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BACKGROUND & AIMS: Criteria defined by the European Association for the Study of the Liver (EASL) and Liver Imaging Reporting and Data System (LI-RADS) enable hepatocellular carcinoma (HCC) diagnosis based on imaging in cirrhosis. Non-cirrhotic patients require biopsy given the lower pre-test probability of HCC. The objective of our study was to assess the performance of EASL and LI-RADS criteria for the diagnosis of HCC in non-cirrhotic patients with chronic HBV infection. METHODS: This was a cross-sectional study performed at a referral center. We included all patients with HBV without cirrhosis with focal liver lesions who underwent contrast-enhanced CT or MRI at our clinic between 2005-2018. Studies were reviewed by 2 radiologists blinded to the diagnosis. RESULTS: We included 280 patients, median age was 56.8 (IQR 48.2-65.45) years and 223 (80%) were male. In 191 (79%) cases the lesion was found as a result of screening. Cirrhosis was excluded based on pathology in 252 (90%) cases. We assessed 338 nodules: 257 (76%) HCC, 40 (12%) non-HCC malignant lesions, and 41 (12%) benign lesions. EASL criteria and LR-5/LR-tumor-in-vein (TIV) categories had a 100% agreement in categorizing lesions as HCC, and 226 nodules (67%) were classified as HCCs. The sensitivity, specificity, positive predictive value, and negative predictive value were 82.1 (76.9-86.6), 81.5 (71.3-89.2), 93.4 (89.3-96.2), and 58.9 (49.2-68.1), respectively. When the pre-test probability of HCC is >70%, estimated as a PAGE-B score above 9, and EASL or LR-5/LR-TIV criteria are met, post-test probability would be >90%. CONCLUSIONS: EASL criteria and LR-5/LR-TIV categories show a positive predictive value in patients with HBV without cirrhosis that is comparable to that seen in patients with cirrhosis. These criteria can be used when the pre-test probability of HCC is >70%. LAY SUMMARY: Current guidelines recommend performing a biopsy to confirm the diagnosis of presumed hepatocellular carcinoma (HCC) in patients without cirrhosis. We showed that specific imaging criteria had a 100% agreement for categorizing lesions as HCC, with a positive predictive value of 93.4%. These imaging criteria could be used to diagnose HCC in HBV patients without cirrhosis with a pre-test probability of HCC of ≥70%, avoiding the need for a liver biopsy.
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The burden of seasonal influenza disease in Argentina is considerable. The cost-effectiveness of trivalent (TIV) versus quadrivalent influenza vaccine (QIV) in Argentina was assessed. An age-stratified, static, decision-tree model compared the costs and benefits of vaccination for an average influenza season. Main outcomes included: numbers of influenza cases; general practitioner (GP) visits; complicated ambulatory cases; hospitalizations; deaths averted; and costs per quality-adjusted life years (QALYs) gained. Epidemiological data from Argentina for 2014-2019 were used to determine the proportion of A and B strain cases, and the frequency of mismatch between vaccine and circulating B strains. To manage uncertainty, one-way and probabilistic sensitivity analyses were performed. Switching from TIV to QIV would prevent 19,128 influenza cases, 16,164 GP visits, 2440 complicated ambulatory cases, 524 hospitalizations, and 82 deaths. Incremental cost-effectiveness ratios (ICERs) per QALY were 13,590 and 11,678 USD from the payer's and societal perspectives, respectively. The greatest health benefits and direct medical cost savings would occur in ≥ 65-year-olds. One-way sensitivity analyses demonstrated the principal drivers of ICER to be vaccine acquisition costs, environmental B strain predominance, and B strain mismatch. Introducing QIV in Argentina would be beneficial and cost-effective relative to TIV, particularly in older adults.
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BACKGROUND: Influenza burden in Brazil is considerable with 4.2-6.4 million cases in 2008 and influenza-like-illness responsible for 16.9% of hospitalizations. Cost-effectiveness of influenza vaccination may be assessed by different types of models, with limitations due to data availability, assumptions, and modelling approach. OBJECTIVE: To understand the impact of model complexity, the cost-utility of quadrivalent versus trivalent influenza vaccines in Brazil was estimated using three distinct models: a 1-year decision tree population model with three age groups (FLOU); a more detailed 1-year population model with five age groups (FLORA); and a more complex lifetime multi-cohort Markov model with nine age groups (FLORENCE). METHODS: Analysis 1 (impact of model structure) compared each model using the same data inputs (i.e., best available data for FLOU). Analysis 2 (impact of increasing granularity) compared each model populated with the best available data for that model. RESULTS: Using the best data for each model, the discounted cost-utility ratio of quadrivalent versus trivalent influenza vaccine was R$20,428 with FLOU, R$22,768 with FLORA (versus R$20,428 in Analysis 1), and, R$19,257 with FLORENCE (versus R$22,490 in Analysis 1) using a lifetime horizon. Conceptual differences between FLORA and FLORENCE meant the same assumption regarding increased all-cause mortality in at-risk individuals had an opposite effect on the incremental cost-effectiveness ratio in Analysis 2 versus 1, and a proportionally higher number of vaccinated elderly in FLORENCE reduced this ratio in Analysis 2. DISCUSSION: FLOU provided adequate cost-effectiveness estimates with data in broad age groups. FLORA increased insights (e.g., in healthy versus at-risk, paediatric, respiratory/non-respiratory complications). FLORENCE provided greater insights and precision (e.g., in elderly, costs and complications, lifetime cost-effectiveness). CONCLUSION: All three models predicted a cost per quality-adjusted life year gained for quadrivalent versus trivalent influenza vaccine in the range of R$19,257 (FLORENCE) to R$22,768 (FLORA) with the best available data in Brazil (Appendix A).
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Vacunas contra la Influenza/economía , Gripe Humana/economía , Gripe Humana/prevención & control , Modelos Económicos , Vacunación/economía , Adolescente , Adulto , Factores de Edad , Anciano , Brasil , Niño , Preescolar , Análisis Costo-Beneficio/métodos , Análisis Costo-Beneficio/estadística & datos numéricos , Técnicas de Apoyo para la Decisión , Femenino , Hospitalización/economía , Humanos , Lactante , Gripe Humana/mortalidad , Masculino , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Reproducibilidad de los Resultados , Medición de Riesgo , Vacunación/estadística & datos numéricos , Adulto JovenRESUMEN
ABSTRACT Background: Influenza burden in Brazil is considerable with 4.2-6.4 million cases in 2008 and influenza-like-illness responsible for 16.9% of hospitalizations. Cost-effectiveness of influenza vaccination may be assessed by different types of models, with limitations due to data availability, assumptions, and modelling approach. Objective: To understand the impact of model complexity, the cost-utility of quadrivalent versus trivalent influenza vaccines in Brazil was estimated using three distinct models: a 1-year decision tree population model with three age groups (FLOU); a more detailed 1-year population model with five age groups (FLORA); and a more complex lifetime multi-cohort Markov model with nine age groups (FLORENCE). Methods: Analysis 1 (impact of model structure) compared each model using the same data inputs (i.e., best available data for FLOU). Analysis 2 (impact of increasing granularity) compared each model populated with the best available data for that model. Results: Using the best data for each model, the discounted cost-utility ratio of quadrivalent versus trivalent influenza vaccine was R$20,428 with FLOU, R$22,768 with FLORA (versus R$20,428 in Analysis 1), and, R$19,257 with FLORENCE (versus R$22,490 in Analysis 1) using a lifetime horizon. Conceptual differences between FLORA and FLORENCE meant the same assumption regarding increased all-cause mortality in at-risk individuals had an opposite effect on the incremental cost-effectiveness ratio in Analysis 2 versus 1, and a proportionally higher number of vaccinated elderly in FLORENCE reduced this ratio in Analysis 2. Discussion: FLOU provided adequate cost-effectiveness estimates with data in broad age groups. FLORA increased insights (e.g., in healthy versus at-risk, paediatric, respiratory/non-respiratory complications). FLORENCE provided greater insights and precision (e.g., in elderly, costs and complications, lifetime cost-effectiveness). Conclusion: All three models predicted a cost per quality-adjusted life year gained for quadrivalent versus trivalent influenza vaccine in the range of R$19,257 (FLORENCE) to R$22,768 (FLORA) with the best available data in Brazil (Appendix A).
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Humanos , Masculino , Femenino , Lactante , Preescolar , Niño , Adolescente , Adulto , Persona de Mediana Edad , Anciano , Adulto Joven , Vacunas contra la Influenza/economía , Vacunación/economía , Modelos Económicos , Gripe Humana/economía , Gripe Humana/prevención & control , Brasil , Reproducibilidad de los Resultados , Técnicas de Apoyo para la Decisión , Factores de Edad , Vacunación/estadística & datos numéricos , Análisis Costo-Beneficio/métodos , Análisis Costo-Beneficio/estadística & datos numéricos , Medición de Riesgo , Años de Vida Ajustados por Calidad de Vida , Hospitalización/economíaRESUMEN
A produção in vitro de embriões (PIV) é uma biotécnica importante para exploração do potencialgenético de fêmeas bovinas e tem sido utilizada em escala comercial no Brasil e no mundo. A PIV envolve asetapas de coleta, maturação, fecundação e cultivo in vitro sendo que a eficiência das etapas de maturação efecundação in vitro não difere daquela obtida in vivo. No entanto, o cultivo in vitro continua sendo a etapa queapresenta a menor eficiência sendo que, em média, apenas 30% dos oócitos maturados in vitro se desenvolvemao estádio de blastocisto. Adicionalmente, os blastocistos produzidos in vitro diferem daqueles produzidos invivo, apresentando menores taxas de prenhez e sendo menos tolerantes à criopreservação. Portanto, o objetivo destarevisão é realizar uma abordagem atualizada das principais etapas da produção in vitro de embriões bovinos.
The in vitro embryo production (IVP) is a major tool for exploration of the genetic potential of cowsand has been used in commercial scale in Brazil and worldwide. The IVP technique involves the steps ofcollecting, maturation, fertilization and in vitro culture and the efficiency of the steps of maturation andfertilization in vitro does not differ from that obtained in vivo. However, the in vitro culture continues to be thestep that has the lowest efficiency and, on average, only 30% of in vitro matured oocytes develop to blastocyststage. In addition, in vitro produced blastocysts differ from those produced in vivo, with lower pregnancy ratesand are less tolerant to cryopreservation. Therefore, the aim of this review is to perform an updated approach tothe main steps of in vitro production of bovine embryos.
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Animales , Bovinos , Bovinos/crecimiento & desarrollo , Bovinos/embriología , Transferencia de Embrión , Transferencia de Embrión/veterinaria , Técnicas In Vitro , Técnicas In Vitro/veterinariaRESUMEN
A produção in vitro de embriões (PIV) é uma biotécnica importante para exploração do potencialgenético de fêmeas bovinas e tem sido utilizada em escala comercial no Brasil e no mundo. A PIV envolve asetapas de coleta, maturação, fecundação e cultivo in vitro sendo que a eficiência das etapas de maturação efecundação in vitro não difere daquela obtida in vivo. No entanto, o cultivo in vitro continua sendo a etapa queapresenta a menor eficiência sendo que, em média, apenas 30% dos oócitos maturados in vitro se desenvolvemao estádio de blastocisto. Adicionalmente, os blastocistos produzidos in vitro diferem daqueles produzidos invivo, apresentando menores taxas de prenhez e sendo menos tolerantes à criopreservação. Portanto, o objetivo destarevisão é realizar uma abordagem atualizada das principais etapas da produção in vitro de embriões bovinos.(AU)
The in vitro embryo production (IVP) is a major tool for exploration of the genetic potential of cowsand has been used in commercial scale in Brazil and worldwide. The IVP technique involves the steps ofcollecting, maturation, fertilization and in vitro culture and the efficiency of the steps of maturation andfertilization in vitro does not differ from that obtained in vivo. However, the in vitro culture continues to be thestep that has the lowest efficiency and, on average, only 30% of in vitro matured oocytes develop to blastocyststage. In addition, in vitro produced blastocysts differ from those produced in vivo, with lower pregnancy ratesand are less tolerant to cryopreservation. Therefore, the aim of this review is to perform an updated approach tothe main steps of in vitro production of bovine embryos.(AU)