Estimating the cost-effectiveness of stroke units in France compared with conventional care.

BACKGROUND AND PURPOSE: The incidence of stroke in France is estimated at between 120 000 and 150 000 cases per year. This modeling study assessed the clinical and economic benefits of establishing specialized stroke units compared with conventional care. METHODS: Data from the Dijon stroke registry were used to determine healthcare trajectories according to the degree of autonomy and organization of patient care. The relative risks of death or institutionalization or death or dependence after passage through a stroke unit were compared with conventional care. These risks were then inserted with the costing data into a Markov model to estimate the cost-effectiveness of stroke units. RESULTS: Patients cared for in a stroke unit survive more trimesters without sequelae in the 5 years after hospitalization than those cared for conventionally (11.6 versus 8.28 trimesters). The mean cost per patient at 5 years was estimated at 30 983 for conventional care and 34 638 in a stroke unit. An incremental cost-effectiveness ratio for stroke units of 1359 per year of life gained without disability was estimated. CONCLUSIONS: The cost-effectiveness ratio for stroke units is much lower than the threshold (53 400 ) of acceptability recognized by the international scientific community. This finding justifies organizational changes in the management of stroke patients and the establishment of stroke units in France.

[Knowledge of an urban population about arterial hypertension: prospective study carried out in Ouagadougou, Burkina Faso]. / Connaissances d'une population urbaine sur l'hypertension artérielle: enquête prospective menée à Ouagadougou, Burkina Faso.

The objective of this prospective survey was to estimate the prevalence of hypertension in the city of Ouagadougou and to evaluate the information level as well as the knowledge of the population regarding hypertension. We carried out a urban community based cross sectional study. Subjects were black African, and aged of 18 years at least. They were considered hypertensive when they were under a treatment for hypertension, or when they had high blood pressure (> or = 140/90 mm Hg) according to the WHO classification in 1999. The study selected 3441 subjects, among them 60.4% of women and 39.6% of men. The average age in the sample was 33.1 +/- 13.3 years; 64.4% of the subjects were 20 to 40 years old. The average systolic blood pressure in the population was of 124 +/- 21 mm Hg, and of 78 +/- 12 mm Hg for the diastolic one. The prevalence of hypertension in our sample was 23%, with 20.4% of unknown hypertensive subjects. Hypertension is highly frequent in urban area in Burkina Faso. As it could be expected, the knowledge of the population regarding hypertension proved inversely proportional to the educational level. Information programs and consciousness-raising campaign as well as detection program should be implemented urgently.

Internet pharmaco-economic studies in metastatic colorectal cancer.

An interactive Web site has been developed: http://smbh7.smbh.univ-paris13.fr, which uses a Markov model to calculate the management costs for metastatic colorectal cancer. This site allows drug usage costs, daily tariff costs per site, local ISA point values and the cost to the society of the chemotherapies prescribed to be recorded by cycle in a de-centralised manner. The overall cost of treatment may be calculated by one of these four units from the time when the first chemotherapy was administered until the patient has escaped from first or second line treatment. The median time to progression and the median survival time are key parameters used to calculate costs as they determine the number of patients who remain on treatment, course by course. Effectiveness results have been measured in terms of progression free survival or of global survival. Eight treatment strategies have been examined. It is possible to add new treatment regimens or new compounds into the existing pre-formatted tables. This software enables budgets to be planned depending on the regimen used and the number of patients treated. It also allows the different treatment options to be classified with respect to their incremental cost effectiveness ratio, which is defined by the additional cost of one treatment option compared to another divided by the corresponding increase in effectiveness.

Hemodynamic response to induction and intubation. Propofol/fentanyl interaction.

BACKGROUND: When given as an intravenous bolus for induction of anesthesia, propofol can decrease postintubation hypertension but can also create moderate to severe postinduction, preintubation hypotension. The addition of fentanyl usually decreases the postintubation hypertension but can increase the propofol-induced preintubation hypotension. The goal of the study was to determine the relation between propofol and fentanyl doses and the hemodynamic changes post-induction, preintubation and postintubation. METHODS: Twelve groups of 10 patients, ASA physical status 1 or 2, first received fentanyl 0, 2, or 4 micrograms.kg-1 and then 5 min later received propofol 2.0, 2.5, 3.0, or 3.5 mg.kg-1 as an intravenous bolus for induction of anesthesia. Arterial blood pressure was continuously monitored. The trachea was intubated 4 min after propofol administration. RESULTS: The mean decrease in systolic blood pressure after propofol was 28 mmHg when no fentanyl was given, 53 mmHg after 2 microgram.kg-1 of fentanyl (P < 0.05 vs. no fentanyl), and 50 mmHg after 4 micrograms.kg-1 (P < 0.05 vs. no fentanyl; no statistically significant difference 4 vs. 2 micrograms.kg-1). There was no statistically significant difference in hemodynamic response to intubation relative to propofol dose. Hemodynamic response to intubation was decreased by the administration of fentanyl; the mean increase of systolic blood pressure after intubation was 65 mmHg from preintubation value without fentanyl, 50 mmHg after 2 micrograms.kg-1, and 37 mmHg after 4 micrograms.kg-1 (P < 0.05 for 2 and 4 micrograms.kg-1 vs. no fentanyl and for 4 vs. 2 micrograms.kg-1). Hemodynamic changes postintubation were not statistically different with increasing doses of propofol. CONCLUSIONS: Hemodynamic changes after induction with propofol or propofol/fentanyl, pre- or postintubation, are not modified when the propofol dose is increased from 2 to 3.5 mg.kg-1. Maximal hypotension preintubation occurs with a fentanyl dose of 2 micrograms.kg-1, whereas the magnitude of postintubation hypertension is significantly decreased with an increase in the fentanyl dose to 4 micrograms.kg-1.

Screening for adrenal medullary disease in patients with medullary thyroid carcinoma.

Adrenal medullary disease (AMD) is clinically silent in most patients with medullary thyroid carcinoma (MTC). It was screened yearly by urinary measurements of catecholamines and derivates, and by abdominal ultrasonography (US) in a series of 174 patients with MTC. In cases with suspicion of AMD, abdominal computerized tomography and scintigraphy with meta-iodobenzylguanidine were also performed. AMD was discovered in 10 patients (one adrenal medullary hyperplasia and 9 pheochromocytomas). Three patients were already known to belong to a type II multiple endocrine neoplasia (MEN-2a) family and two had a MEN-2b syndrome. In 5 patients previously considered as having either a sporadic (4 cases) or a familial type of isolated MTC (one case), the occurrence of AMD led to diagnose a MEN-2a syndrome. The diagnostic values of the tests were evaluated by a case-control study. Urinary metanephrine plus normetanephrine (MN+N) had an acceptable sensitivity (0.8) and specificity (0.8). The other urinary tests had a high specificity (range: 0.8 to 1) but a poor sensitivity (range: 0.1 to 0.5). US had a high sensitivity (0.8) and a specificity of one. MN+N and US performed yearly constitute a simple and efficient strategy to screen for AMD in patients with MTC.