Cost-effectiveness of stereotactic large-core needle biopsy for nonpalpable breast lesions compared to open-breast biopsy

This paper demonstrates that the introduction of large-core needle biopsy (LCNB) replacing needle-localised breast biopsy (NLBB) for nonpalpable (screen-detected) breast lesions could result in substantial cost savings at the expense of a possible slight increase in breast cancer mortality. The cost-effectiveness of LCNB and NLBB was estimated using a microsimulation model. The sensitivity of LCNB (0.97) and resource use and costs of LCNB and NLBB were derived from a multicentre consecutive cohort study among 973 women who consented in getting LCNB and NLBB, if LCNB was negative. Sensitivity analyses were performed. Replacing NLBB with LCNB would result in approximately six more breast cancer deaths per year (in a target population of 2.1 million women), or in 1000 extra life-years lost from breast cancer (effect over 100 years). The total costs of management of breast cancer (3% discounted) are estimated at £4676 million with NLBB; introducing LCNB would save £13 million. The incremental cost-effectiveness ratio of continued NLBB vs LCNB would be £12 482 per additional life-year gained (3% discounted); incremental costs range from £-21 687 (low threshold for breast biopsy) to £74 378 (high sensitivity of LCNB)

Suprachiasmatic nucleus lesion increases corticosterone secretion

The diurnal rhythm of corticosteroid secretion is controlled by the suprachiasmatic nucleus (SCN). In rats, plasma corticosteroid levels rise just before the onset of the activity period during the dark phase. Our previous results indicated that vasopressin as a neurotransmitter from the SCN inhibited corticosteroid secretion in the area of the paraventricular/dorsomedial nucleus of the hypothalamus. We hypothesized that during the day the SCN may serve as an inhibitory system for corticosteroid secretion. To investigate this possibility, intact and SCN-lesioned animals were exposed to mild stress in the morning and evening and their plasma corticosteroid levels were monitored. The results indicate that SCN-lesioned animals have higher morning corticosteroid levels and respond both in the morning and evening with higher corticosteroid levels after stress than do intact control animals. We conclude, therefore, that these results indicate an inhibitory role of the SCN on corticosteroid secretion. The apparent discrepancy with the reported stimulatory role of the SCN on adrenocorticotropic hormone secretion is discusse

GABA receptors in the region of the dorsomedial hypothalamus of rats are implicated in the control of melatonin and corticosterone release

Recently, anatomical evidence was presented that the mammalian circadian clock located in the suprachiasmatic nuclei (SCN) may utilize GABA to transmit diurnal information to the dorsomedial hypothalamus (DMH). The present study provides further physiological evidence for the involvement of this GABAergic projection in the regulation of diurnal rhythms. Infusion of the GABA agonist muscimol in the region of the DMH completely blocked the daily increase of plasma melatonin during darkness and reduced sympathetic output in the pineal gland resulting in lower pineal melatonin production, as measured with transpineal microdialysis. Further experiments in SCN-lesioned animals indicated that the origin of this inhibitory input to the DMH is indeed the SCN. The results of this study imply that the SCN can influence the sympathetic outflow of the hypothalamus through its GABA-containing projection. Furthermore, the present results probably explain the previously reported strong inhibitory effect of benzodiazepines on plasma melatonin in both animals and human

Central vasopressin infusion prevents hibernation in the European hamster (Cricetus cricetus).

The amount of immunocytochemically detectable vasopressin in the brain of the European hamster (Cricetus cricetus) shows a seasonal variation; i.e., dense vasopressin immunoreactivity is present in the lateral septum during summer but is absent in autumn and winter [Buijs, R. M., Pévet, P., Masson-Pévet, M., Pool, C. W., De Vries, G. J., Canguilhem, B. & Vivien-Roels, B. (1986) Brain Res. 371, 193-196]. In the winter period the European hamster hibernates. Since vasopressin in the lateral septum is known to be involved in the control of body temperature, we investigated whether infusion of vasopressin in the lateral septum during autumn-winter could influence hypothermic patterns normally seen in hibernating animals. Hamsters whose lateral septum was infused with vasopressin showed almost no periods of hypothermia, whereas hamsters treated with control infusions displayed a normal hibernation pattern. The results indicate that persistence of vasopressin release in the lateral septum of the European hamster during winter can prevent hibernation

Imaging of carotid arteries in symptomatic patients: cost-effectiveness of diagnostic strategies

To assess the cost-effectiveness of noninvasive imaging strategies in patients who have had a transient ischemic attack (TIA) or minor stroke and are suspected of having significant carotid artery stenosis. From 1997 through 2000, 350 patients were included in a multicenter blinded consecutive cohort study. The sensitivities and specificities of duplex ultrasonography (US), magnetic resonance (MR) angiography, and these two examinations combined were estimated by using digital subtraction angiography (DSA) as the reference standard. The actual costs (from a societal perspective) of performing imaging and endarterectomy were estimated. The survival, quality of life, and costs associated with stroke were based on data reported in the literature. Markov modeling was used to predict long-term outcomes. Subsequently, a decision model was used to calculate costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained for 62 examination-treatment strategies. Extensive sensitivity analyses were performed. Duplex US had 88% sensitivity and 76% specificity with use of conventional cutoff criteria. MR angiography had comparable values: 92% sensitivity and 76% specificity. Combined concordant duplex US and MR angiography had superior diagnostic performance: 96% sensitivity and 80% specificity. Duplex US alone was the most efficient strategy. Adding MR angiography led to a marginal increase in QALYs gained but at prohibitive costs (cost-effectiveness ratio > 1 500 000 per QALY gained). Performing DSA owing to discordant duplex US and MR angiographic findings and to confirm duplex US and MR angiographic findings led to extra costs and QALY loss owing to complications. Sensitivity analyses revealed that duplex US as a stand-alone examination remained the preferred strategy while estimates and assumptions were varied across plausible ranges. Duplex US performed without additional imaging is cost-effective in the selection of symptomatic patients suitable for endarterectomy. Adding MR angiography increases effectiveness slightly at disproportionately high costs, whereas DSA is inferior because of associated complication