Budget Impact Analysis of Warfarin Reversal Therapies Among Hip Fracture Patients in Finland

Background

Hip fractures require operation within 36–48 h, and they are most common in the elderly. A high International Normalized Ratio should be corrected before surgery. In the current study, we analyzed the budget impact of various warfarin reversal approaches.

Methods

Four reversal strategies were chosen for the budget impact analysis: the temporary withholding of warfarin, administration of vitamin K, fresh frozen plasma (FFP), and a four-factor prothrombin complex concentrate (PCC).

Results

We estimated that, annually, 410 hip fracture patients potentially require warfarin reversal in Finland. The least costly treatment was vitamin K, which accounted for €289,000 in direct healthcare costs, and the most costly treatment option was warfarin cessation, which accounted for €1,157,000. In the budget impact analysis, vitamin K, PCC and FFP would be cost-saving to healthcare compared with the current treatment mix.

Conclusion

The various warfarin reversal strategies have different onset times, which may substantially impact the subsequent healthcare costs.     

Pre-operative embolization of a choroid plexus carcinoma: review of the vascular anatomy

Aim

The purpose of this case is to highlight the benefits of preoperative embolization as well as to review the vascular anatomy that needs to be recognized in order to perform pre-operative embolization of choroid plexus tumors.

Method

We achieve this by presenting the case of a 12-month-old female who had symptoms of raised intracranial pressure. MRI demonstrated a large vividly enhancing mass centered within the atria of the right lateral ventricle associated with hydrocephalus in keeping with a choroid plexus tumor.

Result

Enlarged anterior and posterior choroidal arteries supplying the tumor were noted on the MRI scan. Pre-operative embolization was performed with NBCA glue via the anterior and posterior choroidal arteries. Subsequently, total surgical resection was achieved with only 200 cc of blood loss. Pathology confirmed a choroid plexus carcinoma.

Conclusion

Pre-operative embolization can be useful in minimizing blood loss during excision of choroid plexus tumors. It is important to understand the anatomy of the anterior and posterior choroidal arteries to perform embolization of these tumors safely.

     

Longitudinal and cross-sectional associations of adherence to 24-hour movement guidelines with cardiometabolic risk

This study aimed to examine (1) adherence to 24 h movement guidelines over a 2 years follow-up in children aged 6–8 years and (2) association of this adherence with cardiometabolic risk factors. Physical activity and sleep were assessed by a monitor combining heart rate and accelerometry measurements. Screen time was reported by the parents. Body fat percentage, waist circumference, blood glucose, serum insulin, plasma lipids, and blood pressure were assessed, and a cardiometabolic risk score was calculated using z-scores. Children were classified as meeting the guidelines if they had on average ≥60 min/day of moderate-to-vigorous physical activity during the valid days; ≤120 min/day of screen time; and 9–11 h/day of sleep. In total, 485 children had valid data at baseline or at 2 years follow-up. Analyses were conducted using adjusted logistic and linear regression models. Most children adhered to the 24 h movement guidelines at baseline, but the adherence decreased over the 2 years follow-up. Meeting physical activity guidelines individually, or in combination with screen time and/or sleep, was longitudinally associated with a lower cardiometabolic risk score, insulin and waist circumference, and cross-sectionally additionally with lower diastolic blood pressure and higher high-density lipoprotein cholesterol. However, these associations became statistically non-significant after adjustment for body fat. In conclusion, meeting 24 h movement guidelines at baseline increases the odds of meeting them at 2 years follow-up in school-aged children. Furthermore, meeting 24 h movement guidelines is associated with lower levels of cardiometabolic risk factors, but these associations are partly explained by lower body fat. Thus, promoting movement behaviors, especially physical activity, and healthy weight in early childhood is important in supporting cardiometabolic health in children.     

Oxygen and nutrient delivery in tissue engineering: Approaches to graft vascularization

The field of tissue engineering is making great strides in developing replacement tissue grafts for clinical use, marked by the rapid development of novel biomaterials, their improved integration with cells, better‐directed growth and differentiation of cells, and improved three‐dimensional tissue mass culturing. One major obstacle that remains, however, is the lack of graft vascularization, which in turn renders many grafts to fail upon clinical application. With that, graft vascularization has turned into one of the holy grails of tissue engineering, and for the majority of tissues, it will be imperative to achieve adequate vascularization if tissue graft implantation is to succeed. Many different approaches have been developed to induce or augment graft vascularization, both in vitro and in vivo. In this review, we highlight the importance of vascularization in tissue engineering and outline various approaches inspired by both biology and engineering to achieve and augment graft vascularization.     

The Utility of Gingival Crevicular Fluid Matrix Metalloproteinase‐8 Response Patterns in Prediction of Site‐Level Clinical Treatment Outcome

Background: Different gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)‐8 response patterns were studied among non‐smoking and smoking patients with chronic periodontitis (CP) and generalized aggressive periodontitis (GAgP) to test the utility of GCF MMP‐8 levels predicting the site‐level treatment outcome. Methods: Data from four independent longitudinal studies were combined. Altogether, the studies included 158 periodontal sites from 67 patients with CP and 32 patients with GAgP, and GCF samples were collected at baseline, after the treatment, and during the 6‐month maintenance period. All GCF samples were analyzed by immunofluorometric assay for MMP‐8. Different site‐level MMP‐8 response patterns were explored by the cluster analysis. Most optimal MMP‐8 cutoff levels were searched with receiver operating characteristic analyses, and the predictive utility of defined levels was tested. Results: Distinct types of MMP‐8 response patterns were found in both smokers and non‐smokers. MMP‐8 levels exceeding the optimal cutoff levels separately defined for smokers and non‐smokers indicated increased risk for compromised treatment outcome at baseline and during the maintenance period. Seventy‐one percent of non‐smokers (positive likelihood ratio of 4.22) and 88% of smokers (positive likelihood ratio of 5.00) with positive test results at both baseline and the maintenance period had compromised treatment outcome. The double‐positive result indicated 46% and 39% point risk increase for the compromised outcome, respectively. Conclusion: GCF MMP‐8 analysis with defined cutoff levels could be used to predict the site‐level treatment outcome and for longitudinal monitoring of the disease status during the maintenance period.     

Changes in MMP-9 and TIMP-1 Concentrations in Cerebrospinal Fluid after 1 Week of Treatment of Childhood Bacterial Meningitis

We explored the changes of the initially highly upgraded cerebrospinal fluid matrix metalloproteinase 9 (MMP-9) and tissue inhibitor of MMP 1 (TIMP-1) response during recovery of childhood bacterial meningitis and their association with outcome. The sizes of these changes varied substantially, but a steeper decrease in the MMP-9 and an increase of the TIMP-1 concentrations augured a better outcome.     

Do salivary and serum collagenases have a role in an association between obstructive sleep apnea syndrome and periodontal disease? A preliminary case–control study

Objectives

Despite increasing evidence for an association of obstructive sleep apnea syndrome (OSAS) and periodontal disease, the pathophysiological linking mechanisms remain unclear. This study aims to evaluate the salivary and serum matrix metalloproteinase-2, -8, -9 (MMP-2, -8, -9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), myeloperoxidase (MPO), neutrophil elastase (NE), neutrophil gelatinase-associated lipocalin (NGAL), as well as degree of activation of MMP-2, -9 of patients with and without OSAS.

Design

A total of 50 individuals were included in the study. There were 13, 17 and 20 individuals, respectively in the control (non-OSAS) group, mild-to-moderate OSAS and severe OSAS groups. Saliva, serum samples and clinical periodontal parameters were collected. Biofluid samples were analysed by immunofluorometric assay (IFMA), enzyme-linked immunosorbent assay (ELISA), western immunoblotting and gelatine zymography. Statistical analyses were performed using D’Agostino–Pearson omnibus normality test, Kruskal–Wallis test and Spearman rho rank correlation analysis.

Results

There were no statistically significant differences in clinical periodontal parameters between the study groups. Salivary NE and proMMP-2 levels were significantly lower in the OSAS groups than the control group (p < 0.05). Serum proMMP-9 concentration and the degree of MMP-9 activation in saliva were significantly lower in the severe OSAS group than the control group (p < 0.05). There were significant correlations between salivary and serum proMMP-9 and -2 concentrations (p < 0.05). Serum proMMP-2, NE and salivary proMMP-9 and -2 negatively correlated with indicators of OSAS severity (p < 0.05).

Conclusions

The present findings do not support a pathophysiological link between the severity of OSAS and clinical periodontal status via neutrophil enzymes or MMPs.