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OBJECTIVES: To study if clinical, radiographic and MRI markers can predict MRI and radiographic damage progression and achievement of stringent remission in patients with established RA in clinical remission followed by a targeted treatment strategy. METHODS: RA patients (DAS28-CRP <3.2, no swollen joints) receiving conventional synthetic DMARDs were randomized to conventional or MRI-targeted treat-to-target strategies with predefined algorithmic treatment escalations. Potentially predictive baseline variables were tested in multivariate logistic regression analyses. RESULTS: In the 171 patients included, baseline MRI osteitis independently predicted progression in MRI erosion [odds ratio (OR) 1.13 (95% CI 1.06, 1.22)], joint space narrowing [OR 1.15 (95% CI 1.07, 1.24)] and combined damage [OR 1.23 (95% CI 1.13, 1.37)], while tenosynovitis independently predicted MRI erosion progression [OR 1.13 (95% CI 1.03, 1.25)]. A predictor of radiographic erosion progression was age, while gender predicted progression in joint space narrowing. Following an MRI treat-to-target strategy predicted stringent remission across all remission definitions: Clinical Disease Activity Index remission OR 2.94 (95% CI 1.25, 7.52), Simplified Disease Activity Index remission OR 2.50 (95% CI 1.01, 6.66), ACR/EULAR Boolean remission OR 5.47 (95% CI 2.33, 14.13). Similarly, low tender joint count and low patient visual analogue scale pain and global independently predicted achievement of more stringent remission. CONCLUSION: Baseline MRI osteitis and tenosynovitis were independent predictors of 2 year MRI damage progression in RA patients in clinical remission, while independent predictors of radiographic damage progression were age and gender. Following an MRI treat-to-target strategy, low scores of patient-reported outcomes and low tender joint count predicted achievement of stringent remission. TRIAL REGISTRATION: ClinicalTrials.gov (https://clinicaltrials.gov), NCT01656278.
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Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Anciano , Artritis Reumatoide/diagnóstico por imagen , Progresión de la Enfermedad , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Inducción de Remisión , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Background: The choice of treatment for Crohn's disease (CD) and ulcerative colitis (UC) depends among other factors, disease severity. Patients with moderate-to-severe disease should be prescribed biologic response modifiers (biologics), according to guidelines. This study aims to explore the treatment patterns of patients diagnosed with CD and UC between 2003 and 2015 that were treated with biologics in Denmark between the years 2003 and 2016.Methods: This national register study included patients diagnosed between 2003 and 2015, identified in the Danish National Patient Registry. Biologic therapies available during the study period were infliximab, adalimumab, vedolizumab and golimumab. The share of patients initiating and receiving biologic treatment in each year was estimated. Additionally, the time from IBD diagnosis to first biologic treatment and time between treatments was calculated.Results: Among 10,302 CD patients and 22,144 UC patients, 28.5% of CD patients and 11.3% of UC patients received treatment with biologics during the study period, with an increasing trend in the number of patients initiating treatment with biologics each year. About 46% of CD patients and 45% of UC patients received their first biologic treatment within the first year after IBD diagnosis. About 57-68% of CD and UC patients received treatment with their second line biologic within 2 months of the last treatment of their first line.Conclusions: The number of patients initiating biologic treatments after diagnosis increased throughout the study period. Most patients diagnosed with CD and UC are receiving biologic treatments relatively soon after their diagnosis.
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Productos Biológicos/uso terapéutico , Colitis Ulcerosa/tratamiento farmacológico , Colitis Ulcerosa/epidemiología , Enfermedad de Crohn/tratamiento farmacológico , Enfermedad de Crohn/epidemiología , Adalimumab/uso terapéutico , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Niño , Preescolar , Dinamarca/epidemiología , Femenino , Humanos , Lactante , Recién Nacido , Infliximab/uso terapéutico , Masculino , Persona de Mediana Edad , Sistema de Registros , Distribución por Sexo , Adulto JovenRESUMEN
Objective: There is little information on cost-of-illness among patients diagnosed with Crohn's disease (CD) and ulcerative colitis (UC) in Denmark. The objective of this study was to estimate the average 5-year societal costs attributable to CD or UC patients in Denmark with incidence in 2003-2015, including costs related to health care, prescription medicine, home care and production loss.Materials and methods: A national register-based, cost-of-illness study was conducted using an incidence-based approach to estimate societal costs. Incident patients with CD or UC were identified in the National Patient Registry and matched with a non-IBD control from the general population on age and sex. Attributable costs were estimated applying a difference-in-difference approach, where the total costs among individuals in the control group were subtracted from the total costs among patients.Results: CD and UC incidence fluctuated but was approximately 14 and 31 per 100,000 person years, respectively. The average attributable costs were highest the first year after diagnosis, with costs equalling 12,919 per CD patient and 6,501 per UC patient. Hospital admission accounted for 36% in the CD population and 31% in the UC population, the first year after diagnosis. Production loss exceeded all other costs the third-year after diagnosis (CD population: 52%; UC population: 83%).Conclusions: We found that the societal costs attributable to incident CD and UC patients are substantial compared with the general population, primarily consisting of hospital admission costs and production loss. Appropriate treatment at the right time may be beneficial from a societal perspective.
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Colitis Ulcerosa/economía , Colitis Ulcerosa/epidemiología , Costo de Enfermedad , Enfermedad de Crohn/economía , Enfermedad de Crohn/epidemiología , Adolescente , Adulto , Anciano , Dinamarca/epidemiología , Femenino , Costos de la Atención en Salud , Hospitalización/economía , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Sistema de Registros , Adulto JovenRESUMEN
BACKGROUND: Suspicion of deep vein thrombosis (DVT) is common and requires urgent and efficient investigation due to hazardous prognosis. The traditional diagnostic pathway can be complex and time-consuming, and innovative solutions may provide easy access to diagnostics and better use of healthcare resources. We aimed to describe use, clinical outcomes and time used when providing general practitioners (GPs) with a direct-access pathway to hospital-based, single whole-leg compression ultrasound (CUS) for patients with suspected DVT. Furthermore we aimed to describe the resources used in the new direct-access pathway and compare it with the previous pathway. METHODS: We conducted a 2-year descriptive cohort study (2016-2017) including 449 consecutively referred patients for diagnosis of DVT in a Danish regional hospital. The previous pathway included pre-test at the medical department, a proximal leg CUS if required based on the pre-test and a re-scan if the first CUS was negative. The new pathway included two strategies: 1) a 'yes-no strategy', where GPs referred patients directly to whole-leg CUS and if positive, treated at the medical department and if negative, discharged to the GP, 2) a 'follow-up strategy' where GPs could require that patients were seen at the medical department, irrespective of the CUS result. Data included extractions from the Radiology Information and Patient Administrative Systems, and mean salaries of healthcare professionals at Silkeborg Regional Hospital, Denmark. Descriptive statistics were used to describe prevalence, timelines and costs. RESULTS: GPs referred 318 (71%) patients through the yes-no strategy and 131 (29%) via the follow-up strategy with DVT diagnosed in 48 (15%) and 51 (39%) patients, respectively (p < 0.001). For the 263 patients completed after CUS in the yes-no strategy, median pathway time was 24 min (IQI: 16-36), and for those with DVT (including both strategies) 202 min (IQI: 158-273). Direct-access pathway costs were 49.7 less per patient than the previous pathway. CONCLUSION: Direct-access to CUS for suspected DVT was achievable, had short time intervals and required fewer resources. The difference in DVT prevalence indicates that GPs distinguish between patients with low and high risk of DVT.
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Medicina General , Trombosis de la Vena , Estudios de Cohortes , Medicina Familiar y Comunitaria , Humanos , Ultrasonografía , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/epidemiologíaRESUMEN
Importance: Whether using magnetic resonance imaging (MRI) to guide treatment in patients with rheumatoid arthritis (RA) improves disease activity and slows joint damage progression is unknown. Objective: To determine whether an MRI-guided treat-to-target strategy vs a conventional clinical treat-to-target strategy improves outcomes in patients with RA in clinical remission. Design, Setting, and Participants: Two-year, randomized, multicenter trial conducted at 9 hospitals in Denmark. Two hundred patients with RA in clinical remission (disease activity score in 28 joints-C-reactive protein [DAS28-CRP] <3.2 and no swollen joints) were enrolled between April 2012 and June 2015. The final follow-up visit was April 2017. Interventions: Patients were randomly allocated (1:1) to an MRI-guided vs a conventional treat-to-target strategy. In the MRI-guided group, the treatment goal was absence of MRI bone marrow edema combined with clinical remission, defined as DAS28-CRP of 3.2 or less and no swollen joints. In the conventional group, the treatment goal was clinical remission. Main Outcomes and Measures: Co-primary outcomes were proportions of patients achieving DAS28-CRP remission (DAS28-CRP <2.6) and with no radiographic progression (no increase in total van der Heijde-modified Sharp score) at 24 months. Significance testing for the primary outcome was based on 1-sided testing. Secondary outcomes were clinical and MRI measures of disease activity, physical function, and quality of life. Results: Of 200 patients randomized (133 women [67%]; mean [SD] age, 61.6 [10.5] years; median baseline DAS28-CRP, 1.9 [interquartile range, 1.7-2.2]; van der Heijde-modified Sharp score, 18.0 [interquartile range, 7.0-42.5]), 76 patients (76%) in the MRI-guided group and 95 (95%) in the conventional group completed the study. Of these, 64 (85%) vs 83 (88%), respectively, reached the primary clinical end point (risk difference, -4.8% [1-sided 95% CI, -13.6% to + ∞; 1-sided P = .19]) and 49 (66%) vs 58 (62%), respectively, reached the primary radiographic end point (risk difference, 4.7% [1-sided 95% CI, -7.0% to + ∞; 1-sided P = .25). Of 10 key secondary end points, 8 were null and 2 showed statistically significant benefit for the MRI treat-to-target group. Seventeen patients (17%) in the MRI-guided treat-to-target group and 6 patients (6%) in the conventional treat-to-target group experienced serious adverse events. Conclusions and Relevance: Among patients with RA in clinical remission, an MRI-guided treat-to-target strategy compared with a conventional treat-to-target strategy did not result in improved disease activity remission rates or reduce radiographic progression. These findings do not support the use of an MRI-guided strategy for treating patients with RA. Trial Registration: ClinicalTrials.gov Identifier: NCT01656278.
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Antirreumáticos/uso terapéutico , Artritis Reumatoide/diagnóstico por imagen , Médula Ósea/diagnóstico por imagen , Articulaciones/diagnóstico por imagen , Imagen por Resonancia Magnética , Anciano , Antirreumáticos/efectos adversos , Artritis Reumatoide/tratamiento farmacológico , Médula Ósea/patología , Progresión de la Enfermedad , Edema/diagnóstico por imagen , Femenino , Humanos , Articulaciones/efectos de los fármacos , Articulaciones/patología , Masculino , Persona de Mediana Edad , Osteítis/diagnóstico por imagen , Evaluación de Procesos y Resultados en Atención de Salud , Radiografía , Inducción de RemisiónRESUMEN
OBJECTIVES: We investigated whether any change in the use of invasive coronary angiography and coronary revascularisation after CT coronary angiography in patients with a low to intermediate pre-test probability of coronary artery disease could be explained from alterations in patient characteristics. DESIGN: A cohort study based on data samples from the Western Denmark Heart Registry. Follow-up ended on 11 March 2014. RESULTS: A total of 3541 persons were examined during the period of January 2010-December 2013. The median radiation dose was reduced from 4.2 to 2.2 mSv (p < 0.001) due to improved technology. The immediate referral rate for subsequent myocardial perfusion scans was increased from 2.8% to 10.0% (p < 0.001), while the immediate referral rate for invasive coronary angiography decreased from 25.3% to 10.8% (p < 0.001). The revascularisation rate diminished from 10.4% to 6.3%. The multivariable adjusted hazard ratio (95% confidence interval) for invasive coronary angiography during follow-up after CT coronary angiography was 0.59 (0.47-0.74) and that for coronary revascularisation was 0.66 (0.45-0.97) in 2013 compared to that in 2010. CONCLUSIONS: The radiation dose diminished considerably. The reductions in the use of invasive coronary angiography and coronary revascularisation could not be explained by changes in patient characteristics but are driven by an increased use of perfusion scans in combination with increasing use of measurement of functional coronary flow reserve.
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Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Anciano , Enfermedad de la Arteria Coronaria/cirugía , Estenosis Coronaria/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica , Modelos de Riesgos Proporcionales , Dosis de RadiaciónRESUMEN
PURPOSE: To develop a nano-structured porous polycaprolactone (NSP-PCL) scaffold and compare the articular cartilage repair potential with that of a commercially available collagen type I/III (Chondro-Gide) scaffold. METHODS: By combining rapid prototyping and thermally induced phase separation, the NSP-PCL scaffold was produced for matrix-assisted autologous chondrocyte implantation. Lyophilizing a water-dioxane-PCL solution created micro and nano-pores. In vitro: The scaffolds were seeded with rabbit chondrocytes and cultured in hypoxia for 6 days. qRT-PCR was performed using primers for sox9, aggrecan, collagen type 1 and 2. In vivo: 15 New Zealand White Rabbits received bilateral osteochondral defects in the femoral intercondylar grooves. Autologous chondrocytes were harvested 4 weeks prior to surgery. There were 3 treatment groups: (1) NSP-PCL scaffold without cells. (2) The Chondro-Gide scaffold with autologous chondrocytes and (3) NSP-PCL scaffold with autologous chondrocytes. Observation period was 13 weeks. Histological evaluation was made using the O'Driscoll score. RESULTS: In vitro: The expressions of sox9 and aggrecan were higher in the NSP-PCL scaffold, while expression of collagen 1 was lower compared to the Chondro-Gide scaffold. In vivo: Both NSP-PCL scaffolds with and without cells scored significantly higher than the Chondro-Gide scaffold when looking at the structural integrity and the surface regularity of the repair tissue. No differences were found between the NSP-PCL scaffold with and without cells. CONCLUSION: The NSP-PCL scaffold demonstrated higher in vitro expression of chondrogenic markers and had higher in vivo histological scores compared to the Chondro-Gide scaffold. The improved chondrocytic differentiation can potentially produce more hyaline cartilage during clinical cartilage repair. It appears to be a suitable cell-free implant for hyaline cartilage repair and could provide a less costly and more effective treatment option than the Chondro-Gide scaffold with cells.
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Cartílago Articular/fisiología , Colágeno Tipo III , Colágeno Tipo I , Regeneración Tisular Dirigida/instrumentación , Nanoestructuras , Poliésteres , Andamios del Tejido , Agrecanos/metabolismo , Animales , Biomarcadores/metabolismo , Cartílago Articular/citología , Cartílago Articular/lesiones , Condrocitos/trasplante , Colágeno Tipo I/metabolismo , Colágeno Tipo III/metabolismo , Masculino , Modelos Animales , Conejos , Reacción en Cadena en Tiempo Real de la Polimerasa , Factor de Transcripción SOX9/metabolismo , Cicatrización de HeridasRESUMEN
The purpose of this article is to review options for more rapid diagnosis of lung cancer at an earlier stage, thereby improving survival. These options include screening, allowing general practitioners to refer patients directly to low-dose computed tomography scan instead of a chest X-ray and the abolition of the "visitation filter", i.e. hospital doctors' ability to reject referrals from general practitioners without prior discussion with the referring doctor.
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Neoplasias Pulmonares , Hospitales , Humanos , Neoplasias Pulmonares/diagnóstico , Tamizaje Masivo , Derivación y Consulta , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: Magnetic resonance enterography (MRE) is useful for detecting bowel strictures, whereas a number of imaging biomarkers may reflect severity of fibrosis burden in Crohn's disease (CD). This study aimed to verify the association of MRE metrics with histologic fibrosis independent of inflammation. METHODS: This prospective European multicenter study performed MRE imaging on 60 patients with CD with bowel strictures before surgical resection. Locations of 61 histological samples were annotated on MRE examinations, followed by central readings using the Chiorean score and measurement of delayed gain of enhancement (DGE), magnetization transfer ratio, T2-weighted MRI sequences (T2R), apparent diffusion coefficient (ADC), and the magnetic resonance index of activity (MaRIA). Correlations of histology and MRE metrics were assessed. Least Absolute Shrinkage and Selection Operator and receiver operator characteristic (ROC) curve analyses were used to select composite MRE scores predictive of histology and to estimate their predictive value. RESULTS: ADC and MaRIA correlated with fibrosis (R = -0.71, P < 0.0001, and 0.59, P < 0.001) and more moderately with inflammation (R = -0.35, P < 0.01, and R = 0.53, P < 0.001). Lower or no correlations of fibrosis or inflammation were found with DGE, magnetization transfer ratio, or T2R. Least Absolute Shrinkage and Selection Operator and ROC identified a composite score of MaRIA, ADC, and DGE as a very good predictor of histologic fibrosis (ROC area under the curve = 0.910). MaRIA alone was the best predictor of histologic inflammation with excellent performance in identifying active histologic inflammation (ROC area under the curve = 0.966). DISCUSSION: MRE-based scores for histologic fibrosis and inflammation may assist in the characterization of CD stenosis and enable development of fibrosis-targeted therapies and clinical treatment of stenotic patients.
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Enfermedad de Crohn , Constricción Patológica/diagnóstico por imagen , Enfermedad de Crohn/complicaciones , Enfermedad de Crohn/diagnóstico por imagen , Fibrosis , Humanos , Inflamación/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Espectroscopía de Resonancia Magnética , Estudios ProspectivosRESUMEN
BACKGROUND: The diagnostic delay in inflammatory bowel disease (IBD) is well known, yet the costs associated with diagnoses before IBD diagnosis have not yet been reported. This study explored societal costs and disease diagnoses 10 years before Crohn's disease (CD) and ulcerative colitis (UC) diagnosis in Denmark. METHODS: This national register study included patients diagnosed between 2003 and 2015 identified in the Danish National Patient Registry (NPR) and controls who were individually matched on age and sex from the general population. Societal costs included health care services, prescription medicine, home care services, and labor productivity loss. Prediagnostic hospital contact occurring before CD or UC diagnosis was identified using the NPR. Average annual costs per individual were calculated before the patient's first CD or UC diagnosis. A 1-sample t test was then applied to determine significance in differences between cases and controls. RESULTS: Among CD (n = 9019) and UC patients (n = 20,913) the average societal costs were higher throughout the entire 10-year period before the diagnosis date compared with the general population. The difference increased over time and equaled 404 for CD patients and 516 for UC patients 10 years before diagnosis and 3377 and 2960, respectively, in the year before diagnosis. Crohn's disease and UC patients had significantly more diagnoses before their CD and UC diagnosis compared with the general population. CONCLUSIONS: Compared with the general population, the societal costs and number of additional diagnoses among CD and UC patients were substantially higher in the 10-year period before diagnosis.
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Colitis Ulcerosa/economía , Costo de Enfermedad , Enfermedad de Crohn/economía , Diagnóstico Tardío/economía , Costos de la Atención en Salud/estadística & datos numéricos , Adulto , Colitis Ulcerosa/diagnóstico , Enfermedad de Crohn/diagnóstico , Dinamarca , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios RetrospectivosRESUMEN
Background: Extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) may be a frequent complication to an underlying abnormal immune response. This study investigated the occurrence of EIMs in Crohn disease (CD) and ulcerative colitis (UC) patients using population-based data in Denmark from 2003 to 2016. Methods: In this national registry-based study, incident CD and UC patients between 2003 and 2015 were matched on age and gender with non-IBD controls and followed until 2016. The selected EIMs for this study included 51 different diagnoses divided into biological systems of diseases, which were tested for differences in the timing and occurrence of EIMs. Results: The study cohort included 10,302 patients with CD and 22,144 patients with UC. The highest risk of patients experiencing EIM/comorbidities for the first time before their IBD diagnosis was in the skin and intestinal tract systems. For CD, the odds ratio of having an EIM before or after IBD diagnosis, as compared with controls, was significant in the skin, intestinal tract, hepatopancreatobiliary, musculoskeletal, ocular, renal, and respiratory systems. For UC, the risks were similar before and after UC diagnosis, apart from the nervous system where the odds ratio was significantly higher before the diagnosis of UC, and significantly lower after diagnosis for diseases in the ocular system. Conclusions: EIMs in CD and UC patients may also precede their IBD diagnosis. These findings may indicate a significant diagnostic delay of CD and UC, and the occurrence of known EIMs should prompt physicians to look for patients possibly having underlying IBD.
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Aim: Optimal use of scarce resources is a focus in the healthcare sector, as resources devoted to health care are limited. Costs and health economic analyses can help guide decision-making concerning treatments. One important factor is the choice of cost perspective that can range from a focus on narrow drug budget costs to broader economic perspectives. In the case of treatment with oral anticoagulants in patients with venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, the aim of this cost analysis was to illustrate the differences in costs when applying different cost perspectives.Methods: In a cost analysis, pairwise comparisons of average costs of 6 months standard treatment with either a low molecular weight heparin parenteral anticoagulant (LMWH) and a Vitamin K Antagonist (VKA) versus one of the non-vitamin K oral anticoagulants [NOACs; dabigatran etexilate, rivaroxaban, apixaban, and edoxaban) used in daily clinical practice in Denmark for VTE patients were carried out. Each analysis included the results from five different cost analyses with increasingly broader cost perspectives going from the narrowest "drug cost only" perspective to the broadest "societal" perspective.Results: Focusing on "drug costs only", LMWH/VKA was associated with the lowest costs compared to all NOACs. However, including the economic impact of preventing recurrent VTE and limit bleedings, apixaban and rivaroxaban resulted in slightly lower health care costs than LMWH/VKA. When applying the "societal perspective", the total costs saved with apixaban and rivaroxaban compared to LMWH/VKA further increased, with apixaban having the lowest total costs.Conclusions: The present study's case of oral anticoagulants in VTE treatment illustrated the importance of the cost perspective in the choice of therapy. If decision-making were based on drug costs only, instead of applying a health care sector or societal cost perspective, suboptimal decisions may be likely.
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Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Modelos Econométricos , Tromboembolia/tratamiento farmacológico , Administración Oral , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Análisis Costo-Beneficio , Dabigatrán/economía , Dabigatrán/uso terapéutico , Dinamarca , Femenino , Hemorragia/inducido químicamente , Hemorragia/economía , Heparina de Bajo-Peso-Molecular/economía , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Masculino , Embolia Pulmonar/tratamiento farmacológico , Pirazoles , Piridinas/economía , Piridinas/uso terapéutico , Piridonas , Años de Vida Ajustados por Calidad de Vida , Rivaroxabán/economía , Rivaroxabán/uso terapéutico , Tiazoles/economía , Tiazoles/uso terapéutico , Trombosis de la Vena/tratamiento farmacológicoRESUMEN
BACKGROUND AND AIMS: Increased small intestinal wall thickness correlates with both inflammatory activity and fibrosis in Crohn's disease [CD]. Assessment of perfusion holds promise as an objective marker distinguishing between the two conditions. Our primary aim was to determine if relative bowel wall perfusion measurements correlate with histopathological scores for inflammation or fibrosis in CD. METHODS: A total of 25 patients were investigated before elective surgery for small intestinal CD. Unenhanced ultrasonography [US] and magnetic resonance enterography [MRE] were applied to describe bowel wall thickness. Perfusion was assessed with contrast-enhanced US [CEUS] and dynamic contrast-enhanced MRE [DCE-MRE]. Histopathology was used as gold standard. RESULTS: Compared with histopathology, the mean wall thickness was 0.4 mm greater on US [range -0.3 to 1.0, p = 0.24] and 1.4 mm greater on MR [0.4 to 2.3, p = 0.006]. No correlation was found between the severity of inflammation or fibrosis on histopathology, and either DCE-MRE [r = -0.13, p = 0.54 for inflammation and r = 0.41, p = 0.05 for fibrosis] or CEUS [r = 0.16, p = 0.45 for inflammation and r = -0.28, p = 0.19 for fibrosis]. Wall thickness assessed with US was correlated with both histological inflammation [r = 0.611, p = 0.0012] and fibrosis [r = 0.399, p = 0.048]. The same was not true for MR [r = 0.41, p = 0.047 for inflammation and r = 0.29, p = 0.16 for fibrosis]. CONCLUSIONS: Bowel wall thickness assessed with US is a valid marker of inflammation in small intestinal CD. However, relative contrast enhancement of US or of MRE cannot distinguish between inflammatory activity and fibrosis.
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Enfermedad de Crohn/diagnóstico por imagen , Enfermedad de Crohn/patología , Intestinos/patología , Imagen por Resonancia Magnética/métodos , Úlcera/diagnóstico por imagen , Ultrasonografía , Adulto , Anciano , Proteína C-Reactiva/metabolismo , Medios de Contraste , Enfermedad de Crohn/complicaciones , Heces/química , Femenino , Fibrosis , Humanos , Inflamación/sangre , Inflamación/diagnóstico por imagen , Inflamación/patología , Complejo de Antígeno L1 de Leucocito/análisis , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Úlcera/etiología , Úlcera/patología , Adulto JovenRESUMEN
Purpose e Cross-sectional imaging methods are important for objective evaluationof small intestinal inflammationinCrohn'sdisease(CD).The primary aim was to compare relative parameters of intestinal perfusion between contrast-enhanced ultrasonography (CEUS) and dynamic contrast-enhanced magnetic resonance enterography (DCE-MRE) in CD. Furthermore, we aimed at testing the repeatability of regions of interest (ROIs) for CEUS. Methods This prospective study included 25 patients: 12 females (age: 37, range: 19-66) with moderate to severe CD and a bowel wall thickness>3mm evaluated with DCE-MRE and CEUS. CEUS bolus injection was performed twice for repeatability and analyzed in VueBox®. Correlations between modalities were described with Spearman's rho, limits of agreement(LoA) and intraclass correlation coefficient(ICC). ROIrepeatability for CEUS was assessed. Results s The correlation between modalities was good and very good for bowel wall thickness (ICC=0.71, P<0.001) and length of the inflamed segment (ICC=0.89, P<0.001). Moderate-weak correlations were found for the time-intensity curve parameters: peak intensity (r=0.59, P=0.006), maximum wash-in-rate (r=0.62, P=0.004), and wash-in perfusion index (r=0.47, P=0.036). Best CEUS repeatability for peak enhancement was a mean difference of 0.73 dB (95% CI: 0.17 to 1.28, P=0.01) and 95% LoA from -3.8 to 5.3 dB. Good quality of curve fit improved LoA to -2.3 to 2.8 dB. Conclusion The relative perfusion of small intestinal CD assessed with DCE-MRE and CEUS shows only a moderate correlation. Applying strict criteria for ROIs is important and allows for good CEUS repeatability.
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INTRODUCTION: Patients' non-attendance is a significant problem in modern healthcare. Non-attendance delays treatment, reduces efficiency and increases healthcare costs. For several years, the introduction of financial incentives such as a non-attendance fee has been discussed in Denmark. Set in the context of a tax-financed, free-for-all healthcare system, the political hesitance to introduce fees relates to concerns that additional fees may be badly received by tax-paying citizens and may undermine the political priority of patient equity. The aim of this qualitative sub-study was to investigate patients' attitudes towards a fee for non-attendance. METHODS: Six semi-structured focus group interviews were conducted with a total of 44 patients who had been informed about being charged a fee for non-attendance. Data were transcribed verbatim and analysed using a qualitative content analysis. RESULTS: Overall, patients' attitudes towards the non-attendance fee were positive. Non-attendance was viewed as evidence of disregard for the common free-for-all healthcare, and a fee was expected to motivate non-attendees to show up. However, most patients argued that certain groups (e.g. the mentally disabled) should be exempted from the fee. Furthermore, an implementation of fees should be easy to manage administratively and should not increase bureaucracy. CONCLUSION: In general, patients' attitudes towards implementing non-attendance fees are positive. FUNDING: Danish Regions, Ministry of Health and Central Denmark Region. TRIAL REGISTRATION: not relevant.
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Honorarios y Precios/tendencias , Grupos Focales , Costos de la Atención en Salud/tendencias , Accesibilidad a los Servicios de Salud/economía , Hospitales Públicos/economía , Investigación Cualitativa , Dinamarca , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pobreza , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
BACKGROUND: The predictive value of CCTA to predict coronary artery disease is high in particular in the absence of coronary calcification. However, the consideration of both CCTA and the calcium score, in addition to the risk factors to determine the indication for coronary revascularization, has not been yet studied. MATERIALS AND METHODS: This study included 2302 patients (mean age: 60±9.8 years, 46% men), without known coronary artery disease (CAD), who underwent 320-row CCTA. Logistic regression, c-statistic and net reclassification improvement (NRI) were used to assess the role of coronary artery calcium score (CACS) in predicting revascularization after CCTA. RESULTS: The revascularization rates were 0.75% in patients with a CACS of 0, and there were no adverse events during the follow-up period. The revascularization rates were 3.3% in patients with a CACS of 1-99, 15.4% in patients with a CACS of 100-399, 25.6% in patients with a CACS of 400-999, and 42.4% in patients with a CACS≥1000. The crude and adjusted odds ratios (95% confidence interval) for revascularization per CACS group category were 2.89 (2.53-2.3) and 2.71 (2.33-3.15), respectively; the area under the ROC curve (AUC) was 0.85 (0.83-0.88). The addition of CACS to conventional risk factors improved the accuracy of risk prediction model for revascularization (AUC 0.74 vs 0.63, P=0.001), but it did not reclassify a substantial proportion of patients with positive CACS to risk categories (NRI=-0.023, P=0.66). CONCLUSIONS: The 320-row CCTA might rule out CAD in low- to intermediate-risk patients. However, its accuracy in identifying patients who require revascularization is limited. The CACS added to the conventional risk factors did not improve the identification of patients who require revascularization.
Asunto(s)
Angiografía por Tomografía Computarizada , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Tomografía Computarizada Multidetector , Revascularización Miocárdica , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/terapia , Anciano , Área Bajo la Curva , Enfermedad de la Arteria Coronaria/mortalidad , Dinamarca , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Revascularización Miocárdica/efectos adversos , Revascularización Miocárdica/mortalidad , Variaciones Dependientes del Observador , Oportunidad Relativa , Selección de Paciente , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Curva ROC , Reproducibilidad de los Resultados , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Calcificación Vascular/mortalidadRESUMEN
BACKGROUND: In 'real-world' patient populations undergoing coronary CT angiography (CCTA), it is unclear whether a correlation exists between gender, coronary artery calcium (CAC) score and subsequent referral for invasive coronary angiography and coronary revascularisation. We therefore investigated the relationship between gender, CAC and use of subsequent invasive coronary angiography and coronary revascularisation in a cohort of patients with chest discomfort and low to intermediate pretest probability of coronary artery disease who underwent a CCTA at our diagnostic centre. METHODS: This is a cohort study that included patients examined between 2010 and 2013. Data were obtained from the Western Denmark Heart Registry. The follow-up ended 11 March 2014. RESULTS: A total of 3541 people (1621 men and 1920 women) were examined by CCTA. The rate of invasive coronary angiography during follow-up was 28.5% in men versus 18.3% in women (p<0.001). The rate of coronary revascularisation during follow-up was 11.4% in men versus 5.1% in women (p<0.001). The CAC-adjusted HR in women versus men was 0.98 (95% CI 0.85 to 1.13) for invasive coronary angiography and 0.73 (95% CI 0.57 to 0.93) for coronary revascularisation. Further adjustment for age and other risk factors did not change these estimates. CONCLUSIONS: Women had a lower CAC score than men and a corresponding lower rate of invasive coronary angiography. The risk of coronary revascularisation was modestly reduced in women, irrespective of CAC. This may reflect a gender-specific difference in coping with chest discomfort, gender-specific referral bias for CCTA, and/or a gender-specific difference in the balance between coronary calcification and obstructive coronary heart disease.
RESUMEN
Chest pain in children and young people is a frequent cause of contact to general practitioners and outpatient clinics. However, in children, chest pain is typically benign and self-limiting; it is not usually a manifestation of organic disease, and it is very rarely of cardiac origin. The cause of chest pain often remains undiagnosed. There are a number of chronic conditions known to be associated with recurrent chest pain. Symptoms and signs include crushing left-sided precordial pain, pain radiating to the left arm or the jaw, pain onset with exercise and subsiding at rest (with asthma excluded), and an abnormal cardiovascular examination suggests referral for cardiac evaluation. We here report a case of stable angina pectoris in the young.
Asunto(s)
Angina Estable/etiología , Anomalías de los Vasos Coronarios/diagnóstico , Prueba de Esfuerzo/métodos , Adulto , Factores de Edad , Procedimientos Quirúrgicos Cardíacos , Angiografía Coronaria/métodos , Anomalías de los Vasos Coronarios/complicaciones , Anomalías de los Vasos Coronarios/cirugía , Electrocardiografía , Femenino , Humanos , Valor Predictivo de las Pruebas , Factores de Riesgo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Transport of ballast water is one major factor in the transmission of aquatic organisms, including pathogenic bacteria. The IMO-guidelines of the Convention for the Control and Management of Ships' Ballast Water and Sediments, states that ships are to discharge <1 CFU per 100 ml ballast water of toxigenic Vibrio cholerae, emphasizing the need to establish test methods. To our knowledge, there are no methods sensitive and rapid enough available for cholera surveillance of ballast water. In this study real-time PCR and NASBA methods have been evaluated to specifically detect 1 CFU/100ml of V. cholerae in ballast water. Ballast water samples spiked with V. cholerae cells were filtered and enriched in alkaline peptone water before PCR or NASBA detection. The entire method, including sample preparation and analysis was performed within 7 h, and has the potential to be used for analysis of ballast water for inspection and enforcement control.