Primary Prevention of Sudden Cardiac Death: Can We Afford the Cost of Cardioverter-Defibrillators? Data from the Search-MI Registry-Italian Sub-study

Background: Large randomized trials show that in appropriately selected patients with left ventricular dysfunction, implantable cardioverter-defibrillators (ICDs) can improve overall survival at 2–5 years. Since direct implementation of the criteria used in the MADIT II and SCD-HeFT will lead to a marked rise in ICD implants, there is a growing fear that increased use of ICDs may cause a dramatic burden to health care systems. The ICD has traditionally been seen as an expensive form of treatment, which is difficult to accept at the first look. This is mainly due to the nonlinear character of the ICD investment, characterized by high initial expenditure, followed by a deferred pay-off in terms of clinical benefits. Cost-effectiveness analysis may help provide a different perspective on the problem of ICD cost, as may estimation of the daily cost of ICD treatment, assuming a time horizon of 5–7 years—a particularly interesting subject for further registry studies.
Methods and Results: Based on real expenditure data from 2002 to 2005, as recorded in the Search-MI Registry-Italian Sub-study of patients implanted on MADIT II indications, we estimated the daily costs associated with the device and leads. Over a 5–7 year time horizon, the average daily cost was estimated to be €4.60–€6.70. Translation of these figures into U.S. market conditions suggests a daily cost of around $7.90–$11.40.
Conclusions: These findings appear useful to help evaluate the affordability of ICD in comparison with other therapeutic options in a context of limited available economic resources.     

PRESENCE OF POSITIVE FEEDBACK BETWEEN OESTROGEN AND LH IN PATIENTS WITH KLINEFELTER''S SYNDROME, AND SERTOLI-CELL-ONLY SYNDROME

In five adult patients with Klinefelter's syndrome and two with Sertoli-cell-only syndrome, exogenous administration of 17 beta-oestradiol, resulting in a sustained and prolonged elevation of circulating oestrogen levels, had a biphasic effect on LH release. After an initial decrease, a dramatic rise in peripheral levels of LH (positive feedback) was observed in all patients. The timing and magnitude of the induced LH surge was similar to that observed in postmenopausal women after administration of large doses of Ethinyloestradiol. A similar positive feedback effect on the secretion of FSH could not be demonstrated. In two patients with the Sertoli-cell-only syndrome, oestrogen treatment induced marked variations in serum testosterone levels, which appeared to be related to the LH changes. Similar changes were not present in patients with Klinefelter's syndrome, indicating a decrease in the sensitivity of the testicular Leydig cell. These experiments demonstrate that positive feedback between oestrogen and luteinizing hormone is present in the adult human male.     

Tolerance to Lower Body Negative Pressure Exposure: Comparison Between Patients with Neurocardiogenic Syncope and Controls

Lower body negative pressure exposure (LBNPE) produces hemodynamic modifications similar to those produced by head-up tilt test (HUT). Patients with vasovagal syncope are more susceptible to HUT than healthy persons. The supine position during LBNPE would facilitate the simultaneous performance of complementary methods. The aim of this study was to compare tolerance to LBNPE between a group of patients with vasovagal syncope and a group of healthy volunteers. Eleven patients with vasovagal syncope and positive HUT and 13 healthy volunteers without prior history of syncope and negative HUT were included. The following protocol was used: −10 mmHg, 1 minute; −20 mmHg, 1 minute; −30 mmHg, 3 minutes, and −40, −50, −60, and −70 mmHg, 5 minutes for each stage. Tolerance was expressed as: maximum tolerated negative pressure (Max NP), maximum tolerated time (Max T), and Σ P × T, where P = pressure and T = time. Syncope or presyncope during the test was considered positive LBNPE. LBNPE was positive at −50 or −60 mmHg in 8 of 11 patients (73%). One healthy volunteer had presyncope after 5 minutes at −70 mmHg. Tolerance, as expressed by any of the three parameters, was significantly higher for the healthy volunteers (Max NP: −59.1 ± 7.9 vs −70, P < 0.01; Max T: 19.1 ± 4.2 vs 24.4 ± 0.3, P < 0.01; Σ P × T: 836.3 ± 269.5 vs 1214.6 ± 18, P < 0.01). We conclude that patients with neurocardiogenic syncope have a significantly lower tolerance to LBNPE than subjects with no previous history of syncope.     

Re-anatomization of Anterior Eroded Teeth by Stratification with Direct Composite Resin

Gastroesophageal reflux disease (GERD) is a condition where stomach acids are chronically regurgitated into the esophagus and oral cavity, resulting in the irreversible erosion of tooth structure. The dentist often is the first health care professional to identify the affected dentition. Restorative treatment should be accomplished after management of the systemic condition. Dental treatment improves the patient's oral hygiene, reduces thermal sensitivity, prevents pulpal involvement and further abrasion, and esthetics are improved. This article presents a case report where dental erosion was present because of GERD. Conservative dental treatment of the eroded dentition is described, including diagnosis, treatment planning, bleaching, and restorative reconstruction with direct composite layering techniques without any preparation of the tooth structure. After 1 year of clinical service, the restored teeth present an excellent clinical appearance and require no repair or polishing.

CLINICAL SIGNIFICANCE

The treatment of eroded teeth, caused by gastroesophageal reflux disease (GERD), with direct composite resin appears to be a conservative and esthetic procedure that is well accepted by patients. However, this treatment can be carried out only after complete management of the causes of the GERD.