Surgical management for displaced pediatric proximal humeral fractures: a cost analysis

Purpose

The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).

Methods

A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.

Results

A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

Conclusions

Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.     

Polymorphisms in P2X4R and CAMKK2 may affect TNFα production: Implications for a role in HIV-associated sensory neuropathy

Polymorphisms in P2X4R and CAMKK2 associate with susceptibility to HIV-associated sensory neuropathy (HIV-SN) – a condition likely mediated by TNFα. As single nucleotide polymorphisms (SNPs) and haplotypes of CAMKK2, and a neighbouring gene P2X4R, mark susceptibility to HIV-SN in South Africans living with HIV, we examined the relationship between P2X4R and CAMKK2 genotypes and TNFα production. Peripheral blood mononuclear cells from 129 healthy donors were stimulated with killed Escherichia coli, and concentrations of soluble TNFα were assessed. Their DNA was genotyped for 22 SNPs in P2X4R and CAMKK2. Three SNPs within P2X4R and two SNPs within CAMKK2 influenced concentrations of TNFα, but these SNP did not associate with risk for HIV-SN. This incongruence may reflect differences in P2X4R haplotypes present in Africans and Europeans. However some CAMKK2 haplotypes were found in both populations, so CAMKK2 polymorphisms may impact upon HIV-SN via effects of the protein on pathways other than TNFα.     

Morphological features and molecular phylogeny of <Emphasis Type="Italic">Hoferellus azevedoi</Emphasis> n. sp. (Myxozoa: Myxobilatidae) found in <Emphasis Type="Italic">Chaetobranchus flavescens</Emphasis> Heckel, 1840 (Teleostei: Cichlidae) from Marajó Island,northern Brazil

Hoferellus azevedoi n. sp. was found in the urinary bladder of Chaetobranchus flavescens Heckel, 1840 from the Arari River on Marajó Island in Pará, Brazil. This is the first record of a species of the genus Hoferellus in a host from the Brazilian Amazon region. The new species has disporous and polysporous plasmodia, which vary in size and shape, with some being found adhered to the epithelium of the urinary bladder, and others floating in the liquid. The mature spores are sub-spherical in the sutural view, with a number of peripheral projections around the whole surface of the spore. In the sutural view, the spores are 5.3 ± 0.2 (5.2–5.6) μm in length and 7.0 ± 0.7 (6.3–7.7) μm in width, with two piriform polar capsules of equal size, 2.5 ± 0.2 (2.3–2.8) μm long and 1.8 ± 0.2 (1.6–2.0) μm wide. Based on a partial (1312 bps) sequence of the SSU rDNA gene, Hoferellus azevedoi n. sp. was distinguished from all the other myxozoan species deposited in GenBank. Phylogenetically, based on Bayesian inference and p-distances, the new species was allocated to the “Freshwater Urinary-Bladder” clade, together with other myxozoan parasites of the excretory system. Based on the morphological data, supported by the partial sequence of the SSU rDNA gene, we describe a new species of myxozoan, Hoferellus azevedoi n. sp.     

Molecular epidemiology of carbapenem-resistant <Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> in an endemic area: comparison with global data

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is an endemic problem in certain countries including Greece. CRPA and multidrug-resistant P. aeruginosa (MDRPA) firstly emerged in our region during the 80s, right after the launch of imipenem and meropenem as therapeutic agents against P. aeruginosa infections. The role of outer membrane protein (Opr) inactivation has been known to contribute to imipenem resistance since many years, while efflux overexpression systems have been mainly associated with meropenem resistance. Among carbapenemases, metallo-β-lactamases (MBL) and mostly Verona integron-mediated (VIM) MBL’s have played the most crucial role in CRPA emergence. VIM-2 and VIM-4 producing CRPA, usually belonging to clonal complexes (CC) 111 and 235 respectively, have most frequently been isolated. Bla_VIM-2 and bla_VIM-4 are usually associated with a class 1 integron. VIM-17 also has appeared in Greece. On the other hand, other VIM subtypes detected in a global level, such as VIM-3, VIM-5, VIM-6, VIM-7, VIM-11, VIM-14, VIM-15, VIM-16 and VIM-18 have not yet emerged in Greece. However, new VIM subtypes will probably emerge in the future. In addition, MBL carbapenemases other than VIM, detected worldwide have not yet appeared. A single CRPA isolate producing KPC has emerged in our region several years ago. The study of the molecular basis of Opr deficiency and efflux overexpression remains a challenge for the future. In this article, we review the molecular epidemiology of CRPA in an endemic area, compared to global data.