The New England journal of medicine
-
The sensitivity and specificity of the hypertensive intravenous pyelogram and the iodohippuran renogram have been determined for the diagnosis of renovascular disease, and cost-effectiveness calculations have been made for the diagnosis and surgical treatment of patients with renovascular hypertension. When the intravenous pyelogram alone is used to screen representative hypertensive population, 78 per cent of patients with renovascular disease are located, but at the same time an equal number of patients without renovascular diasease have abnormal pyelograms. The renogram, on the other hand, is associated with varying true-positive and false-positive ratios. ⋯ The cost of finding a patient with renovascular disease is about $2,000, and that of a surgical cure is about $20,000. The number of deaths for 100 surgical cures is approximately 15. The dollar cost of screening and treating the total American renovascular hypertensive population is of the order of 10 to 13 billion dollars.
-
An attempt was made to discover the difference in outcomes between treating all patients with essential and renovascular hypertension by drug therapy independent and ignorant of etiologic classification and identifying the patients with renovascular disease and operating on them. Outcomes were categorized as well without complications of hypertension, alive but suffering from a related morbid illness such as coronary or cerebral arterial disease, and dead from the complications of diagnosis, surgery or high blood pressure. The identification and surgical treatment of hypertensive renovascular disease resulted in an incremental benefit in morbidity over blind antihypertensive medical therapy only when the compliance with medical treatment was about 50 per cent or less (the rate suggested for most patient populations). The study underscores the extent to which the quantitative efficacy of diagnositc and therapeutic procedures depends not only on the inherent risks and benefits but also on related social and medical factors.
-
The six sequential stool guaiac protocol has been advocated for screening of colonic cancer. Analysis of the expenditures involved in such a program shows that the cost of detecting cancer rises exponentially so that the marginal cost of the sixth test may be 20,000 times the average cost. ⋯ This result shows that even an inexpensive test can become quite costly in terms of cases detected. The marginal cost per case detected depends on the prevalence of the condition in the population screened and the sensitivity of the test applied.
-
Randomized Controlled Trial Comparative Study Clinical Trial
Nitrogen-sparing intravenous fluids in postoperative patients.
Improved nitrogen sparing was demonstrated in 20 patients undergoing either head-and-neck operations or abdominal explorations, who were randomized to receive intravenously either 3 per cent amino acids or 5 per cent dextrose. Infusions were started immediately after operation and continued for a minimum of six days. In patients receiving amino acids, as compared with those receiving dextrose, mean cumulative six-day nitrogen losses were significantly lower (42 plus or minus 5 g [S. ⋯ M.] and 74 plus or minus 7 g, respectively--P smaller 0.005), as were serum glucose and insulin levels, but beta-hydroxybutyrate, acetoacetate and blood urea nitrogen were significantly elevated. No adverse effects of the amino acid solution were observed. The presumed mechanism for improved nitrogen sparing is a decrease in serum glucose and insulin levels, allowing greater endogenous fat mobilization and utilization, thus sparing lean body mass.