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.     

Clinical experience with minimal flow xenon anesthesia

Xenon is a more potent anesthetic than nitrous oxide, and gives more profound analgesia. This investigation was performed to assess the potential of xenon for becoming an anesthetic inspite of its high manufacturing cost. Seven ASA I—-II patients undergoing cholecystectomy (n = 4), hernia repair (n = 2), or mammoplasty (n=l) were studied. Denitrogenation by 15–20 min of oxygen breathing under propofol anesthesia was followed by fentanyl–supplemented xenon anesthesia administered via an automatic minimal flow system which held the oxygen concentration at 30%. Xenon anesthesia lasted 76–228 min and 8–14 1 of xenon (ATPD) was used, of which 5.6–8.1 1 was expended during the first 15 min. Anesthesia appeared to be satisfactory, and the patients woke up rapidly after xenon was discontinued. The automatic system made minimal flow xenon anesthesia easy to administer, but nitrogen accumulation is still a problem. Assuming a xenon price of 10 US $ per litre, the average cost for xenon was about 65 US $ for the first 15 min and then about 25 USS for each subsequent hour of anesthesia.     

Friction, capacitance and transepidermal water loss (TEWL) in dry atopic and normal skin

The biophysical properties of non-eczematous skin at three locations in atopics and non-atopics were characterized using non-invasive physical methods. Skin friction was measured with a newly developed sliding friction instrument, the degree of hydration with a capacitance meter (Corneometer CM 820), and the transepidermal water loss (TEWL) was determined using an Evaporimeter EP1. The areas examined (dorsum of the hand, volar forearm and lower back) showed lower values of friction and capacitance in the atopic patients than did corresponding sites in the normal controls. In most areas a significant correlation between friction and capacitance was found. The TEWL was increased in atopic skin, but TEWL seems to correlate neither to friction nor to capacitance.     

1,25-Dihydroxyvitamin D3 Exerts Opposing Effects to IL-4 on MHC Class-II Antigen Expression,Accessory Activity,and Phagocytosis of Human Monocytes

To investigate the differentiation and activation of monocytes, the combined effects of 1,25-dihydroxyvitamin D3 (D3) and IL-4 on human blood monocytes were examined with respect to expression of MHC class-II antigens, accessory activity, and phagocytic capacity. IL-4 was reported lo upregulate the expression of MHC class-II antigens and accessory activity of monocytes. The experiments described here demonstrate that D3 inhibits the expression of all three subtypes of MHC class-II antigens (HLA-DR, -DP and -DQ) as well as the accessory activity of monocytes. both in a dose- and time-dependent manner. However, D3 enhances the immunoglobulin- and complement-dependent phagocytosis by monocytes in a dose- and time-dependent manner. When monocytes are treated with both IL-4 and D3, the effects of D3 are reverted by IL-4. suggesting that IL-4 induces the development of monocytes into accessory cells, whereas D3 stimulates differentiation of monocytes into classical macrophages. These findings provide further evidence for the contention that, depending on defined stimuli, monocytes may develop either into accessory cells or into classical macrophages.     

RHEUMATOLOGISTS AND THEIR PATIENTS WHO SEEK ALTERNATIVE CARE: AN AGREEMENT TO DISAGREE

Alternative treatment, such as homoeopathy, acupuncture andspiritual healing, are popular among patients with rheumaticdiseases. Rheumatologists are therefore likely to be confrontedwith patients who make use of less orthodox health care. Patients'and rheumatologists' views on the subject and on the rheumatologists'role, however, have not yet been assessed. A questionnaire on alternative medicine was sent to all 101practising Dutch rheumatologists (response rate: 70%). Afterthe results had been analysed 17 rheumatologists, seven rejectingalternative medicine and ten accepting it, handed out a questionnaireto a sample of their patients: 1466 patient questionnaires weredistributed (response rate: 80%). Of the respondents 43% had visited an alternative practitionerat least once for their rheumatism and 26% in the year beforethe survey was held. Hand healers, homoeopaths and acupuncturistswere most often visited. Rheumatologists, on their part, werenot too enthusiastic about these visits. Only patients' visitsto spa treatment centres were welcomed by a majority of them;visits of their patients to manipulative therapists, acupuncturistsand homoeopaths were judged positively by a large minority,whereas other therapies were strongly disapproved. Nevertheless,most patients informed their rheumatologist about their visitingan alternative practitioner. A surprisingly low percentage ofthese patients noticed that the rheumatologist did not sympathizewith it. Although many patients paid a visit to an alternativepractitioner because regular care did not really help them,their satisfaction with the alternative treatment turned outto be less than their satisfaction with the rheumatologists'help. Although a growing number of Dutch general practitioners andphysiotherapists apply alternative methods themselves—contributingto an integration of (parts of) it in the regular care system—therheumatologists do not follow their example. KEY WORDS: Alternative treatment, Homoeopathy, Acupuncture, Spiritual healing