Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS: This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS: Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS: SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.

Clinical Applications of Meshed Multilayered Anatomical Models by Low-Cost Three-Dimensional Printer.

SUMMARY: In recent years, even low-cost fused deposition modeling-type three-dimensional printers can be used to create a three-dimensional model with few errors. The authors devised a method to create a three-dimensional multilayered anatomical model at a lower cost and more easily than with established methods, by using a meshlike structure as the surface layer. Fused deposition modeling-type three-dimensional printers were used, with opaque polylactide filament for material. Using the three-dimensional data-editing software Blender (Blender Foundation, www.blender.org) and Instant Meshes (Jakob et al., https://igl.ethz.ch/projects/instant-meshes/) together, the body surface data were converted into a meshlike structure while retaining its overall shape. The meshed data were printed together with other data (nonmeshed) or printed separately. In each case, the multilayer model in which the layer of the body surface was meshed could be output without any trouble. It was possible to grasp the positional relationship between the body surface and the deep target, and it was clinically useful. The total work time for preparation and processing of three-dimensional data ranged from 1 hour to several hours, depending on the case, but the work time required for converting into a meshlike shape was about 10 minutes in all cases. The filament cost was $2 to $8. In conclusion, the authors devised a method to create a three-dimensional multilayered anatomical model to easily visualize positional relationships within the structure by converting the surface layer into a meshlike structure. This method is easy to adopt, regardless of the available facilities and economic environment, and has broad applications.

A low-cost microwell device for high-resolution imaging of neurite outgrowth in 3D.

OBJECTIVE: Current neuronal cell culture is mostly performed on two-dimensional (2D) surfaces, which lack many of the important features of the native environment of neurons, including topographical cues, deformable extracellular matrix, and spatial isotropy or anisotropy in three dimensions. Although three-dimensional (3D) cell culture systems provide a more physiologically relevant environment than 2D systems, their popularity is greatly hampered by the lack of easy-to-make-and-use devices. We aim to develop a widely applicable 3D culture procedure to facilitate the transition of neuronal cultures from 2D to 3D. APPROACH: We made a simple microwell device for 3D neuronal cell culture that is inexpensive, easy to assemble, and fully compatible with commonly used imaging techniques, including super-resolution microscopy. MAIN RESULTS: We developed a novel gel mixture to support 3D neurite regeneration of Aplysia bag cell neurons, a system that has been extensively used for quantitative analysis of growth cone dynamics in 2D. We found that the morphology and growth pattern of bag cell growth cones in 3D culture closely resemble the ones of growth cones observed in vivo. We demonstrated the capability of our device for high-resolution imaging of cytoskeletal and signaling proteins as well as organelles. SIGNIFICANCE: Neuronal cell culture has been a valuable tool for neuroscientists to study the behavior of neurons in a controlled environment. Compared to 2D, neurons cultured in 3D retain the majority of their native characteristics, while offering higher accessibility, control, and repeatability. We expect that our microwell device will facilitate a wider adoption of 3D neuronal cultures to study the mechanisms of neurite regeneration.

Cost-effectiveness of silver dressings for paediatric partial thickness burns: An economic evaluation from a randomized controlled trial.

BACKGROUND: Partial thickness burns of up to 10% total body surface area (TBSA) in children are common injuries primarily treated in the outpatient setting using expensive silver-containing dressings. However, economic evaluations in the paediatric burns population are lacking to assist healthcare providers when choosing which dressing to use. The aim of this study was to conduct a cost-effectiveness analysis of three silver dressings for partial thickness burns ≤10% TBSA in children aged 0-15 years using days to full wound re-epithelialization as the health outcome. METHOD: This study was a trial based economic evaluation (incremental cost effectiveness) conducted from a healthcare provider perspective. Ninety-six children participated in the trial investigating Acticoat™, Acticoat™ with Mepitel™ or Mepilex Ag™. Costs directly related to the management of partial thickness burns ≤10% TBSA were collected during the trial from March 2013 to July 2014 and for a one year after re-epithelialization time horizon. Incremental cost effectiveness ratios were estimated and dominance probabilities calculated from bootstrap resampling trial data. Sensitivity analyses were conducted to examine the potential effect of accounting for infrequent, but high cost, skin grafting surgical procedures. RESULTS: Costs (dressing, labour, analgesics, scar management) were considerably lower in the Mepilex Ag™ group (median AUD$94.45) compared to the Acticoat™ (median $244.90) and Acticoat™ with Mepitel™ (median $196.66) interventions. There was a 99% and 97% probability that Mepilex Ag™ dominated (cheaper and more effective than) Acticoat™ and Acticoat™ with Mepitel™, respectively. This pattern of dominance was consistent across raw cost and effects, after a priori adjustments, and sensitivity analyses. There was an 82% probability that Acticoat™ with Mepitel dominated Acticoat™ in the primary analysis, although this probability was sensitive to the effect of skin graft procedures. CONCLUSION: This economic evaluation has demonstrated that Mepilex Ag™ was the dominant dressing choice over both Acticoat™ and Acticoat™ with Mepitel™ in this trial-based economic evaluation and is recommended for treatment of paediatric partial thickness burns ≤10% TBSA.

Cost-Effectiveness of a Nonpharmacological Intervention in Pediatric Burn Care.

OBJECTIVE: To report the cost-effectiveness of a tailored handheld computerized procedural preparation and distraction intervention (Ditto) used during pediatric burn wound care in comparison to standard practice. METHODS: An economic evaluation was performed alongside a randomized controlled trial of 75 children aged 4 to 13 years who presented with a burn to the Royal Children's Hospital, Brisbane, Australia. Participants were randomized to either the Ditto intervention (n = 35) or standard practice (n = 40) to measure the effect of the intervention on days taken for burns to re-epithelialize. Direct medical, direct nonmedical, and indirect cost data during burn re-epithelialization were extracted from the randomized controlled trial data and combined with scar management cost data obtained retrospectively from medical charts. Nonparametric bootstrapping was used to estimate statistical uncertainty in cost and effect differences and cost-effectiveness ratios. RESULTS: On average, the Ditto intervention reduced the time to re-epithelialize by 3 days at AU$194 less cost for each patient compared with standard practice. The incremental cost-effectiveness plane showed that 78% of the simulated results were within the more effective and less costly quadrant and 22% were in the more effective and more costly quadrant, suggesting a 78% probability that the Ditto intervention dominates standard practice (i.e., cost-saving). At a willingness-to-pay threshold of AU$120, there is a 95% probability that the Ditto intervention is cost-effective (or cost-saving) against standard care. CONCLUSIONS: This economic evaluation showed the Ditto intervention to be highly cost-effective against standard practice at a minimal cost for the significant benefits gained, supporting the implementation of the Ditto intervention during burn wound care.

Absorbable poliglecaprone 25 sutures for both subcutaneous and transepidermal closure: a cosmetically and economically appealing option.

The majority of dermatologic surgeons close surgical defects using absorbable sutures to approximate deep subcutaneous tissue and nonabsorbable sutures to close the epidermal tissue. However, the absorbable monofilament poliglecaprone 25 can serve as the sole suture material in closing deep surgical defects involving subcutaneous and epidermal tissue with the benefits of providing aesthetically pleasing outcomes, possibly due to the material's low tissue reactivity and clear colorless appearance, and cost-effectiveness. We discuss the estimated cost savings per procedure when using poliglecaprone 25. Additional advantages include increased versatility, ease of handling, and convenience. Some disadvantages include a slight stiffness of the suture material, which may require a surgeon to make minor adjustments to his/her knot tying technique, as well as a transparent appearance that may make suture removal more challenging when using the undyed version of the suture material. However, the many benefits of using poliglecaprone 25 for closure of surgical defects outweigh the few disadvantages.

A dynamic care pathway to coordinate the use of advanced therapy in diabetic foot ulceration.

The non-coordinated use of advanced therapies is not clinically or cost effective. A care pathway for the sequential use of these interventions on complex wounds provides a more restructured approach, and helped improve patient outcomes.

A retrospective cohort study of Acticoat versus Silvazine in a paediatric population.

We wished to determine whether changing our centre's practice of using Acticoat instead of Silvazine as our first-line burns dressing provided a better standard of care in terms of efficacy, cost and ease of use. A retrospective cohort study was performed examining 328 Silvazine treated patients from January 2000 to June 2001 and 241 Acticoat treated patients from July 2002 to July 2003. During those periods the respective dressings were used exclusively. There was no significant difference in age, %BSA and mechanism of burn between the groups. In the Silvazine group, 25.6% of children required grafting compared to 15.4% in the Acticoat group (p=0.001). When patients requiring grafting were excluded, the time taken for re-epithelialisation in the Acticoat group (14.9 days) was significantly less than that for the Silvazine group (18.3 days), p=0.047. There were more wounds requiring long term scar management in the Silvazine group (32.6%) compared to the Acticoat group (29.5%), however this was not significant. There was only one positive blood culture in each group, indicating that both Silvazine and Acticoat are potent antimicrobial agents. The use of Acticoat as our primary burns dressing has dramatically changed our clinical practice. Inpatients are now only 18% of the total admissions, with the vast majority of patients treated on an outpatient basis. In terms of cost, Acticoat was demonstrated to be less expensive over the treatment period than Silvazine . We have concluded that Acticoat is a safe, cost-effective, efficacious dressing that reduces the time for re-epithelialisation and the requirement for grafting and long term scar management, compared to Silvazine.

Skeletal stability in bimaxillary orthognathic surgery: P(L/DL)LA-resorbable versus titanium osteofixation.

BACKGROUND: One-year skeletal stability following bimaxillary orthognathic surgery was assessed by comparing poly(L-lactide-co-DL-lactide) to titanium osteofixation. METHODS: Thirty patients underwent osteofixation with poly(L-lactide-co-DL-lactide) copolymer and 30 had 2.0-mm titanium-miniplate osteosyntheses. Lateral cephalograms were analyzed preoperatively, postoperatively, and at 1-year follow-up. Average +/- SD values were as follows in resorbable plate-osteosyntheses (number of cases/titanium controls): for maxillary advancement, 3.5 +/- 4.1 mm (n = 19)/5.4 +/- 3.5 mm (n = 21); setback, 2.8 +/- 3.7 mm (n = 9)/1.9 +/- 1.8 mm (n = 8); elongation, 4.2 +/- 3.6 mm (n = 18)/3.7 +/- 5.2 mm (n = 14); and intrusion, 1.9 +/- 1.7 mm (n = 12)/3.3 +/- 2.7 mm (n = 13); for mandibular advancement, 4.6 +/- 3.6 mm (n = 10)/6.3 +/- 8.8 mm (n = 18); setback, 7.5 +/- 8.3 mm (n = 20)/7.2 +/- 3.2 mm (n = 12); enlargement of the mandibular angle, 11.8 +/- 9.9 degrees (n = 19)/7.9 +/- 6.6 degrees (n = 21); and reduction, 4.5 +/- 3.2 degrees (n = 9)/6.3 +/- 6.6 degrees (n = 9). RESULTS: Preoperative to postoperative landmark positions within the study and control groups differed highly significantly (p = 0.008, paired t test), yet the amount of operative movement was comparable between the study and control groups (p = 0.5, two-sided t test). Absolute instability at the advanced A-point was (study group/controls) 2.3 +/- 1.8/2.4 +/- 2 mm, setback was 2.3 +/- 1.9 mm/2.5 +/- 1.7 mm, elongation at the anterior nasal spine was 3.8 +/- 3.1 mm/3.1 +/- 3.6 mm, intrusion was 2.1 +/- 1.9 mm/2.2 +/- 1.5 mm, advancement instability at the B-point was 4.9 +/- 4.3 mm/5.1 +/- 8.2 mm, setback was 3.0 +/- 2 mm/1.7 +/- 2 mm, mandibular angle enlargement instability was 6.7 +/- 8.9 degrees/8.2 +/- 9.6 degrees, and angle narrowing was 6.8 +/- 5.2 degrees/4.2 +/- 5.9 degrees. Absolute postoperative instability did not differ significantly between the study and control groups (p = 0.6). CONCLUSIONS: Resorbable osteofixation as tested proved to be as reliable as titanium, but as the study and control groups were not matched, the results have to be interpreted as preliminary. Resorbable materials permitted clinically faster occlusal and condylar settling than standard titanium osteosyntheses, as bone segments showed slight clinical mobility up to 6 weeks postoperatively.

A silver coated dressing reduces the incidence of early burn wound cellulitis and associated costs of inpatient treatment: comparative patient care audits.

In 2000 and 2002, the Royal Perth Hospital (RPH) Burn Unit, Western Australia, conducted two 'before and after' patient care audits comparing the effectiveness and cost of Silvazine (silver sulphadiazine and chlorhexidine digluconate cream) and Acticoat, a new dressing product for in-patient treatment of early burn wounds. The main outcome variables were: burn wound cellulitis, antibiotic use and cost of treatment. Two patient care audits and a comparative sample were used. The two regimes audited were, 'standard treatment' of twice daily showers or washes with 4% chlorhexidine soap and Silvazine cream as a topical dressing (2000, n=51), compared with the 'new treatment' of daily showers of the burn wound with 4% chlorhexidine soap and the application of an Acticoat dressing (2002, n=19). In 2002, costs were also examined using a sample of matched pairs (n=8) of current and previous patients. The main findings were: when using Acticoat the incidence of infection and antibiotic use fell from 55% (28/51) and 57% (29/51) in 2000 to 10.5% (2/19) and 5.2% (1/19) in 2002. The total costs (excluding antibiotics, staffing and surgery) for those treated with Silvazine were US$ 109,357 and those treated with Acticoat were US$ 78,907, demonstrating a saving of US$ 30,450 with the new treatment. The average length of stay (LOS) in hospital was 17.25 days for the Silvazine group and 12.5 days for the Acticoat group-a difference of 4.75 days. These audits demonstrate that Acticoat results in a reduced incidence of burn wound cellulitis, antibiotic use and overall cost compared to Silvazine in the treatment of early burn wounds.

PHA applications: addressing the price performance issue: I. Tissue engineering.

This paper describes the development of medical applications for polyhydroxyalkanoates (PHAs), a class of natural polymers with a wide range of thermoplastic properties. Methods are described for preparing PHAs with high purity, modifying these materials to change their surface and degradation properties, and methods for fabricating them into different forms, including tissue engineering scaffolds. Preliminary reports characterizing their in vivo behavior are given, as well as methods for using the natural polymers in tissue engineering applications.