Risk factors associated with early and late free flap complications in head and neck osseous reconstruction.

PURPOSE: This study was designed to identify risk factors for post-operative complications in micro-anastomosed osteomyocutaneous free flaps (MOFF) and analyzed their consequences in long term. METHODS: A retrospective review of 100 MOFF realized between May 2007 and October 2019 was performed. Demographic data, perioperative management and postoperative complications were enrolled and analyzed in a multivariate model. Patients were followed for ≥ 6 months. RESULTS: Major surgical complication rate was 20% with 5% of overall free flap failure rate and 6% of anastomosis salvage surgery. Risk identified for major surgical complication was alcohol consumption (p = 0.0054). Minor surgical complications occurred in 26% of patients mostly due to infections (19%). No significant risk factor was associated to minor surgical complications. Major and minor medical complication rates were, respectively, 10% and 10%. Risk identified for major medical complication were age over 70 (p = 0.0253) and history of chemotherapy (p = 0.0277). Risk identified for minor medical complication were alcohol consumption p = 0.0232) and a history of radiotherapy (p = 0.0329). CONCLUSIONS: Alcoholism is an independent risk factor for the surgical complication of MOFF that must be taken into account before surgery. Patients with a history of chemotherapy, radiotherapy or who are over 70 years of age are at greater risk of postoperative medical complications and require special attention.

Estimating willingness to pay for public health insurance while accounting for protest responses: A further step towards universal health coverage in Tunisia?

INTRODUCTION: Developing countries face major challenges in implementing universal health coverage (UHC): a widespread informal sector, general discontent with rising economic insecurity and inequality and the rollback of state and public welfare. Under such conditions, estimating the demand for a health insurance scheme (HIS) on voluntary basis can be of interest to accelerate the progress of UHC-oriented reforms. However, a major challenge that needs to be addressed in such context is related to protest attitudes that may reflect, inter alia, a null valuation of the expected utility or unexpressed demand. METHODS: We propose to tackle this by applying a contingent valuation survey to a non-healthcare-covered Tunisian sample vis-à-vis joining and paying for a formal HIS. Our design pays particular attention to identifying the nature of the willingness-to-pay (WTP) values obtained, distinguishing genuine null values from protest values. To correct for potential selection issues arising from protest answers, we estimate an ordered-Probit-selection model and compare it with the standard Tobit and Heckman sample selection models. RESULTS: Our results support the presence of self-selection and, by predicting protesters' WTP, allow the "true" sample mean WTP to be computed. This appears to be about 14% higher than the elicited mean WTP. CONCLUSION: The WTP of the poorest non-covered respondents represents about one and a half times the current contributions of the poorest formal sector enrolees, suggesting that voluntary participation in the formal HIS is feasible.

The path towards herd immunity: Predicting COVID-19 vaccination uptake through results from a stated choice study across six continents.

Despite unprecedented progress in developing COVID-19 vaccines, global vaccination levels needed to reach herd immunity remain a distant target, while new variants keep emerging. Obtaining near universal vaccine uptake relies on understanding and addressing vaccine resistance. Simple questions about vaccine acceptance however ignore that the vaccines being offered vary across countries and even population subgroups, and differ in terms of efficacy and side effects. By using advanced discrete choice models estimated on stated choice data collected in 18 countries/territories across six continents, we show a substantial influence of vaccine characteristics. Uptake increases if more efficacious vaccines (95% vs 60%) are offered (mean across study areas = 3.9%, range of 0.6%-8.1%) or if vaccines offer at least 12 months of protection (mean across study areas = 2.4%, range of 0.2%-5.8%), while an increase in severe side effects (from 0.001% to 0.01%) leads to reduced uptake (mean = -1.3%, range of -0.2% to -3.9%). Additionally, a large share of individuals (mean = 55.2%, range of 28%-75.8%) would delay vaccination by 3 months to obtain a more efficacious (95% vs 60%) vaccine, where this increases further if the low efficacy vaccine has a higher risk (0.01% instead of 0.001%) of severe side effects (mean = 65.9%, range of 41.4%-86.5%). Our work highlights that careful consideration of which vaccines to offer can be beneficial. In support of this, we provide an interactive tool to predict uptake in a country as a function of the vaccines being deployed, and also depending on the levels of infectiousness and severity of circulating variants of COVID-19.

Health effects from heat waves in France: an economic evaluation.

BACKGROUND: Scarcity of data on the health impacts and associated economic costs of heat waves may limit the will to invest in adaptation measures. We assessed the economic impact associated with mortality, morbidity, and loss of well-being during heat waves in France between 2015 and 2019. METHODS: Health indicators monitored by the French national heat wave plan were used to estimate excess visits to emergency rooms and outpatient clinics and hospitalizations for heat-related causes. Total excess mortality and years of life loss were considered, as well as the size of the population that experienced restricted activity. A cost-of-illness and willingness-to-pay approach was used to account for associated costs. RESULTS: Between 2015 and 2019, the economic impact of selected health effects of heat waves amounts to €25.5 billion, mainly in mortality (€23.2 billion), minor restricted activity days (€2.3 billion), and morbidity (€0.031 billion). CONCLUSION: The results highlight a significant economic burden on the French health system and the population. A better understanding of the economic impacts of climate change on health is required to alert decision-makers to the urgency of mitigation and to support concrete adaptation actions.

Surgical management of MILD hyperparathyroidism.

INTRODUCTION: There is no consensus for management of Mild primary hyperparathyroidism (MILD-pHP). Specific management has been suggested by some authors. We have compared the surgical management of the patients with MILD-pHP to those with Classic primary hyperparathyroidism (C-pHP) treated by surgery according to The Fourth International Workshop on pHP. MATERIALS AND METHODS: Data of 173 patients who underwent a parathyroidectomy were reviewed and retrospectively analysed. Management of 32 patients with MILD-pHPT (18.5%) patients were compared to that of 141 (81.5%) patients with C-pHPT. RESULTS: MILD-pHP group was more often discovered after non-fractured osteoporosis (21.9% vs 7.1%, p = 0.02) and surgery for chondrocalcinosis was more often carried out (6.3% vs 0%, p = 0.03) in the MILD-pHP group. A Mini-Invasive Parathyroidectomy (MIP) was carried out in 81.3% of cases, and 87.5% of patients had a single adenoma. The rate of multiglandular pathology was not different. Same day discharge was significantly higher in MILD-pHP group (37.5% vs 17.7%, p = 0.01). Success was obtained in 87.5% in the MILD-pHP group, there was no significant difference with the C-pHP group (92.9%, p = 0.48). There was no significant difference in the imaging performances. Imaging discordance was observed in 18.8% of cases in MILD-pHP and 33.6% in C-pHP (p = 0.38) without correlation with surgical failure. CONCLUSION: This study suggests that, by selecting patients on the basis of concordant imaging and international recommendations, there is no difference in outcome between MILD-pHP and C-pHP treated surgically.

Neck Surgery with Hypnosis: An Evaluation Based Upon Patient's Self Assessment.

BACKGROUND: Surgery with hypnosis avoids the use of general anesthesia (GA). It also shortens hospitalization and promotes outpatient surgery. The objective of this study has been to assess the satisfaction of operated patients. No previous study has focused on patient satisfaction in a prospective design. METHODS: In this prospective, non-randomized, observational study, all patients operated with hypnosis between 2009 and 2017 in the Ear, Nose, and Throat department of a tertiary care hospital were selected. All patients were asked to fill a questionnaire based on a previously validated questionnaire incremented with complementary questions. Questionnaires were completed immediately after surgery for 31 patients and after 6 months for 20 patients. Global Satisfaction Index (GSI) was self-assessed on a scale ranging from 1 to 10. Patients were asked; whether they felt comfortable during the operation, whether hypnosis helped them, whether the experience matched their expectations, whether they would revisit or recommend it to someone else and whether they considered to have been sufficiently informed before the procedure. The data was analyzed using a linear regression model with P < .05 considered as statistically significant. RESULTS: During the inclusion period, no patient required conversion to GA. A total of 48 questionnaires were evaluated. The median of the GSI was 8/10. GSI significantly correlated with patient comfort (P < 0.0001) and quality of preoperative information (P = .002). The percentage of patients who found hypnosis helpful correlated with the duration of surgery (P = .04). The probability for a patient to consider hypnosis as an experience matching their expectation increased with surgical team experience OR 0.55 (0.3-0.9). CONCLUSION: This study reveals that patients' global satisfaction after hypnosis is high. This is significantly related to the quality of preoperative information and to the experience of the surgical team. It also suggests that patients are more likely to benefit from hypnosis if the surgery is longer.

Fascia Temporalis Free Flap for Cricotracheal Reconstruction: A Novel Approach.

BACKGROUND: The aim of tracheal reconstruction is to provide an airtight and noncollapsible airway covered with a suitable epithelial lining. To date, no ideal treatment is available for large tracheal defects. METHODS: We report 4 patients who underwent one-stage reconstruction for a cricotracheal stenosis with a free temporoparietal fascia flap and costal cartilage grafts. RESULTS: Closure of tracheostoma was achieved for all patients. The main advantage of this flap compared with the free radial forearm flap is that it supplies a more suitable lining allowing the reepithelialization process with respiratory epithelium. CONCLUSIONS: This one-stage procedure provides a reliable construct to substitute for large tracheal defects, even in areas previously exposed to an operation or radiotherapy.

Can a Circular Payment Card Format Effectively Elicit Preferences? Evidence From a Survey on a Mandatory Health Insurance Scheme in Tunisia.

BACKGROUND: The choice of elicitation format is a crucial but tricky aspect of stated preferences surveys. It affects not only the quantity and quality of the information collected on respondents' willingness to pay (WTP) but also the potential errors/biases that prevent their true WTP from being observed. OBJECTIVES: We propose a new elicitation mechanism, the circular payment card (CPC), and show that it helps overcome the drawbacks of the standard payment card (PC) format. It uses a visual pie chart representation without start or end points: respondents spin the circular card in any direction until they find the section that best matches their true WTP. METHODS: We performed a contingent valuation survey regarding a mandatory health insurance scheme in Tunisia, a middle-income country. Respondents were randomly allocated into one of three subgroups and their WTP was elicited using one of three formats: open-ended (OE), standard PC and the new CPC. We compared the elicited WTP. RESULTS: We found significant differences in unconditional and conditional analyses. Our empirical results consistently indicated that the OE and standard PC formats led to significantly lower WTP than the CPC format. CONCLUSION: Overall, our results are encouraging and suggest CPC could be an effective alternative format to elicit 'true' WTP.

The hidden economic burden of air pollution-related morbidity: evidence from the Aphekom project.

Public decision-makers commonly use health impact assessments (HIA) to quantify the impacts of various regulation policies. However, standard HIAs do not consider that chronic diseases (CDs) can be both caused and exacerbated by a common factor, and generally focus on exacerbations. As an illustration, exposure to near road traffic-related pollution (NRTP) may affect the onset of CDs, and general ambient or urban background air pollution (BP) may exacerbate these CDs. We propose a comprehensive HIA that explicitly accounts for both the acute effects and the long-term effects, making it possible to compute the overall burden of disease attributable to air pollution. A case study applies the two HIA methods to two CDs-asthma in children and coronary heart disease (CHD) in adults over 65-for ten European cities, totaling 1.89 million 0-17-year-old children and 1.85 million adults aged 65 and over. We compare the current health effects with those that might, hypothetically, be obtained if exposure to NRTP was equally low for those living close to busy roads as it is for those living farther away, and if annual mean concentrations of both PM10 and NO2-taken as markers of general urban air pollution-were no higher than 20 µg/m3. Returning an assessment of € 0.55 million (95 % CI 0-0.95), the HIA based on acute effects alone accounts for only about 6.2 % of the annual hospitalization burden computed with the comprehensive method [€ 8.81 million (95 % CI 3-14.4)], and for about 0.15 % of the overall economic burden of air pollution-related CDs [€ 370 million (95 % CI 106-592)]. Morbidity effects thus impact the health system more directly and strongly than previously believed. These findings may clarify the full extent of benefits from any public health or environmental policy involving CDs due to and exacerbated by a common factor.

[Epidemiology and anatomy of head and neck cancers]. / Épidémiologie et anatomie des cancers ORL.

Oral cavity and pharyngeal cancers account for 75% of head and neck cancers and are the fourth most spread cancer in men. Their incidence has decreased since 1980 in men (incidence from 2011 gives 13,930 for lip, oral cavity, pharyngeal and laryngeal carcinomas) but has increased in women, linked to the more recent smoking or alcohol intoxication in women. In addition to the smoking or alcohol consumption risk factors, the EBV role in nasopharyngeal carcinomas, HPV in the oropharyngeal carcinomas and professional exposures in paranasal sinuses cancers are recognized. Head and neck cancers are the fifth most common cancer in men mortality in France. Extended anatomical sites reflect the diagnostic's complexity specific to some locations (sinuses, nasopharynx), possible therapies and prognosis depending on the affected site.

Economic valuation of the mortality benefits of a regulation on SO2 in 20 European cities.

BACKGROUND: Since the 1970s, legislation has led to progress in tackling several air pollutants. We quantify the annual monetary benefits resulting from reductions in mortality from the year 2000 onwards following the implementation of three European Commission regulations to reduce the sulphur content in liquid fuels for vehicles. METHODS: We first compute premature deaths attributable to these implementations for 20 European cities in the Aphekom project by using a two-stage health impact assessment method. We then justify our choice to only consider mortality effects as short-term effects. We rely on European studies when selecting the central value of a life-year estimate (€ 2005 86 600) used to compute the monetary benefits for each of the cities. We also conduct an independent sensitivity analysis as well as an integrated uncertainty analysis that simultaneously accounts for uncertainties concerning epidemiology and economic valuation. RESULTS: The implementation of these regulations is estimated to have postponed 2212 (95% confidence interval: 772-3663) deaths per year attributable to reductions in sulphur dioxide for the 20 European cities, from the year 2000 onwards. We obtained annual mortality benefits related to the implementation of the European regulation on sulphur dioxide of € 2005 191.6 million (95% confidence interval: € 2005 66.9-€ 2005 317.2). CONCLUSION: Our approach is conservative in restricting to mortality effects and to short-term benefits only, thus only providing the lower-bound estimate. Our findings underline the health and monetary benefits to be obtained from implementing effective European policies on air pollution and ensuring compliance with them over time.

Chronic burden of near-roadway traffic pollution in 10 European cities (APHEKOM network).

Recent epidemiological research suggests that near road traffic-related pollution may cause chronic disease, as well as exacerbation of related pathologies, implying that the entire "chronic disease progression" should be attributed to air pollution, no matter what the proximate cause was. We estimated the burden of childhood asthma attributable to air pollution in 10 European cities by calculating the number of cases of 1) asthma caused by near road traffic-related pollution, and 2) acute asthma events related to urban air pollution levels. We then expanded our approach to include coronary heart diseases in adults. Derivation of attributable cases required combining concentration-response function between exposures and the respective health outcome of interest (obtained from published literature), an estimate of the distribution of selected exposures in the target population, and information about the frequency of the assessed morbidities. Exposure to roads with high vehicle traffic, a proxy for near road traffic-related pollution, accounted for 14% of all asthma cases. When a causal relationship between near road traffic-related pollution and asthma is assumed, 15% of all episodes of asthma symptoms were attributable to air pollution. Without this assumption, only 2% of asthma symptoms were attributable to air pollution. Similar patterns were found for coronary heart diseases in older adults. Pollutants along busy roads are responsible for a large and preventable share of chronic disease and related acute exacerbations in European urban areas.

Air pollution interventions and their impact on public health.

INTRODUCTION: Numerous epidemiological studies have found a link between air pollution and health. We are reviewing a collection of published intervention studies with particular focus on studies assessing both improvements in air quality and associated health effects. METHODS: Interventions, defined as events aimed at reducing air pollution or where reductions occurred as a side effect, e.g. strikes, German reunification, from the 1960s onwards were considered for inclusion. This review is not a complete record of all existing air pollution interventions. In total, 28 studies published in English were selected based on a systematic search of internet databases. RESULTS: Overall air pollution interventions have succeeded at improving air quality. Consistently published evidence suggests that most of these interventions have been associated with health benefits, mainly by the way of reduced cardiovascular and/or respiratory mortality and/or morbidity. The decrease in mortality from the majority of the reviewed interventions has been estimated to exceed the expected predicted figures based on the estimates from time-series studies. CONCLUSION: There is consistent evidence that decreased air pollution levels following an intervention resulted in health benefits for the assessed population.

Impact of information on intentions to vaccinate in a potential epidemic: Swine-origin Influenza A (H1N1).

Vaccination campaigns to prevent the spread of epidemics are successful only if the targeted populations subscribe to the recommendations of health authorities. However, because compulsory vaccination is hardly conceivable in modern democracies, governments need to convince their populations through efficient and persuasive information campaigns. In the context of the swine-origin A (H1N1) 2009 pandemic, we use an interactive study among the general public in the South of France, with 175 participants, to explore what type of information can induce change in vaccination intentions at both aggregate and individual levels. We find that individual attitudes to vaccination are based on rational appraisal of the situation, and that it is information of a purely scientific nature that has the only significant positive effect on intention to vaccinate.