Outcomes Of Different Treatment Strategies Research Articles

Prognostic factors for radial nerve palsy associated with humeral shaft fracture

Background: Radial nerve palsy (RNP) associated with humeral shaft fracture is a common injury pattern in trauma patients. The management of RNP associated with humeral fractures in high-energy trauma is controversial and poses a challenge to surgeons treating it. Purpose: Based on a review of our experience over the past 15 years, we determined the prognostic factors of radial nerve recovery after humeral fractures, evaluated the diagnostic role of nerve conduction studies and electromyography (EMG), and compared the outcomes of different treatment strategies. Materials and Methods: The data of 26 patients having RNP associated with humeral shaft fractures over a 15-year period were collected for a retrospective review. For statistical analysis, the patients were divided into groups on the basis of their recovery from RNP and the treatment strategies used. Results: The incidence of RNP associated with humeral fractures was 2.05%. In total, 91.3% of patients with primary RNP in this series experienced high-energy trauma. Spontaneous recovery was observed in 9 of 26 patients (34.6%). Radial nerve lesions were found in 7 of 8 patients with high-energy trauma. The severity of humeral shaft fractures was found to be a significant prognostic factor for spontaneous recovery from RNP. The rate of spontaneous recovery was significantly higher in the AO Foundation and Orthopaedic Trauma Association Type A humeral shaft fractures (P = 0.028) and lower in Type C fractures (P = 0.055). The median time to detect initial radial nerve recovery using EMG was 34 and 75 days after injury (P = 0.033). In high-energy trauma, tendon transfers were associated with more predictable outcomes than nerve reconstruction (favorable functional recovery: 100% for tendon transfers vs. 25% for nerve reconstruction, P = 0.007). Moreover, tendon transfers were associated with a shorter overall treatment duration (median treatment duration: 190 days for tendon transfers vs. 422 days for nerve reconstruction, P = 0.007). Conclusion: The prognosis of RNP associated with humeral shaft fractures in high-energy trauma is less favorable, with a low rate of spontaneous recovery. EMG is helpful for the early detection of initial nerve recovery. The outcomes of tendon transfers in high-energy trauma are predictable and the treatment duration is shorter. First-intention tendon transfer is a reasonable treatment strategy in patients with difficult nerve exploration, lower requirement for functional recovery, and lower compliance with treatment.

Partial-thickness scalds in children: A comparison of different treatment strategies

AimThe aim of this study was to compare the clinical outcomes of different treatment strategies for children with partial-thickness scalds at two burn centers. At the first burn center, these burns were treated with a hydrofiber dressing (Aquacel®, Convatec, Inc.®, Princeton, NJ, USA) or silver sulfadiazine (SSD, Flammazine®, Sinclair IS Pharma, London, UK Pharmaceuticals), while at the second burn center, cerium nitrate-silver sulfadiazine (CN-SSD, Flammacerium®, Sinclair IS Pharma, London, UK Pharmaceuticals) was used. MethodsA two-center retrospective study was conducted of children admitted between January 2009 and December 2013 for partial-thickness scalds up to 10% TBSA who were treated primarily with a hydrofiber dressing or silver sulfadiazine (Burn Center Rotterdam) vs. cerium nitrate-silver sulfadiazine (Burn Center Groningen). The Dutch Burn Repository R3 and the electronic medical records of the study population were used for data extraction. The primary outcome was the time to wound healing. The secondary outcomes were the length of hospital stay, wound infection, and surgical treatment. ResultsThe time to wound healing differed between the groups (HR=1.46, 95%CI 1.17–1.82); the shortest time to wound healing was observed in the patients treated with CN-SSD (median 13 days), compared with 15 days for the patients treated with hydrofiber and 16 days for the patients treated with SSD (p<0.01). The length of stay was significantly shorter for the hydrofiber patients (medians: hydrofiber 3 days, SSD 10 days and CN-SSD 7 days; p<0.01), but their outpatient treatment period was significantly longer (medians: hydrofiber 12 days, SSD 6 and CN-SSD 4 days; p<0.01). The proportion of surgeries and the mean time to surgery was similar between the burn centers. ConclusionsThis study compared different burn centers’ treatment strategies for children with partial-thickness scalds and found a shorter time to wound healing in the CN-SSD group. Patients treated with hydrofiber had a shorter clinical period in comparison with the SSD and CN-SSD patients. The results of CN-SSD are promising and warrant further study. A prospective study is needed to gain full insight into the merits and drawbacks of the treatment strategies. This will allow clinicians to make full use of the strengths of particular treatments to benefit specific patients.

Vascular Access Quality Improvement

The aim of this study was to compare the clinical outcomes of different treatment strategies for children with partial-thickness scalds at two burn centers. At the first burn center, these burns were treated with a hydrofiber dressing (Aquacel®, Convatec, Inc.®, Princeton, NJ, USA) or silver sulfadiazine (SSD, Flammazine®, Sinclair IS Pharma, London, UK Pharmaceuticals), while at the second burn center, cerium nitrate-silver sulfadiazine (CN-SSD, Flammacerium®, Sinclair IS Pharma, London, UK Pharmaceuticals) was used.A two-center retrospective study was conducted of children admitted between January 2009 and December 2013 for partial-thickness scalds up to 10% TBSA who were treated primarily with a hydrofiber dressing or silver sulfadiazine (Burn Center Rotterdam) vs. cerium nitrate-silver sulfadiazine (Burn Center Groningen). The Dutch Burn Repository R3 and the electronic medical records of the study population were used for data extraction. The primary outcome was the time to wound healing. The secondary outcomes were the length of hospital stay, wound infection, and surgical treatment.The time to wound healing differed between the groups (HR = 1.46, 95%CI 1.17–1.82); the shortest time to wound healing was observed in the patients treated with CN-SSD (median 13 days), compared with 15 days for the patients treated with hydrofiber and 16 days for the patients treated with SSD (p < 0.01). The length of stay was significantly shorter for the hydrofiber patients (medians: hydrofiber 3 days, SSD 10 days and CN-SSD 7 days; p < 0.01), but their outpatient treatment period was significantly longer (medians: hydrofiber 12 days, SSD 6 and CN-SSD 4 days; p < 0.01). The proportion of surgeries and the mean time to surgery was similar between the burn centers.This study compared different burn centers’ treatment strategies for children with partial-thickness scalds and found a shorter time to wound healing in the CN-SSD group. Patients treated with hydrofiber had a shorter clinical period in comparison with the SSD and CN-SSD patients. The results of CN-SSD are promising and warrant further study. A prospective study is needed to gain full insight into the merits and drawbacks of the treatment strategies. This will allow clinicians to make full use of the strengths of particular treatments to benefit specific patients.

Clinical characteristics, microbiology, and outcomes of prosthetic joint infection in Taiwan

Prosthetic joint infection (PJI) after total knee or hip replacement is a devastating complication associated with substantial morbidity and economic cost. The incidence of prosthetic joint infection is increasing as the use of mechanical joint replacement increases. The treatment approach to prosthetic joint infection is based on different clinical situations such as a patient's comorbidities, epidemic microbiology data, and surgical procedures. The aim of our study was to understand clinical characteristics of prosthetic joint infection, the microbiology of the prosthetic joint infection, and the outcomes of different treatment strategies during 2006-2011. We retrospectively collected cases of prosthetic joint infection in the National Taiwan University Hospital between January 1, 2006 and December 31, 2011. The patients' characteristics, microbiology, outcomes, and factors associated with treatment success were recorded. One hundred and forty-four patients were identified as having PJI. Of these, 92 patients were entered into per-protocol analysis. Staphylococcus aureus was the most common causative organism (29.9%), followed by coagulase-negative Staphylococci (16.7%), and Enterococci (9.7%). The overall treatment success rate was 50%. Patients who received a two-stage revision had a better outcome, compared to patients who underwent other types of surgeries (70% vs. 32.7%, respectively; p < 0.001). In multivariate analysis, the two-stage revision was significantly associated with treatment success (odds ratio = 3.923, 95% confidence interval = 1.53-10.04). Our study demonstrates that Staphylococcus aureus was the most common causative organisms in PJI. Performing two-stage revisions was significantly associated with a better outcome.

Aetiology, microbiology and therapy of periapical lesions around oral implants: a retrospective analysis

The aim of this study was: (i) to evaluate whether an endodontic pathology on the extracted tooth or adjacent teeth of an implant site has an influence on the emergence of a periapical lesion, (ii) to retrospectively analyse the outcome of different treatment strategies, (iii) to determine which bacteria were present in periapical lesions. The endodontic status of the tooth at the implant site and the adjacent teeth was explored and linked to the periapical status of the implant. For all the lesions treated since 2000, their survival was assessed. Finally, microbial samples (culturing) from the periapical lesions, were analysed. If an endodontic treatment or a periapical lesion at the apex of a tooth is present, a periapical lesion around the implant can be detected in 8.2% up to 13.6% (OR 7.2). For periapical pathology at the adjacent teeth, the percentage rises to 25% (OR 8.0). The best treatment option could not be found. Bacteria were found in 9/21 lesions. The most prominent species was P. gingivalis. When an endodontic pathology is present on the extracted or neighbouring teeth, it is significantly more likely that a periapical lesion will develop around a future implant.

Subacromial impingement syndrome

Subacromial impingement syndrome (SAIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. However, the etiology is multi-factorial, and it has been attributed to both extrinsic and intrinsic mechanisms. Management includes physical therapy, injections, and, for some patients, surgery. No high-quality randomized controlled trials are available so far to provide possible evidence for differences in outcome of different treatment strategies. There remains a need for high-quality clinical research on the diagnosis and treatment of SAIS.

Neoplastic pericardial disease in lung cancer: Impact on outcomes of different treatment strategies. A multicenter study

BackgroundLocal (intrapericardial) chemotherapy has been reported to be useful for the treatment of neoplastic pericardial disease, but it has never been compared to systemic chemotherapy, a combination of the two and simple pericardial drainage or sclerosis. MethodsWe analyzed the clinical and echocardiographic data of 119 patients, suffering of neoplastic pericarditis due to lung cancer (97 with non-small-cell), comparing the outcomes of four different treatment strategies (extended catheter drainage/sclerosis, systemic chemotherapy, local chemotherapy, and combined – local plus systemic – chemotherapy) at the last available follow-up or at the change of therapy after a treatment failure. The outcomes (based on semiquantitative evaluation of pericardial disease) were classified as complete, partial, no response and progressing disease. ResultsA complete response was achieved in 37/53 of patients with combined, in 12/22 with local, in 5/27 with systemic chemotherapy, respectively, and in 4/17 after drainage/sclerosis (p<0.001). Overall response was achieved in 51/53 with combined, 18/22 and 16/27 with local or systemic chemotherapy, respectively, and in 5/17 with drainage/sclerosis only (p<0.001). Survival was significantly better after combined chemotherapy (p<0.001) and 12/53 patients (23%) in this subgroup survived more than 1 year. The overall response rate was higher with intrapericardial cisplatinum than with other agents (98% vs 80%, χ2=7.69, p<0.01). ConclusionsLocal chemotherapy, alone or with systemic chemotherapy, is effective in treating pericardial metastases from lung carcinoma, leading to a good control of pericardial effusion in 92% of cases, and to complete disappearance of effusion and masses in 65%. Combined therapy is significantly better than any other treatment. Pericardiocentesis and intrapericardial chemotherapy should be used whenever possible in lung cancer neoplastic pericardial disease, not only in case of tamponade.

Subjective Outcomes Assessment in Chronic Rhinosinusitis

The treatment of chronic rhinosinusitis (CRS) requires an increasing use of medical and economic resources. Therefore, the assessment of objective and subjective outcome of different treatment strategies is of considerable interest. Validated quality of life (QOL) instruments are one important means to assess subjective outcome of the patients. Frequently used generic instruments are the Short Form 36 Health Survey (SF-36) for prospective evaluations and the Glasgow Benefit Inventory (GBI) for retrospective evaluations. Normative data and numerous comparative data sets collected from various diseases are available for the SF-36. Disease-specific QOL instruments for CRS have been developed over the last 15 years. In this review 11 disease-specific instruments are discussed. Only four of these instruments cover all four main symptoms of CRS and are completely validated as well. Most frequently used instruments (Sino-Nasal Outcome Test, SNOT-20; Chronic Sinusitis Survey, CSS) do not query all the main symptoms of CRS. Until the nineteen-nineties the evaluation of success was straitened to the reporting of complications, revision surgery rates etc. It was postulated that normal and non- inflammatory endoscopic clinical findings were always a successful result even for the patient. However, frequently strong divergences between clinical findings and subjective patient reports had to be noted (10). Furthermore, computed tomography (CT) which is the most important imaging method in these patients could not establish significant correlations between imaging and symptom severity. Since the nineteen-eighties quality of life (QOL) instruments were systematically developed and validated for use in clinical medicine to achieve the goal of measuring the subjective outcome of the patients. The first instruments for use in patients with CRS were developed in the nineteen- nineties. In the following general and disease-specific QOL instruments which are in use in patients with CRS are presented.

What Counts: Outcome Assessment After Distal Radius Fractures in Aged Patients

Outcome of surgical interventions at the distal radius does not only depend on the type of intervention used, it also depends on the way the outcome is measured. Substantial differences in outcome assessment between different measurement tools and poor correlation among them result in the question about the best instrument for the evaluation of treatment after distal radius fractures. The aim of the review is to discuss pros and cons of the parameters that are available to assess the outcome after distal radius fractures. The review should help to choose the appropriate instruments for a given research question in aged patients with distal radius fractures. Objective and subjective measures were reviewed with respect to their suitability in outcome assessment. Radiological parameters like inclination, palmar slope, and length of the radius are most common and used to determine especially surgical success. Grip strength and range of motion are considered objective and used as study endpoints in many studies. Functional tests like the Jebsen test provide a realistic feedback about disability but require special skills and resources of the testing personnel. Patient self-assessment adds perceived patient benefit. The patient-rated wrist evaluation (PRWE) provides a reliable and valid instrument for subjective outcome assessment. A combination of objective and subjective parameters should be used to assess the outcome of different treatment strategies due to the known discrepancies. Objective parameters like shortening, radial shift, or others should be clearly defined in the study methodology.

Similar outcome of different treatment strategies in patients 16 to 60 years of age with acute myeloid leukemia (AML)

7080 Background: In order to compare current treatment strategies, four multicenter trial groups in Germany joined for a prospective, individual patient data based study. Methods: To guarantee comparability all patients before treatment started were randomized by phone call to the shared statistical center, to receive either the trial own treatment (90% patients) or a common standard treatment (10%). The common standard arm uniformly contained two courses of CALGB derived araC 100 mg/m²/dx7 and daunorubicin 60 mg/m2/d×3 and in patients attaining complete remission (CR) 3 courses of high-dose araC (HIDAC) 3 g/m2q12h×6. By their trial own treatment the participating trials addressed own strategies. Thus, HIDAC in induction (trial 1) and early allogeneic stem cell transplantation (SCT) (trial 2) were administered in patients with high-risk features and/or slow response. Randomized comparisons of one versus two induction courses by HIDAC/mitoxantrone, and prolonged maintenance versus autologous SCT were done in trial 3, and HIDAC 1g/m2 q12h × 8 versus 2g/m2/d × 4 in trial 4. These trial own randomizations did not result in significant differences of outcome. Results: The four trial populations and the standard arm will be compared according to intention-to-treat with the event-free survival as primary clinical endpoint. Differences will be tested using a log rank test as well as the probability of EFS at 3 years with 95% CI. The upcoming analyses will be after the end of patient's accrual. The current duration of follow-up is 15 (1–53) months. No significant financial relationships to disclose.

Cost-Effectiveness of C-Leg Compared With Non–Microprocessor-Controlled Knees: A Modeling Approach

Brodtkorb T-H, Henriksson M, Johannesen-Munk K, Thidell F. Cost-effectiveness of C-Leg compared with non–microprocessor-controlled knees: a modeling approach. ObjectiveTo estimate the costs and health outcomes of C-Leg and non–microprocessor-controlled (NMC) knees using a decision-analytic model. DesignData on costs, rates and duration of problems, knee survival, and health-related quality of life were obtained from interviews with patients and prosthetists with experience of both C-Leg and NMC knees. Interview data were assessed in a decision-analytic Markov model to estimate cost-effectiveness from a health care perspective. SettingOutpatient. ParticipantsA population sample of 20 patients currently using the C-Leg and prior experience of nonmicroprocessor knees, and 5 prosthetists. InterventionsNot applicable. Main Outcome MeasureIncremental cost per quality-adjusted life year (QALY). ResultsThe mean incremental cost (in 2006 Euros) and QALYs for the C-Leg was €7657 and 2.38, respectively, yielding a cost per QALY gained of €3218. ConclusionsIt is important to provide decision-makers with relevant information on costs and health outcomes of different treatment strategies on actual decision problems despite limited evidence. The results of the study, taking into account both costs and a broadly defined health outcome in terms of QALY, show that given existing albeit limited evidence the C-Leg appears to yield positive health outcomes at an acceptable cost.

Current treatment approaches to early childhood medulloblastoma

Treatment of medulloblastoma, the most common malignant brain tumor of childhood, is particularly challenging in very young children, owing to the increased susceptibility of the immature brain to treatment-induced neurocognitive deficits. Three promising strategies have been developed in combination with systemic postoperative chemotherapy, to avoid craniospinal irradiation for young children with nonmetastatic medulloblastoma, these include: high-dose chemotherapy, with and without local radiotherapy; intraventricular chemotherapy; and local radiotherapy. More intensified strategies may be required for metastatic medulloblastoma. Future studies will clarify the prognostic relevance of desmoplasia, postoperative residual tumor and biological markers to improve stratification criteria by risk-adapted treatment recommendations. An international Phase III trial for young children with nonmetastatic medulloblastoma, comparing survival rates and neurocognitive outcomes of different treatment strategies by standardized criteria, is under discussion.

Evaluation of costs and effects of epidural analgesia and patient-controlled intravenous analgesia after major abdominal surgery

The outcome of different treatment strategies for postoperative pain has been an issue of controversy. Apart from efficacy and effectiveness a policy decision should also consider cost-effectiveness. Since economic analyses on postoperative pain treatment are rare we developed a decision model in a pilot cost-effectiveness analysis (CEA) comparing epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) after major abdominal surgery in routine care. Using a decision-tree model, treatment with EDA (ropivacaine and morphine) was compared with PCIA (morphine). Effects and costs of treatment were established. The number of pain-free days at rest (pain intensity <30 using visual analogue scale 1-100 mm) was the primary measure of effect. An incremental cost-effectiveness ratio (ICER) was calculated as the difference in direct costs divided by the difference in effect. A database on 644 patients collected for the purpose of quality control during the period of 1997 to 1999 was the main data source. Sensitivity analysis was used to test uncertain data. EDA was more effective in terms of pain-free days but more expensive. The additional cost for each pain-free day was 5652 Euros. It is a judgement of value if the additional cost is reasonable. When the cost of around 55,000 Euros per gained life-year with full health for other interventions is debated, our result indicates poor cost-effectiveness for EDA. Before any conclusion can be drawn concerning policy recommendations the difference in costs has to be related to other outcome measures as length of hospital stay, morbidity and mortality are required.

Does multimodality therapy of arteriovenous malformations improve patient outcome?

The strategy for treating arteriovenous malformations (AVMs) has undergone changes and long-term follow-up results remain unclear. To compare the outcomes of different treatment strategies, we divided 112 patients with 113 AVMs into groups with hemorrhagic (n = 71, 62.8%) and nonhemorrhagic (n = 42, 37.2%) AVMs and subdivided these according to the period in which they were treated (before/after 1990). In the more recent period, treatment more frequently involved the use of the γ-knife and microembolization to the AVM as well as combination therapy. Long-term follow-up showed that the complication rate was lower and the Rankin scale better, in the more recently treated group. Based on our findings we suggest that AVMs should be treated aggressively using a multimodality strategy.

Johnson Pump AB, Sweden

Brodtkorb T-H, Henriksson M, Johannesen-Munk K, Thidell F. Cost-effectiveness of C-Leg compared with non–microprocessor-controlled knees: a modeling approach.To estimate the costs and health outcomes of C-Leg and non–microprocessor-controlled (NMC) knees using a decision-analytic model.Data on costs, rates and duration of problems, knee survival, and health-related quality of life were obtained from interviews with patients and prosthetists with experience of both C-Leg and NMC knees. Interview data were assessed in a decision-analytic Markov model to estimate cost-effectiveness from a health care perspective.Outpatient.A population sample of 20 patients currently using the C-Leg and prior experience of nonmicroprocessor knees, and 5 prosthetists.Not applicable.Incremental cost per quality-adjusted life year (QALY).The mean incremental cost (in 2006 Euros) and QALYs for the C-Leg was €7657 and 2.38, respectively, yielding a cost per QALY gained of €3218.It is important to provide decision-makers with relevant information on costs and health outcomes of different treatment strategies on actual decision problems despite limited evidence. The results of the study, taking into account both costs and a broadly defined health outcome in terms of QALY, show that given existing albeit limited evidence the C-Leg appears to yield positive health outcomes at an acceptable cost.

Variation in the management of pediatric diabetic ketoacidosis by specialty training.

To compare management strategies for pediatric diabetic ketoacidosis (DKA) among physicians with different specialty training. We conducted a mail survey of 1000 randomly selected physicians, including 200 pediatric endocrinologists, 200 general emergency physicians, 200 pediatric emergency physicians, 200 pediatric intensivists, and 200 pediatric chief residents. We posed questions regarding a hypothetical 10-year-old patient with new onset of diabetes mellitus who is approximately 10% dehydrated but alert, with venous pH of 7.1 and serum glucose concentration of 34.7 mmol/L (625 mg/dL). Questions involved the rate of rehydration, content of intravenous fluids, insulin therapy, potassium replacement, use of sodium bicarbonate, and adjustments in therapy for decreasing serum glucose concentration. We compared responses of physicians in each specialty and used multiple regression analysis to adjust for potential confounding variables, including number of years in practice, number of children with DKA seen per month, and practice setting. Five hundred eighty-one physicians (58.1%) completed the survey, with responses demonstrating significant, consistent differences between specialties. Extremes of responses included the following: (1) 59% of endocrinologists vs 11% of general emergency physicians would give an initial fluid bolus of less than 20 mL/kg (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.0-27.7) (P < .001); (2) 83.5% of general emergency physicians vs 42.5% of pediatric intensivists would administer an initial insulin bolus (OR, 4.1; 95% CI, 2.0-8.7) (P < .001); (3) 58.2% of pediatric intensivists vs 9% of general emergency physicians would replace fluids over a period of greater than 24 hours (OR, 14.1; 95% CI, 5.5-37.5) (P < .001); and (4) 54.3% of general emergency physicians vs 7.3% of pediatric intensivists would use potassium chloride alone for potassium replacement (OR, 10.8; 95% CI, 5.0-23.8) (P < .001). All of these differences persisted after adjusting for the potential confounding variables. Substantial differences exist in the management of pediatric DKA among physicians of different specialties, presumably due to differences in specialty training. These differences obscure our ability to evaluate the treatment of DKA and highlight the necessity for further studies comparing the outcomes of different treatment strategies.