Short term cost effectiveness of a regional myocardial infarction network

Aims: Myocardial infarction networks have been shown to improve guideline adherent therapy and outcomes in patients presenting with acute ST-elevation myocardial infarction (STEMI). Our objective was to assess the short term cost effectiveness of a network structure. Methods and results: Outcome data and reimbursement data for the index hospital stay were gathered in consecutive patients with acute STEMI (n=536) admitted to any of the hospitals in a 350.000 inhabitant rural network area during the years 2002 (n=185), 2005 (n=163) and 2008 (n=188). Network structure was established between 2002 and 2005 aiming for identical treatment of all acute STEMI patients during 24 h/7d a week with primary angioplasty. Patient baseline characteristics in the different years were quite comparable. From 2002 to 2005 regional hospital mortality in STEMI patients decreased from 16% to 9%. Lower mortality under network conditions was confirmed in 2008. Reimbursement data of different years were standardized to exclude effects not induced by the network. The mean initial costs per saved live during the index stay were 7727 with a 95%-confidence interval of -3.500 to 36.700 (referenced to the German reimbursement in 2005). Conclusion: The short term cost effectiveness of a myocardial infarction network organisation is within well accepted boundaries under conditions of the German reimbursement system

Posttranslational Modification of Human Glyoxalase 1 Indicates Redox-Dependent Regulation

Background: Glyoxalase 1 (Glo1) and glyoxalase 2 (Glo2) are ubiquitously expressed cytosolic enzymes that catalyze the conversion of toxic a-oxo-aldehydes into the corresponding a-hydroxy acids using L-glutathione (GSH) as a cofactor. Human Glo1 exists in various isoforms; however, the nature of its modifications and their distinct functional assignment is mostly unknown. Methodology/Principal Findings: We characterized native Glo1 purified from human erythrocytes by mass spectrometry. The enzyme was found to undergo four so far unidentified posttranslational modifications: (i) removal of the N-terminal methionine 1, (ii) N-terminal acetylation at alanine 2, (iii) a vicinal disulfide bridge between cysteine residues 19 and 20, and (iv) a mixed disulfide with glutathione on cysteine 139. Glutathionylation of Glo1 was confirmed by immunological methods. Both, N-acetylation and the oxidation state of Cys 19/20, did not impact enzyme activity. In contrast, glutathionylation strongly inhibited Glo1 activity in vitro. The discussed mechanism for enzyme inhibition by glutathionylation was validated by molecular dynamics simulation. Conclusion/Significance: It is shown for the first time that Glo1 activity directly can be regulated by an oxidative posttranslational modification that was found in the native enzyme, i.e., glutathionylation. Inhibition of Glo1 by chemical reaction with its co-factor and the role of its intramolecular disulfides are expected to be important factors within th

Cost-effectiveness of a photopethysmographic procedure for screening for atrial fibrillation in 6 European countries

Background: Strokes cause an estimated annual health care burden of 170 billion euros across Europe. Atrial fibrillation is one of the major risk factors for stroke and increases the individual risk 4.2-fold. But prevention with anticoagulants may reduce this risk by 70%. Screening methods are employed to detect previously undetected atrial fibrillation. Screening studies in various European countries show a high degree of undetected atrial fibrillation. This study aims to assess the cost-effectiveness of systematic screening with a smartphone application, named Preventicus Heartbeats. It is a hands-on screening tool for use on smartphone to diagnose AF with high sensitivity and specificity. Methods: A previously published model for calculating screening cost-effectiveness was extended to 6 European countries covering a wide range in terms of treatment costs and epidemiologic parameters. Results: The use of screening lowers the cost per case in countries with comparatively high levels of health care costs (Switzerland: -€75; UK: -€7). Moderate higher costs per case were observed in 4 countries (Greece: €6; Netherlands: €15). Low levels of health care costs result in less or no potential for further cost reduction (Poland: €20; Serbia: €33). In all countries considered, the model showed an increase in effectiveness measures both in the number of strokes avoided and the quality adjusted life years. The number of strokes avoided per 1000 participants ranged from 2.52 (Switzerland) to 4.44 (Poland). Quality-adjusted life-years per case gained from screening ranged from 0.0105 (Switzerland) to 0.0187 (Poland). The screening procedure dominated in two countries (Switzerland, UK). For the remaining countries, the incremental cost effectiveness ratio ranged from €489/QALY (Greece) to €2548/QALY (Serbia). Conclusion: The model results showed a strong dependence of the results on the country-specific costs for stroke treatment. The use of the investigated screening method is close to cost-neutral or cost-reducing in the Western European countries and Greece. In countries with low price levels, higher cost increases due to AF screening are to be expected. Lower costs of anticoagulation, which are expected due to the upcoming patent expiry of direct anticoagulants, have a positive effect on the cost result