Incremental cost-effectiveness analysis of a multidisciplinary renal education program for patients with chronic renal disease.

AIM: The aim of this economic evaluation is to address the economic impact of a multidisciplinary renal patient education on the work maintenance of patients with chronic renal disease. METHOD: A total of 281 patients were recruited. An incremental cost-effectiveness analysis considering direct medical costs and days in the work force was performed. In addition, a Cox proportional hazards survival analysis was performed to investigate the effect of receiving the intervention on early retirement due to work disability. RESULTS: The incremental cost-effectiveness ratio [95% CI] per day in the work force saved was 737.02 degrees euro [-3345.64; 3093.03] in the whole group, 73.74 degrees euro [-995.28; 1429.92] in patients with a mild limitation and -113.25 degrees euro [-3252.06; 1525.58] in patients with a moderate to severe limitation in kidney function. After adjusting for observed time period, serum creatinine and age, having received the intervention had an almost significant medium-term protective effect on early retirement (hazard ratio 0.314, 95% CI 0.10-1.03, p = 0.0557). CONCLUSIONS: The cost-effectiveness of the multidisciplinary patient education highly depends on the level of limitation in kidney function and the intervention may be cost-effective in maintaining patients with mild limitation in kidney function in the work force.

[Differential Diagnosis Macro CK Type 1 in Thoracic Pain Syndrome and Increased CK-MB]. / Differentialdiagnose Makro-CK Typ 1 bei thorakalen Schmerzen und erhöhter CK-MB.

BACKGROUND: Macro CK (creatine kinase) as a reason for high CK values has been known since 1979. Even in the era of troponin determination for the diagnosis of myocardial infarction, an elevated CK value can still cause confusion, especially as CK-MB rises earlier than troponin. The case report should remind us of this often forgotten differential diagnosis of elevated CK. CASE REPORT: A 73-year-old patient was treated with leuprorelin hormone therapy for prostate cancer (stage pT1c G2). In addition, he received percutaneous radiation therapy of the prostate and high-dose-rate brachytherapy twice with 10 Gy each. Close to 1 year later, he complained for the first time of dyspnea on exertion and thoracic tightness. Serum CK was 232 U/l, and CK-MB 62 U/l, which was confirmed by several controls. Troponin T test was negative, and GOT, GPT, LDH, and PSA were all within the normal range. Acute myocardial infarction was ruled out on clinical grounds and by six sequential ECGs. Subsequently, the patient remained without further cardiac complaints and in good condition. Isoenzyme electrophoresis finally solved the problem and revealed CK-BB-IgG complex type 1 (macro CK-1). CONCLUSION: High CK-MB values in cardially healthy patients should remind us of the possibility of macro CK which is seen in approximately 0.5% of cases and should be included in the differential diagnosis.

Comparison of the effects of losartan and atenolol on common carotid artery intima-media thickness in patients with hypertension: results of a 2-year, double-blind, randomized, controlled study.

BACKGROUND: Hypertension induces progressive pathologic changes in the arterial wall. Experimental findings suggest that these changes, which include intima-media thickening, may be mediated, at least in part, by angiotensin II (AII). OBJECTIVE: The Losartan Vascular Regression Study (LAARS) was a double-blind, parallel-group, randomized, controlled, multicenter study designed to compare the effects of the AII antagonist losartan and the beta-blocker atenolol on ultrasonographically determined intimamedia thickness (IMT) of the common carotid artery (CCA) in patients with mild to moderate essential hypertension. METHODS: The primary end point of the study was the yearly rate of change (YRC) from baseline of the mean IMT of the CCA (CCA-IMT(mean)) averaged over 2 years of treatment. Secondary end points included IMT of the common femoral artery and sitting systolic and diastolic blood pressures (SiSBP/SiDBP). Safety assessments of losartan and atenolol were made by statistical and clinical review of the incidence of adverse experiences as well as review of vital signs and laboratory values. A total of 414 patients with essential hypertension were screened for study inclusion at 36 study centers in Germany and Brazil. Patients received losartan (50 mg once daily) or atenolol (50 mg once daily) for 24 months. Target blood pressure (SiSBP/SiDBP <140/<90 mm Hg) was achieved by adding hydrochlorothiazide 12.5 mg once daily, doubling the dose of study drug, or adding an open-label calcium channel blocker sequentially, as needed. RESULTS: Of the original 414 patients screened, 280 hypertension patients (SiDBP 95-115 mm Hg), aged 35 to 65 years, with an IMT of 0.8 to 1.5 mm of the right or left CCA, were randomized to treatment with either losartan (n = 142) or atenolol (n = 138). Both losartan and atenolol therapy produced comparable reductions in CCA-IMTmean over 24 months compared with baseline; the average YRC was -0.038 +/- 0.004 mm/y (P < or = 0.001) for losartan and -0.037 +/- 0.004 mm/y (P < or = 0.001) for atenolol. There were no significant differences between groups. Losartan showed a greater reduction of femoral artery IMT than did atenolol; the average YRC was -0.024 mm/y (P < or = 0.05) for losartan and -0.017 mm/y for atenolol (P = NS), with no significant difference between groups. Both agents produced similar significant reductions in SiSBP and SiDBP and were generally well tolerated. Approximately 7% of losartan patients had drug-related clinical adverse events, compared with 12% of atenolol patients. CONCLUSIONS: The findings of LAARS, the first large study with an AII antagonist that examined IMT, suggest that AII antagonism reverses the early stages of vascular hypertrophy in patients with hypertension. Further studies are needed to delineate the relative importance of AII antagonism versus blood pressure reduction per se in mediating the beneficial vascular effects of losartan.