Objective
To estimate the cost‐effectiveness of tranexamic acid (TXA) use to prevent postpartum haemorrhage.
Design
A trial‐based economic evaluation.
Setting
Fifteen French university maternity ...hospitals.
Population
Women enrolled in the TRAAP randomised controlled trial comparing TXA versus placebo in women with vaginal delivery. TRAAP failed to show a reduction in postpartum haemorrhage of at least 500 ml in the intervention arm but evidenced significant lower rates of secondary outcomes related to blood loss.
Methods & main outcome measures
We estimated direct medical costs from within‐trial hospital resources collected prospectively from the study report form. All resources were costed at their value to the hospital. We estimated incremental cost per incremental haemorrhage averted.
Results
Among the 4079 women in the TRAAP trial, data necessary to calculate costs were available for 3836 (94.0%). The average total costs in the TXA and control groups were €2278 ± 388 and €2288 ± 409 per woman, respectively (P = 0.79). In women with postpartum haemorrhage of at least 500 ml (trial primary endpoint), costs were €2359 ± 354 and €2409 ± 525 (P = 0.14); for provider‐assessed clinically significant postpartum haemorrhage and postpartum haemorrhage of at least 1000 ml, costs were respectively €2316 ± 347 versus €2381 ± 521 (P = 0.22) and €2321 ± 318 versus €2411 ± 590 (P = 0.35) in the tranexamic and placebo groups, respectively. The probabilistic sensitivity analysis showed that the use of TXA had a 65–73% probability of saving costs and improving outcome.
Conclusions
Our findings support the use of TXA, as both bleeding events and cost may be reduced three out of four times.
Tweetable
Tranexamic acid at vaginal delivery reduces both costs and bleeding events 3 times out of 4.
Tweetable
Tranexamic acid at vaginal delivery reduces both costs and bleeding events 3 times out of 4.
An up‐to‐date map of the Antarctic Circumpolar Current (ACC) fronts is constructed from the latest version of mean dynamic topography (MDT) from satellite altimetry and reveals the narrowest ACC ...width in the Udintsev Fracture Zone (UFZ), with the strongest concentration of the three major ACC fronts within a limited distance as short as 170 km, about 40% narrower than that at Drake Passage. At 144°W, at the entrance of the UFZ, which lies between the Pacific‐Antarctic Ridge (PAR) and its eastwardly offset segment (offset PAR segment), there is a triple confluence of the Subantarctic Front, Polar Front, and Southern ACC Front . Downstream of this longitude, the Subantarctic Front progressively meanders northward over the relatively shallow offset PAR segment before channeling through the Eltanin Fracture Zone, thus diverging from the Polar Front which proceeds through the UFZ. In situ observations from two recent cruises at 144°W confirm the satellite altimetry‐derived frontal circulation in the UFZ region and yield a baroclinic transport relative to the bottom of 113 × 106 m3/s, comparable to that through Drake Passage. The hydrographic sections show no Antarctic bottom water colder than 0.2 °C. Characteristics of major water masses are described, and the implications for their potential downstream modifications at Drake Passage are discussed in terms of the meridional overturning circulation across the ACC. Mesoscale eddy activity with periods shorter than 90 days is predominantly concentrated in the immediate downstream area of the offset PAR segment, suggesting a substantial poleward eddy heat flux there.
Key Points
The Antarctic Circumpolar Current is only 170 km wide in the Udintsev Fracture Zone, forming the narrowest circumpolar choke point
First observations of high‐quality hydrography in the Udintsev Fracture Zone show no Antarctic bottom water colder than 0.2 °C
The Udintsev Fracture Zone is a suitable site for a long‐term monitoring of the Antarctic Circumpolar Current
The Thorpe scale is an energy-containing vertical overturning scale of large eddies associated with shear-generated turbulence. This study investigates indirect estimates of vertical diffusivities ...from the Thorpe scale method in the polar front region east of the Kerguelen Islands based on fine-scale density profiles gathered during the 2011 KEOPS2 (KErguelen Ocean and Plateau compared Study 2) cruise. These diffusivities are validated in comparison with diffusivities estimated from the turbulence dissipation rate directly measured via a TurboMAP (Turbulence ocean Microstructure Acquisition Profiler) microstructure profiler. The results are sensitive to the choice of the diffusivity parameterization and the overturn ratio Ro, and the optimal results have been obtained from the parameterization by Shih et al. (2005) and the Ro = 0.25 criterion, rather than the parameterization by Osborn (1980) and the Ro = 0.2 criterion originally suggested by Gargett and Garner (2008). The Thorpe-scale-derived diffusivities in the KEOPS2 region show a high degree of spatial variability, ranging from a canonical value of O(10-5) m2 s-1 in the Winter Water layer and in the area immediately north of the polar front to a high value of O(10-4) m2 s-1 in the seasonal thermocline between the surface mixed layer and the Winter Water. The latter high diffusivities are found especially over the shallow plateau southeast of the Kerguelen Islands and along the polar front that is attached to the escarpment northeast of the islands. The interaction of strong frontal flow with prominent bottom topography likely causes the observed elevated mixing rates.
Cost of stroke in France Chevreul, K.; Durand-Zaleski, I.; Gouépo, A. ...
European journal of neurology,
07/2013, Letnik:
20, Številka:
7
Journal Article
Recenzirano
Background and purpose
A cost of illness study was undertaken on behalf of the French Ministry of Health to estimate the annual cost of stroke in France with the goal of better understanding the ...current economic burden so that improved strategies for care may be developed.
Methods
Using primary data from exhaustive national databases and both top‐down and bottom‐up approaches, the stroke‐related costs for healthcare, nursing care and lost productivity were estimated.
Results
The total healthcare cost of stroke patients in France in 2007 was €5.3 billion, 92% of which was borne by statutory health insurance. The average cost of incident cases was €16 686 per patient in the first year, while the annual cost of prevalent cases was a little less than half that amount (€8099). Nursing care costs were estimated at €2.4 billion. Lost productivity reached €255.9 million and that income loss for stroke patients was partially compensated by €63.3 million in social benefit payments.
Conclusions
With healthcare costs representing 3% of total health expenditure in France, stroke constitutes an ongoing burden for the health system and overall economy. Nursing care added nearly half again the amount spent on healthcare, while productivity losses were more limited because nearly 80% of acute incident strokes were in patients over age 65. The high cost of illness underscores the need for improved prevention and interventions to limit the disabling effects of stroke.
Tricuspid valve malformation is a rare congenital heart disease. Prenatal diagnosis of Ebstein’s anomaly (EA) and tricuspid valve dysplasia (TVD) is associated with high mortality. There are ...conflicting reports concerning accurate prognostication after diagnosis in utero. The aim of our study was to assess prognostic factors based on our experience. We reviewed 37 fetuses between 1984 and June 2010 comprising 26 cases of EA and 11 cases of TVD. There were 10 terminations, 5 intrauterine deaths, 8 neonatal deaths, and 14 survivors. We found that the major prognostic factor for outcome was the flow pattern through the pulmonary valve on the first echocardiogram. Retrograde flow was strongly correlated with fetal or neonatal death (
p
= 8 × 10
−5
), and anterograde flow predicted good outcome (
p
= 8 × 10
−5
). In contrast, cardiothoracic indexes, right to left-ventricular ratio, and Celermajer index were not useful prognostic markers. The Simpson Andrews Sharland score, which was more complex, was well correlated with our series. Flow through the pulmonary valve on the first echocardiogram is a simple and excellent prognostic factor when major tricuspid valve disease is diagnosed in utero. Fetuses should be monitored throughout pregnancy, particularly those with retrograde ductus arteriosus, because several hemodynamic factors may worsen the prognosis.
The sources and mechanisms of inorganic carbon transport for scleractinian coral calcification and photosynthesis were studied using a double labelling technique with H(14)CO(3) and (45)Ca. Clones of ...Stylophora pistillata that had developed into microcolonies were examined. Compartmental and pharmacological analyses of the distribution of(45)Ca and H(14)CO(3) in the coelenteron, tissues and skeleton were performed in dark or light conditions or in the presence of various seawater HCO(3)(-) concentrations. For calcification, irrespective of the lighting conditions, the major source of dissolved inorganic carbon (DIC) is metabolic CO(2) (70-75% of total CaCO(3) deposition), while only 25-30% originates from the external medium (seawater carbon pool). These results are in agreement with the observation that metabolic CO(2) production in the light is at least six times greater than is required for calcification. This source is dependent on carbonic anhydrase activity because it is sensitive to ethoxyzolamide. Seawater DIC is transferred from the external medium to the coral skeleton by two different pathways: from sea water to the coelenteron, the passive paracellular pathway is largely sufficient, while a DIDS-sensitive transcellular pathway appears to mediate the flux across calicoblastic cells. Irrespective of the source, an anion exchanger performs the secretion of DIC at the site of calcification. Furthermore, a fourfold light-enhanced calcification of Stylophora pistillata microcolonies was measured. This stimulation was only effective after a lag of 10 min. These results are discussed in the context of light-enhanced calcification. Characterisation of the DIC supply for symbiotic dinoflagellate photosynthesis demonstrated the presence of a DIC pool within the tissues. The size of this pool was dependent on the lighting conditions, since it increased 39-fold after 3 h of illumination. Passive DIC equilibration through oral tissues between sea water and the coelenteric cavity is insufficient to supply this DIC pool, suggesting that there is an active transepithelial absorption of inorganic carbon sensitive to DIDS, ethoxyzolamide and iodide. These results confirm the presence of CO(2)-concentrating mechanisms in coral cells. The tissue pool is not, however, used as a source for calcification since no significant lag phase in the incorporation of external seawater DIC was measured.
The objective of this study was to assess the ability of different parameters to identify fetuses requiring neonatal care for coarctation of the aorta (CoA). Between January 2003 and December 2012, ...175 fetuses referred for great vessel disproportion were divided into two groups: group A (
n
= 51) with high risk of CoA and delivery planned in tertiary care referral center and group B (
n
= 124) with no increased risk of CoA. In group A, diagnosis of CoA was confirmed in 38/51 (74 %). In group B, 2/124 had CoA. Multiple logistic regression analysis identified the best combination as diffusely hypoplastic and/or angular aortic arches, ventricular septal defect and aortic valve diameter <5 mm at 36-week gestational age (GA). Positive predictive value was 75 % when vessel disproportion was noted before 28-week GA and 73 % in the third trimester. Postnatal diagnosis involved 38 cases of CoA which had not been referred. One case of CoA diagnosed after birth was referred prenatally for difficulty of screening without any defect. The results of our prospective study are in agreement with those of previous series, but our false positive rate was lower especially when the diagnosis of vascular disproportion was made at third trimester. The performance of fetal cardiac screening does not seem to be very good, but prenatal diagnosis is probably not always possible: Among our three false negative cases, two had isolated vascular disproportion and the third no risk factors.
Pulmonary hypertension is characterised by a progressive increase in pulmonary arterial resistance due to endothelial and smooth muscle cell proliferation resulting in chronic obstruction of small ...pulmonary arteries. There is evidence that inflammatory mechanisms may contribute to the pathogenesis of human and experimental pulmonary hypertension. The aim of the study was to address the role of fractalkine (CX3CL1) in the inflammatory responses and pulmonary vascular remodelling of a monocrotaline-induced pulmonary hypertension model. The expression of CX3CL1 and its receptor CX3CR1 was studied in monocrotaline-induced pulmonary hypertension by means of immunohistochemistry and quantitative reverse-transcription PCR on laser-captured microdissected pulmonary arteries. It was demonstrated that CX3CL1 was expressed by inflammatory cells surrounding pulmonary arterial lesions and that smooth muscle cells from these vessels had increased CX3CR1 expression. It was then shown that cultured rat pulmonary artery smooth muscle cells expressed CX3CR1 and that CX3CL1 induced proliferation but not migration of these cells. In conclusion, the current authors proposed that fractalkine may act as a growth factor for pulmonary artery smooth muscle cells. Chemokines may thus play a role in pulmonary artery remodelling.
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