Prior studies have evaluated the safety and effectiveness of a diagnostic work up based on combined use of a clinical decision rule and a D-dimer laboratory test in patients with suspected deep vein ...thrombosis in secondary care facilities. The overall outcome of these studies show that approximately 30% of additional objective evaluation can be avoided without compromising the safety, resulting in failure rates of less than 1%. The objective of our study was to assess the effectiveness of a modified algorithm using a dichotomized clinical decision rule including a point of care D-dimer test in patients suspected of deep vein thrombosis in primary care. The AMUSE study is a prospective cohort study of consecutive patients with clinically suspected acute deep vein thrombosis conducted in 400 general practices coordinated by 3 university affiliated centers in the Netherlands from March 2004 through January 2007. The study population of 1029 patients included 63% women. Patients were categorized as “deep vein thrombosis unlikely” or “deep vein thrombosis likely” using a dichotomized version of a for general practice adapted clinical decision rule based on the Wells rule. Patients classified as unlikely were excluded from further testing. All other patients underwent ultrasonography. Anticoagulants were withheld from patients classified as unlikely. All patients were followed up for 3 months. The main outcome measure was symptomatic or fatal venous thromboembolism (VTE) during 3 months follow-up. Deep vein thrombosis was classified as unlikely in 500 patients (48.6%), all of whom were not treated with anticoagulants; subsequent non fatal VTE occurred in 8 patients (1.6% 95 CI 0.7–3.1%). In 500 patients categorized as likely, deep vein thrombosis was confirmed in 124 patients (24.8%), 3 patients did not receive objective testing (0.6%) and 373 patients were tested negative (74.6%). Two out of 4 patients not receiving objective testing had confirmed deep vein thrombosis in the 3 month follow-up period. In patients that tested negative 4 non fatal events occurred during the 3 month follow-up (1.1%). The algorithm was completed and allowed a management decision in 97.2% of patients. We conclude that this management strategy is both safe and highly effective in patients with suspected deep vein thrombosis in general practice. Its use is associated with low risk for subsequent fatal and nonfatal VTE and a further increase in the yield of objective diagnostic tests.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IntroductionEUROASPIRE V is a cross-sectional survey undertaken by the European Society of Cardiology, EurObservational Research Programme in coronary patients across 27 European countries aiming to ...determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice.MethodsPatients <80 years with coronary disease (CABG, PCI or an acute coronary syndrome) were identified from the hospital medical records and interviewed and examined by trained staff ≥6 months and ≤2 years later using standardized methods including central laboratory measurements.ResultsA total of 8,261 (25.8% females), mean age 63.6 (SD 9.6) were interviewed, with a median time between the index event and interview 1.12 years (IR 0.82-1.56). Overall, 18.7% were smokers, 81.7% overweight (BMI≥25 kg/m), 37.7% obese (BMI≥30 kg/m), 58.5% centrally obese (WC≥102 cm in men or ≥88 cm in women), 46.3% had blood pressure ≥140/90 mmHg (≥140/80 in people with diabetes); 71.0% had LDL-cholesterol ≥70 mg/dL (1.8 mmol/L) and 29.3% reported having diabetes. The use of recommended cardioprotective therapies was 92.5%, 81.0%, 75.2% and 84.2% for antiplatelets, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and lipid-lowering agents, respectively. Only 46.2% were advised to follow a cardiac rehabilitation program and 31.8% attended at least half of the sessions. There were large variations in lifestyle, blood pressure, lipids and glucose management between countries and centres.ConclusionsA large majority of coronary patients in Europe have adverse lifestyles and many do not achieve the lifestyle, blood pressure, lipid and diabetes targets. A significant gap still exists between the prevention guidelines and their adherence and control of CVD risk factors in coronary patients in Europe. Greater efforts are needed for all coronary patients in order to ensure best possible prevention and to reduce the risk of future cardiovascular events.
To evaluate the cost-effectiveness of adenotonsillectomy compared with watchful waiting in Dutch children.
Economic evaluation along with an open, randomized, controlled trial.
Multicenter, including ...21 general and 3 university hospitals in the Netherlands.
Three hundred children aged 2 to 8 years were selected for adenotonsillectomy according to routine medical practice. Excluded were children who had frequent throat infections and those with suspected obstructive sleep apnea.
Incremental cost-effectiveness in terms of costs per episode of fever, throat infection, and upper respiratory tract infection avoided.
Annual costs incurred in the adenotonsillectomy group were euro803 (the average exchange rate for the US dollar in 2002 was $1.00 = euro1.1, except toward the end of 2002 when $0.95 = euro100) and euro551 in the watchful waiting group (46% increase). During a median follow-up of 22 months, surgery compared with watchful waiting reduced the number of episodes of fever and throat infections by 0.21 per person-year (95% confidence interval, -0.12 to 0.54 and 0.06 to 0.36, respectively) and upper respiratory tract infections by 0.53 (95% confidence interval, 0.08 to 0.97) episodes. The incremental costs per episode avoided were euro1136, euro1187, and euro465, respectively.
In children undergoing adenotonsillectomy because of mild to moderate symptoms of throat infections or adenotonsillar hypertrophy, surgery resulted in a significant increase in costs without realizing relevant clinical benefit. Subgroups of children in whom surgery would be cost-effective may be identified in further research. .
A controlled experiment on the effect of ethnic specific diabetes education in Turkish type 2 diabetics revealed substantial problems with compliance. The cost effectiveness of such a programme would ...improve if patients most likely to dropout or overuse the education facility could be identified. The 45 patients of the intervention group were categorized into three groups: non-compliers, compliers and over-compliers, and we assessed the association between patient characteristics and these three groups. Compared to the compliers, non-compliers had a longer history of diabetes and poorer knowledge of diabetes. Over-compliers were more often younger, female, scored low on attitude or self-efficacy, and experienced more stress. Turkish patients having diabetes for a longer period or with poor knowledge of diabetes are at risk to dropout from the programme, while younger Turkish females scoring low on attitude or self-efficacy as well as those with more stress, are more likely to over-use the education facility.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
A recent study trial shows that in high-risk patients with hypertension, blood pressure measurements and initiation of changes in blood pressure lowering drugs by the patient him- or herself reduces ...the systolic blood pressure by on average of 9 mmHg compared with usual care. Even though additional trials confirming these findings are useful, self-management of high-risk patients with hypertension could be considered in daily practice.
Background Recent observational studies suggest that beta -blockers may improve long-term prognosis in patients with chronic obstructive pulmonary disease (COPD). We assessed whether beta -blocker ...use improves all-cause mortality in patients with episodes of acute bronchitis. Methods An observational cohort study using data from the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions. Cox regression was applied with time-varying treatment and covariates. Results The study included 4,493 patients aged 45 years and older, with at least one episode of acute bronchitis between 1996 and 2006. The mean (SD) age of the patients was 66.9 (11.7) years, and 41.9% were male. During a mean (SD) follow up period of 7.7 (2.5) years, 20.4% developed COPD. In total, 22.7% had cardiovascular comorbidities, resulting in significant higher mortality rates than those without (51.7% vs. 12.0%, p<0.001). The adjusted hazard ratio of cardioselective beta -blocker use for mortality was 0.62 (95% confidence interval CI, 0.50-0.77), and 1.01 (95% CI 0.75-1.36) for non-selective ones. Some other cardiovascular drugs also reduced the risk of mortality, with adjusted HRs of 0.60 (95% CI 0.46-0.79) for calcium channel blockers, 0.88 (95% CI 0.73-1.06) for ACE inhibitors/angiotensin receptor blockers, and 0.42 (95% CI 0.31-0.57) for statins, respectively. Conclusion Cardiovascular comorbidities are common and increase the risk of mortality in adults with episodes of acute bronchitis. Cardioselective beta -blockers, but also calcium channel blockers and statins may reduce mortality, possibly as a result of cardiovascular protective properties.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ST-T wave changes of electrocardiographic (ECG) leads have long been recognized as predictors of future cardiac events, but they only imperfectly characterize T-loop morphology. Using ...vectorcardiographic (VCG) parameters, we investigated the predictive value of T-loop abnormality for fatal and nonfatal cardiac events in a prospective cohort study among 5,815 elderly. Separately, the predictive value of an easily obtainable T-loop parameter, the T axis, was also assessed. Measurements were determined by a computer program, using VCGs reconstructed from the standard 12-lead ECGs. During the 3 to 6 (mean 4) years of follow-up, 166 fatal and 193 nonfatal cardiac events occurred. Subjects with an abnormal T-loop morphology had increased risks for fatal cardiac events (hazard ratio 4.3; 95% CI 3.0–6.4) and nonfatal cardiac events (3.0; 1.9–4.8). Risks associated with an abnormal T axis alone were only slightly lower. Additional adjustment for established cardiovascular risk indicators resulted in lower, but still highly significant risks. Both T-loop and T-axis abnormalities appear to be strong, independent risk indicators of cardiac events in the elderly.
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IJS, IMTLJ, KILJ, KISLJ, NUK, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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