Cost-effectiveness of an educational healthcare circuit for bariatric surgery in France.

OBJECTIVES: An educational healthcare circuit (EHC) is proposed with the objective of preventing weight recovery of patients after bariatric surgery through education and lifestyle change. The objective of this study was to measure the viability of the EHC (shared medical appointments [SMAs] combined with bariatric surgery) through cost-effectiveness analysis. The EHC presented in this study is innovative because it offers a multidisciplinary approach based on medical, psychological and dietetic expertise to combat obesity. The strategy is to give the patient a diagnosis and then a personalised follow-up. STUDY DESIGN: A mathematical model based on a decision tree (1 year) and a Markov model (10 years) to measure the efficiency and cost of an EHC in comparison with the customary care offered in France were built. METHODS: The effects of the EHC were observed for the prevalence of type 2 diabetes and the risk of cardiovascular disease. The chosen financial perspective is from the point of view of the French social security system. RESULTS: The EHC records an incremental cost-effective ratio (ICER) of € 48,315.43 per quality-adjusted life year (QALY) over a 1-year horizon and € 28,283.77 per QALY over 10 years (with discount rate of 8%: € 25,362.85 per QALY). CONCLUSION: The results suggest that an EHC is more expensive yet more effective than usual care. That is, in the short term, the costs are high, but at 10 years, the treatment is cost-effective, representing a feasible alternative for those patients who qualify for bariatric surgery in France.

Diagnosis of erectile dysfunction can be used to improve screening for Type 2 diabetes mellitus.

AIMS: To assess the diagnostic accuracy of four undiagnosed Type 2 diabetes mellitus risk scores accounting for erectile dysfunction status. METHODS: This was a population-based cross-sectional study. Type 2 diabetes was defined according to a oral glucose tolerance test and self-reported physician diagnosis. Erectile dysfunction was defined according to the answer to the question, 'Have you had difficulties obtaining an erection in the last 6 months?' (yes/no). The risk scores used were the FINDRISC, LA-FINDRISC, American Diabetes Association score and the Peruvian Risk Score. A Poisson regression model was fitted to assess the association between Type 2 diabetes and erectile dysfunction. The area under the receiver-operating characteristic curve was estimated overall and by erectile dysfunction status. RESULTS: A total of 799 men with a mean (sd) age of 48.6 (10.7) years were included in the study. The overall prevalence of Type 2 diabetes was 9.3%. Compared with healthy men, men with Type 2 diabetes had 2.71 (95% CI 1.57-4.66) higher chances of having erectile dysfunction. Having excluded men aware of Type 2 diabetes status (N=38), the area under the receiver-operating characteristic curve of three of the risk scores (not the American Diabetes Association score) improved among those who had erectile dysfunction in comparison with those who did not; for example, the area under the receiver-operating characteristic curve of the LA-FINDRISC score was 89.6 (95% CI 78.7-99.9) in men with erectile dysfunction and 76.5 (95% CI 68.5-84.4) overall. CONCLUSIONS: In a population-based study, erectile dysfunction was more common in men with Type 2 diabetes than in the otherwise healthy men. Screening for erectile dysfunction before screening for Type 2 diabetes seems to improve the accuracy of well-known risk scores for undiagnosed Type 2 diabetes.

Consensus paper: pathological mechanisms underlying neurodegeneration in spinocerebellar ataxias.

Intensive scientific research devoted in the recent years to understand the molecular mechanisms or neurodegeneration in spinocerebellar ataxias (SCAs) are identifying new pathways and targets providing new insights and a better understanding of the molecular pathogenesis in these diseases. In this consensus manuscript, the authors discuss their current views on the identified molecular processes causing or modulating the neurodegenerative phenotype in spinocerebellar ataxias with the common opinion of translating the new knowledge acquired into candidate targets for therapy. The following topics are discussed: transcription dysregulation, protein aggregation, autophagy, ion channels, the role of mitochondria, RNA toxicity, modulators of neurodegeneration and current therapeutic approaches. Overall point of consensus includes the common vision of neurodegeneration in SCAs as a multifactorial, progressive and reversible process, at least in early stages. Specific points of consensus include the role of the dysregulation of protein folding, transcription, bioenergetics, calcium handling and eventual cell death with apoptotic features of neurons during SCA disease progression. Unresolved questions include how the dysregulation of these pathways triggers the onset of symptoms and mediates disease progression since this understanding may allow effective treatments of SCAs within the window of reversibility to prevent early neuronal damage. Common opinions also include the need for clinical detection of early neuronal dysfunction, for more basic research to decipher the early neurodegenerative process in SCAs in order to give rise to new concepts for treatment strategies and for the translation of the results to preclinical studies and, thereafter, in clinical practice.

Assessing the cost-effectiveness of type 1 diabetes interventions: the Sheffield type 1 diabetes policy model.

AIMS: To build a flexible and comprehensive long-term type 1 diabetes mellitus model incorporating the most up-to-date methodologies to allow a number of cost-effectiveness evaluations. METHODS: This paper describes the conceptual modelling, model implementation and model validation of the Sheffield type 1 diabetes policy model (version 1.0), developed through funding by the U.K. National Institute for Health Research as part of the Dose Adjustment for Normal Eating research programme. The model is an individual patient-level simulation model of type 1 diabetes and it includes long-term microvascular (retinopathy, neuropathy and nephropathy) and macrovascular (myocardial infarction, stroke, revascularization and angina) diabetes-related complications and acute adverse events (severe hypoglycaemia and diabetic ketoacidosis). The occurrence of these diabetes-related complications in the model is linked to simulated individual patient-level risk factors, including HbA1c , age, duration of diabetes, lipids and blood pressure. Transition probabilities were modelled based on a combination of existing risk functions, published trials, epidemiological studies and individual-level data from the Dose Adjustment for Normal Eating research programme. RESULTS: The model takes a lifetime perspective, estimating the impact of interventions on costs, clinical outcomes, survival and quality-adjusted life years. Validation of the model suggested that, for almost all diabetes-related complications predicted, event rates were within 10% of the normalized rates reported in the studies used to build the model. CONCLUSIONS: The model is highly flexible and has broad potential application to evaluate the Dose Adjustment for Normal Eating research programme, other structured diabetes education programmes and other interventions for type 1 diabetes.

The cost-effectiveness of weight management programmes in a postnatal population.

OBJECTIVES: The aim of the study was to estimate the cost-effectiveness of a weight management programme including elements of physical exercise and dietary restriction which are designed to help women lose excess weight gained during pregnancy in the vulnerable postnatal period and inhibit the development of behaviours which could lead to future excess weight gain and obesity. STUDY DESIGN: A mathematical model based on a regression equation predicting change in weight over a fifteen year postnatal period was developed. METHODS: The model included programme effectiveness and resource data based on a randomized controlled trial of a weight management programme implemented in a postnatal population in the United States. Utility and mortality data based on body mass index categories were also included. The model adopted a National Health Service (NHS) and personal social services (PSS) perspective, a lifetime time horizon and estimated the cost effectiveness of a weight management programme against a no change comparator in terms of an incremental cost-effectiveness ratio (ICER). RESULTS: The baseline results show that the difference in weight between women who received the weight management programme and women who received the control intervention was 3.02 kg at six months and 3.53 kg at fifteen years following childbirth. This results in an ICER of £7355 per quality adjusted life year (QALY) for women who were married at childbirth. CONCLUSION: The estimated ICER would suggest that such a weight management programme is cost-effective at a NICE threshold of £20,000 per QALY. However significant structural and evidence based uncertainty is present in the analysis.

Prioritising public health guidance topics in the National Institute for Health and Care Excellence using the Analytic Hierarchy Process.

OBJECTIVES: The Centre for Public Health (CPH), at the United Kingdom's National Institute for Health and Care Excellence (NICE) is responsible for producing national guidance relating to the promotion of good health and the prevention and treatment of disease. Given the challenges of developing guidance in this area, choosing the most appropriate topics for further study is of fundamental importance. This paper explores the current prioritisation process and describes how the Analytic Hierarchy Process (AHP), a multi criteria decision analysis (MCDA) technique, might be used to do so. STUDY DESIGN: A proposed approach is outlined, which was tested in a proof of concept pilot. This consisted of eight participants with experience of related NICE committees building scores for each topic together in a 'decision conference' setting. METHODS: Criteria were identified and subsequently weighted to indicate the relative importance of each. Participants then collaboratively estimated the performance of each topic on each criterion. RESULTS: Total scores for each topic were calculated, which could be ranked and used as the basis for better informed discussion for prioritising topics to recommend to the Minister for future guidance. Sensitivity analyses of the dataset found it to be robust. CONCLUSIONS: Choosing the right topics for guidance at the earliest possible time is of fundamental importance to public health guidance, and judgement is likely to play an important part in doing so. MCDA techniques offer a potentially useful approach to structuring the problem in a rational and transparent way. NICE should consider carefully whether such an approach might be worth pursuing in the future.

The effectiveness of training and support for carers and other professionals on the physical and emotional health and well-being of looked-after children and young people: a systematic review.

Looked-after children and young people (LACYP) are recognized as a high-risk group for behavioural and emotional problems, and additional specialist training for foster carers may reduce such problems. This systematic review aimed to identify and synthesize evidence on the effectiveness of additional training and support provided to approved carers, professionals and volunteers on the physical and emotional health and well-being of LACYP (including problem behaviours and placement stability). Searches of health and social science databases were conducted and records were screened for inclusion criteria. Citation and reference list searches were conducted on included studies. Included studies were synthesized and critically appraised. Six studies were included (five randomized controlled trials and one prospective cohort study), all of which focused on foster carers. Three studies reported a benefit of training and three reported no benefit but no detriment. Those reporting a benefit of training were conducted in the USA, and had longer-duration training, shorter follow-up assessment and recruited carers of younger children than studies that reported no benefit of training, which were conducted in the UK. Whether the difference in results is due to the type of training or to cultural or population differences is unclear. The findings suggest a mixed effect of training for foster carers on problem behaviours of LACYP. The evidence identified appears to suggest that longer-duration training programmes have a beneficial effect on the behaviour problems of LACYP, although future research should examine the impact of training durations and intensity on short-medium and longer-term outcomes of LACYP of different ages. Only training and support for foster carers was identified.

Supporting the transition of looked-after young people to independent living: a systematic review of interventions and adult outcomes.

This systematic review aimed to synthesize evidence on the effectiveness of transition support services (TSSs) that are delivered towards the end of care for looked-after young people (LAYP) on their adult outcomes, including education, employment, substance misuse, criminal and offending behaviour, parenthood, housing and homelessness and health. Searches of health, social science and social care bibliographic databases were conducted and records were screened for relevance. Citation and reference list searches were conducted on included studies. Relevant studies were synthesized and critically appraised. Seven studies were identified (five retrospective and two prospective cohort studies), six of which were conducted in the USA and one in the UK. Overall, LAYP who received TSSs were more likely to complete compulsory education with formal qualifications, be in current employment, be living independently and less likely to be young parents. There was no reported effect of the impact of TSSs on crime or mental health, and mixed findings for homelessness. The range of TSS components investigated and reported varied considerably within and between studies, with limited evidence of long-term outcomes. The literature reviewed offers no reliable conclusions on the effectiveness of TSSs at this time due to variations in research quality and because few formal evaluations of existing TSSs have been conducted, resulting in mixed evidence in terms of positive, negative and neutral impact on outcomes. Further high-quality, robust research to evaluate the effectiveness of TSSs on adult outcomes for young people in the short, medium and longer term is needed to address the health inequalities experienced by this small but vulnerable group and to inform decision making about service provision.

Factors associated with outcomes for looked-after children and young people: a correlates review of the literature.

In 2008, the Department of Health made a referral to the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence to develop joint public health guidance on improving the physical and emotional health and well-being of children and young people looked after by the local authority/state. To help inform the decision-making process by identifying potential research questions pertinent to the outcomes of looked-after children and young people (LACYP), a correlates review was undertaken. Iterative searches of health and social science databases were undertaken; searches of reference lists and citation searches were conducted and all included studies were critically appraised. The correlates review is a mapping review conducted using systematic and transparent methodology. Interventions and factors that are associated (or correlated) with outcomes for LACYP were identified and presented as conceptual maps. This review maps the breadth (rather than depth) of the evidence and represents an attempt to use the existing evidence base to map associations between potential risk factors, protective factors, interventions and outcomes for LACYP. Ninety-two studies were included: four systematic reviews, five non-systematic reviews, eight randomized controlled trials, 66 cohort studies and nine cross-sectional studies. The conceptual maps provide an overview of the key relationships addressed in the current literature, in particular, placement stability and emotional and behavioural factors in mediating outcomes. From the maps, there appear to be some key factors that are associated with a range of outcomes, in particular, number of placements, behavioural problems and age at first placement. Placement stability seems to be a key mediator of directional associations. The correlates review identified key areas where sufficient evidence to conduct a systematic review might exist. These were: transition support, training and support for carers and access to services.

Relation of phase angle tertiles with blood adipocytokines levels, insulin resistance and cardiovascular risk factors in obese women patients.

BACKGROUND: Few studies have evaluated the relation between phase angle (PA) and metabolic syndrome. As long as we know, there are not studies of association between phase angle and adipocytokines. The aim of our study was to evaluate the association of adipocytokines levels and classical cardiovascular risk factors with tertiles of phase angle in obese women. MATERIAL AND METHODS: A cross-sectional study was designed to establish whether phase angle from 228 adult female patients with obesity are related with adipocitokynes and cardiovascular risk factors. These patients were studied in a Nutrition Clinic Unit after signed informed consent. All patients with a 2 weeks weight-stabilization period before recruitment were enrolled. Weight, blood pressure, basal glucose, C-reactive protein (CRP), insulin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides blood and adypocitokines (leptin, adiponectin, resistin Interleukin-6 and TNF-alpha) levels were measured. The phase angle alpha was determined by bioimpedance with the equation [PA degrees =(Xc/R)x(180 degrees/pi)]. RESULTS: Two hundred and twenty-eight females gave informed consent and were enrolled in the study. The mean age was 38.2 +/- 14.7 years and the mean BMI 35.27 +/- 6.5. Patients were divided by tertiles of phase angle. Fat mass was higher in first tertile than third tertile (43.6 +/- 12.6 vs 40.9 +/- 15 kg: p<0.05). HOMA (2.4 +/- 1.6 vs 1.46 +/- 1.6: p<0.05), insulin (14.4 +/- 8.5 vs 11.3 +/- 9.4 mUI/L: p<0.05) and glucose (102.1 +/- 20 vs 90 +/- 19.5 mg/dl: p<0.05) levels were higher in first tertile than second and third tertiles. Leptin (167.3 +/- 98 vs 104.5 +/- 80 ng/ml: p<0.05) and IL-6 (3.84 +/- 5.7 vs 1.8 +/- 2.9 pg/ml: p<0.05) levels were higher in first phase angle tertile than third tertile phase angle. CONCLUSION: Obese women with a low PA tertile have high fat mass with a secondary high level of glucose, HOMA, IL-6 and leptin. Perhaps, a low tertile of phase angle could be a new subrogate cardiovascular risk factor to categorize the obese patients.

Effects of telmisartan vs olmesartan on metabolic parameters, insulin resistance and adipocytokines in hypertensive obese patients.

BACKGROUND: Angiotensin II regulates the production of adipokines. The objective was to study the effect of treatment with telmisartan versus olmesartan in hypertensive obese and overweight patients. SUBJECTS: A sample of 65 overweight and obese patients with mild to moderate hypertension was analyzed in a prospective way with a randomized trial. Patients were randomized to telmisartan (80 mg/day) or olmesartan (40 mg/day) for 3 months. Weight, body mass index, blood pressure, basal glucose, insulin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, HOMA, QUICKI, leptin and adiponectin were determined at basal time and after 3 months of treatment. RESULTS: Sixty five patients gave informed consent and were enrolled in the study. Patients treated with telmisartan had a significative decrease of glucose 10.53 mg/dl (CI 95%: 2.6-18.5), insulin 2.51 mUI/L (CI 95%: 2.07-7.17) and HOMA 1.08 (CI 95%: 0.39-2.55). Patients treated with olmesartan had a significative decrease of total cholesterol 20.2 mg/dl (CI 95%: 5.8-34.9) and LDL cholesterol 22.6 mg/dl (CI 95%: 9.7-35.6). Only leptin levels have a significant decrease in telmisartan group 7.39 ng/ml (CI 95%: 1.47-13.31). CONCLUSION: Telmisartan improved blood pressure, glucose, insulin, HOMA and leptin in hypertensive diabetic patients. Olmesartan improved blood pressure and lipid levels.

Ezetimibe monotherapy for cholesterol lowering in 2,722 people: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: To study the evidence on the efficacy and safety of ezetimibe monotherapy for the treatment of primary (heterozygous familial and non-familial) hypercholesterolaemia. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS: Eleven electronic bibliographic databases covering the biomedical, scientific and grey literature were searched from inception and supplemented by contact with experts in the field. Two reviewers independently determined the eligibility of RCTs, with a minimum treatment duration of 12 weeks, which compared ezetimibe monotherapy (10 mg per day) with placebo. RESULTS: In the absence of data from clinical outcome trials, surrogate endpoints such as changes in lipid concentrations were used as indicators of clinical outcomes. A meta-analysis of eight randomized, double-blind, placebo-controlled trials (all 12 weeks) showed that ezetimibe monotherapy was associated with a statistically significant mean reduction in LDL cholesterol (from baseline to endpoint) of -18.58%, (95% CI: -19.67 to -17.48, P < 0.00001) compared with placebo. Significant (P < 0.00001) changes were also found in total cholesterol (-13.46%, 95% CI: -14.22 to -12.70), HDL cholesterol (3.00%, 95% CI: 2.06-3.94) and triglyceride levels (-8.06%, 95% CI: -10.92 to -5.20). Ezetimibe monotherapy appeared to be well tolerated with a safety profile similar to placebo. CONCLUSIONS: In a meta-analysis restricted to short-term trials in hypercholesterolaemia, significant potentially favourable changes in lipid and lipoprotein levels relative to baseline occurred with ezetimibe monotherapy. Further long-term studies with cardiovascular and other clinical outcome data are needed to assess the efficacy and safety of ezetimibe more fully.

Varicose veins show enhanced chemokine expression.

OBJECTIVES: Leucocyte infiltration in the wall of varicose veins has been reported previously. This study was designed to investigate the expression of pro-inflammatory cytokines and chemokines in control and in patients with varicose veins and to test the effect of treating varicose vein patients with acetylsalicylic acid (ASA) on cytokine expression prior to removal of varices. MATERIAL AND METHODS: Sections of vein were removed during operation from both patient groups, and ribonuclease protection assays (RPAs) were performed to assess the expression of chemokines. Group I included non-varicose saphenous veins from healthy patients undergoing amputation for trauma. Varicose veins were obtained from patients with primary varicose undergoing surgical treatment who received no drug (group II) or treatment with 300 mg day(-1) of ASA for 15 days before surgery (group III). RESULTS: Non-varicose veins constitutively expressed low levels of monocyte-chemoattractant protein (MCP-1) and interleukin (IL)-8 mRNA. Varicose veins had a distinct chemokine expression pattern, since significant up-regulation of MCP-1 and IL-8 and a marked expression of IP-10, RANTES, MIP-1alpha and MIP-1beta mRNA were detected. Removal of the endothelium did not alter this pattern. Varicose veins obtained from patients treated with ASA showed a consistent decrease in chemokine expression, although it did not reach statistical significance. CONCLUSIONS: Varicose veins showed increased expression of several chemokines compared to control veins. A non-significant reduction of activation was observed following treatment with ASA for 15 days.

Effect of omega-3 fatty acids on cardiovascular risk factors in patients with type 2 diabetes mellitus and hypertriglyceridemia: an open study.

BACKGROUND AND OBJECTIVES: Epidemiological and interventional studies suggest that a high dietary intake of n-3 polyunsaturated fatty acids may confer a protective effect against atherosclerotic disease and reduce serum triglycerides levels. The aim of our study was to investigate the effectivity on triglyceride levels and inflammatory markers of a concentrated of n-3 fatty acids in patients with type 2 diabetes mellitus and hypertriglyceridaemia. SUBJECTS: A total of 30 patients (16 males and 14 females) with diabetes mellitus type 2 and hypertriglyceridemia (> 200 mg/dl) were included in the study. Patients received two capsules of eicosapentaenoic 465 mg and docosahexanoic 375 mg daily for 12 weeks. RESULTS: Triglycerides levels and non HDL-cholesterol decreased (326 +/- 113.5 vs. 216.4 +/- 57 mg/dl; p < 0.05) and (103.87 +/- 44 vs. 89.6 +/- 14 mg/dl; p < 0.05), respectively. HDL-cholesterol levels increased (39.6 +/- 10.7 vs. 46.4 +/- 8.7 mg/dl; p < 0.05). C reactive protein decreased (5.98 +/- 3.9 vs. 3.9 +/- 1.6 mg/dl; p < 0.05) and TNF-alpha levels decreased (16.24 +/- 5.5 vs. 13.3 +/- 5.8 pg/dl; p < 0.05), without significant changes in IL-6 levels. In conclusion, an n-3 polyunsaturated intervention improved lipid profile and inflammatory markers in patients with diabetes mellitus type 2 and hypertriglyceridaemia.

Leptin and obesity.

Leptin, a protein containing 167 amino acids, demonstrates structural similarities with cytokine family and is mainly produced by adipocytes. The leptin receptor (OB-R) is a large membrane spanning protein that belongs to the gp 130 family of cytokine class I receptors. Besides the neuroendocrine effects of leptin in the control of food intake and energy expenditure, binding of this hormone has been proven in intestine, liver, kidney, skin, stomach, heart, spleen, lung, and so on. Thus leptin affects maternal, fetal and placental function, it appears to act as an endocrine and paracrine factor for the regulation of reproduction and puberty, prevents ectopic lipid deposition, modifies insulin sensitivity in the muscle or liver, and links the immune and endocrine systems. The LEP gene encodes for leptin. It has been localized in humans on the 7 alpha 31.3 chromosome and consists of three exons separated by two introns. In humans, a mutation in the LEP gene was reported in two children with the same cosanguineous pedigree. Other studies reported a polymorphism in the promoter untranslated exon 1 of the LEP gene (A19G), a polymorphism C(-188)A in the promoter region of the LEP gene (17) and a mutation at codon V110M. The biologic activities of leptin on target tissues are carried out through binding to a specific receptor, LEPR. LEPR maps in humans to the 1p31 chromosome. Variants commonly occur, which cause two nonconservative changes:lysine to asparagine at codon 656 (AAG to AAC) in exon 14 (K656N); lysine to arginine at codon 109 (AAG to AGG) in exon 4 (K109R); a nonconservative change glutamine to arginine at codon 223 (CAG to CGG); a silent TC change at codon 343; and a silent GA transition at codon 1019. Leptin is related with obesity and its metabolic disorders. However, new relation ships have been described; inflammatory bowel disease, cancer, bone formation, asthma and so on. In conclusion, despite the great advances in our knowledge of leptin physiology, many areas of investigation remain. Future research is expected to discover new molecules in the leptin pathway, to treat obesity and its related diseases.

Imaging techniques applied to characterize bitumen and bituminous emulsions.

The purpose of this article is to present some important advances in the imaging techniques currently used in the characterization of bitumen and bituminous emulsions. Bitumen exhibits some properties, such as a black colour and a reflecting surface at rest, which permit the use of optical techniques to study the macroscopic behaviour of asphalt mixes in the cold mix technology based on emulsion use. Imaging techniques allow monitoring in situ the bitumen thermal sensitivity as well as the complex phenomenon of emulsion breaking. Evaporation-driven breaking was evaluated from the shape of evaporating emulsion drops deposited onto non-porous and hydrophobic substrates. To describe the breaking kinetics, top-view images of a drying emulsion drop placed on an aggregate sheet were acquired and processed properly. We can conclude that computer-aided image analysis in road pavement engineering can elucidate the mechanism of breaking and curing of bituminous emulsion.

Cost-effectiveness analysis of different embryo transfer strategies in England.

OBJECTIVE: The objective of this study was to assess the cost-effectiveness of different embryo transfer strategies for a single cycle when two embryos are available, and taking the NHS cost perspective. DESIGN: Cost-effectiveness model. SETTING: Five in vitro fertilisation (IVF) centres in England between 2003/04 and 2004/05. POPULATION: Women with two embryos available for transfer in three age groups (<30, 30-35 and 36-39 years). METHODS: A decision analytic model was constructed using observational data collected from a sample of fertility centres in England. Costs and adverse outcomes are estimated up to 5 years after the birth. Incremental cost per live birth was calculated for different embryo transfer strategies and for three separate age groups: less than 30, 30-35 and 36-39 years. MAIN OUTCOME MEASURES: Premature birth, neonatal intensive care unit admissions and days, cerebral palsy and incremental cost-effectiveness ratios. RESULTS: Single fresh embryo transfer (SET) plus frozen single embryo transfer (fzSET) is the more costly in terms of IVF costs, but the lower rates of multiple births mean that in terms of total costs, it is less costly than double embryo transfer (DET). Adverse events increase when moving from SET to SET+fzSET to DET. The probability of SET+fzSET being cost-effective decreases with age. When SET is included in the analysis, SET+fzSET no longer becomes a cost-effective option at any threshold value for all age groups studied. CONCLUSIONS: The analyses show that the choice of embryo transfer strategy is a function of four factors: the age of the mother, the relevance of the SET option, the value placed on a live birth and the relative importance placed on adverse outcomes. For each patient group, the choice of strategy is a trade-off between the value placed on a live birth and cost.

Effect of atorvastatin on bone mineral density in patients with acute coronary syndrome.

OBJECTIVE: The aim of this paper is to evaluate the effect of atorvastatin on bone mineral density in patients with acute ischemic heart disease. MATERIAL AND METHODS: Eighty-three patients (52 male and 31 female) with acute coronary syndrome were studied. They received treatment with atorvastatin using low doses (20 mg) and high doses (40 mg-80 mg). Initial and final cholesterol, triglyceride, calcium, phosphorus, 25-hydroxyvitamin D were obtained from every patient. Spine and hip bone mineral density were performed at the beginning and one year later. RESULTS: Atorvastatin treatment increases vitamin D (33%, p = 0.007) and decreases the individuals with vitamin D insufficiency. Bone mineral density increased in the spine (1.31%, p = 0.02), but it was significant only in male and patients presenting vitamin D levels higher than 30 nmol/l. CONCLUSION: Atorvastatin has a beneficial effect on bone metabolism in patients with acute ischemic heart disease (mainly males) by incrementing bone mineral density in which vitamin D levels are required to be higher than 30 nmol/l for the drug to be effective.

[Variability in the antibiotics prescription in the Avila Province]. / Variabilidad en la prescripción de antibióticos en la provincia de Avila.

This study analyzed the consumption of systemic antibiotics in the province of Avila, Spain, and its Basic Health Areas (ZBS) during 2005. It was a retrospective observational study of the consumption of systemic antibiotics (ATC class J01) during 2005 using the data collected by the Concylia program. The study population was identified from the 2005 Medical Card Register database. Consumption data was expressed in defined daily doses (DDD) per 1,000 inhabitants per day (DID), calculated in relation to the contribution of the user at the time of acquiring the prescription. It was found that antibiotic consumption in the province of Avila in 2005 was 26.91 DHDAj. There was a considerable difference between rural (36.63) and urban areas (15.44) with a large variability among the different Basic Health Areas. The areas with a smaller number of inhabitants per town or city and per doctor, used more antibiotics, which could be due to more severe pathology, absence of self-medication or lack of diagnostic resources, among other factors. There is no relation between greater consumption and workload. It was concluded that the consumption of antibiotics in the province of Avila is high due to their use in rural areas. A high variability in the consumption of antibiotics was observed between the different areas, which was related to the smaller number of inhabitants per city or town and per doctor, but had no relation to workload.

[Endoscopic treatment of central airway stenosis: five years' experience]. / Cinco años de experiencia en el tratamiento endoscópico de las estenosis de la vía aérea principal.

OBJECTIVE: To describe our experience with interventional bronchoscopy in the treatment of central airway stenosis. PATIENTS AND METHODS: We reviewed patient records and bronchoscopic findings. Clinical data, findings from computed tomography, techniques performed, complications, and results were recorded. RESULTS: One-hundred and thirty-six patients (90 males and 46 females) were treated. The mean (SD) age was 57 (7) years (range, 3-81). A total of 320 therapeutic interventions were performed: 145 laser treatments, 33 balloon or mechanical dilatations, 26 electrocauterizations, and 116 stent insertions. Pathogenesis varied: in 64 (47%) patients, the stenosis was caused by a tumor (48 were bronchopulmonary and 16 nonpulmonary); in 72 (53%) patients, stenosis was secondary to a nontumor-related process, of which the most common was prolonged intubation (42% of these cases). Central airway patency was achieved in 92% (59/64) of the tumor-related stenoses and 96% (69/72) of those unrelated to tumors. Improvement in dyspnea was observed in 96% of all patients. Two deaths (due to hemoptysis and to acute myocardial infarction) occurred in the first week, for a 1.4% mortality rate. The most common complications were stent migration (8%; 9/116 cases) and the formation of granulomas (9%; 11/116). CONCLUSIONS: Interventional bronchoscopy is an effective technique to resolve life-threatening obstructions of the central airways. Dyspnea improves immediately and there is no significant morbidity or mortality.