Cost-benefit analysis of a plant sterol containing low-fat margarine for cholesterol reduction

For decreasing the risk of coronary heart disease (CHD) it has been proposed to enrich food such as margarine with plant sterol esters which have been shown to reduce total and LDL cholesterol concentrations, two of the major risk factors. A Markov model was developed to assess the costs and benefits of consuming a low-fat plant sterol containing margarine (PS margarine). A health insurer's perspective was taken with a time frame of 10 years. Transition probabilities for CHD and CHD-related death were calculated on the basis of the Framingham risk equations. These were applied to a representative sample of the German population. The alteration in cholesterol levels after intake of PS margarine was estimated based on a meta-analysis of ten randomized controlled trials with parallel or crossover design that found a reduction of 5.7% in total cholesterol. Average annual costs of CHD were assumed to be at 3,000 euro. Costs for "no CHD" and "CHD-related death" were set to 0 euro since the intervention would solely be paid by the consumers. Sensitivity analyses were performed with regard to annual costs, risk estimation, PS margarine reduction in total cholesterol, discount factor, and risk of CHD-related death. The 10-year CHD risks are 6.1% (PS margarine) vs. 6.5% (control). Thus expected 10-year CHD costs are 696 euro (PS margarine) vs. 748 euro (control). The cost savings of 52 euro varied between 32 euro and 74 euro in the sensitivity analysis. A projection at the level of the population for which evidence (randomized controlled trials) exists that plant sterols lower cholesterol (25.35 million) leads to a reduction of 117,000 CHD cases over 10 years and a cost reduction of 1.3 billion euro for this time period (sensitivity analysis 0.8-1.9 billion euro).

Intravenöse Midazolam-Ketamin-Anästhesie zur geschlossenen Reposition der Vorderarmfraktur bei Kindern

BACKGROUND

The aim of this study was to compare ketamine requirements in children undergoing closed reduction of forearm fractures under midazolam-ketamine anaesthesia with or without axillary plexus anaesthesia.

METHODS

With hospital ethical committee approval, we retrospectively analyzed the records of children who received midazolam-ketamine anaesthesia in the years 2000-2001 (group A) and midazolam-ketamine anaesthesia combined with axillary plexus anaesthesia in the years 2002-2004 (group B) for closed reduction of forearm fractures. Requirements for ketamine and postoperative analgesics were noted. Groups were compared with the Mann-Whitney U-test or T-test and the chi2-test (p<0.05).

RESULTS

A total of 455 children (group A 225/group B 230) were included in this study. The total amounts of ketamine were not statistically different between the two groups (p=0.154). However, ketamine requirements became less if the time interval between start of axillary plexus anaesthesia and start of intervention became more than 15 min (p<0.05). Patients in group B requested fewer analgesics in the postoperative period (p<0.01).

CONCLUSIONS

In the clinical routine of an emergency department the combination of midazolam-ketamine anaesthesia with axillary plexus anesthesia for closed reduction of forearm fractures in children did not result in lower requirements of ketamine.

Regulation of in vitro and in vivo immune functions by the cytosolic adaptor protein SKAP-HOM

SKAP-HOM is a cytosolic adaptor protein representing a specific substrate for the Src family protein tyrosine kinase Fyn. Previously, several groups have provided experimental evidence that SKAP-HOM (most likely in cooperation with the cytosolic adaptor protein ADAP) is involved in regulating leukocyte adhesion. To further assess the physiological role of SKAP-HOM, we investigated the immune system of SKAP-HOM-deficient mice. Our data show that T-cell responses towards a variety of stimuli are unaffected in the absence of SKAP-HOM. Similarly, B-cell receptor (BCR)-mediated total tyrosine phosphorylation and phosphorylation of Erk, p38, and JNK, as well as immunoreceptor-mediated Ca(2+) responses, are normal in SKAP-HOM(-/-) animals. However, despite apparently normal membrane-proximal signaling events, BCR-mediated proliferation is strongly attenuated in the absence of SKAP-HOM(-/-). In addition, adhesion of activated B cells to fibronectin (a ligand for beta1 integrins) as well as to ICAM-1 (a ligand for beta2 integrins) is strongly reduced. In vivo, the loss of SKAP-HOM results in a less severe clinical course of experimental autoimmune encephalomyelitis following immunization of mice with the encephalitogenic peptide of MOG (myelin oligodendrocyte glycoprotein). This is accompanied by strongly reduced serum levels of MOG-specific antibodies and lower MOG-specific T-cell responses. In summary, our data suggest that SKAP-HOM is required for proper activation of the immune system, likely by regulating the cross-talk between immunoreceptors and integrins.

Overweight and obesity associated with a missense polymorphism in fatty acid amide hydrolase (FAAH)

BACKGROUND

The brain endogenous cannabinoid system modulates reward and craving pathways and consequently may affect body weight. A naturally occurring missense polymorphism in the gene encoding fatty acid amide hydrolase (FAAH), the primary enzyme for inactivation of endocannabinoids, is associated with problem drug use.

AIMS

To investigate the relationship between the FAAH cDNA 385 A/A (P129T) polymorphism and overweight disorders in subjects of multiple ethnic backgrounds attending a medical screening clinic.

SUBJECTS

A total of 2667 subjects of white, black and Asian ancestry were genotyped and stratified by a standardized clinic-based assessment of body mass index (BMI, weight in kilograms/(height in meters)(2) or kg/m(2)).

METHODS

Subjects were genotyped for the FAAH cDNA 385 C --> A polymorphism using allele-specific oligonucleotide hybridization methods by investigators blinded to all clinical information. BMI was calculated based on exact clinical measurements and World Health Organization ranges were used to stratify subjects. Statistical methods included the Fisher exact test, Mann-Whitney U-test and multivariable logistic regression analysis.

RESULTS

The homozygous FAAH 385 A/A genotype was significantly associated with overweight and obesity in white subjects (P=0.005) and in black subjects (P=0.05) but not in a small group of Asians. The median BMI for all subjects was significantly greater in the FAAH 385 A/A genotype group compared to heterozygote and wild-type groups (P=0.0001). In white subjects, there was an increasing frequency of the FAAH 385 A/A genotype with increasing BMI categories of overweight (P=0.02) and obese (P=0.006) with the same trend in black subjects.

CONCLUSIONS

These results suggest a role for the FAAH 385 A/A missense polymorphism as an endocannabinoid risk factor in overweight/obesity and may provide indirect evidence to support cannabinoid antagonist treatment strategies in overweight disorders.

Kosteneffektivität der Prävention der koronaren Herzkrankheit in Deutschland

It is generally accepted that the incidence of coronary heart disease can effectively be reduced by strengthening prevention. At the same time, it is still unclear how large the effects of life-style oriented preventive measurements such as diet and exercising are in everyday life. Furthermore, there is an ongoing debate on what measurements are effective. Thus, against the background of dwindling financial resources in health care the input of health economic evaluation is explicated. General issues of health economic evaluation are presented. After that, an overview on the current findings of cost-effectiveness in primary prevention of coronary heart disease is given. Risk factors are separately discussed. It is demonstrated that preventive measurements dealing especially with hypertension and hypercholesterolemia can be cost-effective.

Therapeutic actions of insulin-like growth factor I on APP/PS2 mice with severe brain amyloidosis

Transgenic mice expressing mutant forms of both amyloid-beta (Abeta) precursor protein (APP) and presenilin (PS) 2 develop severe brain amyloidosis and cognitive deficits, two pathological hallmarks of Alzheimer's disease (AD). One-year-old APP/PS2 mice with high brain levels of Abeta and abundant Abeta plaques show disturbances in spatial learning and memory. Treatment of these deteriorated mice with a systemic slow-release formulation of insulin-like growth factor I (IGF-I) significantly ameliorated AD-like disturbances. Thus, IGF-I enhanced cognitive performance, decreased brain Abeta load, increased the levels of synaptic proteins, and reduced astrogliosis associated to Abeta plaques. The beneficial effects of IGF-I were associated to a significant increase in brain Abeta complexed to protein carriers such as albumin, apolipoprotein J or transthyretin. Since levels of APP were not modified after IGF-I therapy, and in vitro data showed that IGF-I increases the transport of Abeta/carrier protein complexes through the choroid plexus barrier, it seems that IGF-I favors elimination of Abeta from the brain, supporting a therapeutic use of this growth factor in AD.

Proteasome inhibitors modulate chemokine production in lung epithelial and monocytic cells

Proteasome inhibition has become a target for antitumour and anti-inflammatory therapy. The present study investigated the influence of cysteine proteinase and proteasome inhibitors on chemokine production in lung epithelial cells and monocytic cells. The lung carcinoma cell lines A549, SK-MES, NCI-H727, virus-transformed bronchial epithelial cell line BEAS-2B, primary lung epithelial cells, and the acute monocytic leukaemia cell lines Mono-Mac-6 and THP-1 were incubated with proteasome (N-acetyl-L-leucyl-L-leucyl-L-norleucinal (ALLN), beta-lactone) or cysteine proteinase inhibitor (L-trans-Epoxysuccinyl-Leu-3-methylbutylamide-ethyl ester) and the influence on chemokine production (interleukin-8: IL-8, monocyte chemoattractant protein-1, RANTES) was quantified at protein and mRNA levels. Inhibition of proteasome activity by ALLN and beta-lactone resulted in significantly increased IL-8 secretion (5- to 22-fold). Cysteine proteinase inhibitors did not influence chemokine production. The simultaneous rise in IL-8 mRNA was caused by an increased half-life of mRNA and increased RNA synthesis. Moreover, analysis of transcription factor activation revealed induction of activator protein-1 (c-Jun) activity by proteasome inhibition, whereas nuclear factor-kappaB (p50 and p65) was not activated. The significant increase in IL-8 production after proteasome inhibition was also observed in primary lung epithelial cells and in monocytic cells. In addition, the secreted IL-8 was biologically active as shown by the neutrophil chemotaxis assay. In conclusion, it was shown that proteasome inhibitors stimulate interleukin-8 secretion in lung epithelial cells and monocytic cells, thus recruiting neutrophils.

Evidence-based Medicine: Why do Opponents and Proponents use the same Arguments?

There is quite some ethical controversy on Evidence-based Medicine (EbM) with regard to issues of physician autonomy as well as its allocative implications. Yet, there are some shortcomings in the current debate. First of all, some of the arguments brought up against EbM are similarly defaults of "classical medicine" as well, for instance its negligence of social aspects of medicine. Second, it is often maintained that EbM is just a tool to attain cost containment. This argument is false in two regards for neither is there any idea of cutting costs in the roots of EbM nor does EbM once practiced necessarily lead to less costs as there can be underuse as well as overuse. Third, both opponents and proponents of EbM come up with the same arguments against each other. Both maintain that the other way of practicing medicine does not allow for physicians' autonomy and free judgment. Therefore, we are going to search for the different presuppositions on which these "reproaches" rely. In this way we can demonstrate that both opponents and proponents rely on different notions of autonomy and free judgment in their argument. Finally, we hope to show that some of the ethical criticism may be raised against classical medicine as well and that allocation in terms of costs is not primarily an aim of EbM.

Die Primärstabilität von manuell und roboterassistiert implantierten Hüftendoprothesenstielen: eine biomechanische Untersuchung an Kunstfemora

AIM

We investigated the initial stability of cementless stems implanted with robotic milling and conventional manual broaching.

METHODS

Proximally porous structured stems (G2, ESKA-Implants, Luebeck, Germany) were implanted into synthetic femora. In one group, the femoral cavity was prepared by a CT-based robot (CASPAR, URS-Ortho, Germany) with a high-speed milling head. In the other group, femora were rasped manually with broaches. The broaches had 1 mm proximal press-fit, the robotic cavities 1.5 mm. The implants were exposed to 15 000 loading cycles with 1 000 +/- 500 N. The direction of forces on the implant head were chosen to simulate stair climbing. Internal rotation and translation (caudal, dorsal and lateral) of the implants were measured by linear transducers.

RESULTS

The robotic group showed significantly less reversible motion regarding translation in caudal, dorsal and lateral directions. The standard deviations of implant motions were smaller in the robotic group.

CONCLUSION

Using robotic preparation of the femur, initial stability was higher and more consistent than with manual broaching, but differences in undersizing of the cavities created in the femur in relation to the implant may have contributed to these differences for the most part. In-vitro-loading experiments focusing on femoral cavities with varying press-fits are recommended before the introduction of new implants or operating procedures.

Prospective epidemiologic survey of patients with community-acquired pneumonia requiring hospitalization in Switzerland

BACKGROUND

Community-acquired pneumonia (CAP) is a common problem and the principal infection requiring hospitalization, but its treatment is complicated by the difficulty in microbiological diagnosis and the increasing incidence of antibiotic resistance among respiratory pathogens. The purpose of this paper is to present the main epidemiologic features of patients with CAP requiring hospitalization in our country.

METHODS

We enrolled three hundred and eighteen adult patients with CAP requiring hospitalization in seven large medical centers in Switzerland during two winter periods. The patients' mean age was 70.4 years. This study describes the epidemiology of these patients. Clinical, radiologic and microbiological evaluations were performed at study entry during treatment, and at 4 weeks post-therapy. For microbiological diagnostic purposes, sputum culture, throat swab culture, PCR, blood cultures, Legionella urinary antigen and serologic evaluations were also performed.

RESULTS

Despite the higher mean age, the overall mortality rate was 8%, lower than in other comparable studies. The most common underlying diseases present at study entry were cardiac failure (23%), chronic obstructive pulmonary disease (20%), renal failure (15%), and diabetes (12%); 40% of the patients were smokers. Although dyspnea, cough and positive pulmonary auscultation findings were present in about 90% of patients, fever >38 degrees C was present in only 64%. The most frequently isolated respiratory pathogens were Streptococcus pneumoniae (12.6%), Haemophilus influenzae (6%), Staphylococcus aureus (1.6%), and Moraxella catarrhalis (1.6%). Atypical pathogens were frequently found, with the following distribution: Mycoplasma pneumoniae, 7.5%; Chlamydia pneumoniae, 5.3%; and Legionella pneumophila, 4.4%. The mean duration between onset of symptoms and hospital admission was 4.8 days, and the mean treatment duration was 12.1 days. Two weeks after the start of therapy, although clinical symptoms were absent, radiologic infiltrates were still present in 24% of patients.

CONCLUSIONS

The microbiological diagnosis in CAP can be established in only about 50% of cases with the combination of several diagnostic tools. Epidemiologic surveys of CAP should be performed on a regular basis, regionally, as a way to improve the management of these infections.

Pressurized bag pump and syringe pump arterial flushing systems: an unrecognized hazard in neonates?

OBJECTIVE

Hand-held flushing of radial arterial lines at 0.5 ml/s in neonates can result in retrograde embolization of flush solution into the central arterial circulation. We studied flush flow velocities during intermittent arterial line purging using a flow regulating device with an infusion bag pump and a syringe pump system.

MEASUREMENTS AND INTERVENTIONS

In this in vitro experiment we simulated flushing of a 24- and a 22-G cannula against a mean arterial pressure of 45 mmHg. Fluid flow velocities were gravimetrically measured during flushing from an infusion bag system pressurized to 100, 200, and 300 mmHg and from a syringe pump flush system after initialization of boluses of 0.5, 1.0, 1.5, 2.0, and 2.5 ml. The flow regulating device was opened for 1, 2, and 5 s.

RESULTS

Both flush systems tested allowed delivery of flush flow velocities exceeding 0.5 ml/s (e.g., 22-G cannula; bag system, pressure 300 mmHg up to 0.64+/-0.08 ml/s; syringe pump, 2 ml bolus up to 0.74+/-0.05 ml/s). In syringe pump systems the main determinant of flow velocity was bolus size, in bag pump systems flushing time and bag pressure.

CONCLUSIONS

Based on data about critical flow velocities through an radial arterial cannula in neonates, both tested flushing systems carry the risk of exceeding the critical value of 0.5 ml/s. They are likely to cause retrograde embolization of flushing solution into the central arterial circulation with the associated risk of clot and air embolization. In vivo studies should identify margins of safety to minimize the risk of retrograde flushing into the central arterial circulation.

[Screening for aneuploidy by first trimester nuchal translucency measurement: results from a prospective trial including 1980 cases in a single center in Switzerland]

AIM

The purpose of this study was to evaluate the efficiency of first trimester screening for chromosomal abnormalities using the sonographically determined thickness of nuchal translucency (NT) combined with maternal age.

PATIENTS AND METHODS

Risk screening was offered to all patients with a fetal crown rump length (CRL) between 45 and 84 mm after extensive counselling. For the risk assessment the software provided by the Fetal Medicine Foundation was used. In accordance with the recommendation of the Swiss Working Group on First Trimester Screening a cut-off risk of 1 : 400 was chosen.

RESULTS

A total of 1980 consecutive pregnancies participating in the risk screening programme with due dates prior to May 1, 2001 were included. Mean maternal age was 30.1 yrs and 522 (26.4 %) patients were 35 yrs or older. A positive risk screening result was obtained in a total of 219 (11.1 %) pregnancies including 33 of the 37 (1.9 %) cases with unbalanced chromosomal abnormalities.

CONCLUSIONS

The detection rate for unbalanced chromosome abnormalities in general (89.2 %) as well as the one for trisomy 21 (93.3 %) in particular are very high with a moderate false-positive rate (9.6 %) in this series. As a comparison in the series presented here, traditional "maternal age screening" (cut-off age 35 yrs) would have yielded detection rates of 64.9 % for all unbalanced chromosome abnormalities and 73.3 % for trisomy 21 at a false-positive rate of 25.0 %. Reducing the false-positive rate by raising the cut-off age to 38 yrs would yield detection rates of 40.5 % for all unbalanced chromosome abnormalities and 46.7 % for trisomy 21 at a false-positive rate of 8.9 %. The number of invasive procedures performed to detect one unbalanced chromosome count may be calculated as 21.75 using the cut-off age of 35 yrs as compared to 6.4 using NT measurement and maternal age. The outcome of this ongoing study is in good accordance with the earlier observation that the main benefit of the addition of first trimester NT measurements to the risk screening protocol is a very high detection rate at a moderate false-positive rate.

Ketamine for short ambulatory procedures in children: an audit

BACKGROUND

The purpose of this audit was the evaluation of recovery and discharge times and the identification of perioperative events related to anaesthetics with intravenous ketamine and midazolam.

METHODS

In our institution, we use this method as a routine technique for short ambulatory emergency or elective procedures. Two hundred children, aged 1-16 years, were included. Ninety percent of the study patients underwent emergency procedures.

RESULTS

Most perioperative events were minor and easily corrected. Intraoperatively, most events were related to respiration, including oxygen desaturation, apnoea or laryngospasm. Vomiting, vertigo, visual disturbances, nightmares and hallucinations were observed in the postoperative period. Serious complications requiring hospital admission or further interventions in the postoperative period were rare. Mean recovery time was 100 min (range 20-325) and mean discharge time 130 min (range 25-360).

CONCLUSIONS

Intravenous ketamine plus midazolam is a suitable, simple and fast anaesthetic technique for short, painful ambulatory procedures. Considering the possibility of potentially serious respiratory complications, it should be performed only by qualified anaesthesia staff who are trained in advanced airway management.

Sudden cardiac death after coronary artery bypass grafting is not predicted by signal-averaged ECG

BACKGROUND

Sudden cardiac death (SCD) is a major cause of death despite successful revascularization in patients with coronary artery disease. The signal-averaged ECG (SAECG) is a sensitive predictor of SCD and could be used in the screening strategy to select patients for prophylactic cardioverter implantation.

METHODS

The SAECG was recorded in 561 patients (mean age: 60 +/- 8.8 years) within 10 days of coronary artery bypass grafting. Signal-averaged ECG was performed with a bandpass filtering of 40 to 250 Hz for more than 250 beats until a noise level of 0.6 microV was achieved. All patients were followed for 5.5 +/- 1.2 years after the procedure.

RESULTS

Preoperative angiographic ejection fraction was at least 60% in 393 patients (72%), 40% to 60% in 126 patients (23%), and 40% or less in 28 patients (5%). There were 34 deaths, 10 of which were SCD. Late potentials were found in a total of 150 patients (27%) and were equally frequent preoperatively and postoperatively and among patients with (30%) and without (27%) SCD. The only predictors for overall mortality were age and a reduced ejection fraction.

CONCLUSIONS

Signal-averaged ECG did not predict prognosis in low-risk patients undergoing coronary artery bypass grafting.

Anatomy and intracompartmental pressure measurement technique of the pronator quadratus compartment

The compartment of the pronator quadratus muscle in 25 cadaver specimens is described. Defined by the radius, ulna, and distal interosseous membrane dorsally and the pronator quadratus fascia on the palmar side, the osteofibrous walls of the compartment confine the pronator quadratus muscle within a noncompliant space. A safe and reliable location for compartment pressure measurement was defined at a site 4 cm proximal to the scaphoid tubercule, on the radial side of the flexor carpi radialis tendon and on the ulnar side of the radial artery. These clear anatomic definitions might be useful in diagnosis of compartment syndrome of the pronator quadratus; a clinical investigation may be justified on the basis of pressure measurements made using this technique.