## Second Threshold Analysis Nonulcer Dyspepsia [NUD

The next example serves to further illustrate the powers of threshold analysis and deepen the understanding of its versatility. The clinical scenario represents only a slight deviation from the previous examples of above. Consider the case of a 60-year-old man who presents with symptoms of dyspepsia, nausea, and epigastric pain. An upper gastrointestinal endoscopy has not been performed, but a serologic test for H. pylori has returned positive. The patient has had similar symptoms for the past five years and has been diagnosed with NUD. The patient's new physician has to decide whether to continue treating the patient's symptoms with a PPI or start the patient on an empirical trial of ABXs. The decision tree is outlined in Figure 2-4.

The decisions in favor of ABX or PPI are both followed by the same set of possibilities: The patient may suffer from PUD or NUD. The response rates to ABX or PPI therapy (shown in parentheses inside the white boxes) would, of course, vary depending on the type of unknown disease from which the patient actually suffers. The economic outcome was calculated and entered into the analysis, as represented by the set of gray boxes on the far right. For example, a 90% response rate of PUD to ABX leaves a 10% risk for recurrent ulcer associated with complications. The previous analyses yielded an expected value of \$1,020 for ulcer-associated complications. Hence,

\$150 + .1 p x ABX + (1 - p) x (ABX +COX-2) = COX-2 x \$1,020 = \$252.

Similarly, a 40% response rate of NUD to ABX leaves a 60% risk for recurrent pain associated with persistent NUD but no other ulcer-related complications. Based on the previous estimate of \$500 spent per year to alleviate ulcer-like symptoms, \$150 + .6 p x \$500 = \$450. The contents of the two lower boxes were calculated accordingly.

The outcome of the decision tree can be solved by inspection only, without the need to resort to any type of calculation. The costs inside the two upper boxes are both lower than the costs inside the two lower boxes. No matter what type of value the p assumes, the ABX branch always yields a lower expected cost than the PPI branch. Therefore, the decision in favor of ABX provides the better outcome and the preferred choice.

## Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders canâ€™t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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