Is it cost-effective to use a test to decide which individuals with an intermediate cardiovascular disease risk would benefit from statin treatment?

BACKGROUND: The 2012 European guidelines recommend statins for intermediate-risk individuals with elevated cholesterol levels. Improved discrimination of intermediate-risk individuals is needed to prevent both cardiovascular disease (CVD) and statin side-effects (e.g. myopathy) efficiently since only 3-15 in every 100 individuals actually experience a cardiovascular event in the next 10 years. We estimated the potential cost-effectiveness of a hypothetical test which helps to determine which individuals will benefit from statins. METHODS AND RESULTS: Prognosis of different age- and gender-specific cohorts with an intermediate risk was simulated with a Markov model to estimate the potential costs and quality-adjusted life-years for four strategies: treat all with statins, treat none with statins, treat according to the European guidelines, or use a test to select individuals for statin treatment. The test-first strategy dominated the other strategies if the hypothetical test was 100% accurate and cost no more than €237. This strategy and the treat-all strategy were equally effective but the test generated lower costs by reducing statin usage and side-effects. The treat-none strategy was the least effective strategy. Threshold analyses show that the test must be highly accurate (especially sensitive) and inexpensive to be the most cost-effective strategy, since myopathy has a negligible impact on cost-effectiveness and statin costs are low. CONCLUSION: Use of a highly accurate prognostic test could reduce overall CVD risk, frequency of drug side-effects and lifetime costs. However, no additional test would add usefully to risk prediction over SCORE when it does not satisfy the costs and accuracy requirements.

[Addisonian crisis in patients with known adrenal insufficiency: the importance of early intervention]. / Addison-crisis bij patiënten bekend wegens bijnierschorsinsufficiëntie: het belang van vroegtijdig ingrijpen.

In patients known to have adrenal insufficiency, inadequate adjustment of the glucocorticoid dosage during intercurrent illness can be life threatening. We describe two patients with adrenal insufficiency who died after their glucocorticoid dosage was insufficiently increased during an episode of gastroenteritis and pneumonia, respectively. Another patient died after a few days of fever and vomiting of unknown origin, after a period of refusing her medication. To prevent unnecessary death from Addisonian crisis, we have developed a protocol. Patients with known adrenal insufficiency, as well as their relatives and general practitioners, should repeatedly receive verbal and written instructions on how to deal with physical and severe psychic stress. We teach the patients and their relatives how to use an emergency injection of hydrocortisone, and the patients can consult the on-call endocrinologist by telephone 24 hours a day.

[Part-time medical specialist training; experiences with job-sharing for trainee internists]. / De medisch-specialistische opleiding in deeltijd; ervaringen met de duobaan in de internistenopleiding.

Due to various factors such as social changes, an increasing number of couples with two incomes, and a growing proportion of female doctors, there has been a growing demand for part-time work in recent years. This is also true for resident physicians. Objections such as a discontinuity in care and the decline in the quality of education frequently prevent resident physicians from working part-time. Over the past two years, the University Medical Centre Nijmegen, the Netherlands, has experimented with job-sharing on clinical wards for resident physicians in internal medicine. This approach works well in practice, as long as a number of conditions, including the proper transfer of medical information and good communication, are satisfied. Job-sharing is one means of satisfying the growing demand for part-time work among resident physicians and specialists.

Reactions and platelet increments after transfusion of platelet concentrates in plasma or an additive solution: a prospective, randomized study.

BACKGROUND: Reactions after platelet transfusions are rather common and frequently are caused by plasma constituents. In recent developments, the preparation and storage of platelet concentrates (PCs) in a platelet additive solution (PAS-2) have been shown to result in acceptable storage conditions. A major drawback of the use of these PCs is the progressive increase of P-selectin-positive platelets during storage. The clinical benefit of transfusions of PCs in PAS-2 was studied. STUDY DESIGN AND METHODS: PCs prepared from buffy coats were suspended in either plasma or PAS-2 and stored for up to 5 days. Clinical responses were evaluated in a prospective study in 21 patients treated with intensive chemotherapy for hematologic malignancies. Eligible patients were randomly assigned to receive prophylactic transfusions of PCs prepared in either plasma or PAS-2. Reactions and CCIs were recorded after each transfusion. RESULTS: The incidence of reactions in 12 patients given PCs in plasma (n = 192) was 12 percent. Transfusions to 9 patients of PCs in PAS-2 (n = 132) showed a reduction in the incidence of reactions to 5.3 percent (p<0.05). The average 1-hour and 20-hour CCIs after transfusion of PCs in plasma were 20.7 +/- 8. 5 and 11.5 +/- 8.0, respectively. CCIs after transfusion of PCs in PAS-2 were significantly lower: the average 1-hour CCI was 17.1 +/- 6.6 (p<0.001) and the average 20-hour CCI was 9.5 +/- 7.0 (p<0.05). Storage conditions of PCs were optimal: in each group, average 1-hour CCIs of both fresh and stored PCs were similar. The 20-hour CCIs after the transfusion of fresh and stored PCs in PAS-2 also were similar. CONCLUSION: Transfusion of PCs in PAS-2 significantly reduces the incidence of reactions. The 1-hour and 20-hour CCIs after transfusion of PCs in PAS-2 were significantly lower than the CCIs after transfusion of PCs in plasma. Because storage conditions of both PCs were found to be optimal, the decrease in CCIs after transfusion of PCs prepared in PAS-2 may be caused by rapid elimination of a subpopulation of P-selectin-positive platelets from the circulation.

Endoluminal pulse oximetry of the sigmoid colon and the monitoring of the colonic circulation.

Colonic ischaemia is a frequently observed serious complication following abdominal aortic reconstruction. For adequate treatment of this disorder, early diagnosis and resection of the diseased colon is essential. The purpose of this study was to evaluate a new method, based on pulse oximetry, to detect colonic ischaemia at an early preclinical stage. During a 7-year period (1989-1995) colonoscopy and pulse oximetry were performed in all patients at risk of colonic ischaemia: complicated acute or elective aortic reconstructions, colostomies with superficial necrosis and in patients who underwent uncomplicated aortic reconstruction and non-ischaemic colonic problems (n = 90). The sensitivity, specificity and positive predictive values, and negative predictive value, were calculated. All patients, except four for whom an acute relaparotomy was necessary, subsequently underwent colonoscopy combined with endoluminal pulse oximetry. Of the 90 patients, 30 had colonic ischaemia according to endoscopy (n = 26) or relaparotomy (n = 4), and in 33 patients the absence of pulsatile signal was detected by means of pulse oximetry. Thus, in three patients, pulse oximetry was falsely positive for colonic ischaemia. The calculated sensitivity and specificity of pulse oximetry were 100 and 95%, respectively. In comparison to other methods used for early detection of colonic ischaemia, pulse oximetry appears to be a promising method for the evaluation and monitoring of colonic ischaemia because it is non-invasive and easy to apply with a high sensitivity and specificity.

Endoluminal pulse oximetry combined with tonometry to monitor the perfusion of the sigmoid during and after resection of abdominal aortic aneurysm.

Early detection of colonic ischaemia after aortic grafting is essential if mortality is to be decreased when this complication develops. The aim of this study was to determine changes in the sigmoid colon during and after abdominal aortic grafting using endoluminal pulse oximetry (SmO2). Oxygen saturation was measured on the mucosa (SmO2) and serosa (SsO2) of 20 sequential patients undergoing elective surgery for abdominal aortic aneurysm; intramural pHi was also measured. Initially, all patients had a normal SmO2 in the sigmoid; however, before cross-clamping eight patients had a reduction in the SmO2. The pulse curve disappeared immediately after cross-clamping in 15 patients, with only five still showing a pulse curve in the sigmoid colon. Before declamping, 13 patients regained their pulse curve. The intraluminal pHi showed a large interindividual variation (2 S.D. approximately 0.4). Patients were classified into three groups according to SmO2: group A, no pulse; group B, diminished saturation (< 90%); and group C, normal saturation (> or = 90%). There was significant correlation with the pHi after cross-clamping in all groups. One patient who developed ischaemia of the sigmoid colon demonstrated a prolonged reduction in the SmO2, a decreased perioperative pHi, and an increased oxygen saturation in the inferior mesenteric vein during cross-clamping.

Sigmoidal ischaemia after aortic grafting, detected by endoluminal pulse oximetry.

Colonic ischaemia after abdominal aortic grafting is a severe complication. Late detection of transmural ischaemia will result in a high mortality rate. No simple specific methods are available to detect the early stage. The aim of this pilot study was to detect and monitor sigmoidal ischaemia after aortic surgery with a new endoluminal sigmoidal probe, based on pulse oximetry. Twelve patients with sigmoidal ischaemia were included, the endoluminal probe being introduced into the sigmoid at least 25 cm proximal to the anal verge. It is shown that with this method, mucosal and transmural ischaemia can be graded and differentiated. Patients who showed no wave-form had transmural ischaemia; those with mucosal ischaemia showed reliable wave-forms with oxygen saturation from 40-85%. Colonic ischaemia after aortic grafting can be detected by endoluminal pulse oximetry but the clinical outcome will only improve by early detection in the preclinical stage.

Endoluminal pulse oximetry in ischemic colon in a swine model.

BACKGROUND: Postoperative sigmoidal ischemia after aortic grafting is a severe complication. No simple methods are available to detect this entity at an early stage. This study was done to monitor for sigmoidal ischemia with a new endoluminal probe based on pulse oximetry (SmO2). STUDY DESIGN: A prospective controlled animal study was done. Five pigs with low flow in the caudal mesenteric artery (20 percent of the basal flow) and four pigs in a control group were included. General and local circulatory parameters were monitored in the carotid and pulmonary artery and in the caudal mesenteric vein (CMV). Mucosal biopsy specimens were taken for histologic examination. Statistical analysis was done with the Wilcoxon and Mann-Whitney rank sum test and with analysis of variance. RESULTS: During the first two hours of ischemia, no sigmoidal pulse was detected. During the third hour, in three pigs the pulse curve reappeared with a SmO2 of 48 to 88 percent. After two hours, the mean oxygen saturation in the CMV of the ischemic group was 64 percent (compared with the control group, 77 percent, p < 0.05). After one hour, the mean lactate concentrations were 2.0 and 1.3 mmol per L, respectively (p < 0.05). Significant histologic changes occurred with neutrophilic infiltration in the crypts, in the lamina propria, and in the submucosa. CONCLUSIONS: Low-flow sigmoidal ischemia can be detected and monitored with endoluminal pulse oximetry in this model of early sigmoidal ischemia.