Diagnostic yield and cost analysis of electrocardiographic screening in Swiss paediatric athletes.

OBJECTIVES: Athletes performing sports on high level are at increased risk for sudden cardiac death. This includes paediatric athletes, even though data on screening strategies in this age group remain scarce. This study aimed to assess electrocardiogram interpretation criteria in paediatric athletes and to evaluate the cost of screening. METHODS: National, multicentre, retrospective, observational study on 891 athletes of paediatric age (<18 years) evaluated by history, physical examination and 12-lead electrocardiogram. The primary outcome measure was abnormal electrocardiogram findings according to the International Recommendations for Electrographic Interpretation in Athletes. The secondary outcome measure was cost of screening. RESULTS: 19 athletes (2.1%) presented abnormal electrocardiogram findings requiring further investigations, mainly abnormal T-wave inversion. These 19 athletes were predominantly males, performing endurance sports with a mean volume of 10 weekly hours for a mean duration of 6 years of training. Further investigations did not identify any relevant pathology. All athletes were cleared for competition with regular follow-up. Total costs of the screening were 108,860 USD (122 USD per athlete). CONCLUSIONS: Our study using the International Recommendations for Electrographic Interpretation in Athletes identified a low count of abnormal findings in paediatric athletes, yet raising substantially the cost of screening. Hence, the utility of electrocardiogram-inclusive screening of paediatric athletes remains to be elucidated by longitudinal data.

EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

BACKGROUND: The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO2peak when compared with no CR. OBJECTIVE: To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR. METHODS: Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis. The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio. RESULTS: The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO2peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO2peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO2peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants. CONCLUSION: From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

German health-related environmental monitoring: assessing time trends of the general population's exposure to heavy metals.

The German system of a health-related environmental monitoring is based upon two instruments: The German Environmental Survey (GerES) and the Environmental Specimen Bank (ESB). The ESB is a tool to describe time trends of human exposure. Each year approx. 500 students from 4 sampling locations are analysed for their heavy metal contents in blood, blood plasma, and urine. GerES is a nationwide representative cross-sectional study that has been conducted four times up to now. Both instruments have been used to measure heavy metals over the last decades and thus provide complementary information. Both instruments are useful to describe time trends. However, combining the two has an added value, which is demonstrated for heavy metals for the first time in this paper. Major results and the changing importance of sources of exposure to heavy metals (Pb, Cd, Hg, Au, Pt, U and Ni) are shown. This leads to the following conclusion about the today's relevance of exposure in Germany. For the study participants of the city of Muenster, lead in whole blood decreased from about 70 µg/l in 1981 to levels below 15 µg/l in 2009. GerES data of young adults confirmed this time trend and GerES IV on children revealed the decreasing relevance of lead in outdoor air and in drinking water. The concentrations of mercury in urine decreased because in Germany it is no longer recommended to use amalgam fillings for children. However, GerES IV and ESB data also demonstrate that despite the decline of these heavy metals exposures to nickel and uranium originating from drinking water are still of importance.

Genotoxic risk assessment in white blood cells of occupationally exposed workers before and after alteration of the polycyclic aromatic hydrocarbon (PAH) profile in the production material: comparison with PAH air and urinary metabolite levels.

OBJECTIVE: Workers in various industries can be exposed to polycyclic aromatic hydrocarbons (PAHs). The relationship between biomarkers of genotoxic risk, PAH compounds in air (ambient monitoring) and PAH metabolites in urine (internal exposure) were studied in 17 workers exposed to PAHs in a fireproof-material producing plant before and 3 months after the PAH profile was altered in the binding pitch. METHODS: Two biomarkers of exposure, specific DNA adducts of (+/-)-r-7,t-8-dihydroxy-t-9,10-oxy-7,8,9,10-tetrahydrobenzo[a]pyrene (anti-BPDE) and non-specific DNA adduct of 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodGuo) were determined in white blood cells (WBCs). In addition, DNA strand breaks were analysed in lymphocytes by single-cell gel electrophoresis in a genotoxic risk assessment. Sixteen PAH compounds in air were determined by personal air sampling, and hydroxylated metabolites of phenanthrene, pyrene and naphthalene were determined in urine. RESULTS: After substitution of the binding pitch the concentrations of benzo[a]pyrene in air decreased (P<0.01). No changes could be observed for pyrene, while levels of phenanthrene (P=0.0013) and naphthalene (P=0.0346) in air increased. Consequently, median DNA adduct rates of anti-BPDE decreased after alteration of the production material (from 0.9 to <0.5 adducts/10(8) nucleotides). No changes in the excretion of 1-hydroxypyrene in urine could be determined, whereas increased levels of 1-, 2+9-, 3- and 4-hydroxyphenanthrene (P<0.0001) and 1-naphthol and 2-naphthol (P=0.0072) were found in urine. In addition, a statistically significant increase in DNA strand break frequencies (P<0.01) and elevated 8-oxodGuo adduct levels (P=0.7819, not statistically significant) were found in the WBCs of exposed workers 3 months after the PAH profile in the binding pitch had been altered. CONCLUSION: The results presented here show that the increased concentration of naphthalene and/or phenanthrene in the air at the work place could induce the formation of DNA strand breaks and alkali-labile sites in WBCs of exposed workers.

The place of research and the role of academic surgeons in cardiac surgery.

The development of the discipline of cardiac surgery was, to a large extent, guided by the vision and research of its pioneers. On the basis of their efforts, all the different areas of cardiac surgery were able to evolve including coronary artery bypass grafting, heart valve surgery, surgery of the aorta, congenital heart surgery, surgery for rhythm disorders including the implantation of pacemakers and defibrillators, and surgical treatment of advanced heart failure (for example, heart transplantations and mechanical circulatory support). The continued existence of cardiac surgery and its role in medicine in general will depend, to a significant extent, on the future research activities of its protagonists. Cardiac surgeon-scientists will play a pivotal role since they combine clinical experience with scientific knowledge and intuition which make them able to direct research to topics which will matter in the future. However, research costs money, and state or national funds will be not sufficient to support research as much as is necessary. Funding from third parties such as industry will increasingly be required. Due to this, however, the cardiac surgeon-scientist faces various challenges such as the evaluation of his skill in acquiring funds, conflicts with current ethical standards, conflicts of interest when receiving money from industry, and, as a result of the tough competition in this field, the temptation to commit fraud. The head of a department of cardiac surgery holds an important function as his initiative is decisive for the development of visions for the future and for the employment of surgeon-scientists who pursue visionary research. It will take the combined efforts of surgeon-scientists and departmental heads not only to maintain but to extend the position of cardiac surgery in medicine and society even further.

The effects of economic conditions and access to reproductive health services on state abortion rates and birthrates.

The effects that such factors as wages, welfare policies and access to physicians, family planning clinics and abortion providers have on abortion rates and birthrates are examined in analyses based on 1978-1988 state-level data and longitudinal regression techniques. The incidence of abortion is found to be lower in states where access to providers is reduced and state policies are restrictive. Calculations indicate that decreased access may have accounted for about one-quarter of the 5% decline in abortion rates between 1988 and 1992. In addition, birthrates are elevated where the costs of contraception are higher because access to obstetrician-gynecologists and family planning services is reduced. Economic resources such as higher wages for men and women and generous welfare benefits are significantly and consistently related to increased birthrates; however, even a 10% cut in public assistance benefits would result in only one birth fewer for every 212 women on welfare. Economic factors showed no consistent relationship with abortion rates.

Hospice development in a subacute care setting.

In developing inpatient and home hospice services in a subacute care setting, Villa Mercy chose to forego traditional hospice models in favor of a strong medical model. It confronted six basic issues in its pioneering effects. 1. Goal formulation. Villa Mercy provides for inpatient admissions whenever appropriate, but also aims to enable patients to stay at home as long as possible and to educate health professionals and the community on hospice care and the dying process. 2. Medical model functions. A hospice core team--composed of a hospice medical director, a chaplain, a social worker, a pharmacist, and registered nurses--meets weekly and assesses each patient's progress. Each core team member follows a specific role in meeting the patient's physical, psychological, social, and spiritual needs. 3. Pain and symptom management. Specific guidelines are followed in observing and listening to the patient, administering pain medication and controlling dose increases, working with patients who are in chemotherapy or drug therapy, and dealing with symptoms caused by the drug regimen. 4. Inpatient versus home care issues. the staffs of both components must coordinate their efforts and feel comfortable with moving patients from one component to the other. 5. Reimbursement channels. Title 18, Blue Cross, and other commercial third party payers have provided coverage at Villa Mercy. Tightening Health Care Financing Administration (HCFA) regulations, however, will make funding more difficult for providers operating under HCFA guidelines. 6. Volunteers. Volunteers are an essential part of the facility's hospice services and receive 20 hours of intensive classwork over a 10-week period before working with a patient and family.