P>Context In the management of patients with medullary thyroid carcinoma (MTC), calcitonin doubling time (dt) has gained interest as an independent predictor of recurrence and survival.... Show moreP>Context In the management of patients with medullary thyroid carcinoma (MTC), calcitonin doubling time (dt) has gained interest as an independent predictor of recurrence and survival. Objective To perform a structured meta-analysis of the diagnostic value of calcitonin dt, carcinoembryonic antigen (CEA) dt and the combination and to define dt strata with the highest predictive power. Design The study was a meta-analysis using individual data. Methods Ten studies containing data on the post-operative kinetics of tumour marker(s) and (recurrence free) survival were included. Results Calcitonin- and CEA-dt are significant indicators for survival (hazard ratios (HR) 21 center dot 52 respectively infinite for dt 0-1 year compared to dt > 1 year) and recurrence (HR 5 center dot 33 respectively 6 center dot 80 for dt 0-1 year compared to dt > 1 year). The highest predictive power was found for the dt classification 0-1 year vs. > 1 year. CEA dt has a higher predictive value than calcitonin dt in the subgroup of patients for which both parameters were available. Conclusion The dts of both calcitonin and CEA are strong prognostic indicators for MTC recurrence and death. CEA dt has a higher predictive value than calcitonin dt and therefore measuring both tumour markers is essential for proper risk stratification. Show less
Objective: To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs. Design: Cost utility analysis... Show moreObjective: To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs. Design: Cost utility analysis alongside a randomised controlled trial. Setting: Nine Dutch hospitals. Participants: 283 patients with sciatica for 6-12 weeks, caused by lumbar disc herniation. Interventions: Six months of prolonged conservative care compared with early surgery. Main outcome measures: Quality adjusted life years (QALYs) at one year and societal costs, estimated from patient reported utilities (UK and US EuroQol, SF-6D, and visual analogue scale) and diaries on costs (healthcare, patient's costs, and productivity). Results: Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083), the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024 (0.003 to 0.046), and the visual analogue scale of 0.032 (-0.003 to 0.066). From the healthcare perspective, early surgery resulted in higher costs (difference euro1819 (pound1449; $2832), 95% confidence interval euro842 to euro2790), with a cost utility ratio per QALY of euro41 000 (euro14,000 to euro430 000). From the societal perspective, savings on productivity costs led to a negligible total difference in cost (euro-12, euro-4029 to euro4006). Conclusions: Faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. The estimated difference in healthcare costs was acceptable and was compensated for by the difference in absenteeism from work. For a willingness to pay of euro40,000 or more per QALY, early surgery need not be withheld for economic reasons. Trial registration Current Controlled Trials ISRCTN 26872154. Show less
Stiggelbout, A.M.; Brink, M. van den; Hout, W.B. van den; Kievit, J.; Marijnen, C.A.M.; Putter, H.; Velde, C.J.H. van de 2005
