ObjectivesTo determine the potential costs and health benefits of a serum-based spectroscopic triage tool for brain tumours, which could be developed to reduce diagnostic delays in the current clinical pathway.DesignA model-based health pre-trial economic assessment. Decision tree models were constructed based on simplified diagnostic pathways. Models were populated with parameters identified from rapid reviews of the literature and clinical expert opinion.SettingExplored as a test in both primary and secondary care (neuroimaging) in the UK health service, as well as application to the USA.ParticipantsCalculations based on an initial cohort of 10 000 patients. In primary care, it is estimated that the volume of tests would approach 75 000 per annum. The volume of tests in secondary care is estimated at 53 000 per annum.Main outcome measuresThe primary outcome measure was quality-adjusted life-years (QALY), which were employed to derive incremental cost-effectiveness ratios (ICER) in a cost-effectiveness analysis.ResultsResults indicate that using a blood-based spectroscopic test in both scenarios has the potential to be highly cost-effective in a health technology assessment agency decision-making process, as ICERs were well below standard threshold values of £20 000–£30 000 per QALY. This test may be cost-effective in both scenarios with test sensitivities and specificities as low as 80%; however, the price of the test would need to be lower (less than approximately £40).ConclusionUse of this test as triage tool in primary care has the potential to be both more effective and cost saving for the health service. In secondary care, this test would also be deemed more effective than the current diagnostic pathway.

BackgroundThere is growing evidence that maximal surgical resection of primary intrinsic brain tumours is beneficial, both by improving progression free and overall survival and also by facilitating postoperative chemotherapy and radiotherapy. Hence, there has been an increase in the popularity of real-time intraoperative imaging in brain tumour surgery. The complex theatre arrangements, prohibitive cost and prolonged theatre time of intraoperative MRI have restricted its application. By comparison, intraoperative three-dimensional ultrasound (i3DUS) is user friendly, cost-effective and portable and adds little to surgical time. However, operator-dependent image quality and image interpretation remain limiting factors to the wider application of this technique. The aim of this study was to explore objective i3DUS image analysis and its potential therapeutic role in brain tumour surgery.MethodsA prospective, observational study was undertaken (approved by the local Research and Ethics Committee prior to recruitment). Biopsies were taken from the solid, necrotic, periphery and brain/tumour interface of intrinsic primary brain tumours. Digital i3DUS images were analysed to extract quantitative parameters from these regions of interest (ROI) in the i3DUS images. These were then correlated with the histology of the relevant specimens. The histopathologist was blinded to the imaging findings.ResultsNinety-seven patients (62 males; mean 54 years) with varying gliomas (84 high grade) were included. Two hundred and ninety regions of interest were analysed. Mean pixel brightness (MPB) and standard deviation (SD) were correlated with histological features. Close correlations were noted between MPB and cellularity, and SD and intrinsic cellular diversity.ConclusionsMPB and SD are objective measures reflecting the sensitivity of i3DUS in detecting the presence and extent of intrinsic brain tumours. They indirectly suggest heterogeneity, cellularity and invasiveness, providing information of the nature of the tumour, and also reflect the sensitivity of intraoperative US to detect the presence of residual intrinsic brain tumours. Development of this paradigm will enhance i3DUS use as an adjunct in brain tumour surgery. Optimizing its intraoperative application will impact surgical resection and, hence, patient outcome.

Low cost reduction of morbidity in lymphoedema is an essential goal in the management of lymphatic filariasis. This review emphasises the role of movement and elevation, and refers to the literature on the effects of these on the venous and lymphatic system. The patient with lymphoedema becomes increasingly immobile and the affected limb is often in a permanently dependent position causing venous hypertension and resultant overloading of the failing lymphatics. The evidence that breathing exercises are important for reducing venous hypertension and inducing lymphatic flow is discussed.The contribution of a damaged epidermis to lymphatic failure is emphasised. Loss of barrier function encourages penetration of bacteria and stimulates repair mechanisms that generate cytokines, which, in turn lead to inflammation. Management programmes that improve the health of the epidermis play a part in reducing lymphatic load.In taking morbidity management of lymphoedema into the general health services there are benefits in promoting skin hygiene and self-help regimes that can ameliorate many diseases along with lymphoedema.