Cost-effectiveness of balloon kyphoplasty and vertebroplasty versus conservative medical management in the USA.

The cost-effectiveness of surgical versus conservative medical management of vertebral compression fractures in the US was analyzed in the context of inpatient versus outpatient treatment. Surgical intervention (balloon kyphoplasty and vertebroplasty) was found to be cost-effective relative to conservative medical management at a US willingness-to-pay threshold. INTRODUCTION: To date, only one published study has evaluated the cost-effectiveness (C/E) of balloon kyphoplasty (BKP) or vertebroplasty (VP) in US Medicare patients with osteoporotic vertebral compression fractures. This study further evaluates the C/E of surgical treatment vs. conservative medical management (CMM), expanding on prior modeling by accounting for quality-adjusted life-years gained. METHODS: A Markov microsimulation model of 1000 patients was constructed. Cost data were based on an analysis of Medicare claims payments, with propensity-score matching performed for BKP and VP vs. controls (CMM). Mortality inputs were based on US life tables, modified to account for age at initial fracture, presence of subsequent fracture(s), and relative risk of mortality by treatment. Separate incremental cost-effectiveness ratios (ICERs) were calculated for BKP and VP in inpatient and outpatient surgical treatment locations to account for individual clinical profiles presenting to each. RESULTS: The discounted ICER for inpatient BKP vs. CMM was $43,455 per QALY gained; for outpatient BKP vs. CMM, $10,922; for inpatient VP vs. CMM, $39,774; and for outpatient VP vs. CMM, $12,293. Probabilistic sensitivity analysis confirmed that both BKP and VP would be considered C/E vs. CMM at a US willingness-to-pay (WTP) threshold of $50,000/QALY in 80% and 100% of 500 model simulations, respectively. The most sensitive parameters included quality of life estimates and hazard ratios for mortality. CONCLUSION: While VP and BKP are more expensive treatment options than CMM in the short term, model results suggest interventional treatment is cost-effective, among patients eligible for surgery, at a US WTP threshold. This conclusion supports those from economic analyses conducted in EU-member countries.

A novel application for bolus remifentanil: blunting the hemodynamic response to Mayfield skull clamp placement.

OBJECTIVE: Neurosurgery often requires skull immobilization with a Mayfield clamp, which often causes brief intense nociceptive stimulation, hypertension and tachycardia. Blunting this response may help prevent increased intracranial pressure, cerebral aneurysm or vascular malformation rupture, and/or myocardial stress. While various interventions have been described to blunt this response, no reports have compared administration of a propofol versus a remifentanil bolus. METHODS: We retrospectively analyzed the hemodynamic response to Mayfield placement in over 800 patients who received a prior propofol or remifentanil bolus from 2004 to 2010. RESULTS: Patients who received remifentanil experienced a 55% smaller increase in heart rate (p < 0.0001) and a 40% smaller increase in systolic blood pressure (p < 0.0001) after Mayfield placement than patients who received propofol. These data were retrospectively obtained from patients who were not randomized to receive remifentanil versus propofol, and hence these data could be subject to possible confounding. Nonetheless, these differences remained significant after multivariate analysis for possible confounding variables. CONCLUSIONS: Thus, a remifentanil bolus is more effective than a propofol bolus in blunting hemodynamic responses to Mayfield placement, and possibly for other short, intense nociceptive stimuli.

Rehabilitation of athletes following spine injury.

We feel that the described system for staging cervical and lumbar spine injuries in the high-performance athlete affords a basic framework for the rehabilitation of those individuals. With spine injuries, one has to exercise care to rule out those injuries and additional pathologies presenting as neck or back pain that could result in catastrophic sequelae. We stress due diligence in the initial and continued follow-up of these patients with careful evaluation to rule out associated fractures, dislocations, and attendant disc pathology. The treatment of the "stinger" or "burner" is controversial. We suggest a conservative approach, although the orthopedic and neurologic literature reports that these individuals have been returned to full contact sports activity without documented subsequent neurologic sequelae. The final decision remains at the discretion of the treating physician. This program provides a rational approach to the rehabilitation of the spine-injured high-performance athlete that will provide for the return of him or her to preinjury activity level in an expeditious manner with the minimal period of interruption in training.

The effect of zwitterionic detergents on the extraction and functional properties of cartilage proteoglycans.

A range of structurally related zwitterionic detergents, Zwittergents 3-06, 3-08, 3-10, and 3-12, and a derivative of cholic acid (Chaps) were examined for their ability to enhance the extraction of newly synthesized, intracellular proteoglycans and for their effect on the functional properties of cartilage proteoglycan. Although none of the detergents could extract greater than 4% of the intracellular proteoglycans when used alone, Zwittergents 3-10, 3-12, and Chaps proved equally as effective when used in combination with 4 M guanidine HCl extracting greater than 90% of newly synthesized proteoglycans. Rate zonal centrifugation of aggregates containing either 3H-link protein or 3H-monomer, which had been incubated with 2% (w/v) detergent indicated that none of the test detergents caused a disassembly of intact aggregates. However, both Zwittergents 3-10 and 3-12 prevented the reaggregation of components dissociated with 4 M guanidine HCl. Similar to the finding with aggregate, none of the detergents caused a disassembly of monomer-link protein complexes prepared from purified 3H-link protein and proteoglycan monomer, while Zwittergents 3-10 and 3-12 prevented their assembly from free link protein and monomer. However, monomer-link protein complexes once formed were able to associate with hyaluronic acid to form link-stable ternary complexes in the presence of all detergents tested including Zwittergents 3-10 and 3-12.

Efficiency of praziquantel, a new cesticide, against Taenia hydatigena in the dog.

Praziquantel (2 - cyclohexylcarbonyl - 1,3,4,6,7,11b - hexahydro - 2H - pyrazino (2,1 - a) isoquinolin - 4 - one) was tested against artificially established infections of Taenia hydatigena in 39 dogs. The formulation used was a 660 mg tablet containing 50 mg of active ingredient (ai). A single oral dose at 1 mg/kg ai completely removed 14-day-old infections in all dogs. 2.5 mg/kg ai praziquantel was completely effective against 7, 14 and 28-day-old worms. 5 mg/kg ai completely removed two-day-old infestations. No side effects were seen in any treated dog.