SOCIETAL BURDEN OF STROKE REHABILITATION: COSTS AND HEALTH OUTCOMES AFTER ADMISSION TO STROKE REHABILITATION

ObjectiveTo estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after start of medical specialist rehabilitation.DesignObservational.PatientsConsecutive patients who received medical specialist rehabilitation in the Stroke Cohort Out-comes of REhabilitation (SCORE) study.MethodsParticipants completed questionnaires on health-related quality of life (EuroQol EQ-5D-3L), absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after start. Clinical characteristics and rehabilitation costs were extracted from the medical and financial records, respectively.ResultsFrom 2014 to 2016 a total of 313 stroke patients completed the study. Mean age was 59 (standard deviation (SD) 12) years, 185 (59%) were male, and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were US$70,601 and US$27,473, respectively. For inpatients, utility (an expression of quality of life) increased significantly between baseline and 6 months (EQ-5D-3L 0.66–0.73, p = 0.01; visual analogue scale 0.77–0.82, p < 0.001) and between baseline and 12 months (visual analogue scale 0.77–0.81, p < 0.001).ConclusionOne-year societal costs from after the start of rehabilitation in stroke patients were considerable. Future research should also include costs prior to rehabilitation. For inpatients, health-related quality of life, expressed in terms of utility, improved significantly over time.LAY ABSTRACTThe objective of this study was to estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after the start of rehabilitation. Participants were stroke patients who received inpatient or outpatient rehabilitation. They completed questionnaires on quality of life, absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after the start of rehabilitation. Rehabilitation costs were obtained from the financial records. From 2014 to 2016 a total of 313 patients completed the study. Mean age was 59 years, 185 (59%) were male and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were $70,601 and $27,473, respectively. For inpatients, health-related quality of life increased significantly between baseline and 6 months, and between baseline and 12 months. In conclusion, societal costs one year after the start of rehabilitation were considerable and health-related quality of life improved for inpatients.Key words: stroke, rehabilitation, cost analysis, utility, health-related quality of life

The number of people living with stroke in Europe is expected to increase from 1.1 million per year in 2000 to 1.5 million per year in 2025 (1). Stroke survivors may experience severe functional impairments, including impairments in physical functioning (2), cognition (3), and speech/language (4), which, in turn, lead to limitations in activities and participation and to worse quality of life (QoL) (5). Specialist rehabilitation was proven to be effective in improving functional outcomes after stroke (6), such as motor function, balance, walking speed and activities of daily living (7–9). Furthermore, in stroke patients admitted for inpatient rehabilitation, QoL increased significantly between admission and discharge (10).Besides the fact that rehabilitation after stroke is effective, rehabilitation was also found to be the main contributor to the costs of post-stroke care, according to a systematic review published in 2018 including 42 publications (11). Costs of post-stroke care, but not those of acute care, were included. Rehabilitation in different care settings was evaluated, which included primary, secondary and tertiary care, and the costs often applied to part of the patients and were not described in detail. For the delivery of value-based healthcare (VBHC), it is important to consider not only the health effects and patient-reported outcome measures, but to also evaluate the costs of care, since it is important to achieve good patient outcomes per dollar spent (12, 13).The aim of the current study was therefore: (i) to estimate the 1-year societal costs from the start of the rehabilitation in stroke patients treated in a medical specialist rehabilitation facility in The Netherlands; and (ii) to evaluate health changes in terms of utility (an expression of quality of life) over that year.     

Long-Lasting Catch-up Growth under Bio-Methionyl Growth Hormone Treatment in an Infant with Isolated Growth Hormone Deficiency Type 1A1

ABSTRACT. This case report concerns a 7-month-old infant with severe height retardation (–5.0 SD), typical growth hormone (GH)-deficient phenotype, and undetectable GH serum levels in response to three pharmacological stimuli. Diagnosis of isolated GH deficiency type 1A was confirmed by restriction endonuclease analysis of genomic DNA which pointed out GH-N gene deletion. The introduction of bio-methionyl-GH therapy in this patient was followed by a transient and clinically irrelevant appearance of low binding capacity GH antibodies as well as by a long-lasting catch-up growth (42.2 cm) which is continuing 44 months after beginning of treatment. This atypical pattern confirms that immune and growth response to exogenous GH in isolated GH deficiency 1A may be very heterogeneous.     

Ventricular Arrhythmias in Apparently Healthy Subjects

While it is assumed that the normal heart does not predispose to serious arrhyilimias, several conditions are now being recognized as being associated with short-lasting ventricular arrhythmias. It also becomes clear that idiopathic VT (or repetitive monomorphic VT) sometimes exists on the background of a compromised heart. Whether this dysfunction is due to the arrhythmia or vice versa is not evident. Finally, VF occurs in patients who, at a first glance, have no apparent heart disease, and it is then called idiopathic VF. These complex electrical abnormalities probably reflect disorders, which often are genetically determined. Recognition of these syndromes, often characterized by abnormal repolarization or a disturbed autonomic function is possible if appropriate techniques are used.     

Heart rate increment analysis is not effective for sleep-disordered breathing screening in patients with chronic heart failure

Frequency domain analysis of heart rate variation has been suggested as an effective screening tool for sleep-disordered breathing (SDB) in the general population. The aim of this study was to assess this method in patients with chronic congestive heart failure (CHF). We included prospectively 84 patients with stable CHF, left ventricular ejection fraction (LVEF) <45% and sinus rhythm. The patients underwent polygraphy to measure the apnoea/hypopnoea index (AHI) and simultaneous Holter electrocardiogram monitoring to measure the power spectral density of the very low frequency component of the heart rate increment, expressed as the percentage of total power spectral density [% very low frequency increment (%VLFI)]. %VLFI could be determined in 54 patients (mean age, 52.8 ± 12.3 years; LVEF, 33.5 ± 9.8%). SDB defined as AHI ≥15 h⁻¹ was diagnosed in 57.4% of patients. Percent VLFI was not correlated with AHI ( r  =   0.12). Receiver-operating characteristic curves constructed using various AHI cut-offs (5–30 h⁻¹) failed to identify a %VLFI cut-off associated with SDB. The 2.4% VLFI cut-off recommended for the general population of patients with suspected SDB had low specificity (35%) and low positive and negative predictive values (35% and 54%, respectively). Heart rate increment analysis has several limitations in CHF patients and cannot be recommended as an SDB screening tool in the CHF population.     

Global versus domain-specific statuses in identity research: a comparison of two self-report measures

The present study explored the potential usefulness of global identity statuses (ideological identity) as opposed to domain-specific statuses (occupation, religion, politics) using self-report measures rather than identity interviews. A total of 339 college students from two colleges in Belgium (Europe) completed both the Extended Objective Measure of Ego-Identity Status (EOM-EIS) and the Dellas Identity Status Inventory - Occupation, Religious Beliefs, Political Ideology (DISI-ORP). Four types of evidence argued in favour of domain-specific statuses (i.e. low convergence in identity status across domains, moderate convergence between global and domain-specific identity statuses, significant gender differences in domain-specific but not in global identity statuses, and significant associations between identity process and identity content in congruent but not in incongruent domains). In line with earlier research using identity status interviews, it was concluded that adolescent identity is not to be considered a unitary construct and the use of domain-specific identity statuses is recommended whenever possible. Theoretical implications of the findings are discussed in terms of adolescents' temporal spacing of identity concerns. Finally, the limitations of identity questionnaires (additive approach to global identity statuses) are pointed out. Identity interviews (indicative approach to global statuses) can yield a very different picture of identity.     

Clinical Observations with a Dual Sensor Rate Adaptive Single Chamber Pacemaker

The Topaz model 515 (Vitatron B.V.) is a dual sensor rate responsive pacemaker for single chamber stimulation. It can be driven by activity counts (ACT) and QT interval measurements. Inappropriate rate modulation due to one sensor can be corrected by "sensor cross-checking." It was implanted in ten patients (20-86 years) of whom seven had complete heart block and atrial arrhythmias. After implantation T-wave amplitude ranged from 0.9mV-3.5 mV. T-wave sensing ranged from 88%–99% in 9/10 patients at the follow-up of 3 weeks. Eight patients remained in default setting of the activity threshold, after evaluation with a short walking test. An exercise test was performed on all patients. In one test, QT sensing was marginal because of lead implantation in the right ventricular outflow tract. Therefore, this pacing rate was only modulated by ACT sensing. All others were tested with equal contribution of information from both sensors (ACT = QT). In 7/9, rate response was satisfactory. When the treadmill was repeated with ACT in five of these seven patients, rate generally accelerated too fast. In one patient the setting was adjusted to "QT > ACT," because of inappropriate acceleration due to activity sensing, in another it was adjusted to "QT < ACT" because of delayed response to activity. The pacing rate and the ACT during treadmill tests in "QT = ACT" mode were more closely correlated in the first 3 minutes, compared with the last 3 minutes. We feel that rate modulation with this new pacemaker is adequate. Sensor blending and sensor cross-checking are of clinical importance.     

Bradycardiomyopathy: The Case for a Causative Relationship Between Severe Sinus Bradycardia and Heart Failure

Bradycardiomyopathy . A 28‐year‐old man presented with progressive fatigue. Physical examination and ECG revealed severe sinus bradycardia. Echocardiography showed features of noncompaction cardiomyopathy and moderate aortic valve regurgitation. We hypothesized that the chronic volume overload exaggerated by prolonged diastole due to the bradycardia resulted in heart failure and noncompaction cardiomyopathy look‐alike features. After implantation of an AAI pacemaker, his symptoms and signs of cardiomyopathy were fully recovered. (J Cardiovasc Electrophysiol, Vol. pp. 822‐824, July 2010)     

Dental caries and dental care level (restorative index) in children with diabetes mellitus type 1

International Journal of Paediatric Dentistry 2011; 21: 13–22 Introduction. The aim of the study was to investigate caries experience and dental care index in diabetic children and to determine if correlation exists between caries experience and metabolic control, insulin treatment, and the duration of diabetes. Materials and methods. The study group consisted of 52 children and adolescents, 3–16 years of age with type 1 diabetes attending the outpatient diabetic clinic at Ghent University Hospital, Belgium. Fifty healthy subjects recruited from the paediatric dental clinic served as the control group. Caries lesions were assessed using DMF‐index both at cavity and non‐cavity levels. Participants and/or their guardians provided information about oral hygiene habits and dietary habits. Diabetes‐related data (type, duration, insulin regimen) were collected from medical records and completed with the lab data on HbAlc. Conclusion. It became clear that, although children with type 1 diabetes mellitus could be expected to run a potential high caries risk taking into account the diabetes‐associated biological and behavioural alterations, no significant differences were observed regarding caries experience and dental care between diabetic children and healthy controls. The level of untreated dental decay among the diabetic children is, however, considerably high, which was reflected by a significant lower dental attendance.