Screening for Down's syndrome: effects, safety, and cost effectiveness of first and second trimester strategies commentary: rasults may not be widely applicable authors' response

Objective: To compare the effects, safety, and cost effectiveness of antenatal screening strategies for Down's syndrome. Design: Analysis of incremental cost effectiveness. Setting: United Kingdom. Main outcome measures: Number of liveborn babies with Down's syndrome, miscarriages due to chorionic villus sampling or amniocentesis, healthcare costs of screening programme, and additional costs and additional miscarriages per additional affected live birth prevented by adopting a more effective strategy. Results: Compared with no screening, the additional cost per additional liveborn baby with Down's syndrome prevented was £22 000 for measurement of nuchal translucency. The cost of the integrated test was £51 000 compared with measurement of nuchal translucency. All other strategies were more costly and less effective, or cost more per additional affected baby prevented. Depending on the cost of the screening test, the first trimester combined test and the quadruple test would also be cost effective options. Conclusions: The choice of screening strategy should be between the integrated test, first trimester combined test, quadruple test, or nuchal translucency measurement depending on how much service providers are willing to pay, the total budget available, and values on safety. Screening based on maternal age, the second trimester double test, and the first trimester serum test was less effective, less safe, and more costly than these four options

Trombotische trombocytopenische purpura in 13 Nederlandse centra: behandeling en beloop

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Validation of the Rockall risk scoring system in upper gastrointestinal bleeding

BACKGROUND—Several scoring systems have been developed to predict the risk of rebleeding or death in patients with upper gastrointestinal bleeding (UGIB). These risk scoring systems have not been validated in a new patient population outside the clinical context of the original study. 
AIMS—To assess internal and external validity of a simple risk scoring system recently developed by Rockall and coworkers. 
METHODS—Calibration and discrimination were assessed as measures of validity of the scoring system. Internal validity was assessed using an independent, but similar patient sample studied by Rockall and coworkers, after developing the scoring system (Rockall's validation sample). External validity was assessed using patients admitted to several hospitals in Amsterdam (Vreeburg's validation sample). Calibration was evaluated by a χ(2) goodness of fit test, and discrimination was evaluated by calculating the area under the receiver operating characteristic (ROC) curve. 
RESULTS—Calibration indicated a poor fit in both validation samples for the prediction of rebleeding (p<0.0001, Vreeburg; p=0.007, Rockall), but a better fit for the prediction of mortality in both validation samples (p=0.2, Vreeburg; p=0.3, Rockall). The areas under the ROC curves were rather low in both validation samples for the prediction of rebleeding (0.61, Vreeburg; 0.70,Rockall), but higher for the prediction of mortality (0.73, Vreeburg; 0.81,Rockall). 
CONCLUSIONS—The risk scoring system developed by Rockall and coworkers is a clinically useful scoring system for stratifying patients with acute UGIB into high and low risk categories for mortality. For the prediction of rebleeding, however, the performance of this scoring system was unsatisfactory. 

 Keywords: upper gastrointestinal bleeding; risk scoring; prognostic factors; rebleeding; mortalit