Discounting and clinical decision making: physicians, patients, the general public, and the management of asymptomatic abdominal aortic aneurysms.

Clinical decisions often entail in intertemporal trade-off. Moreover, they often involve physicians of different specialities. In an experiment dealing with the management of small asymptomatic abdominal aortic aneurysms (a clinically relevant problem) we find that specialists in internal medicine exhibit higher implicit discount rates than vascular surgeons, general practitioners, and actual and prospective patients. Several personal characteristics expected to be directly related to pure time-preference and risk aversion (gender, smoking habits, age, place of employment) have the hypothesised effects. Additionally, financial incentives appear to affect the estimated implicit discount rates of physicians, but are unlikely to have caused the inter-group differences. Differences in discount rates could lead to variations in clinical practice, which may conflict with equality of treatment or equal access to health care.

Implicit discount rates of vascular surgeons in the management of abdominal aortic aneurysms.

A growing empirical literature has investigated attitudes towards discounting of health benefits with regard to social choices of life-saving and health-improving measures and individuals' time preferences for the management of their own health. In this study, the authors elicited the time preferences of vascular surgeons in the context of management of small abdominal aortic aneurysms, for which the choice between early elective surgery and watchful waiting is not straightforward. They interviewed 25 of a random sample of 30 Swedish vascular surgeons. Considerable variation in the time preferences was found in the choices between watchful waiting and surgical intervention among the otherwise very homogeneous group of surgeons. The discount rates derived ranged from 5.3% to 19.4%. The median discount rate (10.4%) is similar to those usually reported for social choices concerning life-saving measures. The surgeons who were employed in university hospitals had higher discount rates than did their colleagues in county and district hospitals.

[Hospital-based advanced home-care, models from Ekenäs, Finland]. / Sjukhusbaserad avancerad hemsjukvård, Ekenäsmodellen.

In 1995, advanced home treatment services were introduced at Västra Nyland district hospital in Finland. For selected patients the new services constitute an alternative where hospitalisation would otherwise be necessary. Some of the hospital bed resources were moved to the patients' homes together with a trained team with immediate responsibility for the patients and providing 24-hour care, backed up by access to hospital resources in terms of specialised knowledge and sophisticated technology. Two years' experience of 500 patients so treated showed their diseases to have represented the complete spectrum of specialists fields. The most common diagnoses were oncological and infectious diseases. Although preliminary assessment suggests advanced home care to be a cheaper alternative than hospitalised care, the preeminent advantage from the patients' point of view was improved quality of life.

Decisions about treatment of aortoiliac claudication: the current practice among Swedish vascular surgeons.

OBJECTIVE: To find out what information vascular surgeons consider before they decide on treatments for intermittent claudication. SUBJECTS: 25 randomly selected vascular surgeons who participate in the Swedish Vascular Registry. METHOD: Interviews about what information and investigations the surgeons would need before they make recommendations for treatment of 6 test cases. MAIN OUTCOME MEASURES: The pattern of numbers and types of questions and of recommendations for treatment. RESULTS: Surgeons asked a median of five questions (range 0-13) before they came to a decision. Only 9% of those questions concerned the patients' preferences. Open surgery was recommended in 59 of the 150 consultations (39.3%), for some by none and for others by up to 80% of surgeons. CONCLUSIONS: Vascular surgeons primarily consider the patient's history and physical findings when treating claudication. They pay little attention to the preferences of the patients. Vascular surgeons in Sweden differ considerably in their patterns of questioning and do not agree about the treatment of intermittent claudication in individual patients.

Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study.

PURPOSE: The purpose of this prospective randomized study was to compare percutaneous transluminal renal angioplasty (PTRA) and operation as initial therapy with regard to technical results, primary and secondary patency, and effects on blood pressure and renal function in patients with atherosclerotic unilateral renal artery stenosis. METHODS: Fifty-eight patients who did not have diabetes, who were less than 70 years of age, and who had severe hypertension and significant stenosis were randomized to receive PTRA or operation. Angiography was performed 10 days, 1 year, and 2 years after treatment to verify patency, and blood pressure and renal function were simultaneously evaluated. RESULTS: Technically, PTRA was successful in 83% and operation in 97% of patients. The primary patency rate after 24 months was 75% in the PTRA group and 96% in the operative group in technically successful cases. The secondary patency rate in the PTRA group was 90% and in the surgical group 97%. To achieve these results four patients in the PTRA group required operation, and one patient in the surgical group required PTRA. Hypertension was cured or improved after additional treatment in 90% of the patients after PTRA and 86% after operation. The corresponding figures for improved or unchanged renal function were 83% and 72%, respectively. After additional treatment, effects on blood pressure and renal function did not differ. Seventeen percent of the patients treated with PTRA required surgical intervention. CONCLUSIONS: PTRA is recommended as first choice of therapy for atherosclerotic renal artery stenosis causing renovascular hypertension if combined with intensive follow-up and aggressive reintervention.

Determination of urinary N-acetyl-beta-glucosaminidase in patients with hypertension and renal artery stenosis.

The purpose of the study was to measure the urinary excretion of N-acetyl-beta-glucosaminidase (U-NAG) in patients suspected of having renovascular hypertension and to compare the enzyme excretion before and after active intervention with operation or percutaneous transluminal renal angioplasty (PTRA). Eighty-one patients with severe, therapy-resistant hypertension were examined with regard to renal artery stenosis (RAS). At least one significant renal artery stenosis was found in 61 patients, whilst the remaining 20 patients were classified as having essential hypertension. Enzyme levels were found to be significantly higher in RAS patients as compared with patients with severe hypertension lacking significant renal artery stenosis, 0.66 (0.41-0.91, median value, 1st and 3rd quartiles) versus 0.35 (0.27-0.54); P < 0.01. Both groups of patients had significantly higher U-NAG values than a healthy reference population (0.2, 0.13-0.27; P < 0.01). Forty of the RAS patients were randomized to surgery or PTRA and followed prospectively for 2 years. After either renal vascular surgery or PTRA a significant rise in U-NAG excretion was observed 7-10 days after treatment. Urinary NAG excretion remained elevated during long-term follow-up. It is suggested that U-NAG should be determined in patients with therapy-resistant hypertension with suspicion of renal artery stenosis.

Islet cell antibody reactivity with human fetal pancreatic islets.

To evaluate the possibility of autoimmune processes against pancreatic islets in fetal life, we tested islet cell antibody (ICA) reactivity with 14 fetal pancreata obtained after abortion at the 15th up to the 19th week of gestation. Pancreatic islets positive for a monoclonal proinsulin antibody but non-reactive with ICA negative control serum were found in 9/14 pancreata and all (9/9) of them showed a positive reaction with the ICA standard. It is concluded that ICA reactivity may be detected in fetal human pancreata. Further studies on fetal islet cell antibody reactivity in the development of insulin dependent diabetes mellitus (IDDM) are warranted.

Peroperative arterial recanalization with Kensey dynamic angioplasty. Histopathologic studies.

The morphology of occluded superficial femoral artery segments and of particles in the effluent fluid after dynamic Kensey catheter angioplasty was analyzed in six patients treated with an intraoperative retrograde technique. The effluent was collected during the procedure and the arteries were extirpated for microscopy after the recanalization attempt. In three patients with easy recanalization, histologic study showed highly cellular, proliferating connective tissue. In three patients with unsuccessful recanalization, mature, cell-poor connective healing tissue obliterated the lumen. The effluent contained particles measuring 14 to 320 microns, the largest of which had the potential to occlude small arteries. The results of this pilot study are to be regarded as preliminary.

Long-term results after percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis--the importance of intensive follow-up.

The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure gradient and renal venous renin measurement. Patients were scheduled for regular follow-up after the PTRA and a deterioration in blood pressure or renal function was an indication for re-evaluation, and reintervention if necessary. Sixty-five patients had 71 renal artery stenoses where PTRA was attempted. It was technically successful in 59 stenoses and two occlusions and failed in ten (14%). At the end of follow-up (median 56 months [2-99]), the primary patency rate was 55%, 27 had restenosed and four were occluded, all but two within 12 months. Seventeen were treated by a further PTRA and eight by surgical reconstruction. At the end of follow-up the secondary patency after all interventions was 90%. One patient died 1 month after PTRA, and at the end of follow-up 21 patients (32%) had died, most of them (80%) from cardiovascular disease. Multivariate analyses showed a significantly reduced survival rate in patients with multiocular atherosclerosis, renal insufficiency, contralateral renal artery stenosis and ischaemic heart disease. At the end of follow-up 90% of the patients were cured or improved with regard to blood pressure. In patients with impending renal insufficiency renal function was improved in 50% and unchanged in 39%. With this strategy 55% of the patients needed only one treatment with PTRA, 25% needed a re-PTRA and 20% had to be operated on. PTRA can be recommended as initial treatment of atherosclerotic renal artery stenosis provided intensive follow-up and aggressive reintervention are performed when indicated.

Clinical outcome and health care costs in renal revascularization--percutaneous transluminal renal angioplasty versus reconstructive surgery.

Clinical outcome and health care costs related to investigation, treatment with either percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery, and follow-up of patients with renovascular hypertension with or without uraemia were analysed in 21 PTRA-treated and 16 operated patients. Most renal artery stenoses were atherosclerotic. Nineteen PTRAs were successful or partly successful and two failed; the patients were operated on without delay. All surgical reconstructions were successful. In the PTRA group six restenoses occurred after 4-24 months. Four were treated with re-PTRA and two were operated on. No recurrence occurred in the operated group. At the end of follow-up (median 48, range 9-84 months) primary patency in the PTRA group was 69 per cent and in the operated group 100 per cent. Secondary patency in the PTRA group was 100 per cent. With regard to hypertension, including primary and secondary results, 19 out of 21 (90 per cent) patients were improved in the PTRA group and 13 out of 16 (81 per cent) in the operated group. The diagnostic and preprocedure costs were the same in both groups, whereas the procedure and postprocedure costs were lower in the PTRA group. However, the follow-up costs were considerably higher because of recurrences and their treatment in the PTRA group. The total median cost of reconstructive surgery was 12 per cent higher than for PTRA, a non-significant difference.

Enzyme immunoassay of urinary beta-hexosaminidase isoenzymes in patients with renal transplants.

beta-Hexosaminidase (NAG) and percent of NAG B were studied in twenty patients following renal transplantation. Median urinary NAG for twenty reference individuals was 0.26 U/mmol creatinine and NAG B was 24%. Urinary NAG decreased rapidly from a median of 3.7 U/mmol on the third day, to 1.2 U/mmol on the 15th day after transplantation in the patients with no major complications. The percentage of NAG B did not change significantly during this period and did not differ from the reference population. Rejection and cyclosporine toxicity were diagnosed on 17 occasions. Urinary NAG rose more than twofold in 15 of these episodes. The percentage of NAG B was slightly increased in 6 of these. Six months after discharge 17 of the renal transplants functioned well. They exhibited a marked decrease (almost normalized) of urinary NAG with no change in the percentage of NAG B.

Symptoms and signs of thrombotic occlusion of atherosclerotic renal artery stenosis.

Twenty-four patients, with an occluded renal artery diagnosed at angiography or operation, in whom previous angiography had demonstrated an atherosclerotic renal artery stenosis, were compared with a group of patients with a renal artery stenosis that remained patent after a similar interval. The risk of occlusion was found to increase with age, the degree of stenosis and advanced generalised atherosclerosis. At the presumed time of occlusion few patients had symptoms which when present were vague and easily overlooked. The most suggestive sign of occlusion was a rise in serum creatinine which was seen in the majority of the patients.

Acute necrotizing pancreatitis complicating surgery for renovascular hypertension. Case report.

Acute necrotizing pancreatitis is a rare complication of various types of surgery, with a few cases reported after aortic operations. Following renovascular surgery, severe acute pancreatitis developed in three (0.9%) of 332 patients, and was fatal in one case. Various etiologic possibilities are discussed.