Accurate Assessment of Blood Loss during Cesarean Delivery Improves Estimation of Postoperative Hemoglobin.

OBJECTIVE: To determine if accurate blood loss determination during cesarean delivery can improve the prediction of postoperative hemoglobin levels. STUDY DESIGN: This is a retrospective cohort study using visually estimated blood loss (traditional, n = 2,025) versus estimates using a mobile application that photographs sponges and canisters and calculates their hemoglobin content (device, n = 756). RESULTS: The correlation between the actual and predicted postoperative day 1 hemoglobin value (PPO1 Hgb) was better in the device group (R 2 = 0.519, correlation = 0.720) than in the traditional group (R 2 = 0.429, correlation = 0.655) (p = 0.005). For patients in the device group where the estimated blood loss was >1,000 mL (n = 53), the PPO1 Hgb was also better correlated with the actual value (R 2 = 0.319, correlation = 0.565) than the predictions using visually estimated blood loss for those patients in the device group whose visual estimation was >1,000 mL (n = 32) (R 2 = 0.035, correlation = 0.187) (p = 0.027). CONCLUSION: Implementation of a device that accurately measures blood loss allows for a better prediction of postoperative day 1 hemoglobin concentration than is possible using visual blood loss estimation. This improvement was seen in the entire patient group and was particularly prominent in patients with blood losses of > 1,000 mL.

Assessment of Bone Width for Implants in the Posterior Mandible.

PURPOSE: After implants are placed into mandibular molar sites, it is assumed that crestal bone width will not change considerably over time. The purpose of this retrospective study was to determine crestal bone changes for implants placed into mandibular molar locations. The hypotheses for all groups (immediate, delayed, and grafted) were that no major changes in bone width of the posterior mandible would occur in the long term. MATERIALS AND METHODS: This is a retrospective cohort study involving 3 groups of patients within the senior author's practice who had at least 4 years of follow-up cone-beam computed tomograms available for measurement. The primary outcome variable, crestal width, was measured at 3 intervals, namely at tooth removal, before implant placement, and 4 to 5 years after placement. Group A underwent tooth extraction with immediate implant placement; group B underwent tooth extraction with delayed implant placement; and group C underwent tooth extraction with socket grafting and implant placement 4 months after grafting. Standardized cross-sectional cone-beam computed tomograms were used to measure ridge width. Two-sample t tests and regression analysis were used to compare crestal width measurements at different periods among groups. Analysis of variance was adapted to check whether ridge widths among groups were confounded by variables, such as age, gender, and medical comorbidities. RESULTS: Age, gender, medical comorbidities, and smoking were not statistically related to the outcome. Long-term comparisons indicated small yet significant (P = .0124) differences at the crestal level. The greatest change was for the grafted group, with width change from 12.4 ± 2.1 mm before extraction to 9.9 ± 1.8 mm 4 to 5 years after implant placement. Bone width changes 5 and 10 mm inferior to the crest did not change over time. CONCLUSION: Within the time course and sample size evaluated, the thickness of the buccal bone seems to be maintained over time, regardless of method used, with small yet important changes from before tooth removal through the long-term.

Risk Assessment of Tuberculosis in Contacts by IFN-γ Release Assays. A Tuberculosis Network European Trials Group Study.

RATIONALE: Latent infection with Mycobacterium tuberculosis is defined by a positive IFN-γ release assay (IGRA) result in the absence of active tuberculosis. Only few, mostly monocentric studies have evaluated the role of IGRAs to predict the development of tuberculosis in recent contacts in low-incidence countries of tuberculosis. OBJECTIVES: To analyze IGRA results and the effect of preventive chemotherapy on tuberculosis progression rates among recent contacts. METHODS: Results from contact investigations at 26 centers in 10 European countries including testing for latent infection with M. tuberculosis by the QuantiFERON-TB Gold In-Tube (QFT) test or the T-SPOT.TB (TSPOT) were prospectively collected and analyzed. MEASUREMENTS AND MAIN RESULTS: Among 5,020 contacts of 1,023 index cases, 25 prevalent secondary cases were identified at screening. Twenty-four incident cases occurred among 4,513 contacts during 12,326 years of cumulative follow-up. In those with a positive IGRA result, tuberculosis incidence was 0.2 (QFT) and 0 (TSPOT) per 100 patient-years when contacts received preventive chemotherapy versus 1.2 (QFT) and 0.8 (TSPOT) per 100 patient-years in those not treated (38 and 37 patients needed to be treated to prevent one case, respectively). Positive and negative predictive values were 1.9% (95% confidence interval [CI], 1.1-3.0) and 99.9% (95% CI, 99.7-100) for the QFT and 0.7% (95% CI, 0.1-2.6) and 99.7% (95% CI, 99.1-99.9) for the TSPOT. CONCLUSIONS: Tuberculosis rarely developed among contacts, and preventive chemotherapy effectively reduced the tuberculosis risk among IGRA-positive contacts. Although the negative predictive value of IGRAs is high, the risk for the development of tuberculosis is poorly predicted by these assays.

The effectiveness of the cardiovascular disease prevention programme 'KardioPro' initiated by a German sickness fund: a time-to-event analysis of routine data.

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality in the developed world. To reduce this burden of disease, a German sickness fund ('Siemens-Betriebskrankenkasse', SBK) initiated the prevention programme 'KardioPro' including primary (risk factor reduction) and secondary (screening) prevention and guideline-based treatment. The aim of this study was to assess the effectiveness of 'KardioPro' as it is implemented in the real world. METHODS: The study is based on sickness fund routine data. The control group was selected from non-participants via propensity score matching. Study analysis was based on time-to-event analysis via Cox proportional hazards regression with the endpoint 'all-cause mortality, acute myocardial infarction (MI) and ischemic stroke (1)', 'all-cause mortality (2)' and 'non-fatal acute MI and ischemic stroke (3)'. RESULTS: A total of 26,202 insurants were included, 13,101 participants and 13,101 control subjects. 'KardioPro' enrollment was associated with risk reductions of 23.5% (95% confidence interval (CI) 13.0-32.7%) (1), 41.7% (95% CI 30.2-51.2%) (2) and 3.5% (hazard ratio 0.965, 95% CI 0.811-1.148) (3). This corresponds to an absolute risk reduction of 0.29% (1), 0.31% (2) and 0.03% (3) per year. CONCLUSION: The prevention programme initiated by a German statutory sickness fund appears to be effective with regard to all-cause mortality. The non-significant reduction in non-fatal events might result from a shift from fatal to non-fatal events.

Should health insurers target prevention of cardiovascular disease? A cost-effectiveness analysis of an individualised programme in Germany based on routine data.

BACKGROUND: Cardiovascular diseases are the main cause of death worldwide, making their prevention a major health care challenge. In 2006, a German statutory health insurance company presented a novel individualised prevention programme (KardioPro), which focused on coronary heart disease (CHD) screening, risk factor assessment, early detection and secondary prevention. This study evaluates KardioPro in CHD risk subgroups, and analyses the cost-effectiveness of different individualised prevention strategies. METHODS: The CHD risk subgroups were assembled based on routine data from the statutory health insurance company, making use of a quasi-beta regression model for risk prediction. The control group was selected via propensity score matching based on logistic regression and an approximate nearest neighbour approach. The main outcome was cost-effectiveness. Effectiveness was measured as event-free time, and events were defined as myocardial infarction, stroke and death. Incremental cost-effectiveness ratios comparing participants with non-participants were calculated for each subgroup. To assess the uncertainty of results, a bootstrapping approach was applied. RESULTS: The cost-effectiveness of KardioPro in the group at high risk of CHD was € 20,901 per event-free year; in the medium-risk group, € 52,323 per event-free year; in the low-risk group, € 186,074 per event-free year; and in the group with known CHD, € 26,456 per event-free year. KardioPro was associated with a significant health gain but also a significant cost increase. However, statistical significance could not be shown for all subgroups. CONCLUSION: The cost-effectiveness of KardioPro differs substantially according to the group being targeted. Depending on the willingness-to-pay, it may be reasonable to only offer KardioPro to patients at high risk of further cardiovascular events. This high-risk group could be identified from routine statutory health insurance data. However, the long-term consequences of KardioPro still need to be evaluated.