Background and objective Anemia is a common prognosis of chronic kidney disease (CKD). It is predominantly managed with synthetic erythropoietin. The principal objective of this study was to compare the cost-effectiveness of the use of short-acting erythropoietin with the long-acting one to maintain serum hemoglobin (Hb) concentration within the range of 10.5-12 g/dL. Method This was a retrospective cohort study involving patients diagnosed with stage 5 CKD according to the Saudi Society of Nephrology and Transplantation conducted at eight tertiary care centers in the Tabuk region, Saudi Arabia. We compared the cost-effectiveness of long-acting erythropoietin with the short-acting one. The decision analysis model and Markov model were established to simulate a cohort of 55-year-old patients to estimate the incremental cost and quality-adjusted life-year (QALY) for chronic hemodialysis patients (CHP) treated with either darbepoetin-alfa or epoetin-beta for at least nine months. The incremental cost per QALY was the main outcome marker for using both medications. Serum HB levels were monitored on a monthly basis and costs were calculated. Results A total of 291 CHP met our inclusion criteria; 194 of them were treated with darbepoetin-alfa while 97 were treated with epoetin-beta. The mean age was 56.3 ± 11.2 years for the darbepoetin-alfa group and 55.2 ± 7.8 years for the epoetin-beta cohort. The baseline serum Hb was 10.68 ± 0.98 g/dL for darbepoetin-alfa patients and 11.63 ± 0.32 g/dL for the epoetin-beta group (p=0.003). We observed a significant difference between the percentage of patients successfully treated with epoetin-beta and those managed with darbepoetinalfa (80.4% vs. 63.92%, p=0.01) with considerably less cardiovascular side effects. The average annual cost per patient was estimated at $919.47 and $12,319.41 for epoetin-beta and darbepoetin-alfa respectively. Also, the average effectiveness was 0.58 for darbepoetin-alfa vs. 0.
Methotrexate is the standard medical management for ectopic pregnancy. Pharmacologically, it is a folic acid antagonist which inhibits DNA synthesis. 90% of appropriately selected un-ruptured none live ectopic pregnancy respond to methotrexate treatment with no further management is required. In the UK, NICE guidance has identified the selection criteria to achieve the best and safest outcome in ectopic pregnancy treatment with methotrexate. Methotrexate also has a role in management of pregnancy of unknown location. Single administration of 50 mg/m2 body surface area is the most widely acceptable regimen for methotrexate in treatment of ectopic pregnancy. Post treatment b-HCG checks at day 0, 4 and 7 are also a widely accepted follow up regimen to ensure satisfactory decline in b-HCG levels. Methotrexate has a role also in managing none tubal ectopic pregnancies where surgical risks are high. Post treatment transient pain is common and represent a clinical challenge as it can also be failed treatment with ruptured ectopic pregnancy.
Preterm delivery is defined as delivery before 37 weeks completed gestation. It represents a major cause of neonatal morbidity and mortality and accounts for 5–10% of all deliveries. Cervical length assessment between 16–24 weeks and positive fetal fibronectin beyond 21 weeks gestation are proved to useful tools in prediction of preterm labour. Treating asymptomatic bacteruia and bacterial vaginosis in high-risk women reduces the incidence of preterm labour. Cervical cerclage is recommended to reduce the incidence of preterm birth in women with 2nd trimester losses and those with cervical length of 25 mm or less on transvaginal ultrasound between 16–24 weks gestation. Atosiban and nifidipine are currently the agents of choice in tocolysis. Antenal steriods in womens with threating preterm labour reduces the perinatal morbidties. Magnisum sulphate role is established for neuroprotection especially in extreme gestations between 24–30 weeks. Vaginal delivery is mode of choice for delivery with consideration to avoid fetal blood sampling, fetal scalp electrodes and ventouse prior to 34 weeks gestations. Caesarean section is considered for obstetric reasons that guide labour management at term.
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