Subject(s)
Liver Neoplasms/secondary , Pancreatic Neoplasms/diagnosis , Vasoactive Intestinal Peptide/blood , Vipoma/diagnosis , Antineoplastic Agents, Hormonal/therapeutic use , Diagnosis, Differential , Diarrhea/etiology , Female , Humans , Hypokalemia/etiology , Indium Radioisotopes , Irritable Bowel Syndrome/diagnosis , Liver/diagnostic imaging , Liver Neoplasms/diagnosis , Liver Neoplasms/therapy , Middle Aged , Octreotide/therapeutic use , Pancreatic Neoplasms/complications , Pancreatic Neoplasms/drug therapy , Radionuclide Imaging , Tomography, X-Ray Computed , Vasoactive Intestinal Peptide/metabolism , Vipoma/complications , Vipoma/drug therapy , Vipoma/secondaryABSTRACT
OBJECTIVE: Untreated maternal hypothyroidism during pregnancy can have adverse consequences on maternal health and child intelligence quotient (IQ). Our objective was to examine the cost-effectiveness of screening pregnant women for autoimmune thyroid disease. DESIGN: We developed a state-transition Markov model and performed a cost-effectiveness analysis of screening pregnant US women, aged 15-45 years, with no known history of thyroid disease, in the first trimester. METHODS: Three strategies were compared: 1) no screening, 2) one-time screening using anti-thyroid peroxidase (anti-TPO) antibodies, and 3) one-time screening using TSH. Screening tests were added to the laboratory tests of the first prenatal visit. Abnormal screening tests were followed by further testing and subsequent thyroxine treatment of hypothyroid women. RESULTS: Screening pregnant women in the first trimester using TSH was cost-saving compared with no screening. Screening using anti-TPO antibodies was cost-effective compared with TSH screening with an incremental cost-effectiveness ratio of $15,182 per quality-adjusted life year. Screening using TSH remained cost-saving across a wide range of ages at screening, costs of treatment, and probabilities of adverse outcomes. The cost-effectiveness of anti-TPO screening compared with TSH screening was mostly influenced by the probability of diagnosing hypothyroidism in unscreened subjects or subjects with a normal screening test. Screening remained highly cost-effective in scenarios where we assumed no improvement of child IQ outcomes by levothyroxine treatment. CONCLUSION: Screening all pregnant women for autoimmune thyroid disease in the first trimester is cost-effective compared with not screening.
Subject(s)
Autoimmune Diseases/diagnosis , Mass Screening/economics , Thyroid Diseases/diagnosis , Adolescent , Adult , Autoimmune Diseases/metabolism , Cost-Benefit Analysis/methods , Female , Humans , Iodide Peroxidase/metabolism , Markov Chains , Mass Screening/methods , Middle Aged , Models, Economic , Pregnancy , Pregnancy Trimester, First , Thyroid Diseases/metabolism , Thyrotropin/metabolismSubject(s)
Cardiovascular Diseases/etiology , Hypothyroidism/complications , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Hypothyroidism/blood , Male , Middle Aged , Risk Factors , Thyrotropin/bloodABSTRACT
BACKGROUND: The cosyntropin stimulation test is the initial endocrine evaluation of suspected primary or secondary adrenal insufficiency. PURPOSE: To critically review the utility of the cosyntropin stimulation test for evaluating adrenal insufficiency. DATA SOURCES: The MEDLINE database was searched from 1966 to 2002 for all English-language papers related to the diagnosis of adrenal insufficiency. STUDY SELECTION: Studies with fewer than 5 persons with primary or secondary adrenal insufficiency or with fewer than 10 persons as normal controls were excluded. For secondary adrenal insufficiency, only studies that stratified participants by integrated tests of adrenal function were included. DATA EXTRACTION: Summary receiver-operating characteristic (ROC) curves were generated from all studies that provided sensitivity and specificity data for 250-microg and 1-microg cosyntropin tests; these curves were then compared by using area under the curve (AUC) methods. All estimated values are given with 95% CIs. DATA SYNTHESIS: At a specificity of 95%, sensitivities were 97%, 57%, and 61% for summary ROC curves in tests for primary adrenal insufficiency (250-microg cosyntropin test), secondary adrenal insufficiency (250-microg cosyntropin test), and secondary adrenal insufficiency (1-microg cosyntropin test), respectively. The area under the curve for primary adrenal insufficiency was significantly greater than the AUC for secondary adrenal insufficiency for the high-dose cosyntropin test (P < 0.001), but AUCs for the 250-microg and 1-microg cosyntropin tests did not differ significantly (P > 0.5) for secondary adrenal insufficiency. At a specificity of 95%, summary ROC analysis for the 250-microg cosyntropin test yielded a positive likelihood ratio of 11.5 (95% CI, 8.7 to 14.2) and a negative likelihood ratio of 0.45 (CI, 0.30 to 0.60) for the diagnosis of secondary adrenal insufficiency. CONCLUSIONS: Cortisol response to cosyntropin varies considerably among healthy persons. The cosyntropin test performs well in patients with primary adrenal insufficiency, but the lower sensitivity in patients with secondary adrenal insufficiency necessitates use of tests involving stimulation of the hypothalamus if the pretest probability is sufficiently high. The operating characteristics of the 250-microg and 1-microg cosyntropin tests are similar.
