Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial

Background Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. Methods POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. Discussion The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis

Product variety and economic growth: the counteracting effects of scale and idiosyncrasy

Abstract in thesi

Hotspot services in the open spectrum : implications of market organization for coverage and welfare

We consider three ways a market for wireless communication can be organized in the open spectrum. First, a network of hotspots might be owned by a telecommunications company (‘telco’). Second, a decentral- ized network (‘free radio’) might arise in which users connect to indi- vidually owned hotspots. Third, a hotspot aggregator might intermediate between users and individual hotspot providers. The number of hotspots can be larger for the telco market type than for free radio if users care enough about coverage. If the sensitivity of technology to spectrum con- gestion is high, free radio is to be preferred to a telco market. The number of hotspots for a market with a hotspot aggregator is smaller than for free radio because of ‘double marginalization’. None of the three market types is socially optimal because of monopolistic behavior and because of an externality induced by a preference for coverage