Placental growth factor testing for suspected pre-eclampsia: a cost-effectiveness analysis.

OBJECTIVE: To calculate the cost-effectiveness of implementing PlGF testing alongside a clinical management algorithm in maternity services in the UK, compared with current standard care. DESIGN: Cost-effectiveness analysis. SETTING: Eleven maternity units participating in the PARROT stepped-wedge cluster-randomised controlled trial. POPULATION: Women presenting with suspected pre-eclampsia between 20+0 and 36+6  weeks' gestation. METHODS: Monte Carlo simulation utilising resource use data and maternal adverse outcomes. MAIN OUTCOME MEASURES: Cost per maternal adverse outcome prevented. RESULTS: Clinical care with PlGF testing costs less than current standard practice and resulted in fewer maternal adverse outcomes. There is a total cost-saving of UK£149 per patient tested, when including the cost of the test. This represents a potential cost-saving of UK£2,891,196 each year across the NHS in England. CONCLUSIONS: Clinical care with PlGF testing is associated with the potential for cost-savings per participant tested when compared with current practice via a reduction in outpatient attendances, and improves maternal outcomes. This economic analysis supports a role for implementation of PlGF testing in antenatal services for the assessment of women with suspected pre-eclampsia. TWEETABLE ABSTRACT: Placental growth factor testing for suspected pre-eclampsia is cost-saving and improves maternal outcomes.

Resource use and cost of annual health checks in primary care for people with intellectual disabilities.

BACKGROUND: The annual health check (AHC) programme, as part of a Directed Enhanced Service, offers an incentive to general practitioners in England to conduct health checks for people with intellectual disabilities (IDs). The aim of this analysis was to estimate the impact on health care costs of AHCs in primary care to the National Health Service in England by comparing adults with ID who did or did not have AHCs using data obtained from The Health Improvement Network. METHODS: Two hundred eight records of people with ID from The Health Improvement Network database were analysed. Baseline health care resource use was captured at the time the first AHC was recorded (i.e. index date), or the earliest date after 1 April 2008 for those without an AHC. We examined the volume of resource use and associated costs that occurred at the time AHCs were performed, as well as before and after the index date. We then estimated the impact of AHCs on health care costs. RESULTS: The average cost of AHC was estimated at £142.57 (95%CI £135.41 to £149.74). Primary, community and secondary health care costs increased significantly after the index date in the no AHC group owing to higher increase in resource utilisation. Regression analysis showed that the expected health care cost for those who have an AHC is 56% higher than for those who did not have an AHC. Age and gender were also associated with increase in expected health care cost. CONCLUSION: The level of resource utilisation increased in both (AHC and no AHC) groups after the index date. Although the level of resource use before index date was lower in the no AHC group, it increased after the index date up to almost reaching the level of resource utilisation in the AHC group. Further research is needed to explore if the AHCs are effective in reducing health inequalities.

Modelling the cost-effectiveness of preventing major depression in general practice patients.

BACKGROUND: The prevention of depression is a key public health policy priority. PredictD is the first risk algorithm for the prediction of the onset of major depression. Our aim in this study was to model the cost-effectiveness of PredictD in depression prevention in general practice (GP). METHOD: A decision analytical model was developed to determine the cost-effectiveness of two approaches, each of which was compared to treatment as usual (TAU) over 12 months: (1) the PredictD risk algorithm plus a low-intensity depression prevention programme; and (2) a universal prevention programme in which there was no initial identification of those at risk. The model simulates the incidence of depression and disease progression over 12 months and calculates the net monetary benefit (NMB) from the National Health Service (NHS) perspective. RESULTS: Providing patients with PredictD and a depression prevention programme prevented 15 (17%) cases of depression in a cohort of 1000 patients over 12 months and had the highest probability of being the optimal choice at a willingness to pay (WTP) of £20,000 for a quality-adjusted life year (QALY). Universal prevention was strongly dominated by PredictD plus a depression prevention programme in that universal prevention resulted in less QALYs than PredictD plus prevention for a greater cost. CONCLUSIONS: Using PredictD to identify primary-care patients at high risk of depression and providing them with a low-intensity prevention programme is potentially cost-effective at a WTP of £20,000 per QALY.

Improving surveillance of infectious diseases in New South Wales.

OBJECTIVE: To determine the feasibility of laboratory reporting of infectious diseases and to compare the value of this system with the existing medical practitioner notification system. DESIGN: A sample of notifications was selected from medical practitioner notifications and was compared for both completeness and timeliness of notification with a sample of notifications obtained through the Laboratory Infectious Diseases Surveillance Project. SETTING: The New South Wales Health Department and the Public Health Unit of the Eastern Sydney Area Health Service. PARTICIPANTS: Medical practitioners forwarding notifications of infectious diseases to the New South Wales Health Department and laboratories participating in the Laboratory Infectious Diseases Surveillance Project. MAIN OUTCOME MEASURES: We counted the number of infectious diseases reported by medical practitioners and participating laboratories and estimated the proportion of these diseases which were common to both sources of data. We also estimated the time taken between the diagnosis of a notifiable infectious disease and the receipt of the notification by the Medical Officer of Health. RESULTS: There was substantial underreporting of notifiable infectious diseases by medical practitioners. During the study there were 461 cases of a notifiable disease reported by either medical practitioners or by participating laboratories. Of these cases, 75% were reported only by laboratory staff, 20.2% were reported by medical practitioners alone and 4.8% of cases were reported by both laboratory staff and medical practitioners. The Medical Officer of Health received the reports from the participating laboratories within a significantly shorter time than the notifications from medical practitioners. CONCLUSION: The use of infectious disease notifications by laboratories can substantially improve the surveillance of infectious diseases.

One lung anaesthesia. Cardiovascular and respiratory function compared during conventional ventilation and high frequency jet ventilation.

Ten patients about to undergo left-sided thoracotomy for carcinoma of the lung were entered into a crossover trial to compare cardiovascular and respiratory function during high frequency jet ventilation and conventional mechanical ventilation for one lung anaesthesia. All patients were anaesthetised with a standard technique using double lumen tubes and placed in the lateral position with the left chest open. The results showed no significant differences with regard to ventilation sequence but one lung high frequency jet ventilation gave higher values than one lung conventional ventilation for shunt (p less than 0.01) and positive end expiratory pressure (p less than 0.05) and lower peak inflation pressure values (p less than 0.01). There were no significant differences in cardiac output, pulmonary capillary wedge pressure, arterial carbon dioxide or available oxygen. Surgical conditions were satisfactory during both methods of ventilation and satisfactory gas exchange occurred. It was, however, more difficult to assess adequacy of ventilation during high frequency jet ventilation and the routine use of this method of ventilation is not recommended during one lung anaesthesia.

Infected descending aortic fistula.

Two patients, each with an infected descending thoracic aortic fistula, are described. The first patient had a postpneumonitic empyema. Thoracostomy tube drainage resulted in obliteration of the empyema cavity. Upon slight withdrawal of the tube, 49 days after its insertion, massive pulsating bleeding occurred through the sinus tract. The bleeding was controlled with manual pressure at the entry site of the chest tube, and the patient was operated upon immediately. A descending aortic defect, 3 cm long X 1.5 cm wide, at the site of the thoracostomy tube was primarily closed. Ten months after the surgical procedure, the patient has had no difficulty referable to her aortic erosion. In the second patient, 9 months after removal of the T-10 vertebra (which had a large cell tumor) and replacement of the vertebra with Dunn's metallic device, hemoptysis and left lower lobe consolidation developed. Aortography demonstrated a lobulated false aneurysm, 4 cm wide X 6 cm long, at the site of Dunn's device. A 16-mm graft was sutured end to side to the descending aorta just distal to the left subclavian artery and to the abdominal aorta below the renal arteries. The false aneurysm was then removed, the two ends of the aorta were sutured, and the stumps were covered with omental graft. Nine months after the repair the patient has had no difficulty referable to the aortic surgery.

Mucoepidermoid carcinoma of salivary glands.

We reviewed the pathologic slides and clinical data of 44 patients with mucoepidermoid carcinomas of major and minor salivary glands. There were 14 well-differentiated, 20 intermediate, and ten poorly differentiated tumors. Two tumors appeared to have only expansive growth. All of the others were invasive, and we identified two patterns of invasion: broad pushing borders and infiltrative permeation. Infiltrative permeation was seen in 13 of 34 well-differentiated and intermediate tumors of which four (31%) metastasized, and in eight of ten poorly differentiated tumors of which five (63%) metastasized. Six of the nine patients with metastases died of carcinoma. Three patients who died with well-differentiated or intermediate tumors survived 10.5 years after diagnosis. Three patients died of poorly differentiated carcinoma less than one year after diagnosis. No patient died of local disease only, and no tumor with a broad pushing border metastasized. Size of tumor, site of origin, tumor cell mitotic rate, and age and sex of the patient had little, if any, effect on prognosis. A combination of tumor differentiation and pattern of invasion were the most useful factors in predicting carcinoma behavior.

Primary malignant tumors of salivary gland origin. A 52-year review.

Primary carcinoma of salivary glands is uncommon, comprising approximately 30 per cent of salivary gland neoplasms. The natural history of these neoplasms varies greatly, depending largely upon the cell type. Only prolonged follow-up can furnish worthwhile data, and five or even 10 years is inadequate in several cell types. Case records of 202 patients who had major or minor salivary gland carcinomas during the years 1928 through 1979 were reviewed from the files of Vanderbilt University Hospital. We studied these records with regard to site of origin, cell type, lymph node involvement, signs and symptoms, routes of metastatic spread, and survival. Microscopic sections were available for review in 188 patients (93%). Major and minor salivary glands were involved as the primary site in 74 per cent and 26 per cent, respectively. Prognostic factors are discussed, including histologic type and grade, size, lymph node involvement, vascular and perineural invasion, growth pattern (i.e., infiltrating versus pushing margins), and presence or absence of invasion outside the gland. Our 99 per cent follow-up of these patients revealed that the natural course of many of these neoplasms was characterized by long duration, repeated local recurrences, occasional metastases to regional lymph nodes, and frequent metastases to the lungs.

Gastric ulceration after fundic wrapping. Vagal nerve entrapment, a possible causative factor.

Transabdominal fundoplication is an effective operation for control of gastroesophageal reflux in the majority of patients. The operation is, however, associated with several sell-documented early and late complications. Recently, a few reports have appeared describing benign gastric ulceration (GU) occurring from one month to several years postplication. The etiology of GU in this setting is unknown, but preexisting delayed gastric emptying, pyloric incompetence, faulty wrap construction, local ischemia, and trauma to the vagus nerves have been incriminated. During a recent seven-year period, five cases of GU have occurred among a series of 158 patients who underwent fundoplication. The cases are cited in detail, and the recent literature is reviewed. Discussion is addressed to the various proposed factors and combination of factors thought to contribute to GU. Suggestions are included for the preoperative evaluation of patients with gastroesophageal reflux as an aid to intraoperative management. As trauma to the vagus nerves has been frequently mentioned as a contributing factor to postplication ulcer, an operative technique is described in which the vagus nerves are isolated and protected from the fundic wrap.