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Sanjay Sharma

Publications and source records attributed to Sanjay Sharma.

At least 91 records · Page 5Linked to original sources
PubMed2003

Value-based medicine: evidence-based medicine and beyond.

Value-based medicine is the practice of medicine emphasizing the value received from an intervention. Value is measured by objectively quantifying: 1) the improvement in quality of life and/or 2) the improvement in length of life conferred by an intervention. Evidence-based medicine often measures the improvement gained in length of life, but generally ignores the importance of quality of life improvement or loss. Value-based medicine incorporates the best features of evidence-based medicine and takes evidence-based data to a higher level by incorporating the quality of life perceptions of patients with a disease in concerning the value of an intervention. Inherent in value-based medicine are the costs associated with an intervention. The resources expended for the value gained in value-based medicine is measured with cost-utility analysis in terms of the US dollars/QALY (money spent per quality-adjusted life-year gained). A review of the current status and the likely future of value-based medicine is addressed herein.

Cost of Illness↗
PubMed2003

Benign metastasizing meningioma.

Meningiomas represent about one sixth of all primary neoplasms of the central nervous system. They rarely metastasize outside the intracranial compartment. There are no clear criteria to identify the subset of aggressive tumors which recur locally or metastasize. Histological tumor grade is the most important predictor of recurrence or metastases. We report an unusual case of recurrent metastasis in an extrapleural location and review the literature. Our patient developed recurrent thoracic metastases from an intracranial benign meningioma after a disease-free interval of 8 years. She was successfully managed by wide excision of the metastasis and is currently asymptomatic.

Adult↗
PubMed2003

Iliac crest osteocutaneous flap reconstruction for ameloblastoma of the mandible in a patient with bilateral peronea artery magna: case report.

Success of oromandibular reconstructions is increasingly achieved through fundamental microvascular techniques that incorporate innovative adjunct modalities. We report a complex case of a large anterior mandibular plexiform ameloblastoma reconstructed with an iliac crest free flap in a young woman with bilateral peronea arteria magna. This article serves to highlight the application of several new technologies in an effort to provide a functional and cosmetically acceptable result.

Adult↗
PubMed2003

Heterogeneity of chemosensitivity of colorectal adenocarcinoma determined by a modified ex vivo ATP-tumor chemosensitivity assay (ATP-TCA).

Advanced colorectal cancer (CRC) has a poor prognosis with a 5-year survival of only 5% despite treatment with chemotherapeutic agents. Response rate and overall survival varies little between the commonly used single agents, although combinations achieve better outcomes. It is well established that considerable heterogeneity exists between cancers of the same tissue type, but it has been difficult to establish this for CRC. We therefore investigated the heterogeneity of chemosensitivity in CRC using a modified version of the ex vivo ATP-tumor chemosensitivity assay (ATP-TCA) capable of handling infected tumor tissue. Fifty-three specimens of primary solid or malignant effusions of CRC were tested, of which 46 (87%) were evaluable. There were considerable differences in sensitivities between individuals. The most active single cytotoxic agents in the assay were identified as 5-fluorouracil, irinotecan and mitomycin C (MMC). Cells were exposed to combinations of drugs added simultaneously at the same concentrations tested as single agents. All drug combinations achieved greater growth inhibition than drugs used alone. MMC+gemcitabine was found to be the most effective combination in 83% of specimens. The ATP-TCA has previously been shown to be a good predictor of response to chemotherapy in other tissue types. The degree of heterogeneity demonstrated from these results suggests that the ATP-TCA could be used to identify patients who might benefit from specific chemotherapeutic agents alone or in combination.

Adenocarcinoma↗
PubMed2003

Heterogeneity of chemosensitivity of esophageal and gastric carcinoma.

Esophageal and gastric cancer have a poor prognosis, and chemotherapy is rarely of long-term benefit. This may be related in part to heterogeneity of chemosensitivity and to constitutive resistance to individual cytotoxic drugs. This study aimed to demonstrate the degree of heterogeneity of chemosensitivity between tumors. We have examined the heterogeneity of chemosensitivity in esophageal and gastric cancer specimens (n=85) using an ex vivo ATP-based chemosensitivity assay (ATP-TCA). A variety of chemotherapeutic agents were tested. Sixty-four specimens were endoscopic biopsy samples; the remainder were from resection specimens. Cells were obtained from 62 specimens (73%). Eight assays were infected due to contamination/infection of the biopsy material, giving an evaluability rate of 87%. Analysis of the data showed considerable heterogeneity of chemosensitivity. The most active single agents identified by the assay were mitomycin C (56% sensitivity) and 5-fluorouracil (5-FU; 42% sensitivity). Exposure of tumor cells to combinations of drugs showed ECF (epirubicin, cisplatin, 5-FU) and mitomycin C+5-FU to be moderately active regimens. Other experimental drug combinations showed greater activity. There is a marked heterogeneity of chemosensitivity in esophageal and gastric cancers. The degree of heterogeneity observed suggests that the ATP-TCA could be used to individualize chemotherapy by selecting agents for particular patients. This approach provides the rationale for a trial of ATP-TCA-directed therapy to determine whether individualization of chemotherapy might improve patient response and survival.

Adenocarcinoma↗
PubMed2003

CME review: A cost-utility analysis of laser photocoagulation for extrafoveal choroidal neovascularization.

PURPOSE: The purpose of this study was to perform a reference case (average case), cost-utility analysis of laser photocoagulation for extrafoveal choroidal neovascularization associated with age-related macular degeneration using a model incorporating patient preferences. METHODS: Visual acuity data for patients treated and observed over a 5-year period were obtained from previously reported studies by the Macular Photocoagulation Study Group. The results from this prospective, randomized trial were incorporated in a cost-utility model using time-trade-off utility analysis and decision analysis with Markov modeling according to the recommendations of the Panel on Cost-Effectiveness in Health and Medicine. Expenditures and health care benefits were each discounted at a 3% yearly rate. RESULTS: Laser photocoagulation therapy for extrafoveal choroidal neovascularization in age-related macular degeneration, compared with observation, resulted in a mean gain of 0.0740 quality-adjusted life-year per patient treated. The mean cost of treatment for the average patient totaled 1,715 US dollars. The cost divided by the health care benefit resulted in 23,176 year 2001 US dollars per quality-adjusted life-year gained for this procedure for a reference case. Sensitivity analyses, varying the cost, utility values, and discount parameters, resulted in dollars per quality-adjusted life-year gained ranging from 16,117 to 49,766 US dollars. CONCLUSION: Laser photocoagulation for extrafoveal choroidal neovascularization associated with age-related macular degeneration appears to be cost-effective when compared with interventions across multiple medical specialties.

Choroidal Neovascularization↗
PubMed2003

Athlete's heart--effect of age, sex, ethnicity and sporting discipline.

Regular physical training is associated with several physiological and biochemical adaptations which enable an increase in cardiac output and widening of the systemic arterio-venous oxygen difference. An increase in cardiac chamber size is fundamental to the generation of a sustained increase in cardiac output for prolonged periods. Echocardiographic studies have shown that the vast majority of athletes have modest cardiac enlargement although a small proportion exhibit substantial increases in heart size. Recognised determinants of cardiac size include age, sex, ethnicity and type of sport. Cardiac dimensions vary considerably amongst athletes, even when allowances are made for these variables, suggesting that genetic, endocrine and biochemical factors also influence heart size. This review discusses the effects of age, sex, ethnicity and sporting discipline on cardiac dimensions in athletic individuals.

Adaptation, Physiological↗
PubMed2003

Ophthaproblem.

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Adult↗
PubMed2003

Thoracic duct cyst of the mediastinum.

Thoracic duct cysts of the mediastinum are extremely rare. The etiology may be related to a congenital or degenerative weakness in the wall of the thoracic duct. They are generally asymptomatic but may sometimes cause pressure effects on adjacent structures. Imaging studies are supportive but not diagnostic. Excision of these cysts is required for diagnosis and to prevent complications. We describe a 49-year old man who presented to us with hoarseness and a fixed right vocal cord. Computed tomography (CT) showed a cystic posterior mediastinal mass in the right paratracheal region. We performed a posterolateral thoracotomy and found the cyst arising from the thoracic duct and contained chylous fluid with a high lipid concentration. We dissected the cyst from the surrounding structures and excised it. Histopathology revealed a cyst lined by a single layer of endothelial cells. He is asymptomatic now one year after surgery.

Humans↗
PubMed2002

Physiologic limits of left ventricular hypertrophy in elite junior athletes: relevance to differential diagnosis of athlete's heart and hypertrophic cardiomyopathy.

OBJECTIVES: The present study was undertaken to define physiologic limits of left ventricular hypertrophy in elite adolescent athletes. BACKGROUND: Systematic sports training may cause increased left ventricular wall thickness (LVWT), creating uncertainty regarding the differential diagnosis of athlete's heart from hypertrophic cardiomyopathy (HCM). This distinction is crucial because HCM is responsible for about one-third of all sudden deaths in young athletes. Echocardiographic data defining athlete's heart are limited largely to adults, with little information specifically in adolescent athletes (14 to 18 years old), for whom the risk of sudden death from HCM is highest. METHODS: Seven hundred and twenty elite adolescent athletes (75% male) aged 15.7 +/- 1.4 years participating in ball, racket, and endurance sports and 250 healthy sedentary controls of similar age, gender, and body surface area underwent echocardiography. RESULTS: Compared with controls, athletes had greater absolute LVWT (9.5 +/- 1.7 mm vs. 8.4 +/- 1.4 mm; p < 0.0001). Maximal LVWT exceeded predicted upper limits in 38 athletes (5%); however, no female athlete had a LVWT >11 mm and only three trained male athletes had absolute LVWT >12 mm (0.4%). Each of the 38 athletes with a LVWT exceeding predicted limits also showed enlarged left ventricular cavity dimension (54.4 +/- 2.1 mm; range 52 to 60 mm). CONCLUSIONS: Trained adolescent athletes demonstrated greater absolute LVWT compared with nonathletes. Only a small proportion of athletes exhibited a LVWT exceeding upper limits, very rarely >12 mm, and then always with chamber enlargement. Hypertrophic cardiomyopathy should be considered strongly in any trained adolescent male athlete with LVWT >12 mm (females >11 mm) and nondilated left ventricle.

Adolescent↗
PubMed2002

Palliation of advanced/recurrent esophageal carcinoma with high-dose-rate brachytherapy.

PURPOSE: The aim was to assess the improvement in swallowing status, complication rate, and overall survival. PATIENTS AND METHODS: Fifty-eight patients with advanced/recurrent esophageal carcinoma were treated for palliation with high-dose-rate intraluminal brachytherapy (HDR-ILRT) with a remote afterloading microSelectron unit (192Ir source) with or without external radiation from November 1994 to May 2000 at the Tata Memorial Hospital. The mean age was 64 years. The mid-third of the esophagus was involved in 38 patients (66%). The group was comprised of 37 previously untreated patients (29 with < or = 50% Karnofsky performance status and old age, 4 with metastatic disease, and 4 with second primary esophageal lesions) and 21 patients with post-treatment recurrent tumors. Thirty-eight patients (65%) received intraluminal brachytherapy alone, whereas the remaining 20 patients (35%) received a combination of external and intraluminal radiation therapy. All patients received 2 fractions of HDR-ILRT 1 week apart with 600 cGy per fraction at 1 cm off axis. RESULTS: Overall improvement in swallowing status was seen in 22 patients (48%), and 24 (41%) maintained pretreatment swallowing status. Median dysphagia-free survival was 10 months. Overall complication rates were 30%, with stricture seen in 9 patients (15%), ulceration in 6 (10%), and tracheo-esophageal fistula in 3 patients (5%). Complication rates were higher in the post-treatment group (38%) than in the previously untreated group (27%) (p = 0.29). The median overall survival for the entire group was 7 months. Median survival was better, although not significantly, for the previously untreated cohort: 7.8 months vs. 6 months for the post-treatment group (p = 0.77). CONCLUSION: HDR-ILRT brachytherapy achieves good palliation with acceptable complications in advanced/recurrent esophageal carcinoma.

Adult↗
PubMed2002

Quality of life with visual acuity loss from diabetic retinopathy and age-related macular degeneration.

OBJECTIVE: To compare the quality of life in patients with visual acuity loss occurring secondary to diabetic retinopathy with visual acuity loss occurring secondary to age-related macular degeneration (ARMD). METHODS: Consecutive patients with diabetic retinopathy and ARMD were evaluated using the time trade-off method of utility value analysis. Both groups were stratified according to the degree of visual acuity loss in the better-seeing eye (group 1: 20/20-20/25, group 2: 20/30-20/40, group 3: 20/50-20/100, group 4: < or =20/200). Utility values obtained from the patients, once stratified for visual acuity group, were compared with use of the t test and the Mann-Whitney U test. In addition, a 2-way analysis of variance was performed to control for potential confounding variables. RESULTS: No difference was found between the utility value means of the diabetic retinopathy (n = 333) and ARMD (n = 246) subgroups stratified according to visual acuity levels: group 1, P =.54; group 2, P =.96; group 3, P =.09; and group 4, P =.32. A 2-way analysis of variance demonstrated that, among the variables of ocular disease, sex, age, and visual acuity in the better-seeing eye, only visual acuity was significantly associated with utility values (P =.003). CONCLUSIONS: At similar levels of visual acuity loss, that associated with diabetic retinopathy causes a similar reduction in quality of life to that associated with ARMD. This information has important implications for use in cost-utility analyses of ophthalmic interventions.

Aged↗
PubMed2002

A cost-utility analysis of interventions for severe proliferative vitreoretinopathy.

PURPOSE: The purpose of this study was to report a reference case, patient preference-based, incremental, cost-utility analysis for treatments of retinal detachment associated with severe proliferative vitreoretinopathy (PVR). DESIGN: Computer-based economic model utilizing data from the Medicare health insurance system in the United States. METHODS: A cost-utility analysis compared vitreoretinal surgery using expanding gases and silicone oil therapy to the natural course of retinal detachment associated with severe PVR. The model applies long-term published visual data from the Silicone Study Group, time tradeoff utility analysis, decision analysis with Markov modeling, and discounting of costs and health benefits as per the Panel on Cost-Effectiveness in Health and Medicine. The major outcome measure was in year 2000 United States dollars per quality-adjusted life-year (dollars/QALY) gained. RESULTS: Vitreoretinal surgery for retinal detachment complicated by severe PVR, as compared with no treatment, resulted in a mean gain of 0.128-0.200 discounted (3% annual rate) quality-adjusted life-years per treated patient. Silicone oil (dollars/QALY gained of 40,252 dollars) was slightly more cost-effective than perfluoropropane (C(3)F(8)) gas (dollars/QALY gained of 46,926 dollars) in eyes with PVR without previous vitrectomy, whereas C(3)F(8) gas (dollars/QALY gained of 46,162 dollars) was more cost-effective than silicone oil (dollars/QALY gained of 62,383 dollars) with previous vitrectomy and PVR. Sensitivity analysis resulted in a dollars/QALY gained of 13,347 dollars when 10% of opposite eyes had a severe visual loss to 202,128 dollars when a discount rate of 10% was utilized and opposite eyes initially had good vision. CONCLUSIONS: The incremental expense of interventions for retinal detachment associated with PVR is cost-effective when compared with other widely accepted interventional therapies across diverse medical specialties.

Computer Simulation↗
PubMed2002

Small cell carcinoma of the esophagus: the Tata Memorial Hospital experience.

BACKGROUND: Small cell carcinoma of the esophagus is a rare disease, characterized by aggressive progression. It has a high incidence of metastatic disease at presentation and a poor overall prognosis. Treatment protocols are not well established because of the paucity of cases and a lack of large studies. METHODS: We performed a retrospective review of all patients with small cell carcinoma of the esophagus diagnosed at the Tata Memorial Hospital between 1985 and 2001. We retrieved and analyzed data regarding demographic details, diagnosis, staging, type of treatment, and overall survival. RESULTS: Eighteen patients with a mean age of 62 years (range 48 to 80 years) diagnosed as having small cell carcinoma of the esophagus were analyzed. The group included 13 men and 5 women. Seven of the 18 patients (39%) presented with metastatic disease including 5 patients (28%) with liver metastases. Four patients were treated with surgery, with or without chemotherapy or radiotherapy. Three patients were treated with combination chemoradiotherapy, 2 patients with chemotherapy alone, and 5 patients with radiotherapy alone. Four patients with advanced disease and poor general condition were not offered any treatment. The overall median survival of our patients was 6 months. Patients treated with surgery and chemotherapy had a better overall survival. CONCLUSIONS: Small cell carcinoma of the esophagus should be regarded as a systemic disease with a high distant failure rate. Treatment strategies hence must incorporate systemic chemotherapy along with radical surgery or radiotherapy as part of a multimodality approach.

Aged↗