An economic model of long-term use of celecoxib in patients with osteoarthritis

<p>Abstract</p> <p>Background</p> <p>Previous evaluations of the cost-effectiveness of the cyclooxygenase-2 selective inhibitor celecoxib (Celebrex, Pfizer Inc, USA) have produced conflicting results. The recent controversy over the cardiovascular (CV) risks of rofecoxib and other coxibs has renewed interest in the economic profile of celecoxib, the only coxib now available in the United States. The objective of our study was to evaluate the long-term cost-effectiveness of celecoxib compared with nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in a population of 60-year-old osteoarthritis (OA) patients with average risks of upper gastrointestinal (UGI) complications who require chronic daily NSAID therapy.</p> <p>Methods</p> <p>We used decision analysis based on data from the literature to evaluate cost-effectiveness from a modified societal perspective over patients' lifetimes, with outcomes expressed as incremental costs per quality-adjusted life-year (QALY) gained. Sensitivity tests were performed to evaluate the impacts of advancing age, CV thromboembolic event risk, different analytic horizons and alternate treatment strategies after UGI adverse events.</p> <p>Results</p> <p>Our main findings were: 1) the base model incremental cost-effectiveness ratio (ICER) for celecoxib versus nsNSAIDs was $31,097 per QALY; 2) the ICER per QALY was$19,309 for a model in which UGI ulcer and ulcer complication event risks increased with advancing age; 3) the ICER per QALY was $17,120 in sensitivity analyses combining serious CV thromboembolic event (myocardial infarction, stroke, CV death) risks with base model assumptions.</p> <p>Conclusion</p> <p>Our model suggests that chronic celecoxib is cost-effective versus nsNSAIDs in a population of 60-year-old OA patients with average risks of UGI events.</p

Ethics teaching in a medical education environment: preferences for diversity of learning and assessment methods

Background: Ethics and professionalism are an integral part of medical school curricula; however, medical students’ views on these topics have not been assessed in many countries. Objective: The study aimed to examine medical students’ perceptions toward ethics and professionalism teaching, and its learning and assessment methods. Design: A self-administered questionnaire eliciting views on professionalism and ethics education was distributed to a total of 128 final-year medical students. Results: A total of 108 students completed the survey, with an 84% response rate. Medical students reported frequently encountering ethical conflicts during training but stated only a moderate level of ethics training at medical school (mean = 5.14 ± 1.8). They noted that their education had helped somewhat to deal with ethical conflicts (mean = 5.39 ± 2.0). Students strongly affirmed the importance of ethics education (mean = 7.63 ± 1.03) and endorsed the value of positive role models (mean = 7.45 ± 1.5) as the preferred learning method. The cohort voiced interest in direct faculty supervision as an approach to assessment of knowledge and skills (mean = 7.62 ± 1.26). Female students perceived greater need for more ethics education compared to males (p = < 0.05). Students who claimed that they had experienced some unprofessional treatment had a more limited view of the importance of ethics as a subject (P = 0.001). Conclusion: Medical students viewed ethics education positively and preferred clinically attuned methods for learning

Informed consent learning: Needs and preferences in medical clerkship environments.

PURPOSE:Limited information exists regarding students' routine educational needs in support of ethics and professionalism practices faced in real clinical practice. As such the authors aimed to explore medical students learning needs and preferences for informed consent and relevant ethical issues in the clerkship environments. MATERIALS AND METHODS:A cross-sectional study using a self-administered, printed survey distributed to final year clinical clerks. RESULTS:84% completed the survey. Students indicated the need for more attention to all topics related to informed consent (mean = 7.1 on a scale of 0 to 9; ±1.2). Most additional instructional attention was requested for topics raised in discussions with patients concerning the risks, benefits and alternatives to recommended treatments (7.3 ±1.4). The cohort expressed the need for education in the care of vulnerable patients (7.2 ±1.2) with a maximum score for the care of abused children. Women perceived greater need for education concerning informed consent than male respondents (p>0.05). There were significant differences between students who scored high or low on the item "being treated in professional manner" and "endorsement of educational needs for care of adolescents" (p = 0.05). CONCLUSION:There was heightened perception among final year medical students of the need for greater attention to be paid to informed consent education

Perforated Peptic Ulcer: Different Ethnic, Climatic and Fasting Risk Factors for Morbidity in Al-Ain Medical District, United Arab Emirates

To evaluate risk factors, morbidity and mortality rates of perforated peptic ulcer (PPU) and to investigate factors affecting postoperative complications of PPU. Background: The incidence of PPU has remained constant, simple closure with omental patch repair being the mainstay of treatment. Patients and Methods: One hundred and nineteen patients admitted to Al-Ain Hospital with PPU between January 2000 and March 2004 was studied retrospectively; two with deficient data were excluded from the analysis. Logistic regression was used to define factors affecting postoperative complications. Results: The mean age of patients was 35.3 years (range, 20–65). 45.7% of patients were Bangladeshi, and 85.3% originated from the Indian subcontinent. One patient, subsequently found to have a perforated gastric cancer, died. In 116 patients, 26 complications were recorded in 20 patients (17.2%). Common risk factors for perforation were smoking, history of peptic ulcer disease (PUD) and use of non-steroidal anti-inflammatory drugs (NSAIDs). A significantly increased risk of perforation was evident during the daytime fasting month of Ramadan. An increase in the acute physiology and chronic health evaluation (APACHE) II score (p = 0.047) and a reduced white blood cell count (0.04) were highly significant for the prediction of postoperative complications. Conclusion: Patients with dyspeptic symptoms and a history of previous PUD should be considered for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan, especially during the winter time

Bleeding peptic ulcer: an evolving role for surgical intervention

Early surgical intervention was previously advocated in patients > 60 years with bleeding peptic ulcer presenting with haemodynamic instability or ongoing transfusion requirements. It is, however, well recognized that emergency surgical intervention with its inherent risks must be reserved for highly selected patients in whom endoscopy initially fails to control exsanquinating haemorrhage or in whom life-threatening bleeding recurs. Therapeutic endoscopy for bleeding ulcer has led to a remarkable decline in rebleeding rates, the need for emergency surgery and mortality. Octogenarians are at risk, particularly when ulcer size exceeds 2 cm. Poor surgical candidates make up two-thirds of patients with major ulcer bleeding and operation is to be avoided if at all possible. Medical therapy with proton pump inhibitor and subsequent eradication of Helicobacter pylori following endoscopic treatment has been shown to be beneficial to outcomes. Should surgery be deemed necessary, it is likely that laparoscopic techniques to control bleeding, with or without the addition of an acid-reducing procedure, will find a role in haemodynamically stable patients undergoing operation on an early elective basis.link_to_subscribed_fulltex

Relationships and boundaries: Learning needs and preferences in clerkship medical environments.

PurposeRelationship boundaries recognition is an essential element of medical practice. The aim of the study was to assess final year medical students' perceived need for education regarding professional boundaries.Materials and methodsThis was a cross-sectional study. An anonymous paper questionnaire was distributed to 128 final year medical students. Standard descriptive statistics, unpaired t-test to evaluate differences between male and female groups and Pearson correlation to determine relationships between variables were used.ResultsThe survey was completed by 84.4% of students who identified the need for more emphasis in the curriculum for all of topics during training and practice pertaining to boundaries and relationships (mean 6.61±1.32 on a scale of 0 to 9; and 6.66±1.27 respectively). Topics with a high interest ranking requiring additional attention were mistreatment of medical students (mean 7.22±1.96), coping with mistakes in clinical care (mean 7.25±1.63), reporting of medical mistakes (mean 7.58±1.36), and gender bias in clinical care (mean 7.10±1.82). Women perceived a greater need for attention to all topics in the curriculum. Significant differences between the perceptions of female and male students were observed regarding topics such as responding to an impaired colleague (pConclusionMedical students recognized the need for more education and training in the undergraduate medical ethics curriculum regarding patient-physician relationship boundaries