Cost-effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies

BACKGROUND

We sought to determine the cost-effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies in Canada.

STUDY DESIGN AND METHODS

We developed two probabilistic state-transition (Markov) microsimulation models to compare fetal genotyping followed by targeted management versus usual care (i.e., universal Rh immunoglobulin [RhIG] prophylaxis in nonalloimmunized RhD-negative pregnancies, or universal intensive monitoring in alloimmunized pregnancies). The reference case considered a healthcare payer perspective and a 10-year time horizon. Sensitivity analysis examined assumptions related to test cost, paternal screening, subsequent pregnancies, other alloantibodies (e.g., K, Rh c/C/E), societal perspective, and lifetime horizon.

RESULTS

Fetal genotyping in nonalloimmunized pregnancies (at per-sample test cost of C$247/US$311) was associated with a slightly higher probability of maternal alloimmunization (22 vs. 21 per 10,000) and a reduced number of RhIG injections (1.427 vs. 1.795) than usual care. It was more expensive (C$154/US$194, 95% Credible Interval [CrI]: C$139/US$175-C$169/US$213) and had little impact on QALYs (0.0007, 95%CrI: -0.01-0.01). These results were sensitive to the test cost (threshold achieved at C$88/US$111), and inclusion of paternal screening. Fetal genotyping in alloimmunized pregnancies (at test cost of C$328/US$413) was less expensive (-C$6280/US$7903, 95% CrI: -C$6325/US$7959 to -C$6229/US$7838) and more effective (0.19 QALYs, 95% CrI 0.17-0.20) than usual care. These cost savings remained robust in sensitivity analyses.

DISCUSSION

Noninvasive fetal RhD genotyping saves resources and represents good value for the management of alloimmunized pregnancies. If the cost of genotyping is substantially decreased, the targeted intervention can become a viable option for nonalloimmunized pregnancies.

Demographics, prevalence and outcomes of diabetes in pregnancy in NW Ontario

Introduction

Diabetes in pregnancy confers increased risk. This study examines the prevalence and birth outcomes of diabetes in pregnancy at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) and other small Ontario hospitals.

Methods

This was a retrospective study of maternal profile: age, parity, comorbidities, mode of delivery, neonatal birth weight, APGARS and complications. Data were compared to other Ontario hospitals offering an equivalent level of obstetrical services.

Results

Type 2 diabetes mellitus in pregnancy is far more prevalent in mothers who deliver at SLMHC (relative risk [RR]: 20.9, 95% confidence interval [CI]: 16.0-27.2); the rates of gestational diabetes (GDM) are double (RR: 2.0, 95% CI: 1.7-2.3). SLMHC mothers with diabetes were on average 5 years younger and of greater parity with increased substance use. Neonates largely had equivalent outcomes except for increased macrosomia, neonatal hypoglycaemia and hyperbilirubinaemia in GDM pregnancies.

Conclusion

Patients with diabetes in pregnancy at SLMHC differ substantially from mothers delivering at Ontario hospitals with a comparable level of service. Programming and resources must meet the service needs of these patients.

Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery

Background

Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery.

Methods

Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts.

Results

Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies.

Conclusion

There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.

Moral reasoning and decision-making in adolescents who sustain traumatic brain injury

Objective: Emerging evidence suggests that moral processes are disrupted by traumatic brain injury (TBI). The objective of this study was to explore moral reasoning (MR) and decision-making in adolescents with TBI, and to examine potential associations with global manifestations of social competence.Design: This retrospective, cross-sectional research design compared MR and decision-making in adolescents with mild TBI (n = 20), moderate-severe TBI (n = 23) and typically developing controls (n = 93).Methods: Participants completed a visual task of socio-moral reasoning (SoMoral) and the Index of Empathy for Children and Adolescents. Their parents completed questionnaires documenting their child's behavior (Child Behavior Checklist) and adaptive functioning (Adaptive Behavior Assessment System-Second Edition).Main results: Adolescents with both mild and moderate-severe TBI displayed more immature MR than typically developing peers. Participants with TBI also provided fewer socially adapted decisions. Closer inspection revealed that this difference was apparent only in the mild TBI group. No significant group differences were observed for empathy, behavior or adaptive skills.Conclusions: Sustaining TBI appears to affect adolescents' ability to provide mature moral justifications when faced with moral dilemmas representative of everyday social conflicts. These difficulties do not appear to be associated with behavior problems, reduced empathy, or adaptive functioning.

Programmed cell death-1 expression correlates with disease severity and IL-5 in chronic rhinosinusitis with nasal polyps

BACKGROUND

Programmed cell death-1 (PD-1) is a negative regulator of T-cell responses. Expression of PD-1 and its ligands PD-L1 and PD-L2 in chronic rhinosinusitis with nasal polyps (CRSwNP) is poorly studied.

METHODS

Expression of PD-1, PD-L1, PD-L2, TGF-β, IL-5, and IL-10 mRNA was measured by real-time quantitative PCR on tissue homogenates of patients with CRSwNP (n = 21) and healthy controls (n = 21) and on primary epithelial cells. Disease severity was scored using the Lund-Mackay scores of maxillofacial computed tomography (CT) scans. Expression of PD-1 and PD-L1/L2 was evaluated at the cellular and tissue levels (n = 6) by flow cytometry and immunohistochemistry.

RESULTS

Programmed cell death-1 mRNA expression was increased in tissue homogenates from patients with CRSwNP compared with controls, irrespective of the atopy status. Importantly, expression of PD-1 correlated with the total CT scan scores (r = 0.5, P = 0.02). Additionally, a significant association was found between PD-1 mRNA and expression of IL-5 mRNA in control nasal tissue (r = 0.95, P < 0.0001) and in CRSwNP (r = 0.63, P = 0.002). PD-1 was expressed on different subsets of T cells and CD11b^- dendritic cells. Both PD-1 and its ligands were expressed on primary epithelial cells from control nasal tissue and nasal polyp tissue.

CONCLUSIONS

Higher PD-1 expression was found in CRSwNP than in nasal tissue from controls. This was associated with disease severity and tissue IL-5 expression but unrelated to the patients' atopy status.

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population

OBJECTIVES

To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population.

SETTING

A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada.

PARTICIPANTS

A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities.

OUTCOMES

The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres.

RESULTS

No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy.

CONCLUSIONS

Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

Information-Seeking Behaviors of Medical Students: A Cross-Sectional Web-Based Survey

BACKGROUND

Medical students face an information-rich environment in which retrieval and appraisal strategies are increasingly important.

OBJECTIVE

To describe medical students' current pattern of health information resource use and characterize their experience of instruction on information search and appraisal.

METHODS

We conducted a cross-sectional web-based survey of students registered in the four-year MD Program at Dalhousie University (Halifax, Nova Scotia, and Saint John, New Brunswick, sites), Canada. We collected self-reported data on information-seeking behavior, instruction, and evaluation of resources in the context of their medical education. Data were analyzed using descriptive statistics.

RESULTS

Surveys were returned by 213 of 462 eligible students (46.1%). Most respondents (165/204, 80.9%) recalled receiving formal instruction regarding information searches, but this seldom included nontraditional tools such as Google (23/107, 11.1%), Wikipedia, or social media. In their daily practice, however, they reported heavy use of these tools, as well as EBM summaries. Accessibility, understandability, and overall usefulness were common features of highly used resources. Students identified challenges managing information and/or resource overload and source accessibility.

CONCLUSIONS

Medical students receive instruction primarily on searching and assessing primary medical literature. In their daily practice, however, they rely heavily on nontraditional tools as well as EBM summaries. Attention to appropriate use and appraisal of nontraditional sources might enhance the current EBM curriculum.

Improving Film Die Flow Uniformity Using Optimization Methods Coupled with Finite Element Computational Fluid Dynamics (CFD) Analysis

The aim of this study was to evaluate various optimization strategies to be used with computational fluid dynamics (CFD), in order to optimize the geometry for a polymer die to meet the dual objectives of uniform flow at the exit with minimal pressure drop. 3D finite element simulations using the numerically optimized geometry predict a more uniform flow than simulations using the baseline geometry. However, some of the initial optimized results yielded die geometries that would be impractical to fabricate. Additional constraints were placed on the allowable geometric parameters and solution space to push the optimization towards more feasible optimal solutions. Thus we have shown how CFD-based optimization methods, coupled with knowledge of die design technology and fabrication techniques can lead to the design of better performing polymer dies.

Duchenne muscular dystrophy: a 30-year population-based incidence study

Duchenne muscular dystrophy (DMD) is among the most common lethal genetic diseases. It has been proposed that genetic counseling and prenatal diagnosis have begun to lower the incidence. We reviewed the records of all patients with confirmed DMD who were born between 1969 and 2008. Statistics Canada data on annual male births in Nova Scotia were obtained for each year.The overall incidence of 1 per 4700 male births remained stable during the 30-year period of the study. Similarly, the age at diagnosis did not change during that time.

Rural and remote obstetric care close to home: program description, evaluation and discussion of Sioux Lookout Meno Ya Win Health Centre obstetrics

PROBLEM BEING ADDRESSED

Aboriginal and non-Aboriginal women in rural and remote settings struggle to access obstetric care close to home. Objective of the program: To deliver a full range of modern and safe obstetric care to 28 remote Aboriginal communities served by rural-based health care.

PROGRAM DESCRIPTION

Rural family physicians provide intrapartum, cesarean delivery and anesthesia services to 350 rural, primarily Aboriginal women in a collegial, supportive environment.

CONCLUSION

Rural and remote obstetric services need support before they fail. Patient volume, remote location and organizational culture are key elements. Evidence teaches us that outcomes are best when women deliver closer to home.

Canadian adolescents with migraine: impaired health-related quality of life

The objective of this study was to determine the impact of migraine headaches on health-related quality of life among Canadian adolescents. The Canadian Community Health Survey (CCHS) collects information related to health status, health care utilization, and health determinants for the Canadian population. Analysis was limited to those adolescents 12-19 years of age residing in Manitoba. Respondents reported whether they had migraine and mood/anxiety disorders. Health-related quality of life was measured using the Short Form-36 survey, which covers 8 health concepts related to functional status, well-being, and overall health. Multivariate linear regression analysis was used to model each Short Form-36 scale against age (12-14 years vs 15-19 years), gender, migraine, and the presence of a mood or anxiety disorder. The CCHS was completed by 994 respondents; 9.3% (95% confidence interval, 7.3%-11.5%) reported a diagnosis of migraine. Reported migraine predicted both statistically (P < .0001) and clinically significantly lower health-related quality of life in all Short Form-36 domains except vitality and general health perceptions. Adolescents reporting a mood disorder (2.1%) scored significantly lower in 6 of 8 health-related quality of life domains, most pronounced for emotional role, general mental health, and social functioning. Canadian adolescents with migraine report clinically and statistically significant impairment in health-related quality of life compared to their peers, independent of psychiatric comorbidities.

Linkage and mutational analysis of CLCN2 in childhood absence epilepsy

In order to assess the chloride channel gene CLCN2 as a candidate susceptibility gene for childhood absence epilepsy, parametric and non-parametric linkage analysis was performed in 65 nuclear pedigrees. This provided suggestive evidence for linkage with heterogeneity: NPL score=2.3, p<0.009; HLOD=1.5, alpha=0.44. Mutational analysis of the entire genomic sequence of CLCN2 was performed in 24 unrelated patients from pedigrees consistent with linkage, identifying 45 sequence variants including the known non-synonymous polymorphism rs2228292 (G2154C, Glu718Asp) and a novel variant IVS4+12G>A. Intra-familial association analysis using the pedigrees and a further 308 parent-child trios showed suggestive evidence for transmission disequilibrium of the G2154C minor allele: AVE-PDT chi(1)2 = 5.17, p<0.03. Case-control analysis provided evidence for a protective effect of the IVS4+12G>A minor allele: chi(1)2 = 7.27, p<0.008. The 65 nuclear pedigrees were screened for three previously identified mutations shown to segregate with a variety of idiopathic generalised epilepsy phenotypes (597insG, IVS2-14del11 and G2144A) but none were found. We conclude that CLCN2 may be a susceptibility locus in a subset of cases of childhood absence epilepsy.

Laboratory monitoring of mechanical ventilation

This article examines the use of laboratory tests for managing mechanical ventilation. Blood gas analysis is a common test widely used for this purpose, and this is evaluated in detail. Other tests, however, provide valuable insight into the management of patients receiving mechanical ventilation. These include serum electrolytes, thyroid function tests, and adrenal function tests.

Health-related quality of life among Canadians with migraine

The objective was to determine the impact of migraine on health-related quality of life (HRQOL) among Canadians. Analysis was based on the public use microdata set of the Canadian Community Health Survey (CCHS), limited to those aged ≥5 residing in Manitoba. HRQOL was measured using the SF-36 survey, which covers 8 health concepts. Multivariate linear regression was used to model each SF-36 scale against age, gender, education, income, migraine status and presence of mood or anxiety disorders. Of the 7236 CCHS respondents, 9.7% reported a diagnosis of migraine. Reported migraine predicted statistically significant (p<0.0001) lower HRQOL in all SF-36 domains with profound impairment of physical role, bodily pain and general health. Those reporting a mood disorder scored significantly lower in all domains with pronounced effects on emotional role, social functioning and general health. Reported anxiety disorder was associated with lower HRQOL in 6/8 domains. Canadians with migraine report significant impairment in HRQOL compared to the general population, independent of psychiatric morbidity.

The prognosis of childhood headache: a 20-year follow-up

BACKGROUND

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome.

OBJECTIVE

To evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

METHODS

Ninety-five patients with headaches who consulted 1 of the authors in 1983 were previously studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standardized interview protocol was used.

RESULTS

Sixty (78%) of 77 patients responded (60 of the 95 of the original cohort). At 20-year follow-up, 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, and 14 (23%) had migraine and tension-type headaches. Having more than 1 headache type was more prevalent than at diagnosis or initial follow-up (P<.001), and headache type varied across time. Of those with headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although an improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to remit (P<.04). Headache severity at diagnosis was predictive of headache outcome at 20 years. During the month before follow-up, nonprescription medications were used by 31 (70%) of those with ongoing headaches, and prescription medications were used by 6 (14%). However, 20 (45%) believed that nonpharmacological methods were most effective. Medication use increased during the 10 years since last follow-up. No patient used selective serotonin receptor agonists (triptans).

CONCLUSIONS

Twenty years after diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changes across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically.

Health information seeking and its effect on the doctor-patient digital divide

A survey of 224 individuals using SureStart services (for young families) within an inner-London area was complemented by qualitative data from five focus groups of parents and general practitioners in the same area. Descriptive and multivariate statistics were used to identify and describe discrete geographical districts with differing patterns of health information seeking. A geographically defined group of 'information hungry'/'online' health seekers was identified. This group contrasted with those acquiring information through 'assimilation' ('offline' information seekers). Qualitative data revealed the processes underpinning these characteristics and professional attitudes towards the Internet as a source of health information.

Health visiting at the crossroads: which way to the 21st century?

This article presents a response from a group of lecturers at Florence Nightingale School of Nursing and Midwifery, King's College London and one service user to the perception of a crisis of confidence within health visiting. Changes in registration procedures and shifts in policy have led health visiting to question its place within primary care and the model of preparation for health visiting practice. The group argues that this debate is based on a misunderstanding of the changing health care environment and that health visiting can find a place within the primary care team. Key to this is the continued adherence to a basic nursing training. The authors suggest an incremental model of health visitor training to provide the fullest scope to implement the new health agenda.

Successful PCR amplification of genomic DNA from Cryptosporidium parvum oocysts extracted from a human faecal sample: a rapid and simple method suited for outbreak analysis

A method to extract genomic DNA from oocysts of Cryptosporidium parvum in human faecal material was developed and consisted of a simple alkali wash, freeze/boil technique. This method was simple, quick, sensitive, inexpensive and resulted in the production of genomic DNA which was free of PCR inhibitors and as such was a suitable template for the detection of C. parvum by various PCR amplification targets.

Prognostic significance of failure of the initial antiepileptic drug in children with absence epilepsy

PURPOSE

In children with childhood absence epilepsy (CAE) and juvenile absence epilepsy (JAE), to determine the impact of failure of initial antiepileptic drug (AED) for lack of efficacy in eventual seizure control and long-term remission of epilepsy.

METHODS

Centralized EEG records for the province of Nova Scotia allowed identification of all children seen with CAE or JAE between 1977 and 1985. Information regarding success or failure of initial AED in fully controlling seizures and long-term seizure control and remission of epilepsy was collected by patient questionnaire and chart review.

RESULTS

Eighty-six of 92 eligible patients were followed up (75 CAE, 11 JAE). Initial AED treatment was successful in 52 (60%) of 86. Success tended to be greater for valproate (VPA) than for other AEDs (p = 0.07), and lower if generalized tonic-clonic or myoclonic seizures coexisted (p < 0.004 and p < 0.03). Terminal remission was more likely if the initial AED was successful than if it had failed (69% vs. 41%; p < 0.02). Compared with those in whom the initial AED was successful, subjects whose initial AED had failed were more likely to progress to juvenile myoclonic epilepsy (JME) at last follow-up (32% vs. 10%; p < 0.02) and to develop intractable epilepsy (17% vs. 2%; p < 0.04).

CONCLUSIONS

Initial AED was successful in 60% of children with AE. If the first AED failed, the outcome was less favorable, with a lower rate of terminal remission and a higher rate of progression to JME and intractable epilepsy.

Image-guided radiosurgery for the spine and pancreas

A robotic image-guided radiosurgical system has been modified to treat extra-cranial sites using implanted fiducials and skeletal landmarks to locate the treatment targets. The system has been used to treat an artero-venous malformation in the cervical spine, a recurrent schwannoma of the thoracic spine, a metastatic adenocarcinoma of the lumbar spine, and three pancreatic cancers. During each treatment, the image guidance system monitored the position of the target site and relayed the target coordinates to the beam-pointing system at discrete intervals. The pointing system then dynamically aligned the therapy beam with the lesion, automatically compensating for shifts in target position. Breathing-related motion of the pancreas lesions was managed by coordinating beam gating with breath-holding by the patient. The system maintained alignment with the spine lesions to within +/- 0.2 mm on average, and to within +/- 1 mm for the pancreatic tumors. This experience has demonstrated the feasibility of using image-guided robotic radiosurgery outside the cranium.

Effects of a structured curriculum in osteopathic manipulative treatment (OMT) on osteopathic structural examinations and use of OMT for hospitalized patients

Osteopathic manipulative treatment (OMT) is a defining feature of osteopathic medicine; however, use of OMT by osteopathic physicians is declining. Recent studies reveal that many osteopathic physicians are abandoning use of OMT as early as medical school. Current national efforts are aimed at reversing this trend by standardizing osteopathic medical records and clinical training in OMT. The authors found that a structured clinical curriculum in OMT taught to house staff significantly increased the percentage of patients who received osteopathic structural examinations and the percentage of patients who received OMT as part of their hospital care.

Anti-Yo positive paraneoplastic cerebellar degeneration associated with ovarian carcinoma: case report and review of the literature

Paraneoplastic cerebellar degeneration (PCD) is a rare nonmetastatic neurological complication in cancer patients. Anti-Yo is one of the anti-onconeural antibodies found in PCD patients. It is believed that anti-Yo occurs almost always in women and is most likely associated with gynecologic or breast cancers, although exceptions exist. Here we report a PCD patient with ovarian cancer having high-titer anti-Yo. The acute onset of her PCD symptoms mimicked that of a stroke. Her ovarian cancer tissue contained abundant plasma cells and lymphocytes. After a thorough review of the literature, we propose a schematic hypothesis for the autoimmune pathogenesis of PCD. Despite anecdotal case reports of neurological improvement with different combinations of treatment, including IVIg, there is still no definitely effective treatment for PCD. Further research on the pathogenesis of PCD may lead to more effective therapies.

Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents

BACKGROUND

Endoscopic stenting is an effective method of relieving biliary obstruction in patients with unresectable malignancy. If this fails, optimal management is controversial. Percutaneous insertion of plastic or mesh metal stents has been advocated.

AIM

To review the outcome of percutaneous plastic stents and compare this with contemporary data from the literature on mesh metal stenting.

PATIENTS AND METHODS

Over a period of six years, 400 patients had attempted endoscopic stenting for distal malignant biliary obstruction which failed in 54 (13.5%). These 54 patients were treated with percutaneously placed plastic stents.

RESULTS

Percutaneous stenting was technically successful in 48 patients (89%). Early complications occurred in 13 patients (24%), the commonest being acute cholangitis in seven (12%). There was no procedure-related mortality but a 30-day mortality of 11 % (n = 6). Ten patients (18%) required re-admission after 30 days for stent block (mean period 4 months). Forty-seven patients (87%) were followed up until death. The median survival for the patients undergoing palliative stenting was 3 months (5 days to 17 months).

CONCLUSIONS

These results suggest that percutaneous plastic stents can be used safely and effectively in patients who have failed endoscopic stenting.