Cost-effectiveness of identifying aortoiliac and femoropopliteal arterial disease with angiography or duplex scanning.

OBJECTIVES: Cost-effectiveness analysis of three diagnostic imaging strategies for the assessment of aortoiliac and femoropopliteal arteries in patients with peripheral arterial occlusive disease. The strategies were: angiography as the reference strategy, duplex scanning (DS) plus supplementary angiography (S1) and DS plus confirmative angiography (S2). DESIGN, MATERIALS AND METHODS: A decision model was built with sensitivity and specificity data from literature, supplemented with prospective hospital cost data in Euro (euro). The probability of correctly identifying the status of a lesion was taken as the primary outcome. We compared strategies by assessing the extra costs per additional correctly identified case. RESULTS: Assuming no false positive or false negative results, angiography is the most effective strategy if the prevalence of significant obstructive lesions in the aortoiliac and femoropopliteal tract exceeds 70%, or if the sensitivity of duplex scanning is lower than 83%. In case of lower prevalence, strategy S1 becomes equally or even more effective than angiography. At a prevalence of 75%, performing angiography costs euro 8443 per extra correctly identified case compared with strategy S1. CONCLUSIONS: In most situations angiography is more effective than diagnostic strategy S1. However, if society is unwilling to pay more than euro 8443 for knowing a patient's disease status, diagnostic strategy S1 is a cost-effective alternative to angiography, especially at lower prevalence values.

The value of the peak systolic velocity ratio in the assessment of the haemodynamic significance of subcritical iliac artery stenoses.

OBJECTIVES: iliac stenoses with a PSV ratio between 2.0 and 3.0 in patients with symptomatic arterial obstructive disease of the legs might be misinterpreted when compared with intra-arterial pressure measurements (IAPM). The aim of this study was to compare the value of the PSV ratio with IAPM as the reference standard in the assessment of the haemodynamic significance of subcritical iliac artery stenoses (iliac stenosis with PSV ratio between 1.5 and 3.5). DESIGN, PATIENTS AND METHODS: fifty-eight iliac tracts in 53 consecutive patients with symptomatic arterial obstructive disease of the legs with an isolated stenosis with PSV ratio between 1.5 and 3.5 were studied prospectively. The results of those iliac duplex scanning were compared to IAPM. Results a poor agreement was found between IAPM and PSV ratios. For the PSV ratios > or =2.0, 2.5 and 3.0 the sensitivities were 74%, 37% and 16%, respectively. The specificities were 70%, 90% and 95%, the positive predictive values 82%, 88% and 86%, respectively, and the negative predictive values 58%, 43% and 37%, respectively. CONCLUSION: the results of this study show that the PSV ratio parameter is not accurate enough to evaluate the haemodynamic significance of subcritical iliac artery stenoses.

A propos d'un cas de barytome iatrogene chez un nourrisson de 5 mois. [Lettre]

Les auteurs rapportent une observation de peritonite aigue consecutive a une perforation colique lors d'un lavement baryte. L'accident est survenu chez un nourrisson de 5 mois presentant une invagination intestinale aigue. La precocite du diagnostic et du traitement encadre par une reanimation efficace; ont permis l'evolution favorable. Des complications (infection; desordre hydroelectrolytique; trouble hemodynamique) ont emaille cette evolution. Les auteurs font une revue de la litterature sur la question et attirent l'attention des praticiens (chirurgiens; radiologistes et reanimateurs) sur la gravite de l'accident; la necessite de son diagnostic et des difficultes de sa prise en charge tout au long de son evolution. Ils preconisent le suivi a long terme des malades vivants a la recherche de sequelles et de complications ulterieures et enoncent des mesures prophylactiques

Bloc crural associe a la rachianesthesie pour chirurgie de la hanche chez des sujets ages A.S.A. III

Le bloc crural avec 6 ml Bupivacaine a 0;5 et 6 ml de Lidocaine a 2 pour cent a precede la rachianesthesie realisee avec 2 ml de Bupivacaine a 0;5 pour cent; 1ml de G 10 pour cent et 2 ml de Fentanyl. L'indication de cette rachianesthesie etait posee devant une chirurgie de la hanche chez des sujets du grand age (64 a 85 ans) et tares (ASA III). L'analgesie obtenue grace a cette association a ete precoce (6 min.); suffisante pour la chirurgie; et d'une duree prolongee jusque dans le post-operatoire (6h30). Ces auteurs conseillent donc un large usage de ce protocole simple; pas cher et interferant sur les tares preexistantes; surtout dans cette indication particuliere

Utilisation du glycerol buvable dans le traitement preventif de l'hypertension intracranienne

Se proposant de tester l'effet osmotique anti-oedemateux cerebral du glycerol oral; les auteurs de cette communication ont selectionne 53 patients; 25 de sexe masculin et 28 de sexe feminin : 14 accidents vasculaires cerebraux; 30 traumatismes craniens et 9 craniectomies. Tous ces malades avaient a l'admission un score de Glasgow compris entre 13 et 8 et un oedeme papillaire au fond de l'oeil. Les cas d'H.E.D. et d'H.S.D. sont exclus de ce travail. Le glycerol buvable a ete utilise comme element principal de traitement anti-oedemateux cerebral. La resorption de l'oedeme papillaire a ete effective chez 32 pour cent des sujets au bout de 4 jours et chez 47 pour cent des sujets au bout de 7 jours de prise du glycerol et l'evolution finale a ete favorable dans 71;7 pour cent des cas au prix de complications mineures

[Comparison of adrenaline and clonidine to extend the analgesic effect of bupivacaine without glucose in spinal anesthesia]. / Comparaison de l'adrénaline et de la clonidine pour prolonger l'effet analgésique de la bupivacaïne sans glucose au cours de la rachianesthésie.

So as to determine the effects of adrenaline and clonidine on the duration of isobaric bupivacaine spinal anaesthesia, a prospective controlled study was carried out on 20 ASA I or II patients. They were randomly allocated to two groups. The patients of group I were given 4 ml of a mixture including 3 ml of 0.5% bupivacaine, 0.2 mg adrenaline. The patients of group II were given 4 ml of a mixture including 3 ml of 0.5% bupivacaine, 0.15 mg clonidine. The segmental level of sensory loss was tested using forceps. The time course required for maximal spread on the sensory blockade did not differ in the two groups: 4.00 +/- 1.01 min. for group I and 3.60 +/- 0.90 min. for group II. No difference was observed between median highest levels of sensory analgesia. Regression times were 520.70 +/- 79.52 min for group II and 360.40 +/- 51.47 min. for group I. Significant prolongation of motor block was also associated with the addition of vasoconstrictors. It is concluded that addition of 0.15 mg clonidine may be useful to increase duration of isobaric bupivacaine spinal anaesthesia.