Comparing the cost-effectiveness of linezolid to trimethoprim/sulfamethoxazole plus rifampicin for the treatment of methicillin-resistant Staphylococcus aureus infection: a healthcare system perspective

OBJECTIVE

Few industry-independent studies have been conducted to compare the relative costs and benefits of drugs to treat methicillin-resistant Staphylococcus aureus (MRSA) infection. We performed a stochastic cost-effectiveness analysis comparing two treatment strategies-linezolid versus trimethoprim-sulfamethoxazole plus rifampicin-for the treatment of MRSA infection.

METHODS

We used cost and effectiveness data from a previously conducted clinical trial, complementing with other data from published literature, to compare the two regimens from a healthcare system perspective. Effectiveness was expressed in terms of quality-adjusted life-years (QALYs). Several sensitivity analyses were performed using Monte Carlo simulation, to measure the effect of potential parameter changes on the base-case model results, including potential differences related to type of infection and drug toxicity.

RESULTS

Treatment of MRSA infection with trimethoprim-sulfamethoxazole plus rifampicin and linezolid were found to cost on average €146 and €2536, and lead to a gain of 0.916 and 0.881 QALYs, respectively. Treatment with trimethoprim-sulfamethoxazole plus rifampicin was found to be more cost-effective than linezolid in the base case and remained dominant over linezolid in most alternative scenarios, including different types of MRSA infection and potential disadvantages in terms of toxicity. With a willingness-to-pay threshold of €0, €50 000 and €200 000 per QALY gained, trimethoprim-sulfamethoxazole plus rifampicin was dominant in 100%, 96% and 85% of model iterations. A 95% discount on the current purchasing price of linezolid would be needed when it goes off-patent for it to represent better value for money compared with trimethoprim-sulfamethoxazole plus rifampicin.

CONCLUSIONS

Combined treatment of trimethoprim-sulfamethoxazole plus rifampicin is more cost-effective than linezolid in the treatment of MRSA infection.

Estimating the impact of healthcare-associated infections on length of stay and costs

Healthcare-associated infections (HAIs) unquestionably have substantial effects on morbidity and mortality. However, quantifying the exact economic burden attributable to HAIs still remains a challenging issue. Inaccurate estimations may arise from two major sources of bias. First, factors other than infection may affect patients' length of stay (LOS) and healthcare utilization. Second, HAI is a time-varying exposure, as the infection can impact on LOS and costs only after the infection has started. The most frequent mistake in previously published evidence is the introduction of time-dependent information as time-fixed, on the assumption that the impact of such exposure on the outcome was already present on admission. Longitudinal and multistate models avoid time-dependent bias and address the time-dependent complexity of the data. Appropriate statistical methods are important in analysis of excess costs and LOS associated with HAI, because informed decisions and policy developments may depend on them.

Multistate modelling to estimate the excess length of stay associated with meticillin-resistant Staphylococcus aureus colonisation and infection in surgical patients

Currently available evidence on the excess length of stay (LOS) associated with nosocomial infections is limited by methodology, including time-dependent bias. To determine the excess LOS associated with nosocomial meticillin-resistant Staphylococcus aureus (MRSA) infection and colonisation, 797 MRSA-colonised, 167 MRSA-infected and 13,640 MRSA-negative surgical patients were included in a multistate model. The occurrence of MRSA infection or colonisation was the time-dependent exposure, and discharge or death was the study endpoint. The excess LOS was extracted by computing the Aalen-Johansen estimator of the matrix of transition probabilities. Multivariate Cox regression analysis was used to assess the independent effect of MRSA on excess LOS. MRSA infection prolonged LOS by 14.5 [95% confidence interval (CI): 7.8, 21.3] days compared to uninfected patients, and by 5.9 (95% CI: 0.1, 11.7) days compared to patients only colonised by MRSA. The hazard of discharge was reduced by nosocomial MRSA infection both with respect to MRSA-free patients and MRSA carriers [adjusted hazard ratio (HR): 0.69; 95% CI: 0.59, 0.81; and HR: 0.79; 95% CI: 0.65, 0.95, respectively]. MRSA carriage alone did not decrease the hazard of discharge after adjustment for confounding (HR: 1.00; 95% CI: 0.93, 1.07). Multistate modelling is a promising statistical method to evaluate the health-economic impact of nosocomial antibiotic-resistant infections.

Dynamics of saccade target selection: race model analysis of double step and search step saccade production in human and macaque

We investigated how saccade target selection by humans and macaque monkeys reacts to unexpected changes of the image. This was explored using double step and search step tasks in which a target, presented alone or as a singleton in a visual search array, steps to a different location on infrequent, random trials. We report that human and macaque monkey performance are qualitatively indistinguishable. Performance is stochastic with the probability of producing a compensated saccade to the final target location decreasing with the delay of the step. Compensated saccades to the final target location are produced with latencies relative to the step that are comparable to or less than the average latency of saccades on trials with no target step. Noncompensated errors to the initial target location are produced with latencies less than the average latency of saccades on trials with no target step. Noncompensated saccades to the initial target location are followed by corrective saccades to the final target location following an intersaccade interval that decreases with the interval between the target step and the initiation of the noncompensated saccade. We show that this pattern of results cannot be accounted for by a race between two stochastically independent processes producing the saccade to the initial target location and another process producing the saccade to the final target location. However, performance can be accounted for by a race between three stochastically independent processes--a GO process producing the saccade to the initial target location, a STOP process interrupting that GO process, and another GO process producing the saccade to the final target location. Furthermore, if the STOP process and second GO process start at the same time, then the model can account for the incidence and latency of mid-flight corrections and rapid corrective saccades. This model provides a computational account of saccade production when the image changes unexpectedly.

Autologous stem cell transplantation followed by consolidation chemotherapy for patients with multiple myeloma

Although high-dose therapy and autologous stem cell transplant (ASCT) is superior to conventional chemotherapy for treatment of myeloma, most patients relapse and the time to relapse depends upon the initial prognostic factors. The administration of non-cross-resistant chemotherapies during the post-transplant period may delay or prevent relapse. We prospectively studied the role of consolidation chemotherapy (CC) after single autologous peripheral blood stem cell transplant (auto-PBSCT) in 103 mostly newly diagnosed myeloma patients (67 patients were < or =6 months from the initial treatment). Patients received conditioning with BCNU, melphalan+/-gemcitabine and auto-PBSCT followed by two cycles of the DCEP+/-G regimen (dexamethasone, cyclophosphamide, etoposide, cisplatin+/-gemcitabine) at 3 and 9 months post-transplant and alternating with two cycles of DPP regimen (dexamethasone, cisplatin, paclitaxel) at 6 and 12 months post-transplant. With a median follow-up of 61.2 months, the median event-free survival (EFS) and overall survival (OS) are 26 and 54.1 months, respectively. The 5-year EFS and OS are 23.1 and 42.5%, respectively. Overall, 51 (49.5%) patients finished all CC, suggesting that a major limitation of this approach is an inability to deliver all planned treatments. In order to improve results following autotransplantation, novel agents or immunologic approaches should be studied in the post-transplant setting.

Rabeprazole is superior to omeprazole for the inhibition of peptone meal-stimulated gastric acid secretion in Helicobacter pylori-negative subjects

BACKGROUND

Peptone meal-stimulated gastric acid output is considered to be a reliable means to evaluate drug-mediated inhibition of stimulated gastric acid output, an important measure of the efficacy of the agents--such as proton pump inhibitors--used to treat acid-related disorders.

AIM

To compare the initial and overall inhibitory effects on peptone meal-stimulated gastric acid secretion of rabeprazole and omeprazole, 20 mg, in Helicobacter pylori-negative subjects on the first and eighth days of treatment.

METHODS

Healthy volunteers (n = 27) were randomized in a single-centre, double-blind, double-dummy, 2 x 2 cross-over study. Subjects received an oral dose of rabeprazole or omeprazole, 20 mg once daily, for 8 days. After a 2-4-week washout period, subjects were crossed over to receive the other medication for 8 days. Peptone meal-stimulated gastric acid secretion was measured at hours 11 and 23 at baseline and on days 1 and 8 of treatment.

RESULTS

On days 1 and 8, rabeprazole demonstrated a significantly greater inhibition of peptone meal-stimulated gastric acid secretion compared with omeprazole at all time points (P < 0.03). Median values of steady-state inhibition on day 1 were statistically significant at hour 23 (rabeprazole 100% vs. omeprazole 74%, P < 0.02).

CONCLUSIONS

Rabeprazole, 20 mg, demonstrated superior control of peptone meal-stimulated gastric acid secretion compared with omeprazole, 20 mg, after the first dose and after the eighth daily dose. Rabeprazole achieved a more rapid onset of acid inhibition and a greater steady-state reduction in peptone meal-stimulated gastric acid secretion.

Onset of symptom relief with rabeprazole: a community-based, open-label assessment of patients with erosive oesophagitis

BACKGROUND

In numerous clinical trials, proton pump inhibitors have demonstrated potent acid suppression and healing of erosive oesophagitis, as well as successful symptom relief for the entire spectrum of gastro-oesophageal reflux disease.

AIM

The 'Future of Acid Suppression Therapy' (FAST) trial evaluated, in actual clinical practice, the timing of symptom relief, changes in symptom severity, health-related quality of life and safety in endoscopically confirmed erosive gastro-oesophageal reflux disease treated with rabeprazole.

METHODS

This open-label, multicentre study enrolled 2579 patients to receive rabeprazole treatment using 20 mg once daily for 8 weeks. Between two clinical visits (at enrollment and week 8), patients used an interactive voice response system to rate gastro-oesophageal reflux disease symptoms. Subgroup analyses of efficacy were conducted for gender, age, Hetzel-Dent grade, presence of Barrett's oesophagus and for patients reporting previously ineffective symptom relief with omeprazole or lansoprazole.

RESULTS

On day 1, rabeprazole significantly decreased daytime and night-time heartburn severity, regurgitation and belching. Complete relief of daytime and night-time heartburn was achieved in 64.0% and 69.2% of symptomatic patients, respectively, on day 1, and in 81.1% and 85.7% of patients, respectively, on day 7. Patients with moderate or severe heartburn symptoms at baseline achieved an even greater degree of satisfactory symptom relief (none or mild) from day 1 onwards. The median time to satisfactory heartburn relief was 2 days. Subgroup analyses showed no consistent differences in efficacy compared to the overall population treated. Health-related quality of life in patients was significantly lower than that of the US general population and improved significantly after 8 weeks of rabeprazole therapy. Rabeprazole was well tolerated, with headache as the most common adverse event, reported by less than 2% of the study population.

CONCLUSIONS

In this large, open-label trial, rabeprazole rapidly and effectively relieved gastro-oesophageal reflux disease symptoms in most patients with erosive oesophagitis. Substantial symptom relief was noted on day 1; improvement continued over the first week and at week 4. By week 8, the health-related quality of life had also improved vs. baseline.

Dynamic dissociation of visual selection from saccade programming in frontal eye field

Previous studies of visually responsive neurons in the frontal eye fields have identified a selection process preceding saccades during visual search. The goal of this experiment was to determine whether the selection process corresponds to the selection of a conspicuous stimulus or to preparation of the next saccade. This was accomplished with the use of a novel task, called search-step, in which the target of a singleton visual search array switches location with a distracter on random trials. The target step trials created a condition in which the same stimulus yielded saccades either toward or away from the target. Visually responsive neurons in frontal eye field selected the current location of the conspicuous target even when gaze shifted to the location of a distractor. This dissociation demonstrates that the selection process manifest in visual neurons in the frontal eye field may be an explicit interpretation of the image and not an obligatory saccade command.

Search efficiency but not response interference affects visual selection in frontal eye field

Two manipulations of a visual search task were used to test the hypothesis that the discrimination of a target from distractors by visually responsive neurons in the frontal eye field (FEF) marks the outcome and conclusion of visual processing instead of saccade preparation. First, search efficiency was reduced by increasing the similarity of the distractors to the target. Second, response interference was introduced by infrequently changing the location of the target in the array. Both manipulations increased reaction time, but only the change in search efficiency affected the time needed to select the target by visually responsive neurons. This result indicates that visually responsive neurons in FEF form an explicit representation of the location of the target in the image.

Cell types and response timings in the medial interlaminar nucleus and C-layers of the cat lateral geniculate nucleus

Previous evidence concerning the physiological cell classes in the medial interlaminar nucleus (MIN) has been conflicting. We reexamined the MIN using standard functional tests to distinguish X-, Y- and W-cells. Discharge patterns to flashing spots also were used to identify some cells as lagged or nonlagged, as previously done for the geniculate A-layers. Also, each cell's response timing (latency and absolute phase) was measured from discharges to a spot undergoing sinusoidal luminance modulation. Of 71 MIN cells, 48% were Y, 27% were W, 8% were X, and 17% were unclassifiable. Lagged and nonlagged discharge profiles were observed in each cell group, with 28% of all cells being lagged. Lagged cells displayed a response suppression and long latency to discharge following spot onset, and a slow decay in firing at spot offset that was often preceded by a transient discharge. These profiles were indistinguishable from those of lagged cells in the A-layers. MIN cells also were heterogeneous in response timing, displaying a range of latency and absolute phase values similar to that in the A-layers. We extended these analyses to 27 cells in the geniculate C-layers. In layer C, 35% of cells were Y, 10% were X, 25% were W, and 30% were unclassifiable. About 11% had lagged profiles, and were X-cells or unclassifiable cells. Layers C1 and C2 contained only W-cells and no lagged profiles. The range of timings in the C-layers was somewhat narrower than in the MIN. Overall, these results show that the MIN contains a greater variety of functional cell classes than heretofore appreciated. Further, it appears that mechanisms which create different timing delays in the A-layers also exist in the MIN and layer C. These timings may contribute to direction selectivity in extrastriate cortex.

Inhibitory contributions to spatiotemporal receptive-field structure and direction selectivity in simple cells of cat area 17

Intracortical inhibition contributes to direction selectivity in primary visual cortex, but how it acts has been unclear. We investigated this problem in simple cells of cat area 17 by taking advantage of the link between spatiotemporal (S-T) receptive-field structure and direction selectivity. Most cells in layer 4 have S-T-oriented receptive fields in which gradients of response timing across the field confer a preferred direction of motion. Linear summation of responses across the receptive field, followed by a static nonlinear amplification, has been shown previously to account for directional tuning in layer 4. We tested the hypotheses that inhibition acts by altering S-T structure or the static nonlinearity or both. Drifting and counterphasing sine wave gratings were used to measure direction selectivity and S-T structure, respectively, in 17 layer 4 simple cells before and during iontophoresis of bicuculline methiodide (BMI), a GABAA antagonist. S-T orientation was quantified from fits to response temporal phase versus stimulus spatial phase data. Bicuculline reduced direction selectivity and S-T orientation in nearly all cells, and reductions in the two measures were well correlated (r = 0.81) and reversible. Using conventional linear predictions based on response phase and amplitude, we found that BMI-induced changes in S-T structure also accounted well for absolute changes in the amplitude and phase of responses to gratings drifting in the preferred and nonpreferred direction. For each cell we also calculated an exponent used to estimate the static nonlinearity. Bicuculline reduced the exponent in most cells, but the changes were not correlated with reductions in direction selectivity. We conclude that GABAA-mediated inhibition influences directional tuning in layer 4 primarily by sculpting S-T receptive-field structure. The source of the inhibition is likely to be other simple cells with certain spatiotemporal relationships to their target. Despite reductions in the two measures, most receptive fields maintained some directional tuning and S-T orientation during BMI. This suggests that their excitatory inputs, arising from the lateral geniculate nucleus and within area 17, are sufficient to create some S-T orientation and that inhibition accentuates it. Finally, BMI also reduced direction selectivity in 8 of 10 simple cells tested in layer 6, but the reductions were not accompanied by systematic changes in S-T structure. This reflects the fact that S-T orientation, as revealed by our first-order measures of the receptive field, is weak there normally. Inhibition likely affects layer 6 cells via more complex, nonlinear interactions.

Laminar differences in the spatiotemporal structure of simple cell receptive fields in cat area 17

Previous studies of cat visual cortex have shown that the spatiotemporal (S-T) structure of simple cell receptive fields correlates with direction selectivity. However, great heterogeneity exists in the relationship and this has implications for models. Here we report a laminar basis for some of the heterogeneity. S-T structure and direction selectivity were measured in 101 cells using stationary counterphasing and drifting gratings, respectively. Two procedures were used to assess S-T structure and its relation to direction selectivity. In the first, the S-T orientations of receptive fields were quantified by fitting response temporal phase versus stimulus spatial phase data. In the second procedure, conventional linear predictions of direction selectivity were computed from the amplitudes and phases of responses to stationary gratings. Extracellular recording locations were reconstructed histologically. Among direction-selective cells, S-T orientation was greatest in layer 4B and it correlated well (r = 0.76) with direction selectivity. In layer 6, S-T orientation was uniformly low, overlapping little with layer 4B, and it was not correlated with directional tuning. Layer 4A was intermediate in S-T orientation and its relation (r = 0.46) to direction selectivity. The same laminar patterns were observed using conventional linear predictions. The patterns do not reflect laminar differences in direction selectivity since the layers were equivalent in directional tuning. We also evaluated a model of linear spatiotemporal summation followed by a static nonlinear amplification (exponent model) to account for direction selectivity. The values of the exponents were estimated from differences between linearly predicted and actual amplitude modulations to counterphasing gratings. Comparing these exponents with another exponent--that required to obtain perfect matches between linearly predicted and measured directional tuning--indicates that an exponent model largely accounts for direction selectivity in most cells in layer 4, particularly layer 4B, but not in layer 6. Dynamic nonlinearities seem essential for cells in layer 6. We suggest that these laminar differences may partly reflect the differential involvement of geniculocortical and intracortical mechanisms.

NHE-RF, a regulatory cofactor for Na(+)-H+ exchange, is a common interactor for merlin and ERM (MERM) proteins

We have identified the human homologue of a regulatory cofactor of Na(+)-H+ exchanger (NHE-RF) as a novel interactor for merlin, the neurofibromatosis 2 tumor suppressor protein. NHE-RF mediates protein kinase A regulation of Na(+)-H+ exchanger NHE3 to which it is thought to bind via one of its two PDZ domains. The carboxyl-terminal region of NHE-RF, downstream of the PDZ domains, interacts with the amino-terminal protein 4.1 domain-containing segment of merlin in yeast two-hybrid assays. This interaction also occurs in affinity binding assays with full-length NHE-RF expressed in COS-7 cells. NHE-RF binds to the related ERM proteins, moesin and radixin. We have localized human NHE-RF to actin-rich structures such as membrane ruffles, microvilli, and filopodia in HeLa and COS-7 cells, where it co-localizes with merlin and moesin. These findings suggest that hNHE-RF and its binding partners may participate in a larger complex (one component of which might be a Na(+)-H+ exchanger) that could be crucial for the actin filament assembly activated by the ERM proteins and for the tumor suppressor function of merlin.

Low-dose diethyldithiocarbamate attenuates the hepatotoxicity of 1,3-dichloro-2-propanol and selectively inhibits CYP2E1 activity in the rat

The effect of low doses of diethyldithiocarbamate (DEDC) on hepatic cytochrome P450-dependent enzyme activity and 1,3-dichloro-2-propanol (DCP) hepatotoxicity in the rat have been investigated. DEDC at a dose of 5 mg/kg selectively inhibited enzyme markers for CYP2E1 activity, and provided substantial protection against DCP hepatotoxicity. At a higher dose (25 mg/kg), DEDC also inhibited an enzyme marker for CYP1A2 activity and provided complete protection against DCP hepatotoxicity. It is concluded: (a) that DEDC at a dose of 5 mg/kg is a selective CYP2E1 inhibitor in the rat in vivo; and (b) that DCP hepatotoxicity is mediated principally by CYP2E1, with a possible contribution from CYP1A2.

An unusual case of carcinoma polyarthritis with associated vasculitis

This report describes a patient who presented with an unusual polyarthritis syndrome. After extensive evaluation, squamous cell carcinoma of the lung was diagnosed. During the course of the illness, the patient developed vasculitic features and "rheumatoid-like" nodules. Two months after the administration of combined-modality therapy for stage IIIA non-small cell lung carcinoma, the signs and symptoms of polyarthritis and vasculitis had disappeared completely. Ten months later, the patient remains in clinical remission. This is the first published report of simultaneous vasculitic and polyarticular manifestations in a patient with carcinoma polyarthritis.

Identification of a heteromorphic microsatellite within the thymidine kinase gene in L5178Y mouse lymphoma cells

The objective of this work is to identify a heteromorphism within the thymidine kinase (Tk1) gene which can be used to assay for allele loss by means of PCR. Intron F of mouse Tk1 contains two (CA)n microsatellite sequences separated by 107 bp of non-repetitive sequence. We tested this region for heteromorphism in L5178Y mouse lymphoma cells. A PCR primer pair designated Agl1 yielded products of 396 and 194 bp from L5178Y tk+/- genomic DNA. The 194-bp product resulted from a secondary binding site between the two (CA)n repeats for the forward Ag11 primer and was not produced from tk-/- mutants that had lost the functional Tk1b allele. Agl2 primers produced two PCR products of 523 and approximately 440 bp and Agl3 primers produced products of 579 and approximately 500 bp. In both these cases, the difference in product size was approximately equal, indicating that Intron F is approximately 80 bp shorter in the non-functional Tk1a allele than in Tk1b. This heteromorphism forms the basis for an assay for allele loss by means of PCR. Agl1 and Agl3 primers yielded additional products of 91 and 274 bp, respectively, consistent with sizes expected from the mouse Tk1 pseudogenes (Tk1-ps). Our conclusions drawn from an analysis of 122 mutants for Tk1b loss using Agl2 primers agreed with previous analysis of the NcoI heteromorphism. Thus, a simple PCR-based analysis can identify Tk1b loss in the L5178Y mouse lymphoma cells.

Monoclonal gammopathies in asymptomatic HIV-seropositive donors

Twenty two HIV antibody ELISA reactive serum samples from blood donors were subjected to Western blot (WB) test, out of which 12 sera were found WB positive, five were WB-indeterminate and five were WB-negative. Electrophoresis on agar gel and polyacrylamide gel (PAG) was done in all ELISA reactive sera. Two of the 12 WB-positive and one of the five WB-indeterminate donors showed presence of monoclonal (M) immunoglobulin component and which was identified as of IgG isotype on immunoelectrophoresis (IEP). Sera with 'M' component demonstrated decreased levels of IgA and IgM whereas other sera showed polyclonal increase of immunoglobulins. The paraproteins observed in these patients are possibly a reflection of B-cell overactivation.

Primary radiation therapy to T1 and T2 breast cancer following conservative surgery. Which patients should be boosted?

We reviewed 199 radiated patients at our institution (201 breasts treated) and its affiliates treated between 1978 and 1989. Of these, 157 were T1 and T2 invasive breast carcinoma. Our intent was to retrospectively compare the results of those who received standard doses of 4,500 to 5,000 cGy to the breast to those that received an additional boost to the surgical bed to a dose totaling at least 5,500 cGy. There were a total of 5 local recurrences in 159 treated breasts. (The mean follow-up time was 36 months.) Of our T1 and T2 patients with clear resection margins that were boosted, there was 1 local recurrence in 28 treated breasts. There was 1 local recurrence in the nonboosted group of 68 patients. Except for one patient, all patients with positive margins were boosted. There were 2 local recurrences in the 23 T1 and T2 breasts with positive margins that were boosted. Of the patients with uncertain margins who were not boosted, there was one local recurrence in 20 treated breasts. Of those with uncertain margins that were boosted, there were no local recurrences in 19 treated breasts. From our results, it would appear that a boost to the primary site is unnecessary if the margins of resection are negative (by either inking or if it is clearly stated in the pathology report). In those patients with uncertain margins, most were done in the years before margins were routinely inked, but generous excisional biopsies were usually done. In this latter group of patients, there also was no added benefit to boosting.

Adenoid cystic carcinoma of the cervix

Adenoid cystic carcinoma constitute around 0.4 to 1.7% of all carcinomas of cervix. It generally presents in elderly age group, however few cases in younger age have also been reported. Majority of cases present in early stage. Though concluding statement regarding the results cannot be made from the cases accumulated from the various reported series, nonetheless this review shows that radiotherapy too is effective in early stage and even in stage I results with radiotherapy appear better than surgery. In advanced stage outcome is invariably poor. In early stage main pattern of failure is distant metastasis. Both local and distant failure are observed in stage III and IV. Though lung is the commonest site of metastases (51%), abdominal cavity and brain are also found to be involved in some cases. Limited experience shows effectiveness of high doses of cisplatin and multiagent chemotherapy. Cases of early stage disease having risk for metastases and local failure should be identified and managed with multimodality treatment using surgery for bulky disease with post-operative radiotherapy and chemotherapy. In advanced stages combination of chemotherapy and radiotherapy is required. Exenterative surgery for central failure has been used effectively. Overall no evidence of disease rate is found to be about 48%, with mean follow-up of 39 months.