Cost of stroke in France.

BACKGROUND AND PURPOSE: A cost of illness study was undertaken on behalf of the French Ministry of Health to estimate the annual cost of stroke in France with the goal of better understanding the current economic burden so that improved strategies for care may be developed. METHODS: Using primary data from exhaustive national databases and both top-down and bottom-up approaches, the stroke-related costs for healthcare, nursing care and lost productivity were estimated. RESULTS: The total healthcare cost of stroke patients in France in 2007 was €5.3 billion, 92% of which was borne by statutory health insurance. The average cost of incident cases was €16 686 per patient in the first year, while the annual cost of prevalent cases was a little less than half that amount (€8099). Nursing care costs were estimated at €2.4 billion. Lost productivity reached €255.9 million and that income loss for stroke patients was partially compensated by €63.3 million in social benefit payments. CONCLUSIONS: With healthcare costs representing 3% of total health expenditure in France, stroke constitutes an ongoing burden for the health system and overall economy. Nursing care added nearly half again the amount spent on healthcare, while productivity losses were more limited because nearly 80% of acute incident strokes were in patients over age 65. The high cost of illness underscores the need for improved prevention and interventions to limit the disabling effects of stroke.

[Characteristics and prevention among patients with stroke: a study of 36,844 patients hospitalized in France]. / Caractéristiques et traitements des assurés du régime général hospitalisés pour accident vasculaire cérébral au cours du premier semestre 2008.

INTRODUCTION: This study evaluates comorbidities, primary and secondary drug prevention and two years survival among patients hospitalized for stroke during the first half of 2008. METHODS: First hospitalization with stroke diagnosis was identified by using the national hospital discharge database and linked to the reimbursement database of the beneficiaries covered by the general health insurance scheme (74% of the 64 million population). A medication was considered to be used when there were more than two reimbursements over the 6 months following or preceding hospitalization. RESULTS: Among the 36,844 patients with stroke, 31.6% had a main diagnosis of transient ischemic attack (TIA), 53.6% a cerebral infarct (CI) and 14.8% a cerebral hemorrhage (CH). For the 8429 patients aged less than 60 years, high frequency of low-income and full health insurance coverage (11% of the covered population) was found for CI (17.6%) and CH (24.6%). Specific refund for invalidating stroke before hospitalization was found for 16% of patients with CI and 10.5% of those with CH. During the two previous years, around 7% of all patients were hospitalized for stroke, 30% for arterial hypertension, 13% for cardiac electric disorders, 10% for coronary disease and 12% for diabetes. Death rates one month after hospitalization were 11.3% for CI and 33.8% for CH, and two years after 22.5% for CI, 43% for CH and 7.7% for TIA. At least one antihypertensive drug treatment was found for 55.2% of patients with a TIA before hospitalization and 62.9% after and respectively 59.4% and 65.8% for CI and 51.1% and 57.7% for CH. Before hospitalization, beta-blocker was the most frequent antihypertensive class (21 to 25.6% according to stroke type). After hospitalization, frequency increased for angiotensin-converting enzyme inhibitors among CI patients (31% vs. 18.7%) and calcium-channel blockers among CH patients (27.1% vs. 13.7%). Antiplatelet drugs were used by 58% of the patients with CI after hospitalization (27.8% before). An anticoagulant drug was present for 74.8% of patients with CI, 69.5% for TIA and 19.2% for CH. Among patients with ischemic stroke, half of them had a lipid-lowering drug after hospitalization. A combination of antihypertensive, anticoagulant and lipid lowering drugs was found for 32.9% of patients with a TIA, 39.9% for CI and 7.6% for CH after hospitalization. CONCLUSION: These patients presented frequently a history of stroke and comorbidities and their level of secondary prevention must be improved.

[The value of teleradiology in the management of neuroradiologic emergencies]. / Apports de la téléradiologie dans la prise en charge des urgences neuroradiologiques.

First, to summarize the results of teleradiology programs on neurosurgical emergency care in France. Second, to compare French data with the international literature. Third, to discuss the likely developments and future of teleneuroradiology and teleneurosurgery. Data on French use of telemedicine applications in neuroradiology come from a survey of telemedicine applications in France, which has been conducted in year 2003 at the request of the French ministry of the Research. Teleradiology clearly has a positive impact on emergency neurosurgical care by reducing the time to correct diagnosis and initiation of treatment of patients who need to be transferred and avoid unnecessary transfers. However, present teleradiology applications have organizational limitations that are summarized and discussed with reference to the literature. Further developments in information and communications technology have the potential to revolutionise neurosurgical emergency care and contribute to improve the training of neuroradiology and neurosurgery staff.

Comparative impact of standard approach, FDG PET and FDG dual-head coincidence gamma camera imaging in preoperative staging of patients with non-small-cell lung cancer.

We prospectively compared the impact of the standard approach, of fluorodeoxyglucose positron emission tomography (FDG PET) and of FDG dual-head coincidence gamma camera imaging (DHC) in preoperative staging of patients with non-small-cell lung cancer (NSCLC). In addition to traditional staging, 42 patients were studied with a PET system and a DHC system. The number of lesions detected on DHC and on PET were compared independently of the proof of a tumoural invasion. Then, for the sub-group of lesions with the proof of a tumoural invasion, the sensitivity of the different imaging modalities was compared. Finally, stagings were compared with final staging established by histopathological findings (n=28), additional imaging modalities (n=4), clinical and traditional imaging follow-up over at least 4 months. DHC detected 105 of the 145 lesions considered as pathological on PET (73%, P=0.01), with a concurrence of 89% (NS) in lesions larger than 1.5 cm, and only 17% (P=0.03) in those smaller or equal to 1 cm. Traditional staging detected 87 of the 114 verified tumoural lesions (76%), PET 110/114 (96%, P=0.01 vs traditional staging), DHC 88/114 (77%, NS vs traditional staging, P=0.01 vs PET). PET correctly predicted the N stage in 39/42 (93%) patients, DHC in 38/42 (90%), and computed tomography in 32/42 (76%). PET correctly predicted the M stage in 42/42 (100%) patients, DHC in 41/42 (98%), and traditional staging in 38/42 (90%). Identical NM staging was obtained with DHC and PET in 38/42 (90%) patients. Compared to traditional NM staging, PET correctly up-staged 9/42 (21%) patients and down-staged 3/42 (7%), with one additional false N up-staging. DHC correctly up-staged 7/42 (17%) patients and down-staged 3/42 (7%), with one additional false N down-staging. PET correctly reclassified 4/42 (9.5%) patients from resectable to unresectable and incorrectly reclassified one. DHC correctly reclassified 3/42 (7%) patients without false therapeutic reclassification. Although DHC detected fewer lesions than PET, DHC is a possible alternative to PET since the impact on staging was high as compared with traditional staging and was very similar to that of PET.

[Intracoronary brachytherapy: a meta-analysis]. / Curiethérapie endocoronaire: une méta-analyse.

Intracoronary brachytherapy aims at a reduction of in-stent restenosis by lessening neo-intimal proliferation. To assess its clinical potential, a systematic review of the literature indexed in the standard biomedical bibliographic databases selected eight prospective randomized clinical trials; seven of them, comparing coronary brachytherapy and non-treatment or placebo, have been included in the present meta-analysis. This analysis confirms the angiographic benefit of this procedure, as reported in the individual studies; it also shows, however an excess of clinical adverse effects not exhibited by any individual trial. Therefore, intracoronary brachytherapy cannot be recommended as routine practice, while one cannot rule out its interest in special situations.

[Value of stereotaxic biopsy in diagnosis of subclinical breast lesions]. / Place des techniques de biopsie stéréotaxique dans le diagnostic des lésions mammaires infracliniques.

UNLABELLED: ALTERNATIVE TO SURGERY: New stereotactic guided breast biopsy procedures may constitute a major issue for the diagnosis of non-palpable breast lesions detected at mammography by eliminating the need for surgery in many women with benign breast disease. INDICATIONS: Vacuum-assisted core biopsies provide more complete sampling than the conventional 14-gauge stereo-tactic core biopsies, reducing the number of unsatisfactory biopsies. The more invasive advanced breast biopsy device obtains an intact lesion in its entirety for histological assessment. Currently, there is no definite strategy delineating the precise indications for the diagnosis of screening detected abnormalities. PERSPECTIVES: Because of the increase of the diagnostic armamentarium, care of women with non-palpable breast lesions should be multidisciplinary, involving radiologist, surgeons and histologists and rigorous medical and economic evaluation of diagnostic strategies involving these new health technologies should be pursued.

[Evolution of polyvalent intravenous immunoglobulins (IVIg) prescription, at the Assistance Publique - Hopitaux de Paris between 1988 and 1997. Results of the plan of action set up in order to regulate the prescription]. / Evolution des prescriptions des immunoglobulines intraveineuses polyvalentes (IgIV) à l'Assistance Publique -Hôpitaux de Paris entre 1988 et 1997.

In 1991 the public hospitals in Paris set up a plan to regulate the prescription of IVIg. The plan includes an expert committee and reliable data collection. The expert committee has a threefold mission: i) perform an annual up-date of IVIg classification using three categories: accepted indications (group I), currently deabated indications (group II), and unwarranted indications (group III); ii) develop guidelines for improved therapeutic strategies; iii) stimulate research. Data on use of IVIg are collected in 16 pilot hospitals. These data designate IVIg prescriptions by indication. Data are centralized by the CEDIT which publishes an annual report. Between 1988 and 1991, prescription of IVIg increased at an average annual rate of 33%. Between 1991 and 1996, the amount of IVIg used leveled off: approximately 330 kilograms/year, excluding research protocols. In 1997 there was a decline to 299 kilograms accounting for a total expenditure of 44 million French francs (US$ 6.7M). In 1997, group I prescriptions represented 80% of all IVIg prescriptions, group II 9.8% and group III 9.1%. Comparison of medical practice with a scientificaly recognised reference made it possible for AP-HP to set up an effective regulation of IVIg prescriptions. The longevity of this evaluation work is by itself a success.

Evaluation of a new low-dose digital x-ray device: first dosimetric and clinical results in children.

BACKGROUND: A new low-dose digital X-ray device, based on Charpak's Nobel prize-winning multiwire chamber, enables the production of images at very low doses. Objectives. To present the first dosimetric and clinical results. MATERIALS AND METHODS: The analysis was performed on 93 children with scoliosis and 47 undergoing pelvic radiography. The comparative study between conventional X-ray and the new technique focused on three points: (1) the dose delivered by each system (2) the diagnostic information provided by each system and (3) comparison of image quality criteria with European guidelines. RESULTS: The mean ratio of conventional dose to that of the low-dose technique was 13.1 for the spinal examination and 18.8 for the pelvis. There was no significant difference in diagnostic information available from each modality, but there was a slight difference in quality criteria in favour of the conventional technique. CONCLUSION: This new device allows spectacular dose reduction, consistent with adequate clinical information. Improvements of the prototype will lead to extension of potential indications and industrial development.

[Photostimulation plates or conventional films for bedside chest x-ray in pediatric radiology? A comparative study of quality of image and the dose delivered to patients]. / Plaques photostimulables ou films conventionnels pour les clichés pulmonaires "au lit" en radiopédiatrie? Une étude comparative de la qualité de l'image et de la dose délivrée aux patients.

Image quality and patient doses received during chest bedside examinations performed with conventional (film-screen combination) and photostimulable phosphorus plate systems were compared in a study carried out in 1993 in a French pediatric radiology department. Seventy one children (36 males and 35 females) aged between 9 days and 18 years (average: 43 months) were included in the study. Technical performances of all radiological equipment used were permanently checked through a quality control program. One conventional and 3 "photostimulable" films were performed for each patient included (mAs product selected for "photostimulable" system was progressively reduced down to 60% of that of conventional technique). TLD Lithium Fluoride chips were used to measure entrance surface dose during the examination. Image quality of 284 films (213 "photostimulable" + 71 conventional) was assessed by three independent radiologists. Advantages and drawbacks of both studied imaging techniques are discussed in terms of patient dose reduction and image quality.

Evaluation of severity scoring systems in ICUs--translation, conversion and definition ambiguities as a source of inter-observer variability in Apache II, SAPS and OSF.

OBJECTIVE: To explore translation, conversion and definition ambiguities, when using severity scoring systems in patients admitted to intensive care units (ICUs). DESIGN: A prospective study of the prognosis of acute renal failure in ICUs. SETTING: The study was conducted in 20 French ICUs. PATIENTS: 360 patients presenting with severe acute renal failure were studied during their ICU stay. MEASUREMENTS AND RESULTS: The inter-observer variability of Apache II (acute physiology and chronic health evaluation), SAPS (simplified acute physiology score), and OSF (organ-system failure) was considered. For Apache II, we explored the uncertainty of measurements arising from conversion into SI units, the rounding procedures used for the non-inclusive intervals defined for quantitative parameters such as age, mean arterial pressure (MAP) or serum creatinine, the absence of definition of acute renal failure (ARF) and its consequence on doubling serum creatinine values, and the absence of guidelines in the case of spontaneous ventilation when arterial blood gases (ABG) and forced inspiratory oxygen (FIO2) were not measured. The resulting variability was evaluated, calculating the lowest and the highest value of the scoring system for each patient. The mean difference by patient was greater than 1.5 (p < 0.0001). Other examples were presented and discussed for SAPS and OSF. CONCLUSIONS: Translation, conversion and definition ambiguities are a source of inter-observer variability and increase the risk of classification and/or selection biases. This gives rise to particular concern in the design and analysis of multicenter trials of meta-analysis, and improvement of these scoring systems should be envisaged in the future.

Hepatic artery thrombosis after liver transplantation: diagnosis with spiral CT.

OBJECTIVE: The purpose of this study was to prospectively evaluate spiral CT with maximum-intensity projection in the diagnosis of hepatic artery thrombosis in patients with liver transplants. SUBJECTS AND METHODS: Thirty liver transplant recipients (19 men, 11 women; mean age, 49 years) underwent Doppler sonography and spiral CT with maximum-intensity projection to evaluate both hepatic parenchyma and hepatic vessels. In five cases, these examinations were followed by angiography for suspected hepatic artery thrombosis. RESULTS: Among the 30 patients, results of both Doppler sonography and spiral CT were abnormal in five patients. In all five patients, Doppler sonography revealed an absence of intrahepatic arterial signal (sensitivity, 100%). Spiral CT showed the hepatic artery to be patent from its origin to the anastomosis and then occluded distally in four patients and showed occlusion of the entire hepatic artery in one patient (sensitivity, 100%). Aortography and/or selective arteriography of the celiac axis confirmed the diagnosis of hepatic artery thrombosis in all five cases. The other 25 patients had a normal clinical outcome, 24 with normal findings on Doppler sonograms (specificity, 96%), and 23 with normal findings on spiral CT. Two patients had false-positive CT studies because of technical failures (specificity, 92%). CONCLUSION: Spiral CT with maximum-intensity projection is highly accurate in identifying hepatic artery thrombosis after liver transplantation.

MR imaging and CT of surgical materials currently used in ophthalmology: in vitro and in vivo studies.

PURPOSE: To assess methods of imaging postoperative changes in the eyeball by performing in vitro and in vivo studies of the main solid and fluid materials used in the treatment of cataract and retinal detachment. MATERIALS AND METHODS: The samples were analyzed in vitro with computed tomography (CT) and magnetic resonance (MR) imaging performed at 0.5 T. In vivo studies were performed in seven patients who underwent lens implantation (n = 1), scleral buckling with hydrogel or silicone (n = 6), and retinopexy with gas or silicone oil (n = 6). The attenuation and signal intensity of the materials were compared with values for anatomic structures. RESULTS: Lens implants were difficult to visualize. Each scleral buckling and retinopexy material was easily differentiated from the others and from anatomic structures at both CT and MR imaging. CONCLUSION: Postoperative CT or MR imaging may be useful after retinal detachment surgery, particularly when ultrasound is not reliable after intravitreous gas-fluid interchange.

[Value of techniques of measurement of bone. Radiological methods and contribution of ultrasonics]. / Intérêt des techniques de mesure de la masse osseuse. Méthodes radiologiques et apport des ultrasons.

The current interest in bone mineral density measurements is related to the frequency, the morbidity and the cost of osteoporosis, which is considered to be a public health problem in developed countries. The main risk factor of osteoporotic fractures is the reduction of bone mineral density. This risk factor can be prevented by hormonal therapy in post-menopausal women. So it is of interest to develop the bone mineral density measurement methods, in osteoporotic bone areas or the entire skeleton (absorptiometry). But the interpretation of the result in term of individual fracture risk, the choice of the bone site to be examined, and the indication of the measurement are still being discussed. A new method of bone status evaluation is currently available: the broad band ultrasonic attenuation, which measures the attenuation of ultrasounds through the calcaneus bone. The device is portable, inexpensive and radiation free, and may give quantitative and qualitative assessment of bone. However, the normal values, the relation with the absorptiometry results and the contribution of this method in fracture risk evaluation are currently studied. Osteoporosis risk evaluation is an important point of health management in post-menopausal women and elderly people. Large prospective studies with the different methods are in progress.

Cost of allogeneic bone marrow transplantation in four diseases.

The cost of bone-marrow transplantation is compared in 4 diseases: acute myelogenous leukaemia, severe combined immunodeficiency, severe aplastic anaemia and chronic granulocytic leukaemia. Hospital cost components directly related to the clinical protocols applied are valorized. Results confirm the well-known fact that bone-marrow transplantation is a costly technique. The unit cost of a transplantation can vary from 1 to 2 between departments for the sole reason that patients treated are not suffering from the same illness. For one disease, the unit cost may vary from 1 to 2.7 when post-graft complications arise. Furthermore, in the health-care sector, as well as in every other economic sector, costs do not remain stable: they vary in time most especially when treatment protocols evolve. This type of cost information is the basis for management control systems without which physicians, hospital managers and health-care authorities cannot communicate effectively. In countries where health care is largely financed by the community, what is at stake is the future of advanced technologies in medicine.