Relation between frontal lobe symptoms and dementia severity within and across diagnostic dementia categories.

BACKGROUND: To study frontal lobe symptoms in relation to dementia severity within and across diagnostic dementia categories, a cross-sectional analysis of behavioural data was performed. METHODS: Patients with probable Alzheimer's disease (AD) (n = 456), frontotemporal dementia (FTD) (n = 55) and dementia with Lewy bodies (DLB) (n = 48) were included. Dementia severity and frontal lobe symptoms were assessed by means of the global deterioration scale and the Middelheim frontality score (MFS). RESULTS: In FTD, no difference in MFS total scores between patients belonging to the mild and severe dementia stages was found (p = 0.828). In AD and DLB groups, significantly higher MFS total scores were found in severe dementia stages compared to mild dementia stages (p < 0.001). Comparing MFS total scores between FTD and AD patients, significantly higher scores were achieved in FTD patients, irrespective of dementia severity (p < 0.001). CONCLUSIONS: In FTD patients, frontal lobe symptoms were severe in the mild, moderate and severe dementia stages although the nature of frontal lobe symptoms depended on disease severity. AD and DLB patients displayed more frontal lobe symptoms in the advanced disease stages as compared to disease onset, suggesting gradual frontal lobe involvement as the disease progresses. The nature of frontal lobe symptoms related to dementia severity differed between AD, DLB and FTD patients, suggesting different patterns of frontal lobe involvement. Last but not the least, these data point to the potential diagnostic value of behavioural observation of frontal lobe symptoms for (differential) dementia diagnosis, especially at the earliest disease stages. These findings await confirmation through a prospective, longitudinal study.

Cotard's syndrome: a review.

Cotard's syndrome is a rare disorder in which nihilistic delusions concerning one's own body are the central feature. It is not listed as a specific disorder in the DSM-IV, as it is typically viewed as a part of other underlying disorders. However, it remains important to recognize the syndrome because specific underlying mechanisms are present, and prognostic and therapeutic consequences have to be taken into account. This review presents an up-to-date overview of Cotard's syndrome, which was initially described more than a century ago.

Ostomy appliance prices in Europe.

OBJECTIVE: This article aims to compare market prices (i.e., third-party reimbursement and patient co-payment) of one-piece and two-piece colostomy, ileostomy and ureterostomy appliances in Belgium, Denmark, England and the Netherlands in 2005. METHODS: Data were collected through contacts with health authorities, health insurance companies, manufacturers, industry associations and distributors. The price difference between Belgium and another country was expressed as a proportion of the Belgian price. RESULTS: A total of 64 out of the 72 ostomy appliance products considered were cheaper in Belgium. Prices of one-piece colostomy appliances and two-piece ileostomy appliances were consistently lower in Belgium. The highest prices of ostomy appliances were observed in the Netherlands. Sixteen out of 20 products and 21 out of 25 products were more expensive in Denmark and England, respectively, than in Belgium. Colostomy appliances were more expensive in England than in Belgium. CONCLUSIONS: Market prices varied substantially between countries, indicating that manufacturers adapt their pricing strategy to the policy environment existing in the ostomy appliance market of each country. Also, there appears to be scope for reducing prices in some countries.

Is the geriatric depression scale a reliable screening tool for depressive symptoms in elderly patients with cognitive impairment?

OBJECTIVE: To determine the reliability of the 30-item Geriatric Depression Scale (GDS-30) for the screening of depressive symptoms in dementia and mild cognitive impairment (MCI) using the Cornell Scale for Depression in Dementia (CSDD) as the 'gold standard'. METHODS: Diagnosed according to strictly applied clinical diagnostic criteria, patients with MCI (n = 156) and probable Alzheimer's disease (AD) (n = 247) were included. GDS-30, CSDD, Mini Mental State Examination (MMSE) and Global Deterioration Scale were assessed in all patients at inclusion. The AD group was divided in three subgroups: mild AD (MMSE>or=18) (n = 117), moderate AD (MMSE< 18 and >or=10) (n = 89) and severe AD (MMSE<10) (n = 38). RESULTS: In MCI patients, moderate but highly significant correlations were found between GDS-30 and CSDD scores (Pearson: r = 0.565; p < 0.001). In mildly (r = 0.294; p = 0.001), moderately (r = 0.273; p = 0.010) and severely (r = 0.348; p = 0.032) affected AD patients, only weak correlations between GDS-30 and CSDD scores were calculated. ROC curve analysis showed that sensitivity and specificity values of respectively 95% and 67% were achieved when a GDS-30 cut-off score of 8 was applied in MCI patients. In AD patients, too low sensitivity and specificity values did not allow selecting an optimal cut-off score by means of ROC curve analysis. CONCLUSION: Using the CSDD as 'gold standard', we demonstrated that the GDS-30 is a reliable screening tool for depressive symptoms in MCI but not in AD patients.

International comparison of orthotic brace prices.

This study compared market prices (i.e. third-party reimbursement and patient co-payment) of prefabricated neck, wrist and knee braces in Belgium, France, the Netherlands, Ontario (Canada) and the UK. Data were collected through contacts with health authorities, health insurance funds, manufacturers and distributors. Market prices varied substantially between countries, indicating that manufacturers adapt their price setting strategy to the policy environment and the structure of the brace market of a country. Belgian prices tended to exceed prices in other countries for the selected neck, wrist and knee braces. There seems to be scope for reducing Belgian prices of selected braces.

Atherosclerotic cardiovascular diseases in Belgium: a cost-of-illness analysis.

PURPOSE: This study aims to quantify costs of atherosclerotic cardiovascular diseases in Belgium in 2004. METHODS: Costs were estimated using data on prevalence, healthcare resource utilization and unit costs. Healthcare costs included expenditure on ambulatory care, hospital inpatient care, emergency care, and medications. Costs of prevention campaigns and costs of productivity loss were also included. RESULTS: Costs amounted to 3.5 billion euros in Belgium in 2004. Total costs consisted of 80 million euros related to prevention and screening, 1.3 billion euros related to pre-clinical disease, and 2.2 billion euros related to established disease. These costs were incurred by the Belgian third-party payer (58% of costs), patients (10%) and third parties (i.e. employers and supplementary health insurance) (32%). CONCLUSIONS: Atherosclerotic cardiovascular diseases impose a significant economic burden on Belgian society.

Reversal of head drop after discontinuation of olanzapine in a DLB patient.

We present a 72-year-oldpatient with probable diffuse Lewy body disease and visual hallucinations, who developed subacute reversible "dropped head syndrome" and parkinsonian signs after the introduction of olanzapine at a total daily dose of 10 mg. One week after olanzapine was withdrawn, the patient's posture started to improve. Further improvement was achieved after dopaminergic substitution. Clinical and electrophysiological observations might indicate neck extensor myopathy due to axial rigidity or focal neck dystonia, induced by dopamine receptor blockade.

Reforming the Belgian market for orthotic braces: what can we learn from the international experience?

OBJECTIVES: This article aims to review regulation governing outpatient orthotic braces (neck, wrist and knee braces) in France, the Netherlands and Sweden with a view to reforming the Belgian market. METHODS: Information about the regulatory framework was derived from an analysis of legal texts and a survey completed by national experts. RESULTS: Strategies to keep down prices include public procurement in Sweden, maximum prices in France, and exclusion of expensive braces from reimbursement in the Netherlands. Reimbursement is linked to a medical indication or a chronic condition in France, the Netherlands and Sweden. To gain reimbursement, the cost-effectiveness of orthotic braces needs to be demonstrated in France and the Netherlands. Orthotic braces tend to be initially prescribed by a specialist physician and distributed by orthotists, medical equipment shops and/or community pharmacies. CONCLUSIONS: Extensive government intervention exists in the outpatient orthotic brace market in the countries studied. Our recommendations to reform the Belgian market for prefabricated orthotic braces are to separate reimbursement for service provision from reimbursement for braces; to set prices by means of a tendering process or an international price comparison; and to make reimbursement conditional on effectiveness and cost-effectiveness of braces.

Do tariffs and prices correspond with costs? A case study of orthotic braces.

OBJECTIVES: The Belgian third-party payer wishes to set reimbursement tariffs at a level that reflects the costs of orthotic braces. This article aims to calculate production and distribution costs of a prefabricated hard neck and knee brace and to explore whether Belgian tariffs and actual retail prices correspond with estimated costs of these two braces. METHODS: The cost model considered manufacturing costs, general overheads, research and development costs, warehousing costs, profit and distribution margins. Data were gathered from manufacturers, a production site visit, desk research, a decomposition of finished products and stakeholder interviews. The price year was 2007. RESULTS: The cost model estimated a retail price of euro55-euro150 for the neck brace, depending on assumptions. The estimated retail price for the neck brace was lower than the reimbursement tariff of euro194 and the actual retail price of euro241. The estimated retail price of euro331-euro694 for the knee brace was lower than the actual retail price of euro948. CONCLUSIONS: Actual retail prices and reimbursement tariffs for a neck brace and a knee brace exceeded prices based on estimated costs. Therefore, there appears to be scope for reducing tariffs.

Estimation and comparison of ostomy appliance costs with tariffs in Belgium.

This study estimated costs of production and distribution of ostomy appliances, and compared cost estimates with tariffs in Belgium. The cost model took into account manufacturing costs, overhead, R&D, warehousing, profits, and distribution margins. Data were derived from manufacturers, a decomposition of finished products, and interviews with stakeholders. The cost model generated estimated retail prices of euro 2.96 for one-piece appliances, euro 1.62 for two-piece pouches, and euro 2.06 for two-piece flanges. Production and distribution costs accounted for 40 and 60% of retail prices, respectively. Estimated retail prices corresponded well with tariffs for one-piece appliances and for two-piece pouches. For two-piece regular flanges, a substantial difference was observed between the calculated price of euro 2.06 and the tariffs of euro 6.05. In the absence of publicly disclosed information on the cost structure of appliances, estimating ostomy appliance costs is valuable to reimbursement agencies when setting tariffs.

Drawing on international experience to reform the Belgian market for ostomy appliances.

This article aims to review the regulatory framework governing the Belgian ostomy appliance market in the light of the experience of Denmark, France, the Netherlands and Ontario (Canada) with regulation of ostomy appliances. Information about the regulatory framework was derived from the international literature, analysis of legal texts and a survey completed by national experts. The comparative analysis revealed that these countries have adopted varying approaches towards regulating their domestic ostomy appliance market. Strategies to keep down prices include public procurement in Denmark, maximum prices in France and exclusion of expensive appliances from reimbursement in the Netherlands. To contain public expenditure on ostomy appliances, consumption patterns are monitored in the Netherlands, the quantity of reimbursed appliances is limited in Belgium and public reimbursement is restricted in Ontario. Ostomy appliances are generally distributed by community pharmacies and medical equipment shops. In countries that emphasise home care delivery such as Denmark, domiciliary distributors dominate the market to the detriment of community pharmacies which do not seem to be able to offer this service at a competitive price. An avenue for reforming the Belgian ostomy appliance market is proposed which valorizes the role of ostomy care nurses in guiding the choice of ostomy appliances. Furthermore, it is recommended that a competitive tendering process determines the price of ostomy appliances, that reimbursement for service provision by distributors is separated from reimbursement of appliances, and that patients receive a fixed grant from the third-party payer to buy ostomy appliances.