Cost-effectiveness of maternal immunization against neonatal invasive Group B Streptococcus in the Netherlands

BackgroundNeonatal invasive Group B Streptococcus (GBS) infection causes considerable disease burden in the Netherlands. Intrapartum antibiotic prophylaxis (IAP) prevents early-onset disease (EOD), but has no effect on late-onset disease (LOD). A potential maternal GBS vaccine could prevent both EOD and LOD by conferring immunity in neonates.ObjectiveExplore under which circumstances maternal vaccination against GBS would be cost-effective as an addition to, or replacement for the current risk factor-based IAP prevention strategy in the Netherlands.MethodsWe assessed the maximum cost-effective price per dose of a trivalent (serotypes Ia, Ib, and III) and hexavalent (additional serotypes II, IV, and V) GBS vaccine in addition to, or as a replacement for IAP. To project the prevented costs and disease burden, a decision tree model was developed to reflect neonatal GBS disease and long-term health outcomes among a cohort based on 169,836 live births in the Netherlands in 2017.ResultsUnder base-case conditions, maternal immunization with a trivalent vaccine would gain 186 QALYs and prevent more than €3.1 million in health care costs when implemented in addition to IAP. Immunization implemented as a replacement for IAP would gain 88 QALYs compared to the current prevention strategy, prevent €1.5 million in health care costs, and avoid potentially ~ 30,000 IAP administrations. The base-case results correspond to a maximum price of €58 per dose (vaccine + administration costs; using a threshold of €20,000/QALY). Expanding the serotype coverage to a hexavalent vaccine would only have a limited additional impact on the cost-effectiveness in the Netherlands.ConclusionsA maternal GBS vaccine could be cost-effective when implemented in addition to the current risk factor-based IAP prevention strategy in the Netherlands. Discontinuation of IAP would save costs and prevent antibiotic use, however, is projected to lead to a lower health gain compared to vaccination in addition to IAP.     

腹腔镜脾切除术对脾破裂患者白细胞介素-2、人单核细胞表面DR抗原的影响

目的 研究腹腔镜脾切除术对机体术后早期免疫功能的影响程度。方法 将32例外伤性脾破裂患者随机分为腹腔镜脾切除术（LS）组和剖腹脾切除术（OS）组，比较两组术后外周血IL-2和单核细胞HLA-DR的含量变化。结果 术前30 mim两组各指标差异均无显著性（P >0.05）；IL-2：术后第1 d，两组均显著低于术前（P <0.05），但OS组下降程度明显大于LS组（P <0.05）；术后第4 d，OS组较术后第1 d有所升高，但仍显著低于术前（P <0.05），LS组已恢复至术前水平（P >0.05），显著高于OS组（P <0.05）。HLA-DR：术后第l d，两组均显著低于术前（P <0.05），组间差异无显著性（P >0.05）；术后第4 d，两组均有所升高，仍均显著低于术前（P <0.05），但LS组显著高于OS组（P <0.05）。结论 LS和OS对机体术后早期免疫功能均有一定程度的抑制，但LS抑制较小。     

Extensor Mechanism Reconstruction Using Marlex Mesh: Is Postoperative Casting Mandatory?

BackgroundExtensor mechanism (EM) disruption after total knee arthroplasty is a catastrophic complication. Reconstruction using monofilament polypropylene mesh (Marlex Mesh; CR Bard, Franklin Lakes, NJ) has emerged as the preferred treatment, but reports are limited to the designing institution. This study describes a nondesigner experience and compares 2 postoperative immobilization strategies: long leg cast vs knee immobilizer.MethodsA retrospective review of consecutive EM reconstructions between 2012 and 2019 was performed. Primary repairs and allograft reconstructions were excluded, leaving 33 knees (30 patients) who underwent Marlex reconstruction. Mean time from disruption to reconstruction was 14 months, and 14 of 33 (42%) had previous repair or reconstruction attempts. The mean age was 69 years, and mean body mass index was 35 kg/m². Postoperatively, extension was maintained using a knee immobilizer in 19 of 33 (58%) patients, whereas 14 of 33 (42%) patients were long leg casted. Kaplan-Meier analysis determined all-cause survivorship free of mesh failure.ResultsAt mean 25-month follow-up, 19 of 33 (58%) EM reconstructions were functioning. Excluding explanted infections (5 recurrent and 2 new), 19 of 26 (73%) EM reconstructions were in situ. Six-year survivorship was 69% and not influenced by immobilization type (cast: 67%, immobilizer: 71%; P = .74). Extensor lag was not associated with immobilization type, improving from a mean preoperative lag of 43° to a mean postoperative lag of 9°. Among successes, University of California at Los Angeles activity and Knee Injury and Osteoarthritis Outcome Score - Joint Replacement score improvements exceeded minimal clinically important difference (2.2-3.3 and 52.5-64.0, respectively).ConclusionMarlex mesh EM reconstruction is a durable and reliable treatment with acceptable clinical results achievable outside the designer institution. Provided sufficient duration and compliance with postoperative immobilization, similar outcomes can be obtained with either a cast immobilizer or a knee immobilizer.     

Proximal coracobrachialis tendon rupture,subscapularis tendon rupture,and medial dislocation of the long head of the biceps tendon in an adult after traumatic anterior shoulder dislocation

Rupture of the coracobrachialis is a rare entity, in isolation or in combination with other muscular or tendinous structures. When described, it is often a result of direct trauma to the anatomic area resulting in rupture of the muscle belly. The authors present a case of a 57-year-old female who suffered a proximal coracobrachialis tendon rupture from its origin at the coracoid process, with concomitant subscapularis tear and medial dislocation of the long head of biceps tendon after first time traumatic anterior shoulder dislocation. Two weeks after injury, magnetic resonance imaging suggested the diagnosis, which was confirmed during combined arthroscopic and open technique. Soft-tissue tenodesis of coracobrachialis to the intact short head of the biceps, tenodesis of the long head of biceps to the intertubercular groove, and double-row anatomic repair of the subscapularis were performed. The patient did well postoperatively, and ultimately at 6 months follow-up, she was without pain, and obtained 160° of active forward elevation, 45° of external rotation, internal rotation to T8, 5/5 subscapularis and biceps strength. Scoring scales had improved from the following preoperative to final follow-up: American Shoulder and Elbow Surgeons, 53.33-98.33; constant, 10-100; visual analogue scale-pain, 4-0. DASH score was 5.     

Intrapericardial rupture of a mitral subannular aneurysm: A case report and review of the literature

Mitral subannular aneurysm is a rare heart disease that can have many different forms of clinical presentations. It was first described in young men of African descent and was later reported in other geographical areas of the world. The etiopathogenesis as per data from the literature can be congenital, acquired or idiopathic. We report the case of a 19-year-old male in whom we made the diagnosis of mitral subannular aneurysm. The evolution was fatal following a rupture of the aneurysm into the pericardium. Through this case report, we stress the importance of echocardiography in the diagnosis of this condition. In resource-limited countries, the prognosis is unfortunately often unfavorable especially the ruptured forms. Therefore, a high degree of suspicion is needed to make a prompt diagnosis and timely surgical intervention.     

Natural history of descending thoracic and thoracoabdominal aortic aneurysms

ObjectivesElucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes.MethodsAortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan–Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated.ResultsEstimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm.ConclusionsAcute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.