Two-stage Intervention Research Articles

THE MODERN CONCEPT OF EARLY DETECTION AND TREATMENT OF IDIOPATHIC SCOLIOSIS

RETRACTED The paper presents the tactics of early detection and treatment of idiopathic scoliosis adopted in Novosibirsk NIITO. Idiopathic scoliosis is a genetically determined disease. Its early detection requires screening of children and adolescents. The most effective conservative method is brace treatment. Surgical treatment is strictly differentiated depending on the age of a patient. Patients in the first decade of life are treated by multi-stage surgery with VEPTR instrumentation. Patients aged 11-13 years undergo one-step intervention using transpedicular fixation of the whole curve. Patients aged 14-20 years are treated in one- or two-stage intervention depending on the curve mobility. Deformities over 90° require multi-stage intervention with anterior and posterior mobilization of the spine.

Results of the modified bi-pectoral muscle flap procedure for post-sternotomy deep wound infection.

Post-sternotomy deep sternal wound infection (DSWI) is a severe complication of cardiac surgery. The introduction of omental and muscle flaps has resulted in a significant decrease in morbidity and mortality. In this article, we present the findings for a series of 55 consecutive patients with DSWI treated using an alternative bi-pectoral musculofascial flap technique. The patients were stratified into two groups (one-or two-stage intervention). Patients with septic wounds initially underwent debridement and wound treatment, while vacuum therapy was used in a subset of the subjects. All patients were treated with wound debridement and bi-pectoral advancement flap reconstruction. 30-day mortality was 5.4%. Most patients (72%) were treated in two stages, while vacuum therapy was used in 20% of the patients. The mean number of hospitalization days was 8 and 12 for the one- and the two-stage groups, respectively. Reconstruction was successful in all but three patients, each of whom developed recurrent infection. No major morbidity was reported at a mean follow-up of 82 months with excellent functional and aesthetic outcomes. Pectoralis-major muscle flaps remain relevant in the modern management of post-sternotomy mediastinitis. The addition of an omental flap should be considered in cases in which the lower sternum is involved. Prompt diagnosis and a meticulous surgical technique ensure favorable results for the majority of patients.

Single Stage Debridement, Cement-Interposition and Stabilization from Posterior for Progressive, Erosive Spondylodiscitis of the Lumbar Spine

Introduction The rate of hematogenous infections of the intervertebral disc is increasing as mostly elderly and immunocompromised patients are affected. Surgery is indicated if the disease is progressive with destruction of the local with instability and/or neurological impairment. Debridement of intervertebral abscess, decompression of the spinal canal, and stabilization of the segment is necessary. At the lumbar spine, the ventral approach allows a radical debridement of the abscess but is less suited for stabilization, especially, in cases with poor bone quality. Therefore, often a two-stage intervention with additional decompression and stabilization from posterior is performed. In this study, we report on the midterm to long-term outcome of a single stage strategy with debridement, cement-interposition, and stabilization from posterior for progressive, erosive spondylodiscitis. Methods In a retrospective, single center case series, patients were evaluated who were surgically treated for progressive, erosive spondylodiscitis. The single stage strategy consists of a lamino- and recessotomy for decompression, debridement of the disc space, and the affected bone through annulotomy, filling of the resulting defect with an antibiotic containing cement spacer and monosegmental to bisegmental stabilization with transpedicular screw fixation. Results From 1997 to 2012, 62 patients (34 males, 28 females, mean age 70 years [range, 32–92 years]) were treated with this technique. Overall, 54 patients were available for a minimal follow-up of 1 year (mean FU, 23.2 months; six died in the first year, two lost). Overall, two patients required additional debridement from ventral for persisting infection in all other the infection was treated successfully with the posterior intervention alone. Mean operation time was 164 (range, 120–347) minutes, blood loss 812 (range, 100–2,500) mL, length of hospital stay 11.7 (range, 2–42) days. Overall, 2 patients died during initial hospitalization, 12 patients during follow-up; in 4 cases, the cause of death was unknown in the other cases not related to the infection. Of the 14 patients, 8 with neurological impairment recovered completely. Three other patients needed a second intervention during the initial hospital stay (one hematoma, one revision of a dural tear, and one decompression for foraminal cement leakage). Nine patients required a secondary intervention of the spine during the first year (three implant loosening/failure, two adjacent segment disease, two spondylodiscitis with a different germ, and two persisting infection with debridement of the psoas abscess from anterior). Conclusion The single stage strategy with debridement, cement-interposition, and stabilization from posterior is a valid option for the treatment of progressive, erosive spondylodiscitis of the lumbar spine. The complication rate is relatively low and the rate of persisting infection with 3.2% comparable with the results of two-stage procedures.

Early two-stage repair of clefts in holoprosencephaly

Holoprosencephaly (HPE) presents with a spectrum of severity, but in its totality is the most common malformation of the embryonic forebrain occurring 1 in 10,000 to 1 in 20,000 live births. Due to the poor prognosis, treatment of mid-face clefts in HPE patients have classically been addressed in a delayed fashion after 1-year of age. Improvements in the ability to manage medical complications associated with HPE along with an increased understanding and lower mortality rates in less severe forms have challenged these previous practiced routines. Accompanied by advances in understanding of HPE and identification of genes responsible for sporadic forms, we are able to better guide timing of surgical intervention. We present a patient with lobar HPE and a type IV facial deformity treated with early repair of the median facial cleft. We believe this treatment strategy was safe, given her relatively good prognosis. We propose that patients with HPE displaying less severe neural non-cleavage may be good candidates for earlier two-stage intervention. SummaryThe historically poor prognosis of patients with holoprosencephaly (HPE) has led to midline facial clefts have being addressed in a delayed fashion after 1-year of age. Improvements in the ability to manage medical complications associated with HPE and lower mortality rates in less severe forms have challenged these previous practiced routines. Additionally, the identification of genes responsible for sporadic forms of HPE can better guide timing of surgical intervention and improve developmental outcomes. We present a patient with lobar HPE and a type IV facial deformity treated with an early two-stage repair of the median facial cleft. We propose patients with HPE displaying less severe neural non-cleavage may be good candidates for earlier intervention.

ANESTHETIC MANAGEMENT FOR TWO-STAGE COMBINED SURGERY FOR POST-TRAUMATIC DEFORMITY OF THE SPINE

Objective. To analyze the influence of the sequence of anterior and posterior fusion procedures performed under combined anesthesia in a single surgical session on gas exchange and hemodynamics in patients. Material and Methods . The performance of gas exchange and hemodynamic status was analyzed in 125 patients who underwent simultaneous two-stage combined intervention for post-traumatic spine deformity. All operations were performed under combined anesthesia with low flow sevoflurane. Patients were divided into two groups depending on the sequence of anterior and posterior fusion procedures: Group I (posterior-anterior sequence) included 60, and Group II (anterior-posterior sequence) - 65 patients. Results . An open pneumothorax, mechanical compression of the lungs, and hyperextension of the spine are the main factors affecting the degree of deviations in hemodynamics and gas exchange, which require adjustment of mechanical ventilation and infusion rate parameters. The most statistically significant changes in analyzed indicators were registered in patients in Group I. Conclusion . The anterior-posterior sequence of fusion procedure is more physiological treatment of patients comparing to the posterior-anterior one.

Cultivating Mind: Mindfulness Interventions for Children with Autism Spectrum Disorder and Problem Behaviours, and Their Mothers

Problem behaviours in children with Autism Spectrum Disorder (ASD) are a major source of parenting stress, as they restrict family capacity to maintain quality domestic and social life. It is therefore critical to support parents to manage the problem behaviours of their child with ASD. Recent mindfulness intervention studies have successfully addressed this issue. The current pilot study pursues this line of enquiry and extends the scope of mindfulness intervention by training parents to become a mindfulness teacher of their own child with ASD and problem behaviours, so together they can work on enhancing the quality of their domestic and social life. A total of six dyads of mothers (CA range 34–48 years) and children with ASD and problem behaviours (CA range 8–15 years) participated in a two-stage mindfulness intervention. Mothers attended an 8-week mindfulness program to attain fluency in the theory and practice of mindfulness meditation (Stage 1). Based on this fluency they then taught mindfulness activities to their child (Stage 2). This paper reports on the effects of the mindfulness intervention provided for mothers (Stage 1) and children (Stage 2) as demonstrated by the level of mindfulness, parenting stress, and family quality of life for mothers, and problem behaviours for children. The results highlight overall improvements in the targeted areas. Some benefits, issues, and challenges of mindfulness training for parents and their children with ASD are discussed.

The impact of electronic decision support and electronic remote blood issue on transfusion practice.

To assess the impact on transfusion practice of a two-stage electronic intervention: the introduction of a decision support system (DSS) followed by the addition of electronic remote blood issue (ERBI). With increasing evidence to show the benefit of restrictive transfusion policies, it is important to ascertain which interventions can increase clinician compliance with their implementation. A DSS provides patient-specific recommendations to clinicians. ERBI reduces delays in acquiring blood and may alter the transfusion behaviour of clinicians. All electronically requested blood transfusions administered outside of surgical theatres or recovery were identified in an orthopaedic hospital. These were divided into three time periods corresponding to pre-intervention, the successive introduction of DSS alone and DSS with ERBI. Pre- and post-transfusion haemoglobin (Hb) concentration levels, and the number of units ordered and transfused were recorded. A total of 204 transfusions for 92 patients were assessed; 38 of 85 (45%) transfusions in the first time period were compliant. This did not significantly change after introduction of the DSS, but with DSS and ERBI together significantly increased to 39 of 60 (65%) (P < 0·05). Mean pre-transfusion Hb reduced from 8·24 g dl(-1) in the first time period to 7·67 g dl(-1) in the third (P < 0·0001). There was no significant change in overall blood usage, although ERBI significantly reduced the amount of unused blood orders from 70 to 25%. Electronic DSS was not sufficient to change practice in the form implemented in this study. ERBI can contribute to significant improvements in blood usage as well as the efficiency of blood provision.

RARE CLINICAL CASE – AN ABNORMAL DRAINAGE OF PORTAL SYSTEM TO THE CORONARY SINUS, HYPOPLASIA OF THE RIGHT BRANCH OF THE PORTAL VEIN AND HIGH PULMONARY HYPERTENSION

Aim: to present an exceptional case of the combined pathology – an abnormal drainage of portal system to the coronary sinus, hypoplasia of the right branch of the portal vein and high pulmonary hypertension. Materials and methods. The patient P. of 22 years old arrived at congenital heart diseases surgical unit of V.I. Shumakov Federal Research Center of Transplantology and Artifi cial Organs. After the examination he was diagnosed with congenital disease – abnormal confl uence of the portal vein in the right atrium. Insuffi ciency of the tricuspid valve 3–4. High pulmonary hypertension. Insuffi ciency of blood circulation of IIa, III functional class. After computer tomography there is no division of the portal vein. Vein is drained in the right atrium bypass with a diameter of 2,3 cm following from the portal vein to the coronary sinus. Results. Considering hopelessness of conservative therapy the only method of the radical help to the patient is two-stage surgical intervention – transplantation of a heart-pulmonary complex and liver transplantation. Conclusion. Presented rare clinical case demonstrates the combination of congenital anomalies of the portal system and the heart with high pulmonary hypertension, and is based on a functioning fetal venous duct (ductus venosus), bypassing the liver in the right atrium (coronary sinus) in combination with hypoplasia of the right portal vein.

Comparison of Three Intervention Models for Promoting Circumcision among Migrant Workers in Western China to Reduce Local Sexual Transmission of HIV

ObjectiveThree models for promoting male circumcision (MC) as a preventative intervention against HIV infection were compared among migrant worker populations in western China.MethodsA cohort study was performed after an initial cross-sectional survey among migrant workers in three provincial level districts with high HIV prevalence in western China. A total of 1,670 HIV seronegative male migrants were cluster-randomized into three intervention models, in which the dissemination of promotional materials and expert- and volunteer-led discussions are conducted in one, two, and three stage interventions. Changes in knowledge of MC, acceptability of MC, MC surgery uptake, and the costs of implementation were analyzed at 6-month and 9-month follow-up visits.ResultsAll three models significantly increased the participants’ knowledge about MC. The three-stage model significantly increased the acceptability of MC among participants and led to greatest increase in MC uptake. At the end of follow-up, 9.2% (153/1,670) of participants underwent MC surgery; uptake among the one-, two-, and three-stage models were 4.9%, 9.3%, and 14.6%, respectively. Multivariable Cox regression analysis showed that three-stage model was the most effective method to scale up MC, with RR = 2.0 (95% CI, 1.3-3.1, P=0.002) compared to the on-site session model. The two-stage intervention model showed no significant difference with either the on-site session model (RR=1.5, 95% CI, 0.92-2.4, P=0.12) or three-stage model (P=0.10).ConclusionsA three-stage intervention with gradual introduction of knowledge led to the significantly increase in MC uptake among migrant workers in western China, and was also the most cost-effective method among the three models.

ERCP in acute cholangitis during third trimester of pregnancy.

To explore the efficacy and safety of modified endoscopic retrograde cholangiopancreatographies (ERCP) management of acute cholangitis during the third trimester of pregnancy. Seventeen pregnancy women who were diagnosed as acute cholangitis during their third trimester and received modified ERCP between January 2000 and January 2012 in our solo medical center, were included in this study. All cases received two-stage interventions: 7 cases had caesarean birth in one week with endoscopic nasobiliary drainage (ENBD) after the first ERCP, and cleaned their bile ducts by second ERCP 1 week postpartum; 10 cases received endoscopic retrograde biliary drainage (ERBD) by bile duct plastic stents, and took out stents and stones by second ERCPs between 2 weeks and 1 month after termination of pregnancy. The complication rate was 5.88% (2/34) in all 34 ERCPs on 17 cases (one biliary tract hemorrhage and one case of acute mild pancreatitis). All clinical symptoms were significantly alleviated; 11 cases had term labors and 6 cases had premature delivery. All 18 babies were healthy in follow-up 3 months postpartum. Modified ERCP is a safe procedure for acute cholangitis in pregnant women during the third trimester.

Image fusion for hybrid repair of dislocated superior mesenteric branch of a branched endovascular aortic graft

Recent advances in imaging technology allow the projection of volumetric imaging data from the preacquired computed tomography angiography over live fluoroscopy during interventions. This "fusion" technology is currently underused, although its application carries distinct advantages. We introduce a case in which fusion technology was used for the placement of two thoracic and one branched abdominal aortic endograft and to treat late dislocation of its side branch using a hybrid technique.

Laparoendoscopic rendezvous reduces perioperative morbidity and risk of pancreatitis

The ideal management of cholelithiasis and common bile duct stones still is controversial. Although the two-stage sequential approach remains the prevalent management, several trials have concluded that the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, such as a reduced risk of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. This study aimed to compare the single-stage LERV technique with the two-stage endoscopic sphincterotomy followed by laparoscopic cholecystectomy. A search for randomized controlled trials (RCTs) comparing LERV and the two-stage sequential approach was conducted. The outcomes considered were overall complications and pancreatitis. Medline, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1998 to July 2012. Odds ratios (ORs) were extracted and pooled using a fixed or random-effect model depending on I (2) used as a heterogeneity measure. Four RCTs, including a total of 430 patients, met the inclusion criteria. The incidence of overall complications was lower in the LERV group (11.2 %) than in the two-stage intervention group (18.1 %) (OR, 0.56; 95 % confidence interval [CI], 0.32-0.99; P = 0.04; I (2) = 45 %). The findings showed that LERV was associated with less clinical pancreatitis (2.4 %) than the two-stage technique (8.4 %) (OR, 0.33; 95 % CI, 0.12-0.91; P = 0.03; I (2) = 33 %). Despite the limitation of a small number of studies completed, the evidence of RCTs shows that LERV is superior to two-stage treatment due to a reduction in overall complications, particularly pancreatitis.

Abstract 3678: Pilot walnut intervention study in human volunteers to establish and justify criteria for future screening and clinical intervention trials

Abstract A two-stage pilot intervention study with walnuts was conducted in human volunteers (n = 4) to establish the bioavailability of urolithins which are the terminal end-products of ellagitannin metabolism by the faecal flora. Biosamples (blood, faeces and urine) were evauated for their cancer chemopreventive potential in a range of in vitro assays (DPPH, FRAP, ORAC). Urolithin metabolites were identified and quantitated by HPLC-ESI-MS. Furthermore individual metabolites were isolated and purified by semi-preparative HPLC and characterized by HPLC-ESI-MS, nano-ESI-MS-MS and NMR (600 MHz). These were urolithin-A glucuronide, urolithin-B glucuronide (four isomers), urolithin-C glucuronide (two isomers) and urolithin-D glucuronide (four isomers). Additionally the following free urolithins were characterized namely urolithin-A, urolithin-B (two isomers), urolihin-C (two isomers), urolithin-D and methyl urolithin-D. The concentrations of glucuronidated urolithins measured in urine and calculated per g/walnuts were volunteer-1 (female) 69.9 µM, volunteer-2 (male) 60.4 µM, volunteer-3 (female) 15.7 µM and volunteer-4 (male) 20.0 µM. There was a wide inter-individual variation in gastrointestinal polyphenol metabolism, among the four volunteers, as judged by the profiles in urine: volunteer-1 excreted mainly di-, tri- and tetrahydroxyurolithin glucuronides, volunteer-2 excreted mainly mono- and di-hydroxyurolithin glucuronides, volunteer-3 mainly trihydroxyurolithin glucuronide and volunteer-4 only dihydroxyurolithin glucuronides. In one individual the concentration of total urolithin glucuronides rose in plasma to 186 µM and then slowly declined 24 h after ingestion. The distribution in plasma followed a gaussian curve. The major dibenzopyrone excreted in feces was tetrahydroxydibenzopyran-(6)-one with the highest concentration at 299 mg/day day on day 3 and 414 mg on day 10, respectively. The second was trihydroxydibenzopyrone excreted in highest concentration on day 4 (two days after ingestion) in feces (60.3 mg/day) followed by day 9 (88.4 mg/day) (one day after ingestion). The antioxidant capacity of the glucuronidated urolithins was weak in the DPPH and FRAP assays whereas in the more biologically relevant ORAC assay the antioxidant capacity was strong. However a strong positive correlation was only evident with uric acid concentration in urine across the assays. The free urolithins displayed high antioxidant capacity in the DPPH and ORAC assays and this correlated positively with the concentration of urolithins (especially tetrahydroxydibenzopyran-(6)-one) in the fecal extracts. The data indicates that free urolithins may be protective against oxidation in the large intestine. Preclinical trials are warranted to assess the efficacy of urolithins as protective agents against colorectal cancer. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3678. doi:10.1158/1538-7445.AM2011-3678

Laparoscopic Reinforced Sleeve Gastrectomy: Early Results and Complications

Sleeve gastrectomy (SG) was pioneered as a two-stage intervention for super and super-super obesity to minimize morbidity and mortality; it is employed increasingly as a primary procedure. Early outcomes and integrity of laparoscopic SG (LSG) against leak using a technique incorporating gastric transection-line reinforcement were studied. Between 2003 and 2009, 121 patients underwent LSG (16, two-stage; 105, primary). Of the patients, 66% were women, mean age 38.8 ± 10.9 (15.0-64.0), and body mass index (BMI, kg/m(2)) 48.7 ± 9.3 (33.7-74.8). Bovine pericardium (Peri-Strips Dry [PSD]) was used to reinforce the staple line. Parametric and nonparametric tests were used, as appropriate. The paired t test was used to assess change from baseline; bivariate analyses and logistic regression were used to identify preoperative patient characteristics predictive of suboptimal weight loss. Mean operative time was 105min (95-180), and mean hospitalization was 5.6days (1-14). There was no mortality. There were 6 (5.0%) complications: 1 intraoperative leak, 1 stricture, 1 trocar-site bleed, 1 renal failure, and 2 wound infections. There were no postoperative staple-line leaks. Following 15 concomitant hiatal hernia operations, 3 (20%) recurred: 1 revised to RYGB and 2 in standby. Two post-LSG hiatal hernias of the two-stage series required revisions because of symptoms. BMI decreased 24.7% at 6months (n = 55) to 37.5 ± 9.3 (22.2-58.1); %EWL was 48.1 ± 19.3 (15.5-98.9). Twelve-month BMI (n = 41) was 38.4 ± 10.5 (19.3-62.3); %EWL was 51.7 ± 25.0 (8.9-123.3). Forty-eight-month BMI (n = 13) was 35.6 ± 6.8 (24.9-47.5); %EWL was 61.1 ± 12.2 (43.9-82.1) (p < 0.001). Preoperative BMI was predictive of >70% of patients who experienced <50% EWL at 6months. At 2weeks, 100% of type 2 diabetes patients (n = 23) were off medication (mean HbA(1C), 5.9 ± 0.5%; glycemia, 90.0 ± 19.9mg/dL (p < 0.01) at 3months). Laparoscopic PSD-reinforced LSG as a staged or definitive procedure is safe and effective in the short term and provides rapid type 2 diabetes mellitus reduction with a very low rate of complications.

Two-stage hybrid coronary intervention and minimally invasive aortic valve replacement for patients with concomitant aortic valve and coronary artery disease

Two-stage hybrid coronary intervention and minimally invasive aortic valve replacement for patients with concomitant aortic valve and coronary artery disease

Autologous Blood Donation Programs in Surgical Correctionof Spinal Scoliotic Deformity

Objective. To develop the programs of autologous blood deposition to compensate blood loss in surgical correction of spinal deformity. Material and Methods. The study included 145 patients with spinal deformities who underwent one- and two-stage selective surgical interventions. In the study group (n = 100) autologous blood components were preoperatively deposited for intra- and postoperative blood loss compensation; in the control group (n = 45) prior deposition was not performed. Results. It was found that, taking into account the terms of autologous blood shelf life and efficacy, a prior deposition of 20 % of total blood volume (TBV) providing compensation of blood loss up to 40–45 % of TBV is optimal for one-stage surgical intervention, and deposition of 30 % of TBV allowing loss compensation of 50–55 % of TBV is enough for twostage surgery. Conclusion. Autologous blood deposition is an effective method for blood loss compensation. Blood deposition volume and techniques are determined by an expected blood loss associated with specific surgical intervention.

Simultaneous bilateral hip replacement reveals superior outcome and fewer complications than two-stage procedures: a prospective study including 1819 patients and 5801 follow-ups from a total joint replacement registry

BackgroundTotal joint replacements represent a considerable part of day-to-day orthopaedic routine and a substantial proportion of patients undergoing unilateral total hip arthroplasty require a contralateral treatment after the first operation. This report compares complications and functional outcome of simultaneous versus early and delayed two-stage bilateral THA over a five-year follow-up period.MethodsThe study is a post hoc analysis of prospectively collected data in the framework of the European IDES hip registry. The database query resulted in 1819 patients with 5801 follow-ups treated with bilateral THA between 1965 and 2002. According to the timing of the two operations the sample was divided into three groups: I) 247 patients with simultaneous bilateral THA, II) 737 patients with two-stage bilateral THA within six months, III) 835 patients with two-stage bilateral THA between six months and five years.ResultsWhereas postoperative hip pain and flexion did not differ between the groups, the best walking capacity was observed in group I and the worst in group III. The rate of intraoperative complications in the first group was comparable to that of the second. The frequency of postoperative local and systemic complication in group I was the lowest of the three groups. The highest rate of complications was observed in group III.ConclusionsFrom the point of view of possible intra- and postoperative complications, one-stage bilateral THA is equally safe or safer than two-stage interventions. Additionally, from an outcome perspective the one-stage procedure can be considered to be advantageous.

Cost-effectiveness Analysis of a Two-stage Screening Intervention for Hepatocellular Carcinoma in Taiwan

Hepatocellular carcinoma (HCC) has been the leading cause of cancer death in Taiwan since the 1980s. A two-stage screening intervention was introduced in 1996 and has been implemented in a limited number of hospitals. The present study assessed the costs and health outcomes associated with the introduction of screening intervention, from the perspective of the Taiwanese government. The cost-effectiveness analysis aimed to assist informed decision making by the health authority in Taiwan. A two-phase economic model, 1-year decision analysis and a 60-year Markov simulation, was developed to conceptualize the screening intervention within current practice, and was compared with opportunistic screening alone. Incremental analyses were conducted to compare the incremental costs and outcomes associated with the introduction of the intervention. Sensitivity analyses were performed to investigate the uncertainties that surrounded the model. The Markov model simulation demonstrated an incremental cost-effectiveness ratio (ICER) of NT$498,000 (US$15,600) per life-year saved, with a 5% discount rate. An ICER of NT$402,000 (US$12,600) per quality-adjusted life-year was achieved by applying utility weights. Sensitivity analysis showed that excess mortality reduction of HCC by screening and HCC incidence rates were the most influential factors on the ICERs. Scenario analysis also indicated that expansion of the HCC screening intervention by focusing on regular monitoring of the high-risk individuals could achieve a more favorable result. Screening the population of high-risk individuals for HCC with the two-stage screening intervention in Taiwan is considered potentially cost-effective compared with opportunistic screening in the target population of an HCC endemic area.

Thoracoscopically Assisted Anterior Fusion for Unstable Thoracolumbar Spine Fractures

Objective. To assess the efficacy of endoscopic surgery for treatment of thoracolumbar spine fractures. Material and Methods. Retrospective case history review of 88 patients operated on for acute unstable fractures of thoracic and lumbar vertebrae was performed. Radiological dynamics of kyphosis, operation time, intraoperation blood loss, and pain syndrome severity were assessed in the early postoperative period using visual analogue scale. Results. The best results in combined interventions were achieved using anterior spinal fusion with implant insertion. The average operation time for thoracoscopic fusion exceeded that for thoracotomic approach. The blood loss was less than during open surgery. The pain syndrome intensity was less in patients who underwent thoracoscopic fusion. Conclusion. A two-stage combined intervention provides a reliable short-segment stabilization at the injured level with minimal loss of correction due to a circumferential fixation. Endoscopic fusion ensures formation of a solid bone block by less invasive surgery. The smallest loss of correction is observed when anterior implants are used.

Quality Improvement Toward Decreasing High‐Risk Medications for Older Veteran Outpatients

To examine the effectiveness of a quality improvement program to decrease prescribing of high-risk medications. Single cohort, pre- and postintervention. Regional network of Department of Veterans Affairs medical facilities. Outpatient veterans aged 65 and older who received one or more high-risk medications and the prescribing clinicians. A two-stage intervention was implemented. First, a real-time warning message to prescribers appeared whenever one of the high-risk drugs was ordered; second, a personally addressed letter from the Chief Medical Officer asking prescribers to consider discontinuing the high-risk medication along with a copy of the Beers criteria article, a list of suggested alternatives to high-risk medications, and a list of older patients receiving the high-risk medications who had upcoming appointments with these prescribers. The primary outcome was the absence of prescribed high-risk medications for all patients in the cohort during the postintervention period. For a subgroup of the cohort whose prescribers received the second-stage intervention, an additional outcome was the absence of prescribed high-risk medications within the subgroup. Two thousand seven hundred fifty-three unique patients were identified in the cohort; 1,396 (50.7%) had high-risk medications discontinued, resulting in a significant decrease in the number of patients prescribed high-risk medications from the preintervention period to the postintervention period (P<.001). Of the 801 patients in the subgroup, 72.0% (n=577) had high-risk medications discontinued (P<.001). This multimethod intervention significantly decreased prescribing of high-risk medications to older patients. Further studies are needed to confirm the findings.