High-Intensity Focused Ultrasound or Uterine Artery Embolization Combined With Ultrasound-Guided Dilatation and Curettage in Cesarean Scar Pregnancy: A Retrospective Cohort Study

BackgroundCesarean scar pregnancy (CSP) is a rare and new form of ectopic pregnancy. With increasing rate of cesarean delivery worldwide during the decades, the incidence of CSP increases as well. It may cause massive hemorrhage, uterine rupture, placenta percreta, hysterectomy or even maternal death. This study is to compare the efficacy of high-intensity focused ultrasound (HIFU) and uterine artery embolization (UAE) associated with ultrasound-guided dilatation and curettage (UGDC) in three types of CSP. Methods403 CSP patients were treated with UGDC after pretreatment. Among them, 288 patients chose HIFU before UGDC, while the others (n=115) chose UAE. The body mass index (BMI), gravidity, parity, the number of cesarean delivery, the interval of previous cesarean delivery (PCD), the length, thickness and width of uterus and gestational sac, fetal cardiac activity, the types of CSP, the baseline of beta-human chorionic gonadotropin (β-HCG), the value of β-HCG before and 24 hours after pretreatment, hospital expenditure, the value of hemoglobin before and 24 hours after dilatation and curettage (D&C) and severe complications were collected and compared between the two groups. ResultsAll patients were successfully treated without severe complications. There was no significant difference in maternal age, BMI, gravidity, parity, the number of cesarean delivery, the interval of PCD, the volume of uterus and gestational sac, fetal heart activity, types of CSP and baseline serum β-HCG level between the two groups. The median hospital expenditure and blood loss were less in HIFU group and the median decline rate of β-HCG was higher in HIFU group (p=0.000, p=0.000, p=0.006, respectively). 39 (13.54%) patients in HIFU group, while 21 (18.26%) cases in UAE group used Foley balloon to control the vaginal bleeding.ConclusionBoth HIFU and UAE combined with UGDC have high successful rate in the treatment of CSP. While, HIFU followed by UGDC might be better for less hospital expenditure, blood loss and higher decline rate of β-HCG.

Therapeutic Effect and Cost-Benefit Analysis of Three Different Nutritional Schemes for Esophageal Cancer Patients in the Early Post-operative Period

Objective: To retrospectively investigate the comparative efficacy, safety and cost-benefits of three nutritional treatment schemes including short peptide jejunal nutrition (SPJN), whole protein jejunal nutrition (WPJN), and partial parenteral nutrition (PPN) in patients underwent esophagectomy for esophageal cancer in our hospital. This study was carried out in accordance with the conceptual framework of nutritional therapy in fast-track rehabilitation surgery.Methods: We retrospectively reviewed 305 patients who were assigned to receive esophagectomy for esophageal cancer. Eligible patients was naturally divided into SPJN group [n = 98 (32.1%)], WPJN group [n = 95 (31.1%)], and PPN group [n = 112 (36.7%)] according to the type of nutritional scheme which was actually prescribed to patients by the attendingphysician in clinical practice. The differences of the serum total protein (TP), albumin (ALB), pre-albumin (PA), hemoglobin (HGB), white blood cells (WBCs), red blood cells (RBCs) and neutrophils were compared among 3 nutritional schemes groups. We also investigated the relationship of the fluid intake, urine output, gastric juice drainage volume and thoracic drainage volume among 3 nutritional groups at 3 days after surgery. Moreover, the differences of cost-benefit indexes, complications, length of hospitalization and hospital expenditure were also compared.Results: The serum TP, ALB, and PA in the SPJN group were all higher than those in the WPJN and PPN groups (p < 0.05). The gastric juice volume of gastrointestinal decompression drainage and fluid volume of thoracic drainage in the SPJN group were all less than that in the WPJN group (p < 0.05). The overall hospital stay and post-operative hospital stay in the SPJN group were all shorter than that in WPJN group (p < 0.05). Moreover, the incidence of post-operative complications including anastomotic leakage, infection, and gastrointestinal reaction was remarkably lower in the SPJN group compared to the WPJN group (p < 0.05). Interesting, hospital expenditure in the PPN group was less than that in the SPJN and the WPJN groups (p < 0.001).Conclusion: Patients may obtain benefits in improving protein level after receiving SPJN scheme at the early stage after esophagectomy. Meanwhile, patients may obtain benefits in improving post-operative complications and hospital stay after receiving SPJN or PPN compared to WPJN protocol. However, the difference between SPJN and PPN requires further study because no difference was detected in terms of clinical outcomes including complications and the length of hospitalization although PPN may achieve a possible decrease of medical expenditure.

Evolution of health care utilization and expenditure during the year before death in 2015 among people with cancer: French snds-based cohort study

Background Cancer patients have one of the highest health care expenditures (HCE) at the end of life. However, the growth of HCE at the end of life remains poorly documented in the literature. Objective To describe monthly reimbursed expenditure during the last year of life among cancer patients, by performing detailed analysis according to type of expenditure and the person’s age. Method Data were derived from the Système national des données en santé (SNDS) [national health data system], which comprises information on ambulatory and hospital care. Analyses focused on general scheme beneficiaries (77% of the French population) treated for cancer who died in 2015. Results Average reimbursed expenditure during the last year of life was €34,300 per person in 2015, including €21,100 (62%) for hospital expenditure. "Short-stays hospital" and "rehabilitation units" stays expenditure were €14,700 and €2000, respectively. Monthly expenditure increased regularly towards the end of life, increasing from 12 months before death €2000 to €5200 1 month before death. The highest levels of expenditure did not concern the oldest people, as average reimbursed expenditure was €50,300 for people 18–59 years versus €25,600 for people 80–90 years. Out-of-pocket payments varied only slightly according to age, but increased towards the end of life. Conclusion A marked growth of HCE was observed during the last 4 months of life, mainly driven by hospital expenditure, with a more marked growth for younger people.

Hospital Expenditure at the End-of-Life: A Time-to-Death Approach

Background: In recent years the use of time to death (TTD) variables in the modeling of individual health expenditures has been of interest to health economics researchers. The aim of this study was to investigate the effect of age and TTD on hospital inpatient expenditure (HIE). Methods: We used a claims database from Iran Health Insurance Organization of Tehran city that includes considerable proportion of Tehran residents and contains information on insured individuals’ HIE. We included HIE of all insured decedents (30 to 90 years old) who died during March 2013 and March 2014 (n=1018). No sampling was required. According to the decedents’ date of death, we extracted their last 24 months HIE. The period of time March 30, 2011 until March 30, 2014 (3 years) was used to guarantee a full 24 months of observations for decedents. A two-part econometric model was employed to investigate the effect of age, TTD, and some demographic variables on probability and conditional amount of individuals’ hospital expenditure. Stata software (version 16.0) was used for data processing and analysis. Results: Our results demonstrated that the month-based TTDs especially near months before death of decedents (TTD1 to TTD10) significantly affected both probability and conditional amount of HIE. One month before death incurred more HIE than the rest of the months. A further interesting finding is that after including TTD, age variable as a conditional driver of HIE loses its direct effect on decedents’ HIE, but age TTD interaction effect on HIE is still positive and statistically significant. Conclusion: The results confirm that TTD as a proxy of mortality indicator has a considerable effect on decedents’ HIE. The age variable has not directly affected decedents’ HIE but indirectly and through its interaction with TTD has a statistically significant effect on HIE. In addition to age, policy-makers should consider TTD to make better predictions of future HIE.

The Impact of the Maternal Sepsis Intervention

This chapter presents data on maternal mortality in Uganda and the contribution that sepsis makes to mortality. Against this backdrop, it identifies key outcomes of the intervention including major improvements in maternal mortality and reductions in the length of patient stays, readmission rates and hospital expenditure.