Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.
SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.
Sixteen economic analyses were included; all studies used decision-tree structures to model acute prophylaxis, and 13 included a chronic-phase Markov module to capture long-term complications and recurrent VTE events. The model structures generally captured the important events needed to accurately estimate differences in costs and outcomes between different treatment strategies. Eleven studies included rivaroxaban, 9 studies included dabigatran, 3 studies included apixaban, and no studies included edoxaban. The analyses that compared a NOAC with low molecular-weight heparin (LMWH) predominantly resulted in the NOAC dominating LMWH for patients with both THR and TKR. The results of analyses that compared NOACs with each other suggested that dabigatran is the least cost-effective option. There is limited evidence directly comparing rivaroxaban with apixaban, but our results suggested that rivaroxaban dominates apixaban for patients with TKR in the United Kingdom. ConClusions: Economic analyses of NOACs for primary VTE prophylaxis following THR and TKR surgeries show reasonable consistency in the model structures used and events captured. The results strongly suggest that NOACs are cost-effective alternatives to LMWH. Dabigatran appears to be the least cost-effective NOAC. However, more research is needed to assess the cost-effectiveness of apixaban and edoxaban.
ObjectivOs: Evaluar el impacto sobre el presupuesto anual de salud de Chile por la inclusión de Daclatasvir/Asunaprevir (DCV/ASV) para el tratamiento de la Hepatitis C genotipo 1b. MetOdOlOgíAs: Se modeló la cohorte de pacientes Chilenos con Hepatitis C genotipo 1b utilizando datos de prevalencia e incidencia locales de acuerdo a la metodología sugerida por la guía de buenas prácticas ISPOR. Se comparó el escenario en el que todos los pacientes reciben Peginterferon/Ribavirina (PR) versus el escenario donde todos los pacientes son tratados con DCV/ASV. El análisis fue realizado desde la perspectiva del sistema de salud público Chileno asumiendo 100% de cobertura de los fármacos. Se introdujeron costos asociados al tratamiento farmacológico, de eventos adversos, recursos relevantes (monitoreo mediante exámenes de laboratorio, anatomía patológica, imágenes y controles médicos) y costos asociados a complicaciones de la enfermedad. Se consideró un horizonte de tiempo de 5 años. ResultAdOs: El impacto sobre el presupuesto anual (tomando como base el de 2015) se presenta para tres precios posibles de DCV/ASV. A CL$1.500.000 pesos chilenos (CL$) semanales se requieren CL$42.928.668.276 adicionales el primer año (tratamiento de casos prevalentes) lo que equivale a un 0.71% del presupuesto anual. Desde el año 2 en adelante (asumiendo tratar sólo casos incidentes) el monto asciende a CL$8.031.019.832 adicionales (0,13% del presupuesto nacional 2015). A CL$1.000.000 semanal, se requieren CL$25.015.902.617 adicionales el primer año y CL$4.679.931.106 adicionales desde el año 2 (0,11% y 0,6% del presupuesto anual de salud 2015). A CL$500.000 semanales se requieren CL$ 7.103.136.957 adicionales el primer año y CL$1.328.842.381 adicionales a partir del segundo año (0,3% y al 0,057% del presupuesto nacional 2015 respectivamente). cOnclusiOnes: En los rangos de precios estudiados, el impacto sobre el presupuesto de salud chileno oscila entre el 0,3% y 0,71% para el primer año, el cual disminuiría a menos del 0,15% desde el segundo año.Inflammatory bowel disease (IBD) is associated with high costs, high morbidity and decreased quality of life in patients. In Mexico and Brazil, there is no concise data about prevalence of Crohn´s Disease (CD) estimated to range from 0.0008% to 1.11% and no cost data attributable to IBD.Objectives: To assess the average annual cost per patient with CD treated with biologics from the perspective of the government healthcare system both in Mexico and Brazil. MethOds: Biologic treatments examined included certolizumab pegol (CZP) 400 mg weeks 0, 2, 4 and then every 4 weeks; adalimumab (ADA) 160 mg week 0, 80 mg week 2 and then 40 mg every 2 weeks; infliximab (INF) 5 mg / kg at weeks 0, 2, 6, and every 8 weeks thereafter. Medication acquisition costs were assessed for CZP and ADA, while costs for INF assessed both acquisition and administration (infusion). Average weight per patient in the analyses was 70kg. Prices were obtained from the Mexican Social Security Institute (IMSS) and ANVISA for Brazil. Ex...
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