Neel Shah

New-generation platinum agents for solid tumors

Cisplatin was one of the first chemotherapeutic agents to exhibit broad efficacy in solid tumors and it remains among the most widely used agents in the treatment of cancer. Its introduction inspired great efforts to design similarly effective platinum agents that overcome the three main limitations of cisplatin: toxicity, tumor resistance and poor oral bioavailability. However, 40 years after the initial discovery of cisplatin, only two platinum agents have garnered US FDA approval: carboplatin and oxaliplatin. Although hundreds of promising agents were tested in clinical trials during the 1990s, only oxaliplatin made it past clinical development. For a brief period, the economic cost of these unsuccessful efforts retarded further efforts to develop new agents. However, two exciting platinum agents have been brought to Phase III trials: satraplatin in hormone-refractory prostate cancer and picoplatin in small-cell lung cancer. If successful, they may inspire a new effort to bring better-designed platinum agents to market. This article reviews the clinical development of platinum agents to date and speculates on the role of platinum agents in the near future.

Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies.

Complication rates did not vary significantly among minimally invasive methods of hysterectomy; however, patient costs were significantly influenced by the technique used for hysterectomy.

Shoulder Arthroscopy Simulator Training Improves Shoulder Arthroscopy Performance in a Cadaveric Model

PURPOSE The purpose of this study was to quantify the benefits of shoulder arthroscopy simulator training with a cadaveric model of shoulder arthroscopy. METHODS Seventeen first-year medical students with no prior experience in shoulder arthroscopy were enrolled and completed this study. Each subject completed a baseline proctored arthroscopy on a cadaveric shoulder, which included controlling the camera and completing a standard series of tasks using the probe. The subjects were randomized, and 9 of the subjects received training on a virtual reality simulator for shoulder arthroscopy. All subjects then repeated the same cadaveric arthroscopy. The arthroscopic videos were analyzed in a blinded fashion for time to task completion and subjective assessment of technical performance. The 2 groups were compared by use of Student t tests, and change over time within groups was analyzed with paired t tests. RESULTS There were no observed differences between the 2 groups on the baseline evaluation. The simulator group improved significantly from baseline with respect to time to completion and subjective performance (P < .05). Time to completion was significantly faster in the simulator group compared with controls at the final evaluation (P < .05). No difference was observed between the groups on the subjective scores at the final evaluation (P = .98). CONCLUSIONS Shoulder arthroscopy simulator training resulted in significant benefits in clinical shoulder arthroscopy time to task completion in this cadaveric model. This study provides important additional evidence of the benefit of simulators in orthopaedic surgical training. CLINICAL RELEVANCE There may be a role for simulator training in shoulder arthroscopy education.

Drivers of maternity care in high-income countries: can health systems support woman-centred care?

In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facilitys women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by womens experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

The Feasibility of Societal Cost Equivalence between Robotic Hysterectomy and Alternate Hysterectomy Methods for Endometrial Cancer

Objectives. We assess whether it is feasible for robotic hysterectomy for endometrial cancer to be less expensive to society than traditional laparoscopic hysterectomy or abdominal hysterectomy. Methods. We performed a retrospective cohort analysis of patient characteristics, operative times, complications, and hospital charges from all (n = 234) endometrial cancer patients who underwent hysterectomy in 2009 at our hospital. Per patient costs of each hysterectomy method were examined from the societal perspective. Sensitivity analysis and Monte Carlo simulation were performed using a cost-minimization model. Results. 40 (17.1%) of hysterectomies for endometrial cancer were robotic, 91 (38.9%), were abdominal, and 103 (44.0%) were laparoscopic. 96.3% of the variation in operative cost between patients was predicted by operative time (R = 0.963, P < 0.01). Mean operative time for robotic hysterectomy was significantly longer than other methods (P < 0.01). Abdominal hysterectomy was consistently the most expensive while the traditional laparoscopic approach was consistently least expensive. The threshold in operative time that makes robotic hysterectomy cost equivalent to the abdominal approach is within the range of our experience. Conclusion. It is feasible for robotic hysterectomy to be less expensive than abdominal hysterectomy, but unlikely for robotic hysterectomy to be less expensive than traditional laparoscopy.

A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth

The U.K.s National Institute for Health and Care Excellence has concluded that healthy women with low-risk pregnancies are safer delivering at home or in a midwife-led unit than in a hospital under an obstetricians supervision. Across the pond, eyebrows went up.

Too Much Medicine Happens Too Often The Teachable Moment and a Call for Manuscripts From Clinical Trainees

A columnist at theNew York Times asked readers, “Have you experiencedtoomuchmedicine?”Shereceivedmorethan1000 responses detailing examples ranging fromunnecessary testing and hospitalizations to useless office visits and specialist referrals.1 Patients are not the only ones worried about too muchmedicine: 42%of anational sampleofprimary carephysicians believe that patients in their own practice are receiving too muchmedical care.2 Too much medicine, or overuse, occurs in at least 3 contexts: when benefits from medical care are negligible, when thepotential for harmexceeds thepotential benefit,3 orwhen a fully informed patient would decide to forego the service. Examples of overuse include overtesting (eg, routinely ordering preoperative chest x-rays; see the Perspective in this issue4) and overtreatment (eg, coronary revascularization inpatientswith stable anginanot receivingoptimalmedical therapy). Spending on overuse is thought to substantially contribute to theunsustainablegrowth inUShealthcarecosts.5 Wastefulhealthcare is estimated tocost

Fostering value in clinical practice among future physicians: Time to consider COST

750billionannually,6 limiting equitable access tonecessaryhealth care6 andcrowdingout spendingonotherpriorities suchaspublichealth, education, and valuable social programs.When passed on to our patients, health care costs can be financially catastrophic.7 The costs of overuse are not measured in dollars alone. Overtesting and overtreatment expose patients to potential harmsanddownstreamcomplications8—andoften lead tonet harm.Farbeyondcostconsciousness, theethicalcase foravoiding overuse, “first, do no harm,” is a powerful appeal to our professionalism.8 All thoughtful physicians want to minimize harms fromoveruse. The challenge is recognizingwhen an intervention is likely to represent overuse.

A biophysical basis for the inter-spike interaction of spike-timing-dependent plasticity

Over the past 50 years, U.S. health care expenditures have grown 5 times faster than the gross domestic product and 50 times faster than real wages. Although much of this spending has helped Americans become healthier, at least one third (

Creating an Effective Campaign for Change: Strategies for Teaching Value

800 billion annually) is wasted on unnecessary care and inefficiency. Because of mounting scrutiny from policy makers and patients, the medical profession has recently focused attention on providing better care at a lower cost. Achieving this goal will require a comprehensive approach through the engagement of clinicians at every level of training to identify opportunities for improvement. Currently, a lack of education among physicians presents a significant barrier.