Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort.

BACKGROUND AND PURPOSE: Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort. METHODS: Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses. RESULTS: Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]). CONCLUSIONS: We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.

Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years.

INTRODUCTION: An infected non-union is a major complication following bone fracture. While bone union can be obtained in 70% to 100% of cases, treatment of osteomyelitis is less predictable, with reported healing rates ranging from 40% to 100%. The primary aim of this study was to assess the success rate of treating infected non-unions of the tibia and femur by a team specializing in complex bone and joint infections. MATERIAL AND METHODS: This single-center retrospective study included all patients operated between 2002 and 2012 due to an infected non-union of the femur or tibia using standardized surgical methods. The procedure was typically done in two phases: excision of the infected site and stabilization, followed by bone reconstruction after a waiting period. Additional procedures (lavage and/or bone grafting) were performed in some cases. A minimum 6-week course of antibiotic therapy was given. The primary endpoint was successful medical and surgical treatment after a minimum 2 years' follow-up defined as healing of the infection (no local clinical signs of infection, ESR≤20mm and CRP≤10mg/L, no mortality attributed to the infection) and radiological and clinical bone union, with the lower limb spared. RESULTS: Fifty-five patients (39 men, 16 women) were included with an average age of 37±11 years. There were 40 tibial fractures and 15 femur fractures. A polymicrobial infection was present in 47% of cases. Repeat surgery was required in 56.4% of patients. At an average of 4±2 years from the first surgical procedure, the treatment was successful in 49 patients (89%): 36 tibia (90%) and 13 femur (87%). The mean time to union was 9±4 months. There were six failures: 3 amputations at 5, 6 and 16 months; 1 mechanical and infection-related failure; 2 failed union. CONCLUSION: This study found that 89% of patients with an infected tibial or femoral non-union treated by a team specialized in complex bone and joint infections using a standardized surgical protocol had bone union and healing of the infection in an average of 9 months. LEVEL OF EVIDENCE: IV, retrospective study.

Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique).

In comminuted fractures of the intercondyloid eminence of the tibial spine, the quality of the reduction and the arthroscopic fixation, notably adjustable suture button fixation, is sometimes disappointing with reduction defects of the anterior bone block. In the Speed-Bridge technique, the two traction sutures of the adjustable button fixation are replaced with two braided sutures of different colors. After the button is placed above the eminence, reduction is obtained by tightening the loop of the button. The accessory communitive fragments are then packed in the depression around the main fragment. A second row provides bone suturing for these accessory fragments; traction sutures of the button are attached anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-type inverted-V bone suture. The Speed-Bridge arthroscopic reinsertion technique of the tibial eminence effectively completes the adjustable button bone suture technique for communitive fractures to obtain better reduction and good stability.

Health needs and public health functions addressed in scientific publications in Francophone sub-Saharan Africa.

OBJECTIVE: To describe the reporting of public health research in Francophone sub-Saharan Africa (FSA). STUDY DESIGN: A bibliometric research study of scientific public health publications in FSA, which includes 24 countries and approximately 260 million people. METHODS: Two researchers analysed original articles published in 2007 in the medical or social sciences fields and indexed in Scopus. At least one co-author of articles had to be based in FSA. The analysis focused on research field, public health function (WHO classification), FSA country author's affiliation, language, journal type and global burden of disease (WHO classification). RESULTS: Of 1047 articles retrieved by the search, 212 were from the public health field. The number of articles per country varied from 0 to 36. Public health functions examined were health service research (24.5%), health monitoring (27.4%), prevention (15%) and legislation (0.5%). The distribution of health needs described in the articles was close to that of the WHO data for Africa for 2004: infectious and parasitic diseases (70% vs 54%), maternal and perinatal conditions (15% vs 17%), non-communicable diseases (15.6% vs 21%), and injuries (0.5% vs 8%). CONCLUSION: The areas reported in published articles from sub-Saharan Africa reflect the health needs distribution in Africa; however, the number of publications is low, particularly for prevention. In light of the current focus on evidence-based public health, this study questions whether the international scientific community adequately considers the expertise and perspectives of African researchers and professionals.

[An optimum donor site for venous grafting for microsurgery]. / Un site optimal de greffons veineux microchirurgicaux (étude anatomique des veines satellites de l'artère radiale).

We report the results of an anatomic study based on 10 cadavers. The aim of this work is to find an optimum donor site for venous grafts which is safe, reproducible, and suitable for microsurgery stitches especially in finger reimplantation, when a long and small calibre graft is needed. This study describes the deep venous network of the radial artery, an original donor site for microsurgical venous grafts. The second aim is to describe our technique of harvesting. Dissections always show two satellite veins, that can be harvested with optimal average diameter of 1.8mm constant over the whole length. The maximum length available is about 126.5mm for the radial satellite vein, and 125 mm for the ulnar one, with a few number of collateral ligatures needed. No tying is required in 60% cases for radial satellite vein, and one ligature for the other 40%, whereas in the ulnar satellite vein, no tying is needed in 80% and just one in the other 20%. This original site is advantageous in microsurgery of the upper limb, offering an easy, quick, safe and reproducible option in an emergency situation.

[A qualitative study for identifying determinants of the quality of stroke patient referral]. / Etude qualitative pour l'identification des facteurs influençant la qualité de l'orientation et du transfert de patients atteints d'accident vasculaire cérébral.

BACKGROUND: Referral of patients from acute to rehabilitation care is a key stage in the overall quality of stroke care. The aim is to choose the most appropriate care pathway taking into account patient needs and preferences, as well as constraints such as bed availability. The objective of the project was to identify factors contributing to the quality of transfer decisions. METHODS: Semi-directive interviews were conducted among health care professionals, patients and their relatives. From this work, a preliminary list of factors contributing to the quality of the referral decision was issued. In order to identify their pertinence and feasibility, these factors were re-phrased into criteria, and introduced into a Delphi questionnaire which was circulated twice among a panel of 39 health care professionals. RESULTS: At the end of the Delphi survey there was consensus about: the importance of the mutual knowledge between acute and rehabilitation teams, the possibility to call on rehabilitation competencies in order to define rehabilitation objectives while the patient is hospitalised in acute care, the attention given to patient preferences, and reliability of information exchange between teams. A consensus was reached for one of the six criteria regarding feasibility, specifically the awareness of admission procedures in rehabilitation wards. CONCLUSION: Establishing a list of selected criteria is a first step in the development of an evaluation tools which could be used within a network of health care structures involved in the care of stroke patients.

[Mortality rates in rural and urban areas of Brittany]. / Mortalité urbaine et rurale en Bretagne.

Relative differences in environment, behaviour, social composition as well as access to health care tend to suggest that levels of health may vary between urban and rural areas. The aim of this study was to identify rural-urban variations in mortality risks in the region of Brittany for the period from 1988 to 1992. The definition of urban and rural areas used adhered to that of the zoning of urban areas established by the INSEE (the National Statistical Office). The amalgamation of all causes of standardised mortality ratios (SMR) show only a moderately increased risk in the rural areas compared with the overall regional level (+4% in men, +5-7% in women). The analysis of cause specific SMRs display higher rural mortality for cardiovascular diseases and external causes of death, road traffic accidents in particular (+24% in men). Among all specific causes investigated, only lung cancer mortality risk appears to be higher in urban areas.

Color Doppler study of the venous circulation in the fetal brain and hemodynamic study of the cerebral transverse sinus.

OBJECTIVES: To describe the venous circulation in the fetal brain; to describe the normal blood flow velocity waveform in the transverse sinus and to establish normal reference ranges for the second half of gestation. POPULATION: A total of 126 pregnant women with uncomplicated pregnancies at 20-42 weeks of gestation. METHODS: A combination of color-coded Doppler and two-dimensional real-time ultrasound was used to identify the main venous systems in the fetal brain. Blood flow velocity waveforms of the transverse sinus were obtained from a transverse plane of the head at the level of the cerebellum. RESULTS: A waveform could be obtained in the cerebral transverse sinus in 98% of the cases. The waveform obtained was triphasic with a forward systolic component, a forward early diastolic component and a lower forward component in late diastole. Reverse flow during atrial contraction was seen before 28 weeks and the diastolic flow increased with gestation thereafter. Pulsatility and resistance indices decreased and flow velocities increased in the transverse sinus throughout gestation. CONCLUSION: The venous circulation of the fetal brain can be identified by color Doppler. The gestational age-related decrease in resistance and increase in flow velocities suggest that hemodynamic studies of the cerebral transverse sinus might have clinical implications in studying compromised fetuses.

Pneumococcal bacteraemia and meningitis in England and Wales, 1993 to 1995.

A total of 10,346 blood and 682 cerebrospinal fluid (CSF) isolates of Streptococcus pneumoniae were reported to the PHLS Communicable Disease Surveillance Centre from laboratories in England and Wales from 1 January 1993 to 31 December 1995. This corresponds to a mean annual incidence of 6.7 per 100,000 episodes of bacteraemia and 0.44/100,000 of meningitis. Absolute numbers of pneumococcal bacteraemia were similar to levels reported between 1990 and 1992, but fewer isolates of pneumococci were made from CSF. There was no discernible overall trend between 1993 and 1995, but age specific incidence suggested a slight increase in bacteraemia in older age groups. Estimated case fatality rates were 20% for pneumococcal bacteraemia and 22% for meningitis. The proportion of pneumococcal strains resistant to penicillin and erythromycin rose between 1989 and 1995 from 0.3% to 2.9% and 3.3% to 10.9%, respectively. The persistent threat of invasive pneumococcal infections highlights the need for continuing laboratory surveillance (including serotyping), appropriate use of antibiotics, and immunisation of groups at risk. The development of conjugate vaccines offers new prospects for prevention.

The provision of private charitable hospital care in west Africa--a case study.

The Hôpital Protestant de Dabou (HPD), a private charitable hospital located in a rural area of the Ivory Coast, has seen its activity decreasing significantly since the beginning of the 1990s. The decrease affected mainly the paediatric and the general medicine specialties. An evaluation suggested that this appeared to have resulted from a combination of determinants including decreasing level of financial support from government and aid agencies, rise in the hospital price list rendering services financially inaccessible to the local population, and episodes of drug shortage. The HPD is facing two options, the first being to evolve towards a self-sufficient organization offering expensive health care to the wealthiest part of the population, thus departing from the original driving principles of affordability and value for money. The second option is to try to stick to these principles by actively seeking greater financial support from government and aid agencies. External donors may find that only with their continued support can the qualities of responsiveness, flexibility and innovation displayed by the HPD and other comparable hospitals be preserved.