RESUMEN
Purpose Assessment of prognosis of work disability is a challenging task for occupational health professionals. An evidence-based decision support tool, based on a prediction model, could aid professionals in the decision-making process. This study aimed to evaluate the efficacy of such a tool on Dutch insurance physicians' (IPs) prognosis of work ability and their prognostic confidence, and assess IPs' attitudes towards use of the tool. Methods We conducted an experimental study including six case vignettes among 29 IPs. For each vignette, IPs first specified their own prognosis of future work ability and prognostic confidence. Next, IPs were informed about the outcome of the prediction model and asked whether this changed their initial prognosis and prognostic confidence. Finally, respondents reported their attitude towards use of the tool in real practice. Results The concordance between IPs' prognosis and the outcome of the prediction model was low: IPs' prognosis was more positive in 72 (41%) and more negative in 20 (11%) cases. Using the decision support tool, IPs changed their prognosis in only 13% of the cases. IPs prognostic confidence decreased when prognosis was discordant, and remained unchanged when it was concordant. Concerning attitudes towards use, the wish to know more about the tool was considered as the main barrier. Conclusion The efficacy of the tool on IPs' prognosis of work ability and their prognostic confidence was low. Although the perceived barriers were overall limited, only a minority of the IPs indicated that they would be willing to use the tool in practice.
Asunto(s)
Personas con Discapacidad , Seguro , Médicos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Evaluación de Capacidad de TrabajoRESUMEN
BACKGROUND: Reduction of blood transfusion in cardiac surgery is an important target. The aim of this study was to investigate the cost-effectiveness of the use of CryoSeal®, an allogeneic single-donor fibrin sealant, in patients undergoing coronary artery bypass grafting (CABG). METHODS: This randomized clinical study involved seven cardiac surgery centres in the Netherlands. Patients undergoing elective isolated CABG with the use of at least one internal thoracic artery (ITA) graft were assigned randomly to receive either CryoSeal® (5 ml per ITA bed) or no CryoSeal®. Primary efficacy endpoints were units of transfused red blood cells, fresh frozen plasma and platelet concentrates, and duration of intensive care unit stay. Secondary efficacy endpoints were 48-h blood loss, reoperation for bleeding, mediastinitis, 30-day mortality and duration of hospital stay. RESULTS: Between March 2009 and January 2012, 1445 patients were randomized. The intention-to-treat (ITT) population comprised 1436 patients; the per-protocol (PP) population 1292. In both the ITT and the PP analysis, no significant difference between the treatment groups was observed for any of the primary and secondary efficacy endpoints. In addition, no significant difference between the groups was seen in the proportion of transfused patients. Estimated CryoSeal® costs were 822 (95 per cent c.i. 808 to 836) per patient, which translated to 72,000 per avoided transfusion (unbounded 95 per cent c.i.). CONCLUSION: The use of the fibrin sealant CryoSeal® did not result in health benefits. Combined with the high cost per avoided transfusion, this study does not support the implementation of routine CryoSeal® use in elective isolated CABG. REGISTRATION NUMBER: NTR1386 ( http://www.trialregister.nl).
Asunto(s)
Pérdida de Sangre Quirúrgica/prevención & control , Puente de Arteria Coronaria , Análisis Costo-Beneficio , Procedimientos Quirúrgicos Electivos , Adhesivo de Tejido de Fibrina/uso terapéutico , Hemostasis Quirúrgica/métodos , Hemostáticos/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Cuidados Críticos/economía , Cuidados Críticos/estadística & datos numéricos , Transfusión de Eritrocitos/economía , Transfusión de Eritrocitos/estadística & datos numéricos , Femenino , Adhesivo de Tejido de Fibrina/economía , Hemostasis Quirúrgica/economía , Hemostáticos/economía , Costos de Hospital/estadística & datos numéricos , Humanos , Análisis de Intención de Tratar , Modelos Logísticos , Masculino , Persona de Mediana Edad , Países Bajos , Plasma , Transfusión de Plaquetas/economía , Transfusión de Plaquetas/estadística & datos numéricosRESUMEN
A 75-year-old woman with a history of asthma, rhinitis and nasal polyps was admitted due to petechial lesions on the lower left leg and weakness of the right foot. Six weeks prior to admission, she had started treatment with montelukast 10 mg daily. Based on the asthma, eosinophilia, mononeuritis of the right leg and a skin biopsy showing small vessel vasculitis with eosinophilic granulocytes, the patient was diagnosed with Churg-Strauss syndrome (CSS). After consulting with the pulmonologist, montelukast therapy was discontinued and replaced with a combined preparation of a parasympatholytic and a P2-sympathomimetic. The patient was also given prednisone 60 mg daily, which resulted in prompt clinical improvement and resolution of the eosinophilia. Development of CSS has been associated with the use of montelukast and should be considered in patients with asthma who develop new symptoms, such as neuritis, vasculitis of the skin or pulmonary infiltrates with an increase in eosinophilia during montelukast therapy. In these patients, treatment with montelukast should be discontinued, although whether a causal relationship exists between montelukast and CSS continues to be debated in the literature.