Can preoperative radiographs predict hardware complication or fracture displacement after operative treatment of pelvic ring injuries?

INTRODUCTION: Operative fixation of pelvic ring injuries is associated with a high risk of hardware failure and loss of reduction. The purpose of this study was to determine whether preoperative radiographs can predict failure after operative treatment of pelvic ring injuries and if the method of fixation effects their risk. PATIENTS AND METHODS: We conducted a retrospective cohort study of 143 patients with pelvic ring injuries treated with operative fixation at a level 1 trauma center. Preoperative radiographs were examined for the presence of the following characteristics: bilateral rami fractures, segmental or comminuted rami fractures, contralateral anterior and posterior injuries, complete sacral fracture, and displaced inferior ramus fractures. The method of fixation was classified based on the presence of anterior, posterior, or combined anterior and posterior fixation as well as whether or not posterior fixation was performed at a single or multiple sacral levels. Post-operative radiographs were examined for hardware failure or loss of reduction. RESULTS: Twenty-one patients (14.7%) demonstrated either hardware complication or fracture displacement within 6 months of surgery. Male sex was associated with a decreased risk of hardware complication (OR 0.11 [0.014, 0.86]; p=0.03). Posterior pelvic ring fixation at multiple sacral levels was associated with a decreased risk of fracture displacement (OR 0.21 [0.056, 0.83]; p=0.02). We were unable to demonstrate a significant association between preoperative radiographic characteristics and risk of hardware failure or fracture displacement. CONCLUSION: Our study demonstrates that both gender and the method of posterior fixation are associated with hardware failure or displacement.

Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy.

OBJECTIVE: Epidural steroid injections (ESIs) are a commonly used treatment strategy for low back pain and lumbar radiculopathy. However, their cost-effectiveness and ability to mediate long-term quality of life (QOL) improvements is debated. We sought to analyze the cost-effectiveness of lumbar epidural steroid injections (ESIs) compared to medical management alone for patients with lumbar radiculopathy and low back pain. PATIENTS AND METHODS: QOL outcomes were prospectively collected at 3- and 6-months following initial consultation. Metrics included the EuroQol-5 Dimensions (EQ-5D) questionnaire, the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire (PHQ-9) and the Visual Analogue Scale (VAS). Cost estimations were based on Medicare national payment amounts, median income, and missed workdays. A cost-utility analysis was performed based upon cost estimations and a cost-effectiveness threshold of $100,000/Quality-adjusted life year (QALY). RESULTS: One hundred forty-one patients met our inclusion/exclusion criteria; 89 received ESI and 52 were treated with medical management alone. Both cohorts showed improved EQ-5D scores at 3 months but were similar to one another: ESI (ΔEQ-5D = 0.06; p = 0.03) and medical-alone (ΔEQ-5D = 0.07; p = 0.03). No significant difference was seen between groups for total costs ($2,190 vs. $1,772; p = 0.18) or cost-utility ratios ($38,710/QALY vs. $27,313/QALY; p = 0.73). At both the 3-month and 6-month endpoints, absolute differences in cost-utility was driven by overall costs as opposed to QALY gains. Medical management alone was more cost effective at both points owing to lower expenditures, however these differences were not significant. No benefits were seen in either group on the EQ-5D or any of the patient reported outcomes at the 6-month time point. CONCLUSION: ESIs were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, ESIs provide similar improvements in QOL outcomes relative to medical management and at similar costs. At 6 months, neither ESIs nor conservative management provide significant improvements in QOL outcomes.

Field Marshal Erwin Rommel: the head injury that may have prolonged the Second World War.

War-related head injury, indeed neurological injury in general, has been a part of the history of humankind for as long as there has been warfare. Such injuries can result in the removal of the individual from combat, thus eliminating any subsequent contribution that he or she might have made to the battle. However, at times, the injuries can have more wide-reaching effects. In the case of commanders or leaders, the impact of their injuries may include the loss of their influence, planning, and leadership, and thus have a disproportionate effect on the battle, or indeed the war. Field Marshal Erwin Rommel was a talented military strategist and leader who was respected by friends and foes alike. He held an honored reputation by the German people and the military leadership. His head injury on July 17, 1944, resulted in his being removed from the field of battle in northern France, but also meant that he was not able to lend his stature to the assassination attempt of Adolph Hitler on July 20. It is possible that, had he been able to lend his stature to the events, Hitler's hold on the nation's government might have been loosened, and the war might have been brought to an end a year earlier. The authors review Rommel's career, his injury, the subsequent medical treatment, and his subsequent death.

Identification and characterization of a welwitindolinone alkaloid biosynthetic gene cluster in the stigonematalean Cyanobacterium Hapalosiphon welwitschii.

The identification of a 36 kb welwitindolinone (wel) biosynthetic gene cluster in Hapalosiphon welwitschii UTEX B1830 is reported. Characterization of the enzymes responsible for assembling the early biosynthetic intermediates geranyl pyrophosphate and 3-((Z)-2'-isocyanoethenyl)indole as well as a dedicated N-methyltransferase in the maturation of N-methylwelwitindolinone C isothiocyanate solidified the link between the wel pathway and welwitindolinone biosynthesis. Comparative analysis of the ambiguine and welwitindolinone biosynthetic pathways in two different organisms provided insights into the origins of diverse structures within hapalindole-type molecules.