Routine Use of Low-Molecular-Weight Heparin For Deep Venous Thrombosis Prophylaxis After Foot and Ankle Surgery: A Cost-Effectiveness Analysis.

The purpose of the present study was to determine whether certain foot/ankle surgeries would benefit from the routine use of low-molecular-weight heparin (LMWH) as postoperative deep venous thrombosis prophylaxis. We conducted a formal cost-effectiveness analysis using a decision analytic tree to explore the healthcare costs and health outcomes associated with a scenario of no prophylaxis and a scenario of routine LMWH prophylaxis for 4 weeks. The 2 scenarios were compared for 5 procedures: (1) Achilles tendon repair (ATR), (2) total ankle arthroplasty (TAA), (3) hallux valgus surgery (HVS), (4) hindfoot arthrodesis (HA), and (5) ankle fracture surgery (AFS). The outcomes assessed included short- and long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2015 price base. In the short term, routine prophylaxis was always associated with greater costs compared with no prophylaxis. For ATR, TAA, HA, and AFS, prophylaxis was associated with slightly better health outcomes; however, the gain in QALYs was minimal compared with the cost of prophylaxis (incremental cost-effectiveness ratio well above $50,000/QALY threshold). For HVS, prophylaxis was associated with both worse health outcomes and greater costs. In the long term, routine prophylaxis was always associated with worse health outcomes and either cost more (HA, AFS, HVS) or saved very little (ATR, TAA). We concluded that policies encouraging the routine use of LMWH after foot/ankle surgery are unlikely to be cost-effective. Decisions to perform prophylaxis should be on a case-by-case basis and should emphasize individual patient risk factors.

[Development and implementation of a state-wide "train the trainer" model of the school-based prevention programme "Join the Healthy Boat - Primary School"]. / Entwicklung und Implementierung eines landesweiten Multiplikatorensystems zur flächendeckenden Umsetzung des schulbasierten Präventionsprogramms "Komm mit in das gesunde Boot - Grundschule"

STUDY AIM: This paper shows how a state-wide health-promotion intervention at primary schools can be implemented by considering the example of the programme "Join the Healthy Boat - Primary School". Additionally, it is illustrated how quality control throughout the whole process can be incorporated. METHODS: To operate long-term and target-group orientated in the whole state of Baden-Württemberg, the school-based prevention programme "Join the Healthy Boat" uses a "train the trainer" model. The trainers are teachers who were instructed by the project team. In the school year 2009/10, these trainers offered quadrinominal training courses for further teachers. Every urban and rural district is covered by 1 trainer. The trainers evaluated the 6 preparatory training courses they had been given using questionnaires. The following 4 training courses the trainers offered to the teachers were reviewed by the trainers as well as the teachers using questionnaires, too. Additionally, at the end of the school year 2009/10, the teachers completed a questionnaire about their satisfaction regarding the programme itself and the work with the trainer. RESULTS: During the school year 2009/10, 453 teachers were trained by 32 trainers. According to indications on the questionnaires about the preparatory training courses, all trainers felt themselves "very well" or "well" prepared for their task. The teachers evaluated the expertise of the respective trainer, the quality of the training courses and the satisfaction with the programme itself throughout highly. CONCLUSION: Based on the excellent results of the process evaluation and the programme's wide coverage, an adoption of a "train the trainer" model seems worthwhile for other school-based prevention programmes, as well.

Identification of a brain stone as calcified hemangioma: case report.

A 71-year-old woman with progressive hemiparesis had a large cerebral calculus (brain stone) removed from the temporal lobe. Her condition thereafter improved remarkably. The differential diagnosis and specific methods to determine the angiomatous nature of this almost acellular mass are discussed. Reticulin impregnation, elastic tissue stain, and electron microscopy were of greatest value.

Intraventricular administration of amikacin for complicated Gram-negative meningitis and ventriculitis.

Four pediatric neurosurgical patients with Gram-negative meningitis and ventriculitis were treated with parenteral and intraventricular amikacin, a new aminoglycoside. The organisms infecting these patients were resistant to multiple antimicrobial drugs but were sensitive to amikacin. Treatment was continued for 14 days after cerebrospinal fluid cultures became negative. All four patients were cured and have demonstrated no nephrotoxicity, ototoxicity, or evidence of persistent infection on follow-up examination.

The use of ketorolac in lumbar spine surgery: a cost-benefit analysis.

The use of ketorolac was studied in patients undergoing lumbar laminectomy and those receiving lumbar fusion with or without instrumentation. Laminectomy patients in the ketorolac group used significantly less narcotic analgesic than did those in the narcotic treatment group. Ketorolac patients in both surgical categories experienced better pain control than narcotic group patients did. Laminectomy ketorolac patients experienced less sedation than did those in the narcotic group, and a similar trend was noted for fusion patients. A significant improvement in postoperative ambulation was demonstrated in the fusion ketorolac group. Postoperative total drug costs were significantly greater in both ketorolac treatment groups. A one-half day decrease in hospitalization was noted for laminectomy ketorolac patients. The overall annual financial impact of the use of ketorolac in lumbar spine patients is a net savings of $211,095.

Treatment of postoperative wound infections following spinal fusion with instrumentation.

Postoperative wound infections following spinal fusion with instrumentation often present diagnostic and therapeutic difficulties. This article reviews 34 such infections. An infection rate of 3.7% was noted. Depending on various clinical indicators, treatment strategies included short-course antibiotics, prolonged intravenous antibiotics, or intravenous antibiotics followed by suppressive antibiotics and eventual hardware removal. To eradicate these infections, removal of instrumentation is often required; this option, however, may result in an unstable spine. Treatment algorithms were developed for treatment of postoperative spinal surgical site infections and to minimize the possibility of spine instability. All patients were cured of their infections.

Purine nucleoside phosphorylase deficiency (PNP-def) presenting with lymphopenia and developmental delay: successful correction with umbilical cord blood transplantation.

Purine nucleoside phosphorylase deficiency is a primary immunodeficiency syndrome characterized by the triad of recurrent infection, neurologic dysfunction, and autoimmunity. This patient presented atypically with few infections and normal T-cell function. Progressive lymphopenia, ataxia, and developmental delay led to diagnosis. Umbilical cord blood transplantation corrected the immunodeficiency.