[Modelling of burden of femoral neck fracture from purchaser’s point of view]


DECEMBER 28, 2009

Ca&Bone - 2009;12(03)

[OBJECTIVE - This study provides a model of the treatment cost of femoral neck fracture and financial burden of the annual fracture cases at 2009 financial level from health insurance point of view. METHOD - The costs of the treatment of femoral neck fractures are modelled according to the actually OEP reimbursed types of care including acute inpatient care, chronic inpatient care, outpatient care, pharmaceuticals and medical devices, home care (nursing), cost of travelling or transport and the disability to work. Cases healing following primary treatment (without complications) and cases with complications are examined separately. The costs of most common complications with large surgical operation are calculated. RESULTS - The cost of patients in active age-groups cured by primary treatment can vary in a range of 1.010.110- 1.479.034 HUF depending on cost level of individual care and utilization, while the cost of patients in retired agegroups (pensioners) can vary in a range 635.350- 1.104.274 HUF. The cost of patients with complication (primary treatment and complication) in active agegroups can reach. 1 858.438-3.133.096 HUF depending on cost level of individual care and utilization, while the cost of patients in retired age-groups (pensioners) can reach 1.108.918-2.383.576 HUF. According to our model calculations, the cost of primary treatment of femoral neck fractures and essential further treatment represents an annual burden of 4.373.857.668-6.247.717.438 HUF for the health insurance system. CONCLUSION - In order to reduce the incidence of hip fractures one should emphasize the importance of current and future interventions, which projects the possibility of reducing the financial burden at societal level. The analysis of financial burden could serve as a base for health-economics studies, by elaborating a cost-effective strategy supported by professional and political decision makers.]



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[MOOT News 2009;12(03)]


[Vitamin D in autoimmun disorders: the immunregulatory effect of vitamin D and therapeutic opportunities]


[There is recent evidence that genetic and environmental factors play an important role in the development of autoimmune diseases. Vitamin D deficiency is one of the environmental factors that may play a role in developing autoimmune diseases. Low vitamin D status has been implicated in the etiology of autoimmune diseases such as multiple sclerosis, systemic lupus erythematosus, rheumatoid arthritis, inzulin dependent diabetes mellitus, and inflammatory bowel disease. Experimentally, vitamin D deficiency results in an increased incidence of autoimmune disease. The authors discuss the accumulating evidence pointing to a link between vitamin D and autoimmunity. The optimal level of vitamin D intake is necessary to normalize the immune functions and it plays an important role in the development of self-tolerance. Targets for vitamin D in the immune system have been identified and the mechanism of vitamin D mediated immunoregulation is beginning to be understood. On the basic of recent knowledge, vitamin D causes a decrease in Th1-driven autoimmune response and repairs the function of regulatory T cells. Increased vitamin D intakes might decrease the incidence and severity of autoimmune diseases.]


[Overcome of bisphosphonate resistance with alphacalcidol: results of a one year, open follow-up study]

GAÁL János, BENDER Tamás, VARGA József, HORVÁTH Irén, KISS Judit, SOMOGYI Péter, SURÁNYI Péter

[INTRODUCTION - A considerable part of osteoporotic patients do not respond satisfactorily to adequate treatment with a bisphosphonate plus supplementation with calcium and conventional vitamin D3. This study intended to determine whether the replacement of vitamin D3 with alphacalcidol results in any BMD increase, i.e. is it possible to overcome resistance to bisphosphonates. PATIENTS AND METHOD - In 76 patients unresponsive to the combination of alendronate and conventional vitamin D3, the latter had been replaced with alphacalcidol (0.5 μg/day), and then the patients were followed up for a year. Clinical and laboratory parameters were recorded at baseline and after one year of treatment; and their changes were analysed by statistical methods. RESULTS - After treatment for one year, Wilcoxon test revealed a small but statistically significant (p<0.001) increase in the BMD values of the forearm (+2.2%) and lumbar vertebrae (+1.4%). At the end of the treatment period, the following, significant changes were observed compared to baseline (median values): serum calcium level increased by 0,06 mmol/l; serum phosphorus level decreased by 0.05 mmol/l, serum alkaline phosphatase activity decreased by 13 U/l, and urinary calcium/creatinine ratio in first-voided morning urine increased by 0.1. Additionally, serum PTH level decreased by 10.7 pg/ml (median). Serum levels of osteocalcin decreased by 0.4 ng/ml, along with the urinary D-Pyr /kreatinine ratio by 0.2 nmol/mmol (median). No significant increase of adverse events occurred. DISCUSSION - As suggested by our results, combination therapy with alendronate and alfacalcidol increases bone density and improves the biochemical markers of bone turnover - without any substantial increase in the incidence of adverse effects.]


[Hip fractures in Hungary between 2001 and 2008 - Assessment of the beneficial effect of bisphosphonates on the risk of hip fractures on the basis of Hungarian data]

HÉJJ Gábor

[The overall prevalence of osteoporosis in developed countries is estimated to be 9-15%. Mortality in the first year after the fracture is 15-20%, and half of the survivors remain partly or fully dependent on others’ support. Owing to the increasing life expectance and the diseases of civilisation, the incidence of osteoporotic fractures is expected to double in the next thirty years. The network of centers that has been developed since 1995 under the National Osteoporosis Program and the accreditation system of the National Osteoporosis Center provided up-to-date education of the physicians (densitometry assistants) who work within the network. The diagnostic restrictions followed by the reduction of support to 70% since 2006 fall resulted in a dramatic reduction in the number of treated patients.]

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Cholinesterase inhibitors and memantine for the treatment of Alzheimer and non-Alzheimer dementias


In aging societies, the morbidity and mortality of dementia is increasing at a significant rate, thereby imposing burden on healthcare, economy and the society as well. Patients’ and caregivers’ quality of life and life expectancy are greatly determined by the early diagnosis and the initiation of available symptomatic treatments. Cholinesterase inhibitors and memantine have been the cornerstones of Alzheimer’s therapy for approximately two decades and over the years, more and more experience has been gained on their use in non-Alzheimer’s dementias too. The aim of our work was to provide a comprehensive summary about the use of cholinesterase inhibitors and memantine for the treatment of Alzheimer’s and non-Alzheimers’s dementias.

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[The importance of patient reported outcome measures in Pompe disease]

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[In recent decades it has become increasingly important to involve patients in their diagnostic and treatment process to improve treatment outcomes and optimize compliance. By their involvement, patients can become active participants in therapeutic developments and their observations can be utilized in determining the unmet needs and priorities in clinical research. This is especially true in rare diseases such as Pompe disease. Pompe disease is a genetically determined lysosomal storage disease featuring severe limb-girdle and axial muscle weakness accompanied with respiratory insufficiency, in which enzyme replacement therapy (ERT) now has been available for 15 years. In our present study, patient reported outcome measures (PROMs) for individuals affected with Pompe disease were developed which included questionnaires assessing general quality of life (EuroQoL, EQ-5D, SF36), daily activities and motor performance (Fatigue Severity Score, R-PAct-Scale, Rotterdam and Bartel disability scale). Data were collected for three subsequent years. The PROM questionnaires were a good complement to the physician-recorded condition assessment, and on certain aspects only PROMs provided information (e.g. fatigue in excess of patients’ objective muscle weakness; deteriorating social activities despite stagnant physical abilities; significant individual differences in certain domains). The psychological effects of disease burden were also reflected in PROMs. In addition to medical examination and certain endpoints monitored by physicians, patient perspectives need to be taken into account when assessing the effectiveness of new, innovative treatments. With involvement of patients, information can be obtained that might remain uncovered during regular medical visits, although it is essential in determining the directions and priorities of clinical research. For all orphan medicines we emphasize to include patients in a compulsory manner to obtain general and disease-specific multidimensional outcome measures and use them as a quality indicator to monitor treatment effectiveness.]

Clinical Neuroscience

A new method to determine the optimal orientation of Slim Modiolar cochlear implant electrode array insertion

HORVÁTH Bence, PERÉNYI Ádám, MOLNÁR Fiona Anna, CSANÁDY Miklós, KISS József Géza, ROVÓ László

Our goal was to determine the optimal orientation of insertion of the Slim Modiolar electrode and develop an easy-to-use method to aid implantation surgery. In some instances, the electrode arrays cannot be inserted in their full length. This can lead to buckling, interscalar dislocation or tip fold-over. In our opinion, one of the possible reasons of tip fold-over is unfavourable orientation of the electrode array. Our goal was to determine the optimal orientation of the Slim Modiolar electrode array relative to clear surgical landmarks and present our method in one specified case. For the measurement, we used the preoperative CT scan of one of our cochlear implant patients. These images were processed by an open source and free image visualization software: 3D Slicer. In the first step we marked the tip of the incus short process and then created the cochlear view. On this view we drew two straight lines: the first line represented the insertion guide of the cochlear implant and the second line was the orientation marker (winglet). We determined the angle enclosed by winglet and the line between the tip of the incus short process and the cross-section of previously created two lines. For the calculation we used a self-made python code. The result of our algorithm for the angle was 46.6055°. To validate this result, we segmented, from the CT scan, the auditory ossicles and the membranaceous labyrinth. From this segmentation we generated a 3D reconstruction. On the 3D view, we can see the position of the previous lines relative to the anatomical structures. After this we rotated the 3D model together with the lines so that the insertion guide forms a dot. In this view, the angle was measured with ImageJ and the result was 46.599°. We found that our method is easy, fast, and time-efficient. The surgery can be planned individually for each patient, based on their routine preoperative CT scan of the temporal bone, and the implantation procedure can be made safer. In the future we plan to use this method for all cochlear implantation surgeries, where the Slim Modiolar electrode is used.

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Risk factors related to intracranial infections after transsphenoidal pituitary adenomectomy under endoscope

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Background – Up to now, the risk factors related to intracranial infections after transsphenoidal pituitary adenomectomy remain controversial. Purpose – To analyze the risk factors related to intracranial infections after transsphenoidal pituitary adenomectomy under an endoscope, and to provide evidence for preventing and controlling the occurrence and development of infections. A total of 370 patients receiving endoscopic transsphenoidal pituitary adenomectomy in our hospital from January 2014 to October 2017 were selected. The risk factors related to postoperative intracranial infections were analyzed. The hospitalization lengths and expenditures of patients with and without intracranial infections were compared. Of the 370 patients, 18 underwent postoperative intracranial infections, with the infection rate of 4.86%. Intraoperative blood loss >120 mL, cerebrospinal leakage, diabetes, preoperative use of hormones, macroadenoma as well as surgical time >4 h all significantly increased the infection rate (P<0.05). Preoperative use of antibacterial agents prevented intracranial infection. Compared with patients without intracranial infections, the infected ones had significantly prolonged hospitalization length and increased expenditure (P<0.05). Discussion – It is of great clinical significance to analyze the risk factors related to intracranial infection after endoscopic transsphenoidal pituitary adenomectomy, aiming to prevent and to control the onset and progression of infection. Intracranial infections after endoscopic transsphenoidal pituitary adenomectomy were affected by many risk factors, also influencing the prognosis of patients and the economic burden.

Clinical Neuroscience

Validation of the Hungarian PHQ-15. A latent variable approach

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Somatic symptoms without a clear-cut organic or biomedical background, also called “medically unexplained” or “somatoform” symptoms, are frequent in primary and secondary health care. They are often accompanied by depression and/or anxiety, and cause functional impairment. The Patient Health Question­naire Somatic Symptom Scale (PHQ-15) was developed to measure somatic symptom distress based on the frequency and bothersomeness of non-specific somatic symptoms. The study aimed to (1) evaluate the Hungarian version of the PHQ-15 from a psychometric point of view; (2) replicate the bifactor structure and associations with negative affect described in the literature; and (3) provide the Hungarian clinical and scientific community with reference (normal) values split by sex and age groups. PHQ-15, depression (BDI-R), and subjective well-being (WHO-5) scores obtained from a large (n = 5020) and close to representative community sample (Hun­garostudy 2006) were subjected to correlation analysis and linear structural equation modeling. The PHQ-15 showed good internal consistency (Cronbach’s α = 0.810; McDonald’s ω = 0.819) and moderate to strong correlation with the BDI-R (rs = .49, p < 0.001) and WHO-5 (rs = -.48, p < 0.001). Fit of the bifactor structure was excellent; in independent analyses, the general factor was strongly associated with depression (β = 0.656±0.017, p < 0.001) and well-being (β = -0.575±0.015, p < 0.001), whereas the symptom specific factors were only weakly or not related to these constructs. The PHQ-15 score was higher in females and showed a weak positive association with age. The Hungarian PHQ-15 is a psychometrically sound scale which is positively associated with depression and ne­gatively related to subjective well-being. The bifactor structure indicates the existence and meaningfulness of a gene­ral factor representing the affective-motivational component of somatic symptom distress. The Hungarian version of the PHQ-15 is a brief and usable tool for the pre-screening of somatization disorder (DSM-IV) or somatic symptom disorder (DSM-5). The reported reference values can be used in the future for both clinical and research purposes.