Cost-Effectiveness of Therapeutic Hypothermia to Treat Neonatal Encephalopathy

ObjectiveTo estimate the cost-effectiveness (CE) of total body hypothermia plus intensive care versus intensive care alone to treat neonatal encephalopathy.MethodsDecision analytic modeling was used to synthesize mortality and morbidity data from three randomized controlled trials, the Total Body Hypothermia for Neonatal Encephalopathy Trial (TOBY), National Institute of Child Health and Human Development (NICHD), and CoolCap trials. Cost data inputs were informed by TOBY, the sole source of prospectively collected resource utilization data for encephalopathic infants. CE was expressed in terms of incremental cost per disability-free life year (DFLY) gained. Probabilistic sensitivity analysis was performed to generate CE acceptability curves (CEACs).ResultsCooling led to a cost increase of £3787 (95% confidence interval [CI]: ?2516, 12,360) (€5115; 95% CI: ?3398–16,694; US$5344; 95% CI: ?3598, 26,356; using 2006 Organisation for Economic Co-operation and Development (OECD) purchasing power parities) and a DFLY gain of 0.19 (95%CI: 0.07–0.31) over the first 18 months after birth. The incremental cost per DFLY gained was £19,931 (€26,920; US$28,124). The baseline CEAC showed that if decision-makers are willing to pay £30,000 for an additional DFLY, there is a 69% probability that cooling is cost-effective. The probability of CE exceeded 99% at this threshold when the throughput of infants was increased to reflect the national incidence of neonatal encephalopathy or when the time horizon of the economic evaluation was extended to 18 years after birth.ConclusionsThe probability that cooling is a cost-effective treatment for neonatal encephalopathy is finely balanced over the first 18 months after birth but increases substantially when national incidence data or an extended time horizon are considered.     

Ultrasound-guided fine-needle puncture of the thyroid

If properly performed, modern high-resolution real-time ultrasonography will disclose subtle differences in the texture of thyroid tissue and thereby enable the examiner to suggest a diagnosis. Nevertheless, there is often a need for a more specific diagnosis of solid or semisolid thyroid lesions - especially when the lesion might be malignant. Ultrasonically guided fine-needle aspiration biopsy (UG-FNB) allows a final cytological and/or histological diagnosis to be made in patients with benign or malignant space-occupying growths even if they are small. In its simplest form, thyroid nodules (diameter greater than 1.5 cm) with a uniform sonographic texture are punctured blind after determination of the site and size of the lesion on the basis of ultrasonic imaging. When the lesion is small and deeply situated (diameter less than or equal to 1.5 cm), this method will not be sufficiently accurate and more precise needle guidance is mandatory. In ultrasonically guided fine-needle puncture, the idea is to place the tip of an appropriate needle safely and accurately in the suspect lesion, so that representative specimens of solid tissue or fluid can be obtained and technical failures reduced. The main indication for biopsy of the thyroid gland is to differentiate between benign and malignant tumors. To compare the accuracy of conventional puncture techniques and ultrasonically guided puncture methods, 835 patients with benign or malignant space-occupying growth (even the small ones) were examined simultaneously with conventional and ultrasonically guided fine-needle aspiration biopsy over a period of 3 years (prospectively). Our results showed a significant difference in the sensitivity between conventional puncture without sonographic guidance and ultrasonically guided puncture techniques performed on patients with small and very small lesions (phi less than 2 cm). The size, macroscopic structure, and topographic-anatomical localization of the lesions were found to influence the diagnostic accuracy of the puncture techniques. UG-FNB is an excellent, effective, safe and painless method of treating uncomplicated thyroid cysts; it should be considered an alternative to surgery, if there are no clinical and cytological findings indicating malignancy and no severe space-occupying complications. Since the tip of the needle can be visualized on the scan, the needle may be advanced or withdrawn during aspiration so it is possible to empty the cyst completely. The use of ultrasound in the follow-up of patients with thyroid cyst puncture is mandatory to evaluate the results. Surgical therapy should be reserved for large cysts causing space-occupying complications.     

Reliability of leg alignment using the OrthoPilot system depends on knee position: a cadaveric study

Despite the increase in clinical use of navigation systems in total knee arthroplasty, few studies have focused on the reproducibility of these systems. The aim of the present study was to assess the influence of knee position and observer experience on intra- and inter-observer agreement in limb alignment assessment with the OrthoPilot system. Limb alignment in the coronal plane and extension range of the knee were assessed in four embalmed cadaveric specimens by five independent observers and measurements were repeated four times to determine intra- and inter-observer agreement, expressed as intraclass correlation coefficients (ICCs). Additionally, navigation results were compared against figures from conventional measurement of leg alignment (ground truth). Intra- and inter-observer agreements were excellent for assessing the extension range (ICC, 0.97 and 0.95) and the coronal femuro-tibial axis in knee extension (ICC, 0.92 and 0.88) but were generally worse in knee flexion (ICC, 0.62 and 0.55). There was an increased tendency of intraobserver errors in observers with less clinical experience. Mean correlation with conventional measurements was fair (Spearman’s rho 0.61). The OrthoPilot system showed excellent reproducibility for assessment of extension range and coronal limb alignment. However, assessments of coronal limb alignment in flexion were prone to error and caution should be taken when relying on these measurements.     

Der „AO/ASIF-Flexnail“

BACKGROUND: The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation. METHOD: Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score. RESULTS: Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome. CONCLUSION: We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.     

Management von Kombinationsfrakturen des Femurschafts und des proximalen Femurs

Purpose

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

Material and methods

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

Results

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

Conclusion

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.     

Injury severity and localisations seen in polytraumatised children compared to adults and the relevance for emergency room management

PURPOSE: The treatment of paediatric polytrauma patients in the emergency room is not common. The knowledge of specific injuries in consideration of the age-specific characteristics is of particular importance for precise diagnostics and therapy. The goal of this study is the aquisition of the frequency, the localisation and the severity of paediatric polytrauma (age: 0-16 years) in comparison with adults. PATIENTS AND METHODS: In the period 7 / 01 to 5 / 04 the localisation and injury severity of 23 paediatric polytrauma patients (age: 2-16 years) were compared retrospectivly with those of 324 adults (age: 17-88 years). In the paediatric group (ISS: 31) the lethality was 17 % and so much higher than that in the grown-up population (ISS: 33) with 10 % at comparable injury severity. The cause of accident and the injury severity of the affected body region were analysed. The severity of the diffferent body regions were classified by the Abbreviated Injury Severity Score (AIS). The results were discussed with regard to the current literature. RESULTS: With 65 %, more than every second child suffered from severe head injuries (AIS > 2), whereas only 37 % of the adults were affected in this way. The different types of intracranial bleedings were analysed and compared. Heavy injuries of the thorax (AIS > 2) were the result of an accident in 61 % of the children and in 54 % of the adults. The incidence of children with injuries to the abdomen was 30 % compared to 31 % in the grown-up collective. Lesions of the spleen and liver had a frequency of 13 to 16 %. Injuries of the spine could be only found in 4 % of the children compared to 40 % of the adult group. The frequencies of pelvic injuries were similar at 22 % for children and 28 % for adults. With 13 % for the upper extremities and 17 % for the lower extremities, children were much less injured in these body regions. In the group of adults 43 % had injuries to the upper extremities and 33 % injuries to the lower extremities. CONCLUSIONS: Taking the results into account with consdieration of the literature data, the authors recommend that the emergency room management for adults and, especially, the radiolgical diagnostic chain with CT scans should also be applied to polytraumatised children. The main reasons for this are the extremely high incidence of intracranial injuries and the high sensitivity of CT scans also for abdominal trauma and pelvic injuries.     

Stapes surgery in otosclerosis and small middle ear abnormality]

Stapes surgery in otosclerosis (first and revision operation) and in minor middle ear malformation follows the same principles, but the surgical problems are rather different. When analyzing three groups of patients, which had been operated on the same technique, we could show that the risks of the operation in malformation and revision surgery are not greater than they are in primary otosclerosis surgery. The audiologic results are more satisfying in the latter; malformation surgery and revision surgery have almost the same results which are lying somewhat below those of primary otosclerosis surgery. In the hands of an experienced surgeon, who is able to adopt his surgical technique at the individual situation, stapes surgery is nearly without risk in all these indications; an improvement of the air-conducting level of 18-23 dB can be expected and a social hearing above 35 dB can be provided in 83% of otosclerosis patients, in 79% of malformation patients and in 57% of revision patients.