Cost-utility analysis of total shoulder arthroplasty : a prospective health economic study using real-world data

Background: With increasing health care expenditures, knowledge about the benefit and costs of surgical interventions such as total shoulder arthroplasty (TSA) becomes important for orthopedic surgeons, social insurances and health policy decision makers. We examined the impact of TSA on quality of life (QOL), direct medical costs and productivity losses, and evaluated the cost-utility ratio of TSA compared to ongoing nonoperative management using real-world data. Methods: Patients with shoulder osteoarthritis and/or rotator cuff tear arthropathy indicated for anatomical or reverse TSA were included in this prospective study. Quality of life (EQ-5D-5L) and shoulder function (Constant Score, Shoulder Pain and Disability Index, short version of the Disabilities of the Arm, Shoulder and Hand questionnaire, Subjective Shoulder Value) were assessed before (preop) and up to 2 years after surgery (postop). Health insurance companies provided all-diagnoses direct medical costs for 2018 in Swiss francs (CHF), where 1 CHF was equivalent to 1.02 USD. Indirect costs were assessed using the work productivity and activity impairment questionnaire. Baseline data at recruitment and the total costs of the preop year served as a proxy for nonoperative management. The incremental cost-effectiveness ratio (ICER) was calculated as the total costs to gain one extra quality-adjusted life year (QALY) based on both the health care system and societal perspective. The relationship between QOL and shoulder function was assessed by regression analysis. Results: The mean preOP EQ-5D-5L utility index of 0.68 for a total of 150 patients (mean age 71 years; 21% working; 58% female) increased to 0.89 and 0.87 at 1 and 2 years postop, respectively. Mean direct medical costs were 11,771 CHF (preop), 34,176 CHF (1 year postop) and 11,763 CHF (2 years postop). The ICER was 63,299 CHF/QALY (95% confidence interval [CI]: 44,391; 82,206). Mean productivity losses for 30 working patients decreased from 40,574 CHF per patient (preop) to 26,114 CHF at 1 year postop and 10,310 CHF at 2 years postop. When considering these productivity losses, the ICER was 35,549 CHF/QALY (95% CI: 12,076; 59,016). Quality of life was significantly associated with shoulder function (p < 0.001). Conclusion: Using real-world direct medical cost data, we calculated a cost-utility ratio of 63,299 CHF/QALY for TSA in Switzerland, which clearly falls below the often suggested 100,000 CHF/QALY threshold for acceptable cost-effectiveness. In view of productivity losses, TSA becomes highly cost-effective with an ICER of 35,546 CHF/QALY

Factors influencing overall survival rates for patients with pineocytoma

Given its rarity, appropriate treatment for pineocytoma remains variable. As the literature primarily contains case reports or studies involving a small series of patients, prognostic factors following treatment of pineocytoma remain unclear. We therefore compiled a systematic review of the literature concerning post-treatment outcomes for pineocytoma to better determine factors associated with overall survival among patients with pineocytoma. We performed a comprehensive search of the published English language literature to identify studies containing outcome data for patients undergoing treatment for pineocytoma. Kaplan–Meier analysis was utilized to determine overall survival rates. Our systematic review identified 168 total patients reported in 64 articles. Among these patients, 21% underwent biopsy, 38% underwent subtotal resection, 42% underwent gross total resection, and 29% underwent radiation therapy, either as mono- or adjuvant therapy. The 1 and 5 year overall survival rates for patients receiving gross total resection versus subtotal resection plus radiotherapy were 91 versus 88%, and 84 versus 17%, respectively. When compared to subtotal resection alone, subtotal resection plus radiation therapy did not offer a significant improvement in overall survival. Gross total resection is the most appropriate treatment for pineocytoma. The potential benefit of conventional radiotherapy for the treatment of these lesions is unproven, and little evidence supports its use at present

Basler interdisziplinäre Sprechstunde für Eltern von Säuglingen und Kleinkindern : Konzept und empirische Ergebnisse

The Basel clinic for parents with infants and toddlers is a special interdisciplinary service. The authors present the concept and practice of treatment. Further they show the results of documentation and evaluation. In most cases regulation and sleeping disorders are treated. Temperament ratings made by the mothers of the treated children exhibit more difficult behaviour in comparison to a normal sample. These ratings had no correlation with the mothers’ depression scores which rank much higher than the control group. The outcome ratings by the psychotherapists show that despite the short duration of the treatment and severe cases therapeutical success could be achieved. This outlines the importance of such specialized services for early infant crying and other disturbances of the early childhood. Die Basler interdisziplinäre Sprechstunde für Eltern von Säuglingen und Kleinkindern ist ein spezialisiertes interdisziplinäres Angebot. Die Autoren stellen das Konzept und die Behandlungspraxis vor. Außerdem werden Ergebnisse der Dokumentation und Evaluation dargestellt. Es zeigte sich, dass vor allem Regulations- und Schlafstörungen behandelt werden. Mütterliche Temperamentseinschätzungen zeigen, dass sich die behandelten Kinder deutlich von einer Normstichprobe unterscheiden, also schwieriger sind. Dabei korrelierte diese Einschätzung der Mütter nicht mit ihrer depressiven Befindlichkeit. Die depressive Befindlichkeit der Mütter ist deutlich über der einer Vergleichsgruppe. Eine Einschätzung des Behandlungserfolges durch die TherapeutInnen zeigt, dass vielfach mit relativ kurzer Behandlungsdauer ein Therapieerfolg erreicht werden konnte, und dies trotz der oft schwierigen Fälle. Dies unterstreicht die Bedeutung eines spezialisierten Behandlungsangebotes für Schreibabys und andere Probleme des frühen Kindesalters

Swiss health services research in orthopedics : gaining cost-utility data about common procedures in routine care

Orthopedic procedures can have a relevant impact on quality of life (QOL) as well as on return to work rates of patients and are often associated with high medical costs. For procedures in the upper extremities, the impact on patient benefits and costs in swiss routine care is poorly documented

Impact of Sports Activity on Medium-Term Clinical and Radiological Outcome after Reverse Shoulder Arthroplasty in Cuff Deficient Arthropathy; An Institutional Register-Based Analysis

There is a lack of consensus on what physicians can recommend and what patients can expect concerning sports activity after reverse shoulder arthroplasty (RSA). The purpose of this retrospective register-based observational study was to investigate the association between participation in sports or physical activity involving the upper extremity and 5-year clinical and radiological outcomes for primary RSA patients. We screened the institutional arthroplasty registry for patients reporting the type and level of sports postoperatively after primary, unilateral RSA due to rotator cuff deficiency. One hundred thirty-eight patients with clinical and radiological outcomes documented at a minimum 5-year follow-up were divided into three groups comprising those who participated regularly in: sports mainly involving the upper extremity (sports upper extremities, SUE, n = 49), sports mainly involving the lower extremities (sports lower extremities, SLE, n = 21), and those who did not participate in sports at all (no sports, NS, n = 68). The participants had a mean age of 72 years (standard deviation (SD) 8) and were overall predominantly female patients (62%). Primary clinical outcomes included the Constant Score (CS) and Shoulder Pain and Disability Index (SPADI). Secondary radiographs were analyzed for radiolucent lines (RLL), signs of glenoid or humeral prosthesis loosening, bone resorption, bone formation, and scapular notching. A total number of 8 senior surgeons were involved in treatment of patients, and two types of prosthesis were used. The SUE group had non-significantly higher mean scores for CS (75 points) and SPADI (88 points) compared to SLE (71 and 78 points, respectively) and NS patients (66 and 78 points, respectively) (p ≥ 0.286). The incidence of RLL around the humeral diaphysis was higher in NS compared to SUE patients (32% versus 12%, respectively) (p = 0.025); all other radiological parameters were similar between the groups. There were no cases of loosening in the SUE group that led to revision surgery. Patients engaging in sports activities involving the upper extremity show similarly good functional scores 5 years post-RSA as the other groups, without additional signs of implant loosening as a result of increased shoulder use

Prospective study on central venous line associated bloodstream infections

Objective To prospectively assess the incidence rates and characteristics of central venous line associated bloodstream infections (CLABSI) in one institution. Methods All patients with indwelling central venous catheters (CVC) between 1 April 2008 and 31 March 2009 were enrolled. The medical records of patients were reviewed and information on relevant characteristics entered into a standardised questionnaire. Central laboratory records were regularly checked for positive blood cultures in study patients. Results There were 209 CVC for a total of 14752 CVC days in 152 patients (88 males, 58%) including neonates and patients with surgical conditions and haemato-oncological and other underlying diseases. Median age at CVC insertion was 3 months (IQR 0-56 months). Fourteen CLABSI occurred in 13 patients. Overall CLABSI incidence (per 1000 CVC days) was 0.95 (9.71 for silastic percutaneous CVC, 7.65 for other CVC, 1.97 for Broviac, 0.18 for Port-a-cath). CVC remained in place for ?14 days in 109 (52%) instances, 15-90 days in 45 (22%) instances and <90 days in 55 (26%) instances. The incidence of CLABSI in these three categories was 3.36, 4.36 and 0.47, respectively. Predominating cultured organisms were coagulase-negative staphylococci (N=3), S. aureus (N=3), and Enterococcus spp. (N=3). Conclusions CLABSI incidence varied by type of catheter and type of patient, with the highest risk in neonates (with silastic percutaneous CVC) and by far the lowest risk for Port-a-cath CVC. Prophylactic measures to reduce CLABSI should be tailored to individual types of catheters and patient characteristics

Epicondylopathia humeri radialis Epicondylopathia humeri radialis (Epicondylitis radialis) - Diagnosis and Therapy taking into account of the current S2k Guidelines

Background Lateral epicondylitis is a common orthopaedic condition often massively restricting the quality of life of the affected patients. There are a wide variety of treatment options - with varying levels of evidence. Method The following statements and recommendations are based on the current German S2k guideline Epicondylopathia radialis humeri (AWMF registry number: 033-2019). All major German specialist societies participated in this guideline, which is based on a systematic review of the literature and a structured consensus-building process. Outcomes Lateral epicondylitis should be diagnosed clinically and can be confirmed by imaging modalities. The Guidelines Commission issues recommendations on clinical and radiological diagnostic workup. The clinical condition results from the accumulated effect of mechanical overload, neurologic irritation and metabolic changes. Differentiating between acute and chronic disorder is helpful. Prognosis of non-surgical regimens is favourable in most cases. Most cases spontaneously resolve within 12 months. In case of unsuccessful attempted non-surgical management for at least six months, surgery may be considered as an alternative, if there is a corresponding structural morphology and clinical manifestation. At present, it is not possible to recommend a specific surgical procedure. Conclusion This paper provides a summary of the guideline with extracts of the recommendations and statements of its authors regarding the pathogenesis, prevention, diagnostic workup as well as non-surgical and surgical management

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

Background: Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures. Methods: This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case. Results: The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), debridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision. Conclusions: The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly. (C) 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserve

Exome Sequencing Identifies a Novel MAP3K14 Mutation in Recessive Atypical Combined Immunodeficiency

Primary immunodeficiency disorders (PIDs) render patients vulnerable to infection with a wide range of microorganisms and thus provide good in vivo models for the assessment of immune responses during infectious challenges. Priming of the immune system, especially in infancy, depends on different environmental exposures and medical practices. This may determine the timing and phenotype of clinical appearance of immune deficits as exemplified with early exposure to Bacillus Calmette-Guérin (BCG) vaccination and dissemination in combined immunodeficiencies. Varied phenotype expression poses a challenge to identification of the putative immune deficit. Without the availability of genomic diagnosis and data analysis resources and with limited capacity for functional definition of immune pathways, it is difficult to establish a definitive diagnosis and to decide on appropriate treatment. This study describes the use of exome sequencing to identify a homozygous recessive variant in MAP3K14, NIKVal345Met, in a patient with combined immunodeficiency, disseminated BCG-osis, and paradoxically elevated lymphocytes. Laboratory testing confirmed hypogammaglobulinemia with normal CD19, but failed to confirm a definitive diagnosis for targeted treatment decisions. NIKVal345Met is predicted to be deleterious and pathogenic by two in silico prediction tools and is situated in a gene crucial for effective functioning of the non-canonical nuclear factor-kappa B signaling pathway. Functional analysis of NIKVal345Met- versus NIKWT-transfected human embryonic kidney-293T cells showed that this mutation significantly affects the kinase activity of NIK leading to decreased levels of phosphorylated IkappaB kinase-alpha (IKKα), the target of NIK. BCG-stimulated RAW264.7 cells transfected with NIKVal345Met also presented with reduced levels of phosphorylated IKKα, significantly increased p100 levels and significantly decreased p52 levels compared to cells transfected with NIKWT. Ideally, these experiments would have been conducted in patient-derived immune cells, but we were unable to source these cells from the patient. The functional analysis described in this paper supports previous illustrations of the importance of NIK in human immune responses and demonstrates the involvement of function-altering mutations in MAP3K14 in PIDs. The genomic approach used for this patient demonstrates its value in the diagnosis of an unusual PID and as a tool for detecting rarer mutations to help guide treatment approaches