Analytical decision model for the cost-effective management of solitary pulmonary nodules.

PURPOSE AND METHODS: Multiple strategies are currently being used to manage patients who present with indeterminate solitary pulmonary nodules (SPN). We have used decision-analysis models to assess the cost-effectiveness of various strategies for the diagnosis and management of SPN. Four decision strategies were compared: a wait and watch strategy, a surgery strategy, a computed tomography (CT)-based strategy, and a CT-plus-positron emission tomography (PET) strategy. An incremental cost-effectiveness ratio (ICER) was used to compare all strategies to the wait and watch strategy. RESULTS: A CT-plus-PET strategy was the most cost-effective over a large pretest likelihood (probability of having a malignant nodule), with a range of 0.12 to 0.69. Furthermore, within this likelihood range, the potential cost savings of using the CT-plus-PET strategy over the CT strategy ranged from $91 to $2,200 per patient. This translates to a yearly national savings of approximately $62.7 million. CONCLUSION: Decision-analysis modeling indicates the potential cost-effectiveness of [18F]2-fluoro-2-deoxy-D-glucose (FDG)-PET in the management of SPN. Furthermore, the decision trees developed can be used to model various features of the management of SPN, including modeling the cost-effectiveness of other newly emerging technologies.

Three balanced anesthetic techniques for neuroanesthesia: infusion of thiopental sodium with sufentanil or fentanyl compared with inhalation of isoflurane.

STUDY OBJECTIVE: To compare emergence from anesthesia and the hemodynamic and respiratory depressant effects of thiopental sodium infusion plus sufentanil or fentanyl with those of isoflurane as the primary component of a balanced technique for neuroanesthesia. DESIGN: Randomized, double-blind, prospective study. SETTING: University hospital and its affiliated Veterans Affairs Medical Center. PATIENTS: Thirty patients undergoing elective craniotomy for aneurysm or tumor. INTERVENTIONS: Thiopental with infusion of sufentanil 0.1 microgram/kg/hr, thiopental with infusion of fentanyl 1 microgram/kg/hr, or inhalation of 0.25% to 2% isoflurane as the major component of a balanced anesthesia technique that included nitrous oxide (N2O) and vecuronium (potency ratio of sufentanil to fentanyl, 10:1). MEASUREMENTS AND MAIN RESULTS: Intraoperative stress response (as indicated by intraoperative hypertension) was said to be the percentage of time the patient required administration of an antihypertensive drug, measuring from the first dose of thiopental to discontinuation of N2O at the end of the procedure, excluding any period of induced hypotension. Rapidity of emergence was measured by the number of minutes from discontinuation of N2O to first opening of the eyes on command. Adequacy of spontaneous ventilation was evaluated by determining partial pressure of arterial carbon dioxide 1, 2, and 3 hours after discontinuation of N2O. Extent of vasoactive drug administration for control of intraoperative hypertension (as determined by the clinicians caring for the patients) was described by minutes of vasodilator infusion and milligrams of propranolol or labetalol administered. The frequency of postoperative hypertension was defined as the number of patients in each group who required medication for postoperative hypertension. No significant differences in variables were found for thiopental/sufentanil, thiopental/fentanyl, or isoflurane when these drugs were used with N2O and vecuronium. CONCLUSIONS: Any one of these balanced anesthetic techniques appears appropriate for craniotomy.

Comparison of glycohemoglobin determination and the one-hour oral glucose screen in the identification of gestational diabetes.

A prospective study was undertaken to evaluate the use of glycohemoglobin (HbA1) as a screening tool for the detection of gestational diabetes in 90 subjects. At 28 to 30 weeks, these patients had an HbA, determination prior to diabetes screening with a 1-hour serum glucose after 50 gm of oral glucose. Those women with an abnormal screening result were then evaluated with a standard 3-hour oral glucose tolerance test. Forty-seven women had an abnormal 1-hour serum glucose (greater than or equal to 140 mg/dl). Nine of these 47 women (19%) had an abnormal HbA1. Four of these nine women (44.4%) with an abnormal screening glucose as well as an abnormal HbA1 demonstrated an abnormal oral glucose tolerance test. Eleven of 38 women (29%) with an abnormal glucose screen but normal HbA1 had an abnormal glucose tolerance test. The combination of two abnormal tests, glucose screen and HbA1, predicted gestational diabetes in only four of 15 (27%) of our patients. The sensitivity and specificity of this combination were 22.4% and 87.8%, respectively. The median values of HbA, with normal and abnormal glucose tolerance tests were 7.8% (range, 4.9% to 11.5%) and 8.2% (range, 5.4% to 12%), respectively. These values were not significantly different. These data confirm that HbA, alone or in combination with a 50 gm glucose screen is not a sensitive screening tool for the detection of gestational diabetes mellitus.