Evaluation of patient reported outcome measures and costs of managing osteoarthritis of the hip.

The number of hospital admissions for a hip prosthesis increased by more than 91% between 2002 and 2019 in Belgium (1), making it one of the most common interventions in hospitals. The objective of this study is to evaluate patient-report- ed outcomes and hospital costs of hip replacement six months after surgery. Both generic (EQ-5D) and specific (HOOS) PROMs of general hospital patients undergoing hip replacement surgery in 2021 were conducted. The results of these PROMs were then combined with financial and health management data. The mean difference (SD) in QALYs between the preoperative and postoperative phases is 0.20 QALYs (0.32 QALYs). The average cost (SD) of all stays is €4,792 (€1,640). Amongst the five dimensions evaluated in the EQ-5D health questionnaire, the 'pain' dimension seems to be associated with the greatest improvement in quality of life. As regards Belgium, the 26,066 arthroplasties performed in 2020 might constitute a gain of 123,000 years of life in good health. The relationship between QALYs and costs described in this study posits a ratio of €23,960 per year of life gained in good health. Given that in Belgium more than 3% of the hospital healthcare budget is devoted to hip prostheses, it would seem relevant to us to apply PROM tools to the entire patient population to assess treatment effectiveness more broadly, identify patient needs and, also, monitor the quality of care provided.

Umbilical spider's web.

Question: We report the case of a 38y old woman who consulted for chronic diffuse abdominal pain related to previous irritable bowel syndrome diagnosis. Physical examination showed nonblanching reddish hyperpigmented reticular peri-umbilical skin patch (figure 1). What's your diagnosis? Answer: The diagnosis of erythema ab igne was made. Additional investigations confirmed repeated use of hot water bottles applied on abdominal wall for 3 weeks overnight for pain relief. Erythema ab igne is a pathognomonic cutaneous presentation of long-lasting exposure to heat sources (1). The pathophysiology of erythema ab igne remains uncertain. It has been suggested that heat exposure damages dermal vascular plexus and subsequent hemosiderin deposition leading to spider's web-like hyperpigmentation. Differential diagnosis of peri -umbilical dermatological manifestations includes digestive-related entities as caput medusae's sign (related to portal hypertension), Cullen's sign or Walzel's sign (related to acute pancreatitis); and non-digestive-related entities such as livedo reticularis (2). Erythema ab igne is well known from the dermatologists, mostly located on the lower limbs due to prolonged close exposition to heaters or on thighs due to laptop batteries (3). Erythema ab igne is usually of benign course, most often self-resolving after heat exposure discontinuation (3). We believe that it is of paramount to take into consideration the patients' pain and to propose an adapted management to avoid self-treatment.

Immune profile at HIV infection diagnosis: Evolution in the French Alps area over the last 20 years.

OBJECTIVES: Health of HIV-infected people relies on early antiretroviral therapy, i.e. early diagnosis. We aimed to determine whether the characteristics at HIV diagnosis in two French medical centres changed over the last 20 years. PATIENTS AND METHODS: All individuals diagnosed with HIV infection in Grenoble University Hospital (N=814) and Annecy Hospital (N=246) between 1997 and 2015 were included. We collected age, country of birth, mode of transmission, CD4T cell count, CD4/CD8 ratio, and HIV viral load. RESULTS: Among the 1060 patients (mean age 37.4±11 years, 70.2% of men), 42.5% were men having sex with men (MSM); 65.2% were born in France, and 24.4% were born in Africa. Mean CD4T cell count at diagnosis was 396±288/mm3 and was stable over the study period when considering all patients; when considering the MSM group, a significant increase over time was observed, with a mean increase of 7.3 CD4/mm3 per year (P<0.001). A higher CD4 count at diagnosis was observed after 2005 (400±289 vs 468±271/mm3, P=0.005). The proportion of MSM patients with a CD4 count<200/mm3 at diagnosis was lower after 2005 (14.7% after 2005 and 25.6% before, P=0.028) This was not observed in heterosexual patients (born in Africa or not). CONCLUSION: In the MSM population, CD4 count at diagnosis is higher after 2005, suggesting that screening campaigns have become more efficient. This was not observed in other populations, who should be better targeted in future strategies.

[Chronic autoimmune gastritis : a multidisciplinary management]. / La gastrite chronique auto-immune : une prise en charge multidisciplinaire.

Chronic autoimmune gastritis (CAG) is a continuum of histological changes in gastric mucosa including: atrophy, intestinal metaplasia, dysplasia and finally, the occurrence of a neoplasm (gastric Neuroendocrine Tumors -NETs- and adenocarcinoma). The association with Hashimoto and Graves-Basedow disease is known as the thyrogastric autoimmune syndrome. While Helicobacter pylori (Hp) infection may be associated with CAG, the role of the gastric microbiota is ill-defined. The gastric hypochlorhydria determines a malabsorption of different micronutrients (iron, magnesium, calcium, vitamin B12) as well as drugs (thyroxine, etc.). Pernicious anemia is favoured by the deficit of parietal intrinsic factor that contributes to B12 malabsorption. Serology for Hp, serum pepsinogen I/II, increased gastrin levels, the presence of parietal cell antibodies and intrinsic factor antibodies may reveal CAG. High definition endoscopy associated with virtual chromoendoscopy seems promising for CAG diagnosis and follow-up. NETs type 1 treatment includes: endoscopic and surgical resection, somatostatin analogues and the recent availability of netazepide, a gastrin antagonist. We review herein advances in the treatment and diagnosis of CAG and associated autoimmune disorders, which may involve, in a multidisciplinary way, all practitioners.

La gastrite chronique auto-immune (GAI) est un continuum d'altérations de la muqueuse gastrique incluant : atrophie, métaplasie intestinale, dysplasie et, enfin, la survenue d'une néoplasie (tumeurs neuroendocrines [NETs] gastriques et adénocarcinome). L'association avec la maladie de Hashimoto et de Graves-Basedow est connue comme syndrome thyrogastrique auto-immun. Alors que l'Helicobacter pylori (Hp) peut s'associer avec la GAI, le rôle du microbiote gastrique est mal défini. L'hypochlorhydrie gastrique détermine une malabsorption de micronutriments (fer, magnésium, calcium, vitamine B12) et de médicaments (thyroxine et autres). L'anémie de Biermer est favorisée par le déficit de production du facteur intrinsèque pariétal, contribuant à la malabsorption de B12. Un rapport diminué de pepsinogène I/II, une augmentation de la gastrine, la présence d'anticorps anti-cellule pariétale, les anticorps anti-facteur intrinsèque et la sérologie pour Hp contribuent à révéler précocement le diagnostic de GAI. L'endoscopie haute définition, associée à la chromoendoscopie virtuelle, semble prometteuse dans le diagnostic et dans le suivi. Le traitement des NETs gastriques de type 1, favorisées par la GAI, inclut : la résection endoscopique/chirurgicale, les analogues de la somatostatine et l'antagoniste de la gastrine nétazépide. Nous résumons ici les avancées diagnostiques et thérapeutiques dans la GAI et dans les affections associées : elles impliquent, de façon multidisciplinaire, l'ensemble des praticiens.

[Study of cancer risks associated with Lynch syndrome in the Liège region]. / Etude des risques oncologiques associés au syndrome de Lynch en région liégeoise.

Lynch syndrome is a hereditary predisposition to several cancers. The goals of our study were to know the different mutations in our Lynch population, to evaluate the prevalence of cancers in this population and to determine the mean age of onset of those cancers. This retrospective study includes proven carriers of a MMR mutation diagnosed either by the CHU of Liège or either by the CHC Saint-Joseph in Liège, Belgium. We noted a clear majority of MSH2 mutations (50 %) in the Lynch families recorded in Liège, which is different from the main literature. In our study population (106 subjects), 65 % of subjects were affected by at least one cancer. Prevalences for colorectal and endometrial cancers are, respectively, 50 % and 27.5 %. We found no difference in the mean age of onset of cancers compared to literature. We discuss the follow-up of Lynch patients and the interest of additional exams such as hysteroscopy and cystoscopy.

Le syndrome de Lynch est un syndrome de prédisposition héréditaire à un certain nombre de cancers. Les objectifs de notre étude sont de connaître la répartition des différentes mutations dans la population Lynch prise en charge dans nos centres, d'évaluer la prévalence des cancers présentés par les patients Lynch de cette population et de déterminer l'âge moyen d'apparition de ces cancers. Cette étude rétrospective inclut les porteurs confirmés d'une mutation MMR ayant été diagnostiqués, soit par le CHU de Liège, soit par le CHC Saint-Joseph à Liège. Nous avons constaté une nette majorité de mutations MSH2 (50 %) parmi les familles Lynch répertoriées à Liège, ce qui est différent de ce qui est décrit dans la littérature. Dans notre population d'étude (106 sujets), 65 % des sujets ont présenté au moins un cancer. Les prévalences du cancer colorectal et de l'endomètre sont, respectivement, de 50 % et 27.5 %. Nous n'avons pas trouvé de différence dans les âges moyens de présentation des cancers par rapport à la littérature existante. Nous discutons du suivi des patients porteurs d'un syndrome de Lynch et de la place d'examens supplémentaires comme l'hystéroscopie et la cystoscopie.

Evaluation of cost and length of stay, linked to complications associated with major surgical procedures.

INTRODUCTION: A lot of studies have demonstrated the possibility of reducing the number of post-operative complications in the domain of major surgical procedures with the use of medical preventive techniques. However, complications following surgical procedures are unfortunately frequent and are a major problem, not only because of the impact for the patient, but also because of economic consequences that they provoke. The aim of the present study is to evaluate the extra length of stay and the extra cost, born by the hospital and the social security, linked to complications, incurring after major surgical procedures. MATERIAL AND METHODS: Study based on the data from 13 Belgian hospitals for the year 2012. Complications were extracted through medical discharge summaries. The cost born by the social security was assessed on the basis of the billing data, hospital cost are taken from cost accounting studies. RESULTS: The rate of complication for all the hospitals is 6.6%. About 30.3% of inpatient stays having a major or extreme severity of index had a complication during the stay, 1.8% of stays with a minor or moderate severity of index had a complication. The extra length of stay is 19.38 days when the stay has had a complication (p < 0.001). The additional mean cost borne from the hospital perspective is €21 353.07 and €8 026.65 for the social security. This additional mean cost varies greatly from one hospital to another. DISCUSSION/CONCLUSION: The present study has shown that the actual financing do not cover real hospital costs in the field of major surgical procedures having caused complications. Results should encourage Belgian authorities to propose and finance preventive measures in order to reduce these complications, which represent major economic impacts, not only for authorities but also for hospitals.

[Cost evaluation of organ harvesting in a Belgian academic hospital]. / Evaluation du coût de revient des prélèvements d'organes effectués dans le cadre de l'activité de transplantation d'un centre universitaire belge.

INTRODUCTION: The aim of this study is (1) to describe the characteristics of the organ harvesting activity conducted in 2012 at the Erasme's Hospital, Brussels University Hospital, (2) to highlight the different combinations " type of donor/types of organ's retrieved " in relation to organ harvestings carried out within the hospital, and (3) to calculate the organ harvesting's cost of acts. METHODS: The study is conducted according to the hospital perspective. It assesses the consumption of medical and nursing staff resources, disposable material costs, medical device costs, drugs costs, sterile instruments and biomedical equipment costs, of the 34 organ harvesting procedures that has been conducted this year. Costs are calculated by procedure, by donor's type, by organ and by combinations. RESULTS: Total cost is 99.442 €, with an average cost per donor of 3.016 €, 3.292 € for DBD postmortem donor (Donor Brain Death) and 2.456 € for DCD type (Donor Cardio-Circulatory Death). The average cost per organ leading to a transplantation is 1.842 € for DCD type and 1.297 € for DBD. CONCLUSION: The results show that there is as many costs as the number of organ harvesting's combinations. Integrate the revenue generated by organ harvestings could establish whether funding sources cover the costs generated by this activity or if a reform of the nomenclature should be considered.

INTRODUCTION: Les objectifs de ce travail sont (1) de décrire les caractéristiques de l'activité de prélèvement d'organes réalisée en 2012 par l'Hôpital Erasme, Cliniques Universitaires de Bruxelles, (2) de mettre en évidence les différentes combinaisons " type de donneur/types d'organes prélevés " rencontrées dans le cadre des prélèvements d'organes effectués au sein de l'institution, et (3) de calculer le coût de revient des actes de prélèvement d'organes. Matériel et méthodes : L'évaluation du coût est menée du point de vue du fournisseur de soins. Elle évalue la consommation des ressources en personnel médical et soignant, produits médicaux courants, dispositifs médicaux de viscérosynthèse, spécialités pharmaceutiques, instruments stériles et équipements biomédicaux, de 34 procédures de prélèvement d'organes. Les coûts sont calculés par type de donneur, par organe et par combinaison de prélèvement. Résultats : Le coût total calculé s'élève à 99.442 €, avec un coût moyen par donneur vivant à 3.016 €, par donneur post-mortem de type DBD (Donor Brain Death) à 3.292 €, et de type DCD (Donor Cardio-Circulatory Death) à 2.456 €. Par organe prélevé ayant abouti à la transplantation, le coût moyen est de 1.842 € lorsqu'il provient d'un donneur de type DCD, et de 1.297 € s'il provient d'un donneur de type DBD. CONCLUSION: Les résultats montrent qu'il y a autant de coûts de prélèvement que de combinaisons de prélèvement. Intégrer les recettes générées par les prélèvements permettrait d'établir si les sources de financement couvrent les frais engendrés par cette activité, ou si une réforme de la nomenclature devrait être envisagée dans ce secteur d'activité.

Observation-Based Estimates of Global Glacier Mass Change and Its Contribution to Sea-Level Change.

Glaciers have strongly contributed to sea-level rise during the past century and will continue to be an important part of the sea-level budget during the twenty-first century. Here, we review the progress in estimating global glacier mass change from in situ measurements of mass and length changes, remote sensing methods, and mass balance modeling driven by climate observations. For the period before the onset of satellite observations, different strategies to overcome the uncertainty associated with monitoring only a small sample of the world's glaciers have been developed. These methods now yield estimates generally reconcilable with each other within their respective uncertainty margins. Whereas this is also the case for the recent decades, the greatly increased number of estimates obtained from remote sensing reveals that gravimetry-based methods typically arrive at lower mass loss estimates than the other methods. We suggest that strategies for better interconnecting the different methods are needed to ensure progress and to increase the temporal and spatial detail of reliable glacier mass change estimates.

What can we learn from international comparisons of costs by DRG?

OBJECTIVES: The objective of this study was to compare costs data by diagnosis related group (DRG) between Belgium and Switzerland. Our hypotheses were that differences between countries can probably be explained by methodological differences in cost calculations, by differences in medical practices and by differences in cost structures within the two countries. METHODS: Classifications of DRG used in the two countries differ (AP-DRGs version 1.7 in Switzerland and APR-DRGs version 15.0 in Belgium). The first step of this study was to transform Belgian summaries into Swiss AP-DRGs. Belgian and Swiss data were calculated with a clinical costing methodology (full costing). Belgian and Swiss costs were converted into US$ PPP (purchasing power parity) in order to neutralize differences in purchasing power between countries. RESULTS: The results of this study showed higher costs in Switzerland despite standardization of cost data according to PPP. The difference is not explained by the case-mix index because this was similar for inliers between the two countries. The length of stay (LOS) was also quite similar for inliers between the two countries. The case-mix index was, however, higher for high outliers in Belgium, as reflected in a higher LOS for these patients. Higher costs in Switzerland are thus probably explained mainly by the higher number of agency staff by service in this country or because of differences in medical practices. CONCLUSIONS: It is possible to make international comparisons but only if there is standardization of the case-mix between countries and only if comparable accountancy methodologies are used. Harmonization of DRGs groups, nomenclature and accountancy is thus required.

The neuroinflammatory response in humans after traumatic brain injury.

AIMS: Traumatic brain injury is a significant cause of morbidity and mortality worldwide. An epidemiological association between head injury and long-term cognitive decline has been described for many years and recent clinical studies have highlighted functional impairment within 12 months of a mild head injury. In addition chronic traumatic encephalopathy is a recently described condition in cases of repetitive head injury. There are shared mechanisms between traumatic brain injury and Alzheimer's disease, and it has been hypothesized that neuroinflammation, in the form of microglial activation, may be a mechanism underlying chronic neurodegenerative processes after traumatic brain injury. METHODS: This study assessed the microglial reaction after head injury in a range of ages and survival periods, from <24-h survival through to 47-year survival. Immunohistochemistry for reactive microglia (CD68 and CR3/43) was performed on human autopsy brain tissue and assessed 'blind' by quantitative image analysis. Head injury cases were compared with age matched controls, and within the traumatic brain injury group cases with diffuse traumatic axonal injury were compared with cases without diffuse traumatic axonal injury. RESULTS: A major finding was a neuroinflammatory response that develops within the first week and persists for several months after traumatic brain injury, but has returned to control levels after several years. In cases with diffuse traumatic axonal injury the microglial reaction is particularly pronounced in the white matter. CONCLUSIONS: These results demonstrate that prolonged microglial activation is a feature of traumatic brain injury, but that the neuroinflammatory response returns to control levels after several years.

Comparison of cost-weights scales methodologies in the perspective of a financing system based on pathologies.

OBJECTIVES: Objectives of this article are to evaluate the possibility to create a CW scale by pathology on the basis of cost data from Belgian hospitals, to compare several methodologies to create this CW scale, and to evaluate the financial impact of a modification of the financing system on hospitals' income. METHODS: CW scales were elaborated according to various methodologies in order to isolate the scale allowing the most adequate financing system, i.e. approaching the real costs as much as possible. Twelve scales were created. They vary according to the type of data used, according to DRGs and severities of illness included within the scale, and according to the variable used in order to isolate outliers. RESULTS: For a similar case-mix, Hospitals H2 and H5 would see their financing increased through a prospective system based on the selected CW scale (No. 6). This modification would generate a reduction in financing going from -1 to -9% according to hospitals. CONCLUSIONS: The cost database created made it possible to create a CW scale according to a technique which could constitute the first step of a PPS if advantages of a such financing system were established. In the Belgian context, it would be probably judicious to envisage regional databases allowing diversified methodological approaches whose results would be confronted, discussed, and coordinated at the federal level.

[Are extra costs generated by patients justifiable? Methodology and results from a study carried out in a Belgian general hospital]. / Les surcoûts engendrés par certains patients sont-ils justifiables? Méthodologie et résultats d'une étude réalisée dans un hôpital général belge.

Cost outliers account for 6 to 8% of hospital inpatient stays and concentrate 22 to 30% of inpatient costs. Explanatory factors were highlighted in various studies. They are the lenght of stay, an intensive care unit stay, the severity of illness index related to DRG and social factors. Patients are not always explained by these factors. The objective of this study is to analyse cases not explained by those factors, through a detailed analysis of medical files. In the studied hospital, there are 6,3% high cost outliers and 1,1% low cost outliers. These stays were isolated on the basis of a rule based on percentiles. Extra costs generated by high cost outliers are 6.999 euro per stay. The extra lenght of stay for these patients is 20,42 days. Among the 454 patients high cost outliers, 334 patients are explained by factors extracted from a statistical analysis based on a logistic regression (intensive care unit stay, severity of illness index, lenght of stay and social factors). The analysis of medical files of the 120 not explained inpatient stays highlights new explanatory factors (coding errors, heterogeneity of DRGs, etc.). At the end of this study, the conclusion is that a statistical analysis combined with a precise analysis of medical files allowed to explain the majority of cost outliers. An explanation is however not necessarily synonymous with medical justification.

Financial consequences of hospital-acquired bacteraemia in three Belgian hospitals in 2003 and 2004.

The financial and human costs of hospital-acquired infections are increasingly recognised in many healthcare systems. This study seeks to quantify excess expenditures on hospital-acquired bacteraemia (HAB) in three Belgian general hospitals in 2003 and 2004. Patients with HAB were compared with patients in the same All Patient Refined Diagnosis Related Groups (APR-DRGs) without HAB. Patient level costs were estimated using a hospital costing system developed by the 'Université Libre de Bruxelles', and compared with DRG-based funding for the three hospitals. HAB incidence was consistent with the national rate for two of the three hospitals, but considerably higher for the third. Both severity of illness and mortality were higher in the HAB group. Nosocomial bacteraemia was associated with an increased length of stay of 30 days and of 6.1 days in intensive care units. When compared with uninfected patients in the same DRG, treatment of HAB patients cost an additional euro 16,709. At current funding rates, hospitals made a mean profit of euro 446 for uninfected patients, but a mean loss of euro 2,431 for patients with HAB. Our findings suggest that hospitals have a financial interest in reducing the rate of HAB, even in a system which funds such complications through severity adjustments in the APR-DRG system. Growing international interest in pay for performance and other funding schemes will only strengthen these financial incentives.

[Rationale for a fixed implant-supported transitional prosthesis in full-arch implant restorations]. / De l'importance de la prothèse transitoire implantoportée fixée au cours des réhabilitations implantaires complètes.

The use of a fixed transitional prosthesis in implantology remains quite seldom, although the concept of temporization and progressive loading of prosthetic restorations has become a main issue in modern dentistry. Fixed tansitional prostheses play an important role in the validation of full-arch implant-supported restorations, and in the success of implant treatments in general. This paper reviews the basic treatment principles, and discusses the different technical options available to the clinician. In simple cases, a hard resin bridge may be sufficient. However, for complex cases, we should better use fixed implant-supported temporary prosthesis, made in resin on a metallic infrastructure. Moreover, this one could be use as the framework of the permanent prosthesis. This technical solution offers the best guaranty for implant and oral rehabilitation validation before the permanent prosthesis installation.

[Immune reconstitution syndrome and mycobacterial disease during highly active antiretroviral therapy. Retrospective study of six cases]. / Reconstitution immunitaire et infections à mycobactéries sous traitement antirétroviral. Etude rétrospective de 6 observations.

INTRODUCTION: Soon after starting highly active antiretroviral therapy (HAART), some patients experience clinical deterioration due to the reactivation of their immune system. Mycobacteria are the principal agents complicating this immune reconstitution period. CASES: A retrospective examination of patients with mycobacterial disease before or shortly after beginning HAART at Grenoble University Hospital from January 2001 through July 2004 identified six subjects (among 650 outpatients per year) with a new or aggravated mycobacterial disease after starting HAART. Clinical manifestations were: adenopathy (4/6), hyperthermia (3/6), thoracic pain (2/6), abscess (2/6), and neurological deterioration (1/6). DISCUSSION: Severely immunosuppressed patients who begin HAART may reactivate or aggravate a mycobacterial disease such as tuberculosis. In such cases, current recommendations call for continuing HAART, beginning or continuing the antimycobacterial therapy, and considering corticosteroids on a case-by-case basis. For patients with AIDS, opportunistic infections that might be reactivated should be actively sought before HAART.