The costs and effects of contrast-enhanced magnetic resonance angiography and digital substraction angiography on quality of life in patients with peripheral arterial disease.

BACKGROUND: Contrast-enhanced magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) both have a high diagnostic performance in the imaging of peripheral arterial occlusive disease (PAOD). However, little is known about the effects of initial, preoperative imaging using MRA or DSA on quality of life (QoL) in relation to costs (cost-utility). PURPOSE: To compare cost-utility of treatment strategies using either MRA or DSA as the principal imaging tool, related to QoL, in patients with PAOD. MATERIAL AND METHODS: In a prospective subgroup analysis of patients randomized between MRA and DSA (n = 79) for preoperative imaging, QoL questionnaires (SF-36) were obtained at randomization and at 4-month follow-up. Cost-effectiveness from hospital perspective was subsequently compared between groups and the difference in gained or lost QoL per € spent assessed using bootstrap analysis. RESULTS: No difference in quality of life was found. A treatment trajectory employing MRA as the principal imaging modality was almost 20% cheaper, leading to a better cost-utility ratio in favor of MRA. CONCLUSION: A treatment plan for peripheral arterial occlusive disease employing MRA versus DSA as the principal imaging modality yields a better cost/QoL ratio for MRA.

Hybrid treatment of a ruptured diverticulum of Kommerell.

PURPOSE: To report a patient with a ruptured diverticulum of Kommerell and to discuss treatment options and complications. CASE REPORT: An 82-year-old woman with no prior medical history was diagnosed with a ruptured aneurysmal proximal aberrant right subclavian artery (diverticulum of Kommerell). She was treated with a carotid-subclavian bypass, a thoracic aortic stent-graft covering both subclavian orifices, and a vascular plug in the proximal right subclavian artery. After an initially uneventful recovery, the patient developed delayed ischemic esophageal ulcerations and subsequent perforation at 6 weeks postoperatively, leading to mediastinitis and stent-graft infection. CONCLUSION: A hybrid approach may be of value in cases of ruptured diverticulum of Kommerell. However, despite the anticipated reduction in perioperative mortality, this technique still yields a considerable risk of postoperative complications and mortality.

Upper abdominal ultrasound in general practice: indications, diagnostic yield and consequences for patient management.

BACKGROUND: Abdominal ultrasound (US) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care. OBJECTIVE: To assess the influence of upper abdominal US on patient management in general practice. METHODS: A prospective cohort study with 76 GPs and three general hospitals in The Netherlands. A total of 395 patients aged >or=18 years referred by their GPs for upper abdominal US were included. The main outcome was change in anticipated patient management assessed by means of questionnaires filled in by GPs before and after abdominal US. RESULTS: Mean age of the patients was 54.0 +/- 15.8 years, 35% were male. Clinically relevant abnormalities were found in 29% of the abdominal US, mainly cholelithiasis. Anticipated patient management changed in 64% of the patients following abdominal US. Main changes included fewer referrals to a medical specialist (from 45 to 30%); and more frequent reassurance of the patient (from 15 to 43%). However, this reassurance was not perceived as such in almost 40% of these patients. A change in anticipated patient management occurred significantly more frequently in patients with a prior cholecystectomy (82%). CONCLUSION: Anticipated patient management by the GP changed in 64% of patients following upper abdominal US. Abdominal US substantially reduced the number of intended referrals to a medical specialist, and more patients could be reassured by their GP.

Myoma expulsion after uterine artery embolization: complication or cure?

A 54-year-old woman had an expulsed myoma 10 weeks after uterine artery embolization. After treatment with antibiotics and a small surgical intervention, she recovered completely without any sign of myomatous disease afterwards. Patients should be informed about the possibility of expulsion. Expulsion of myomas after uterine artery embolization occurs relatively frequently and may be just one of the ways to attain cure.