Background: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that results from regurgitation of acid from the stomach into the esophagus. Treatment available for GERD includes lifestyle changes, antacids, histamine-2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and anti-reflux surgery. Aim: The aim of this review is to assess the cost-effectiveness of the use of PPIs in the long-term management of patients with GERD. Method: We searched in PubMed to identify related original articles with close consideration based on inclusion and exclusion criteria to choose the best studies for this narrative review. The first section compares the cost-effectiveness of PPIs with H2RAs in long-term heartburn management. The other sections shall only discuss the cost-effectiveness of PPIs in 5 different strategies, namely, continuous (step-up, step-down, and maintenance), on-demand, and intermittent therapies. Results: Of 55 articles published, 10 studies published from 2000 to 2015 were included. Overall, PPIs are more effective in relieving heartburn in comparison with ranitidine. The use of PPIs in managing heartburn in long-term consumption of nonsteroidal anti-inflammatory drug (NSAID) has higher cost compared with H2RA. However, if the decision-maker is willing to pay more than US$174 788.60 per extra quality-adjusted life year (QALY), then the optimal strategy is traditional NSAID (tNSAID) and PPIs. The probability of being cost-effective was also highest for NSAID and PPI co-therapy users. On-demand PPI treatment strategy showed dominant with an incremental cost-effectiveness ratio of US$2197 per QALY gained and was most effective and cost saving compared with all the other treatments. The average cost-effectiveness ratio was lower for rabeprazole therapy than for ranitidine therapy. Conclusion: Our review revealed that long-term treatment with PPIs is effective but costly. To achieve long-term cost-effective approach, we recommend on-demand approach to treat heartburn symptoms, but if the symptoms persist, treatment with continuous step-down therapy should be applied.
Objectives: The main objective of this study was to evaluate cardiovascular outcome in patients with normal nuclear myocardial perfusion imaging but ischemic ECG changes during pharmacological or exercise stress test. Methods: In this retrospective study, we included a cohort of patients who underwent either pharmacological or exercise stress MPS and have a normal scan with ischemic EKG changes at Aga Khan University Hospital, from January 2013 to December 2014. All cardiac events including angina, myocardial infarction, heart failure, coronary revascularization and cardiac death as well as non-cardiac death were determined for the whole follow up period. Results: Among 2770 eligible patients, 296 patients (10.6%) developed ischemic EKG changes during stress test but myocardial perfusion scan was normal. Out of 296 patients 181(61%) were male and mean age was 61.98 + 15 years. We were able to follow 280 patients (94.5%). During a mean follow-up of 4 years + 7 months, 8 patients (2.8 %) died, of which only one patient (0.3%) died due to cardiac cause. Angina occurred in 25patients (8.9%), myocardial infarction in 2 patients (0.7%) and one patient hospitalized with heart failure (0.3%). We performed coronary angiography of 16 patients (5.7%), of which nine underwent percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) was done in three patients. Conclusion: The ischemic electrocardiographic changes during stress testing in patients with normal MPI are not associated with poor out come and the risk of cardiovascular events is relatively low for an intermediate follow up period. Continuous....
There is increasing popularity in the use of herbal medicine for different ailments as these natural products are considered safer than conventional medicines; however, their use in dosage exceeding prescribed limits can result in serious toxic side effects. We present a case of a 63-year-old male who presented with complaints of restlessness, nausea, vomiting and tingling sensation on his body and ECG evidence of bi-directional ventricular tachycardia. On interrogation, it was revealed that the patient had self-prepared and consumed large quantity of an herbal medication (containing toxic aconite roots) as therapy for erectile dysfunction resulting in a fatal outcome.
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