group (425 EUR versus 289 EUR, difference 136 EUR), the costs for fertility treatments are higher in the HSG group. The base case outcome is that THL costs less and is more effective than HSG, making THL the dominant strategy. The spread of the bootstrap indicates that there is uncertainty regarding the effectiveness of THL over HSG but less uncertainty regarding the cost difference between THL and HSG.

Limitations, reasons for caution

This trial was conducted in the Netherlands, using price calculations of the Dutch healthcare system in Euro’s. Since prices of fertility treatments and especially ART or fertility enhancing surgery can vary widely worldwide, it is possible that the outcomes of our study are not generalizable to other countries.

Wider implications of the findings

The findings of our trial suggest that in a preselected group of women with low risk for tubal pathology, a diagnostic strategy starting with THL is cost-effective compared to a diagnostic strategy starting with HSG in the workup for subfertility.

Trial registration number

NTR3462

Brain morphology in antipsychotic-naïve schizophrenia: A study of multiple brain structures

Background

Although brain volume changes are found in schizophrenia, only a limited number of structural magnetic resonance imaging studies have exclusively examined antipsychotic-naïve patients.

Aims

To comprehensively investigate multiple brain structures in a single sample of patients who were antipsychotic-naïve.

Method

Twenty antipsychotic-naïve patients with first-episode schizophrenia and 20 healthy comparison subjects were included. Intracranial, total brain, frontal lobe, grey and white matter, cerebellar, hippocampal, parahippocampal, thalamic, caudate nucleus and lateral and third ventricular volumes were measured. Repeated-measures analyses of (co)variance were conducted with intracranial volume as covariate.

Results

Third ventricle volume enlargement was found in patients compared with the healthy subjects. No differences were found in other brain regions.

Conclusions

These findings suggest that some brain abnormalities are present in the early stages of schizophrenia. Moreover, it suggests that brain abnormalities reported in patients with chronic schizophrenia develop in a later stage of the disease and/or are medication induced.

Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial

Objective

To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect.

Design

Multicentre randomised controlled trial.

Setting

Eleven hospitals collaborating in a consortium for women's health research in the Netherlands.

Population

Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography.

Methods

Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months.

Main outcome measures

The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation.

Results

We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2–7 days) in the intervention group and 7 days (IQR 3–10 days) in the control group (P = 0.04); on a scale of 0–10, discomfort as a result of spotting had a median score of 2 (IQR 0–7) in the intervention group, compared with 7 (IQR 0–8) in the control group (P = 0.02).

Conclusions

In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting‐related discomfort.

Tweetable abstract

A hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.

A hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.

Intradiurnal Fluctuations of Off-Resonance Saturation Effects in Healthy Human Achilles Tendons Assessed with a 3D Ultrashort Echo Time MRI Sequence at 3 Tesla

PURPOSE

The purpose of this study was to evaluate whether gravitational interstitial fluid accumulation in healthy subjects has an impact on off-resonance saturation ratios (OSR) or the volume of the Achilles tendon after a prolonged time of reduced levels of physical activity.

MATERIALS AND METHODS

7 healthy volunteers were repeatedly investigated on 3 consecutive days on a 3 T whole body MR scanner using an ultrashort echo time (UTE) imaging sequence with a Gaussian off-resonance saturation pulse at a frequency offset of 2000 Hz to calculate OSR values. For accurate volumetric quantification of the Achilles tendon, a newly developed contour detection snake algorithm was applied on high-resolution isotropic T2-weighted SPACE sequence datasets. Single-measure intraclass correlation coefficients (ICC) were calculated to estimate test-retest reliability.

RESULTS

For OSR and tendon volume measurements on three consecutive days, excellent reproducibility could be achieved with ICC values above 0.96 and 0.97, respectively. Comparing the results of all three days, a statistically significant mean individual percentage decrease (- 4.1  ± 1.5 %; p = 0.001) of calculated tendon OSR values was found for the evening measurements. No statistically significant difference between tendon volumes in the morning and the evening could be detected (p = 0.589).

CONCLUSION

The results of this in-vivo study demonstrate a significant influence of gravitational interstitial fluid accumulation after reduced physical activity on OSR values in the Achilles tendon, but not on tendon volume. Taken together with the demonstrated excellent reproducibility, these findings are important for future studies investigating temporal changes of the Achilles tendon microstructure.

Assessment of the hepatic veins in poor contrast conditions using dual energy CT: evaluation of a novel monoenergetic extrapolation software algorithm

PURPOSE

To evaluate a novel monoenergetic post-processing algorithm (MEI+) in patients with poor intrahepatic contrast enhancement.

MATERIALS AND METHODS

25 patients were retrospectively included in this study. Late-phase imaging of the upper abdomen, which was acquired in dual-energy mode (100/140 kV), was used as a model for poor intrahepatic contrast enhancement. Traditional monoenergetic images (MEI), linearly weighted mixed images with different mixing ratios (MI), sole 100 and 140 kV and MEI+ images were calculated. MEI+ is a novel technique which applies frequency-based mixing of the low keV images and an image of optimal keV from a noise perspective to combine the benefits of both image stacks. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the intrahepatic vasculature (IHV) and liver parenchyma (LP) were objectively measured and depiction of IHV was subjectively rated and correlated with portal venous imaging by two readers in consensus.

RESULTS

MEI+ was able to increase the SNR of the IHV (5.7 ± 0.4 at 40keV) and LP (4.9 ± 1.0 at 90keV) and CNR (2.1 ± 0.6 at 40keV) greatly compared to MEI (5.1 ± 1.1 at 80keV, 4.7 ± 1.0 at 80keV, 1.0 ± 0.4 at 70keV), MI (5.2 ± 1.1 M5:5, 4.8 ± 1.0 M5:5, 1.0 ± 3.5 M9:1), sole 100 kV images (4.4 ± 1.0, 3.7 ± 0.8, 1.0 ± 0.3) and 140 kV images (2.8 ± 0.5, 3.1 ± 0.6, 0.1 ± 0.2). Subjective assessment rated MEI+ of virtual 40 keV superior to all other images.

CONCLUSION

MEI+ is a very promising algorithm for monoenergetic extrapolation which is able to overcome noise limitations associated with traditional monoenergetic techniques at low virtual keV levels and consequently does not suffer from a decline of SNR and CNR at low keV values. This algorithm allows an improvement of IHV depiction in the presence of poor contrast.

KEY POINTS

• The evaluated new image-based algorithm for virtual monoenergetic imaging allows calculating low virtual keV images from dual energy datasets with significantly improved contrast-to-noise ratios. • The image based novel monoenergetic extrapolation algorithm applies frequency-based mixing of the low keV images and an image of optimal keV from a noise perspective to combine the benefits of both image stacks.• When compared to traditional monoenergetic images, the novel monoenergetic algorithm has improved contrast-to-noise ratios for both low and high virtual keV images.• Contrast-enhanced dual energy images with poor contrast conditions can be significantly improved, e.g. late phase imaging of the liver.

Significance testing of synergistic/antagonistic, dose level-dependent, or dose ratio-dependent effects in mixture dose-response analysis

In ecotoxicology, the state of the art for effect assessment of chemical mixtures is through multiple dose-response analysis of single compounds and their combinations. Investigating whether such data deviate from the reference models of concentration addition and/or independent action to identify overall synergism or antagonism is becoming routine. However, recent data show that more complex deviation patterns, such as dose ratio-dependent deviation and dose level-dependent deviation, need to be addressed. For concentration addition, methods to detect such deviation patterns exist, but they are stand-alone methods developed separately in literature, and conclusions derived from these analyses are therefore difficult to compare. For independent action, hardly any methods to detect such deviations from this reference model exist. This paper describes how these well-established mixture toxicity principles have been incorporated in a coherent data analysis procedure enabling detection and quantification of dose level-and dose ratio-specific synergism or antagonism from both the concentration addition and the independent action models. Significance testing of which deviation pattern describes the data best is carried out through maximum likelihood analysis. This analysis procedure is demonstrated through various data sets, and its applicability and limitations in mixture research are discussed.

Efficacy of temazepam in frequent users: a series of N-of-1 trials

BACKGROUND

Benzodiazepines are frequently prescribed for sleep disturbances. However, benzodiazepines are associated with side effects, and may be ineffective when used for a prolonged period of time.

OBJECTIVES

To investigate for individual patients whether placebo was as effective as temazepam, or whether 10 mg was as effective as 20 mg temazepam, and whether these results influenced their future temazepam use.

METHODS

A series of randomized double-blind N-of-1 trials were conducted in general practices in The Netherlands for patients who were using temazepam regularly. Each patient received five pairs of treatments consisting of one week of temazepam (10 or 20 mg) and one week of the control intervention (placebo or 10 mg temazepam). Per pair, the sequence of treatments was randomized. Main outcome measures were: time to fall asleep, and the individual main complaint.

RESULTS

Twelve out of 15 patients completed their trial. In three patients there was no difference, in five a large difference, and in four a small difference in favour of temazepam. At follow-up, seven patients had stopped or reduced their temazepam use.

CONCLUSION

The results regarding the efficacy of temazepam varied across patients. N-of-1 trials seem to be valuable in patients who are motivated to stop or reduce their temazepam use. They clearly demonstrate the efficacy of temazepam, and may give patients additional confidence to discontinue regular hypnotic use. The value of N-of-1 trials for patients who are less motivated is unclear, as the size of treatment effect does not seem to influence future hypnotic use.

The effect of counterion and percolation on the toxicity of lead for the springtail Folsomia candida in soil

In standard soil toxicity tests, heavy metals are amended as water-soluble salts. The role of the counterion in metal salt toxicity is scarcely looked into. In this study, we assessed the contribution of nitrate and chloride to the toxicity of lead to Folsomia candida in a natural standard soil. Both lead salts were tested according the standard test protocol as well as after percolation of the soil with deionized water. Lead nitrate was more toxic than lead chloride for survival as well as reproduction. Percolation proved to be an effective method to remove counterions from the soil. Survival of F. candida increased for both metal salts when percolation was included. Percolation reduced the reproduction toxicity of lead, the effect of which was largest for the nitrate salt. In percolated treatments, the nitrate and chloride lead salts did not differ in toxicity. It is concluded that counterions contribute to metal toxicity and that nitrate is more toxic to F. candida than chloride.

Purity of factor VIII product and incidence of inhibitors in previously untreated patients with haemophilia A

It has been suggested that ultrapure clotting factor products carry a greater risk for inhibitor development in patients with haemophilia. We compared the incidence of inhibitors in 59 previously untreated patients (PUPs) with severe haemophilia (endogenous factor VIII < 0.01 U L-1) A, who were initially treated with cryoprecipitate or intermediate purified products, with that in 22 patients exclusively treated with monoclonally purified and recombinant factor VIII. Persistent inhibitors were those with 1 Bethesda unit per mL or more, on more than one occasion, combined with a decrease in recovery. Incidences of persistent inhibitors were 17% (10/59) for patients who were treated with cryoprecipitate or intermediate-purity products and 9% (2/10) for monoclonally purified and recombinant factor VIII. Transient inhibitors appeared to develop earlier during treatment with ultrapure products as compared to treatment with intermediate/low-purity products. In conclusion, ultrapure products appear not to carry a higher risk for inhibitor development.