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BACKGROUND AND OBJECTIVES We evaluated the economic impact of routine childhood immunization in the United States, reflecting updated vaccine recommendations and recent data on epidemiology and coverage rates. METHODS An economic model followed the 2017 US birth cohort from birth through death; impact was modeled via a decision tree for each of the vaccines recommended for children by the Advisory Committee on Immunization Practices as of 2017 (with annual influenza vaccine considered in scenario analysis). Using information on historic prevaccine and vaccine-era incidence and disease costs, we calculated disease cases, deaths, disease-related healthcare costs, and productivity losses without and with vaccination, as well as vaccination program costs. We estimated cases and deaths averted because of vaccination, life-years and quality-adjusted life-years gained because of vaccination, incremental costs (2019 US dollars), and the overall benefit-cost ratio (BCR) of routine childhood immunization from the societal and healthcare payer perspectives. RESULTS Over the cohort’s lifetime, routine childhood immunization prevented over 17 million cases of disease and 31 000 deaths; 853 000 life years and 892 000 quality-adjusted life-years were gained. Estimated vaccination costs ($8.5 billion) were fully offset by the $63.6 billion disease-related averted costs. Routine childhood immunization was associated with $55.1 billion (BCR of 7.5) and $13.7 billion (BCR of 2.8) in averted costs from a societal and healthcare payer perspective, respectively. CONCLUSIONS In addition to preventing unnecessary morbidity and mortality, routine childhood immunization is cost-saving. Continued maintenance of high vaccination coverage is necessary to ensure sustained clinical and economic benefits of the vaccination program.

BACKGROUND AND OBJECTIVES Current routine immunizations for children aged ≤10 years in the United States in 2019 cover 14 vaccine-preventable diseases. We characterize the public-health impact of vaccination by providing updated estimates of disease incidence with and without universally recommended pediatric vaccines. METHODS Prevaccine disease incidence was obtained from published data or calculated using annual case estimates from the prevaccine period and United States population estimates during the same period. Vaccine-era incidence was calculated as the average incidence over the most recent 5 years of available surveillance data or obtained from published estimates (if surveillance data were not available). We adjusted for underreporting and calculated the percent reduction in overall and age-specific incidence for each disease. We multiplied prevaccine and vaccine-era incidence rates by 2019 United States population estimates to calculate annual number of cases averted by vaccination. RESULTS Routine immunization reduced the incidence of all targeted diseases, leading to reductions in incidence ranging from 17% (influenza) to 100% (diphtheria, Haemophilus influenzae type b, measles, mumps, polio, and rubella). For the 2019 United States population of 328 million people, these reductions equate to >24 million cases of vaccine-preventable disease averted. Vaccine-era disease incidence estimates remained highest for influenza (13 412 per 100 000) and Streptococcus pneumoniae-related acute otitis media (2756 per 100 000). CONCLUSIONS Routine childhood immunization in the United States continues to yield considerable sustained reductions in incidence across all targeted diseases. Efforts to maintain and improve vaccination coverage are necessary to continue experiencing low incidence levels of vaccine-preventable diseases.

Background Varicella is a highly contagious childhood disease. Generally benign, serious complications necessitating antibiotic use may occur. The objective of this study was to characterize the rate, appropriateness and patterns of real-world antibiotic prescribing for management of varicella-associated complications, prior to universal varicella vaccination (UVV) implementation. Methods Pooled, post-hoc analysis of 5 international, multicenter, retrospective chart reviews studies (Argentina, Hungary, Mexico, Peru, Poland). Inpatient and outpatient primary pediatric (1–14 years) varicella cases, diagnosed between 2009 and 2016, were eligible. Outcomes, assessed descriptively, included varicella-associated complications and antibiotic use. Three antibiotic prescribing scenarios were defined based on complication profile in chart: evidence of microbiologically confirmed bacterial infection (Scenario A); insufficient evidence confirming microbiological confirmation (Scenario B); no evidence of microbiological confirmation (Scenario C). Stratification was performed by patient status (inpatient vs. outpatient) and country. Results Four hundred one outpatients and 386 inpatients were included. Mean (SD) outpatient age was 3.6 (2.8) years; inpatient age was 3.1 (2.8) years. Male gender was predominant. Overall, 12.2% outpatients reported ≥1 infectious complication, 3.7% ≥1 bacterial infection, and 0.5% ≥1 microbiologically confirmed infection; inpatient complication rates were 78.8, 33.2 and 16.6%, respectively. Antibiotics were prescribed to 12.7% of outpatients and 68.9% of inpatients. Among users, β-lactamases (class), and clindamycin (agent), dominated prescriptions. Scenario A was assigned to 3.9% (outpatients) vs 13.2% (inpatients); Scenario B: 2.0% vs. 6.0%; Scenario C: 94.1% vs. 80.8%. Conclusions High rates of infectious complications and antibiotic use are reported, with low rates of microbiological confirmation suggesting possible antibiotic misuse for management of varicella complications. Electronic supplementary material The online version of this article (10.1186/s12889-019-7071-z) contains supplementary material, which is available to authorized users.

Background Persistent human papillomavirus (HPV) infection is an important risk factor for a subset of head and neck cancers (HNCs). However, estimates of the HPV-attributable fraction of oropharyngeal cancers vary greatly, and the proportion is increasing. Growing evidence indicates smaller proportions of oral cavity and laryngeal cancers are also HPV-attributable, but this requires further investigation. The primary objective of the BROADEN study is to estimate the fraction of HNCs attributable to HPV in selected European and Asian countries by anatomic site. Secondary objectives are to determine HPV genotypes involved and to describe primary tumor and patient characteristics by HPV status. Methods BROADEN is a non-interventional, cross-sectional study of patients with HNC in China, France, Germany, Italy, Japan, Portugal, and Spain. The HPV-attributable HNC fraction will be determined within pre-defined time-periods (2008–2009, 2013–2014 [China only], 2018–2019). Approximately 9000 patients from an estimated 90 hospitals with reference HNC diagnostic units and local reference pathology laboratories will participate. Sample size estimates were generated by grouped anatomic site (oropharynx, oral cavity, nasopharynx, hypopharynx, and larynx) and country. HPV testing (HPV-DNA and p16 immunohistochemistry [IHC]) will be performed at a central laboratory on formalin-fixed paraffin-embedded tissue samples. All HPV-DNA-positive samples and HPV-DNA-negative/p16 IHC-positive samples, plus 10% of remaining HPV DNA-negative (control) samples will be tested for HPV mRNA. Discussion BROADEN is a large global epidemiologic study to estimate current and recent past HPV burden in oropharyngeal and non-oropharyngeal HNCs. BROADEN is expected to provide robust estimates of HPV attributability by anatomic site in participating countries.

BackgroundThe World Health Organization (WHO)-defined radiological pneumonia is a preferred endpoint in pneumococcal vaccine efficacy and effectiveness studies in children. Automating the WHO methodology may support more widespread application of this endpoint.MethodsWe trained a deep learning model to classify pneumonia CXRs in children using the World Health Organization (WHO)’s standardized methodology. The model was pretrained on CheXpert, a dataset containing 224,316 adult CXRs, and fine-tuned on PERCH, a pediatric dataset containing 4,172 CXRs. The model was then tested on two pediatric CXR datasets released by WHO. We also compared the model’s performance to that of radiologists and pediatricians.ResultsThe average area under the receiver operating characteristic curve (AUC) for primary endpoint pneumonia (PEP) across 10-fold validation of PERCH images was 0.928; average AUC after testing on WHO images was 0.977. The model’s classification performance was better on test images with high inter-observer agreement; however, the model still outperformed human assessments in AUC and precision-recall spaces on low agreement images.ConclusionA deep learning model can classify pneumonia CXR images in children at a performance comparable to human readers. Our method lays a strong foundation for the potential inclusion of computer-aided readings of pediatric CXRs in vaccine trials and epidemiology studies.

BACKGROUND The health and economic benefits of immunization may extend beyond the elements traditionally included in cost-effectiveness analyses (CEAs). This review investigated how broader impacts are considered in economic evaluations of vaccines and whether their inclusion would substantially change CEA findings. METHODS We reviewed CEAs of vaccines associated with the largest global health burden, published from 2014 to 2019 using the Tufts CEA Registry and Tufts Global Health CEA Registry. We supplemented this with a systematic review of published and grey literature. We conducted descriptive analyses to examine the frequency of inclusion of specific social factors and study characteristics associated with their inclusion. We also conducted a case study of the human papilloma virus (HPV) vaccine to illustrate the potential change in CEA findings from selected social impacts. RESULTS We identified 475 relevant health economic assessments. Overall, 40% of studies included at least one category of social impact. The most commonly included non-healthcare cost among cost-per-QALY studies was productivity (25%), while cost-per-DALY studies reported transportation costs most frequently (24%). Few studies examined the impact of vaccination on other sectors such as education and housing (

The coronavirus disease 2019 (COVID-19) pandemic has significantly affected utilization of preventative health care, including vaccines. We aimed to assess HPV vaccination rates during the pandemic, and conduct a simulation model-based analysis to estimate the impact of current coverage and future pandemic recovery scenarios on disease outcomes. The model population included females and males of all ages in the US. The model compares pre-COVID vaccine uptake to 3 reduced coverage scenarios with varying recovery speed. Vaccine coverage was obtained from Truven Marketscan™. Substantially reduced coverage between March- August 2020 was observed compared to 2018-2019. The model predicted that 130,853 to 213,926 additional cases of genital warts; 22,503 to 48,157 cases of CIN1; 48,682 to 110,192 cases of CIN2/3; and 2,882 to 6,487 cases of cervical cancer will occur over the next 100 years, compared to status quo. Providers should plan efforts to recover HPV vaccination and minimize potential long-term consequences.

Highlights • Vaccine preventable diseases continue to impact human health. • Web-based geographic temporal visualizations of large datasets were developed. • Data on rotavirus vaccination uptake and related medical visits was used as an example. • Visualizations show vaccine effectiveness by geographic levels and over time. • Project informs strategies to monitor the impact of new vaccines on SARS-CoV-2., Background Infectious diseases continue to cause significant impact on human health. Vaccines are instrumental in preventing infectious diseases and mitigating pandemics and epidemics. SARS-CoV-2 is the most recent example of an urgent pandemic that requires the development of vaccines. This study combined real-world data and geospatial visualization techniques to demonstrate methods to monitor and communicate the uptake and impact of existing and new vaccines. Methods Observational data of existing pediatric rotavirus vaccines were used as an example. A large US national insurance claims database was accessed to build an analytic dataset for a 20-year period (1996–2017). For each week and multiple geographic scales, animated spatial and non-spatial visualization techniques were applied to demonstrate changes in seasonal rotavirus epidemic curves and population-based disease rates before, during, and after vaccine introduction in 2006. The geographic scales included national, state, county and zip code tabulation areas. An online web-based digital atlas was built to display either continuous or snapshot visualizations of disease patterns, vaccine uptake, and improved health outcomes after vaccination (http://www.mapvaccines.com). Results Over 17 million zip code-weeks of data were available for analysis. The animations show geospatial patterns of rotavirus-related medical encounter rates peaking every year from November – February prior to vaccine availability in 2006. Visualizations showed increasing vaccination coverage rates at all geographic scales over time. Declines in medical encounter rates accelerated as vaccination coverage rapidly increased after 2010. The data maps also identified geographic hotspots with low vaccination rates and persistent disease rates. Conclusion This project developed novel web-based methods to communicate location and time-based vaccine uptake and the related reduction in medical visits due to viral infection. Future applications of the visualization could be used by health agencies to monitor known or novel disease patterns over time in conjunction with close assessment of current and future vaccine utilization.

The Advisory Committee on Immunization Practices (ACIP) recommended catch-up 9-valent Human Papillomavirus (HPV) vaccination through age 26 years, and shared clinical decision-making for adults aged 27–45 years, compared with catch-up through age 26 years and 21 years for females and males, respectively (status quo; pre-June-2019 recommendations). This study assessed the public health impact and cost-effectiveness of expanded catch-up vaccination through age 45 years (expanded catch-up) compared with status quo. We used an HPV dynamic transmission infection and disease model to assess disease outcomes and incremental cost-effectiveness ratio (ICER) of expanded catch-up compared with status quo. Costs (2018 USD), calculated from a healthcare sector perspective, and quality-adjusted life years (QALY) were discounted at 3% annually. Historical vaccination coverage was estimated using NIS-TEEN survey data (NHANES data for sensitivity analysis). Alternative scenario analyses included restricting upper age of expanded catch-up through 26 years (June-2019 ACIP recommendation), 29 years, and further 5-year increments. Our results show expanded catch-up vaccination would prevent additional 37,856 cancers, 314,468 cervical intraepithelial neoplasia-2/3s, 1,743,461 genital warts, and 10,698 deaths compared with status quo over 100 years at cost of $141,000/QALY. With NHANES coverage, the ICER was $96,000/QALY. The June-2019 ACIP recommendation also provided public health benefits with an ICER of $117,000/QALY, compared with status quo. The ICER for expanded vaccination through age 34 years was $107,000/QALY. Expanding catch-up vaccination program through age 45 years-old in the US is expected to provide public health benefits, and cost-effectiveness improves with expanding catch-up through age 34.

Background The COVID-19 pandemic and stay-at-home orders have caused an unprecedented decrease in the administration of routinely recommended vaccines. However, the impact of this decrease on overall vaccination coverage in a specific birth cohort is not known. Methods We projected measles vaccination coverage for the cohort of children becoming one year old in 2020 in the United States, for different durations of stay-at-home orders, along with varying catch-up vaccination efforts. Results A 15% sustained catch-up rate outside stay-at-home orders (compared to what would be expected via natality information) may be necessary to achieve projected vaccination coverage similar to previous years. Permanent decreases in vaccine administration could lead to projected vaccination coverage levels below 80%. Conclusion Modeling measles vaccination coverage under a range of scenarios provides useful information about the potential magnitude and impact of under-immunization. Sustained catch-up efforts are needed to assure that measles vaccination coverage remains high.

Distal humerus fractures in the elderly population are challenging injuries. Treatment can be controversial and must be tailored to each injury and each patient. Historical treatment methods include nonsurgical treatment—the “bag of bones” technique. However, poor functional results and advancements in available implants have shifted the majority of surgeons to recommend operative treatment. Options for surgery include total elbow arthroplasty and open reduction with internal fixation. The experience of the surgeon as well as the characteristics of the patient and the injury serve to guide surgical decision-making. While total elbow arthroplasty is considered for some injuries and some patients, we treat the majority of these injuries with open reduction and internal fixation. We present our surgical setup, operative technique, and postoperative protocols as possible options for treatment of these challenging injuries.

The mechanical role of supplemental fibula fixation in both bone lower leg fractures is not well defined. The benefit of fibula plate fixation in this context is controversial. The purpose of this study was to ascertain the mechanical contributions of the fibula under three conditions (intact, fractured, or plated fibula) following standard tibia locked plating.A laboratory fracture model was created with 10 cadaveric legs (5 matched pairs) with no known history of lower extremity trauma or other musculoskeletal conditions. A both bone lower leg fracture was simulated by performing distal osteotomies, 3 to 5 cm above the tibia plafond, leaving a bony defect to simulate an unstable fracture (AOTrauma OTA classification 43-A3). Coronal and sagittal gauge-pins were placed above and below the fracture sites to measure relative displacement across three planes of motion. Axial and torsional loads were applied to the leg under the following conditions: tibia intact and fibula intact (control 1), tibia fracture and fibula intact, tibia fracture and fibula fracture (control 2), and the three conditions of primary interest: tibia plated and fibula intact, tibia plated and fibula fracture (osteotomy), and tibia plated and fibula plated. The load applied for level 1 was 75 N of axial compression and 0.3 Nm of torque, and the load for level 2 was 175 N of axial compression and 1.3 Nm of torque.There were significant differences in motion across the fracture site of the injured leg when the tibia was not plated compared with an intact and plated tibia, p0.05. However, when the tibia was plated, there were no significant differences in fracture motion when the fibula was left either intact, osteotomized, or underwent supplemental plate fixation, p0.05. This was true regardless of the loads applied.The mechanical stability of supplemental fibula fixation in a both bone lower leg fracture model was not significantly improved from standalone distal tibia fixation in this laboratory model. The clinical effects of these findings are yet to be demonstrated.

Background Routine immunizations for children aged 10 years and younger in the United States (US) currently cover 14 diseases. Updated estimates of public health impact are needed, given changes in disease epidemiology, evolving recommendations, and the dynamic nature of compliance with the immunization schedule. Methods Pre-vaccine disease incidence was estimated before each routine vaccine was recommended, with average values across multiple years obtained directly from published literature or calculated based on disease surveillance data or annual case estimates from the published literature. Pre-vaccine incidence then was compared to current, post-vaccine incidence, which was generally calculated as average values over the most recent 5 years of available incidence data. Overall incidence estimates and estimates by age group were calculated. Differences in pre- and post-vaccine disease incidence rates were used to calculate the annual number of cases averted, based on 2019 US population estimates. This analysis did not separately estimate the proportion of disease incidence reduction that may be attributed to adult vaccines or booster doses. Results Post-vaccine disease incidence decreased overall and for all age groups across all diseases evaluated (Table 1). Decreases ranged from 17.4% for influenza to 100.0% for polio (Figure 1). Over 90% reduction in incidence was achieved for 10 of the 14 diseases evaluated (including reduction in incidence of rotavirus hospitalizations). Overall post-vaccine disease incidence estimates were highest for influenza, rotavirus, and varicella. Estimated annual cases averted by vaccination in 2019 ranged from 1,269 for tetanus to more than 4.2 million for varicella. Table 1. Pre- and Post-Vaccine Disease Incidence Estimates, Annual Cases, and 2019 Cases Averted, by Disease Figure 1. Percentage Reduction in Disease Incidence Post-Vaccine, by Disease Conclusion Routine childhood immunization in the US continues to result in high, sustained reduction in disease across all vaccines and for all age groups evaluated. Disclosures Elizabeth M. La, PhD, RTI Health Solutions (Employee) Justin Carrico, BS, GlaxoSmithKline (Consultant) Sandra E. Talbird, MSPH, RTI Health Solutions (Employee) Ya-Ting Chen, PhD, Merck & Co., Inc. (Employee, Shareholder) Mawuli K. Nyaku, DrPh, Merck & Co. Inc. (Employee, Shareholder) Cristina Carias, PhD, Merck (Employee, Shareholder) Gary S. Marshall, MD, GlaxoSmithKline (Consultant, Scientific Research Study Investigator)Merck (Consultant, Scientific Research Study Investigator)Pfizer (Consultant, Scientific Research Study Investigator)Sanofi Pasteur (Consultant, Grant/Research Support, Scientific Research Study Investigator, Honorarium for conference lecture)Seqirus (Consultant, Scientific Research Study Investigator) Craig S. Roberts, PharmD, MPA, MBA, Merck & Co., Inc (Employee, Shareholder)

Health care is a business. Health care providers must become familiar with terms such as opportunity costs, the potential loss or gain when one choice is made in lieu of another. The purpose of this study was to calculate the opportunity cost of two orthopaedic surgery society board meetings and discuss these in the context of behavioral economics and regret. A literature search was conducted to determine an orthopaedic surgeon's average yearly salary, hours worked per week, and weeks worked per year. The details of two orthopaedic surgery professional society meetings that one senior author (CSR) attended were used to calculate opportunity cost. Although the true benefits are multifactorial and difficult to objectively quantify, awareness of the cost-benefit ratio can help guide time and resource management to maximize the return on investment while minimizing buyer's remorse and perhaps influence the media by which medical meetings are held in the future. (Journal of Surgical Orthopaedic Advances 27(1):10-13, 2018).

BACKGROUND This static cadaveric model pilot study evaluated the agreement between planned and resected margins of simulated soft tissue tumors (SSTT) using skin fiducial markers for computerized navigation registration. METHODS Markers were applied before magnetic resonance imaging scans of lower extremities implanted with SSTT. A navigation pointer was used for registration and to guide SSTT resection with approximately 10 mm planned margins. Digital calipers were used to measure resection margins. Kolmogorov-Smirnov tests were used to confirm measurement normality. A one-sample t test was used to determine measurement group differences (P ≤ 0.05). Bland-Altman analysis and histogram plots compared planned and resected margins. RESULTS Ninety-eight resection margins were measured. The planned margin mean was 10.0 mm (95% confidence interval [CI] = 9.8-10.2 mm) and the resected margin mean was 11.5 mm (95% CI = 11.0-12.1 mm). One-sample t test results identified a 0.75 mm, 95% CI = 0.5-0.99 mm difference (P

Background Positive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription. Objective Our objective was to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed. Methods Using generic adherence terms, an international research panel identified IMA publications from 1966 to 2014. Their data sources were classified as to whether the primary source reflected the perspective of a prescriber, patient, or pharmacist or a combined perspective. Terminology and methodological differences were documented among core (essential elements of presented and unpresented prescribing events and claimed and unclaimed dispensing events regardless of setting), supplemental (refined for accuracy), and contextual (setting-specific) design parameters. Recommendations were made to encourage and guide future research. Results The 45 IMA studies identified used multiple terms for IMA and operationalized measurements differently. Primary data sources reflecting a prescriber's and pharmacist's perspective potentially misclassified core parameters more often with shorter/nonexistent pre- and postperiods (1–14 days) than did a combined perspective. Only a few studies addressed supplemental issues, and minimal contextual information was provided. Conclusions General recommendations are to use IMA as the standard nomenclature, rigorously identify all data sources, and delineate all design parameters. Specific methodological recommendations include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.

This perspectives report discusses the need to create a surgical and procedural skills competency for orthopedic surgery residency training programs.

Remediation and due process are tools for the Program Director (PD) to apply to problems of unprofessional behavior and/or poor academic performance. Although the concept of due process for orthopaedic surgeons conjures up visions of courtrooms and legal arguments, the term “due process” for the purposes of this chapter is a nonlegal definition in an academic setting. This chapter discusses concepts of remediation and due process in the academic environment, reviews their application to orthopaedic surgery residency training programs, and presents a working framework for applying these concepts to unprofessional behavior and/or poor academic performance by orthopaedic residents in training. In orthopaedics, PDs use the concept of due process when they are concerned that the resident’s unprofessional behavior or academic performance is serious and could result in termination. The PD should consult legal counsel and institutional graduate medical education leadership with situations requiring due process. Remediation and due process are essential elements of the toolbox of PDs in orthopaedic surgery.

Objective The goal of this study was to analyze the economic benefits of introducing the 7-valent pneumococcal conjugate vaccine (PCV7) into the City Immunity Program in Shanghai. Methods A decision-analytic model designed for pneumococcal disease and outcomes of pneumococcal infection was populated with local, age-specific incidence and cost data to estimate the expected economic benefits from vaccinating a birth cohort of 172,183 infants in Shanghai over a 1-year period using a cross-sectional approach. The analysis was assumed to occur in a year at which time the direct and indirect effects of vaccination have reached a steady state. Costs were calculated from a payer perspective and included vaccination program costs and direct medical expenditures from pneumococcal-related disease. Results The model predicts that 112,629 cases of pneumococcal-related disease could be prevented during a given year following the introduction of the PCV7 vaccine into the City Immunity Program in Shanghai, leading to a reduction of ¥187,923,359 (US $29,067,790) in direct medical costs. Overall, the inclusion of the PCV7 vaccine is estimated to have a cost-per-life-year saved of ¥37,468 (US $5,796) and a cost-per-quality-adjusted-life-year gained of ¥41,603 (US $6,435) when both the direct and indirect effects of the vaccine resulting from herd protection are taken into account. Conclusions Results suggest that including PCV7 into the City Immunity Program in Shanghai could be considered cost-effective under generally accepted willingness-to-pay thresholds when both the direct and indirect effects of the vaccine are considered in the analysis.

Background Current pneumococcal vaccine campaigns take a broad, primarily age-based approach to immunization targeting, overlooking many clinical and administrative considerations necessary in disease prevention and resource planning for specific patient populations. We aim to demonstrate the utility of a population-specific predictive model for hospital-treated pneumonia to direct effective vaccine targeting. Methods Data was extracted for 1,053,435 members of an Israeli HMO, age 50 and older, during the study period 2008–2010. We developed and validated a logistic regression model to predict hospital-treated pneumonia using training and test samples, including a set of standard and population-specific risk factors. The model's predictive value was tested for prospectively identifying cases of pneumonia and invasive pneumococcal disease (IPD), and was compared to the existing international paradigm for patient immunization targeting. Results In a multivariate regression, age, co-morbidity burden and previous pneumonia events were most strongly positively associated with hospital-treated pneumonia. The model predicting hospital-treated pneumonia yielded a c-statistic of 0.80. Utilizing the predictive model, the top 17% highest-risk within the study validation population were targeted to detect 54% of those members who were subsequently treated for hospitalized pneumonia in the follow up period. The high-risk population identified through this model included 46% of the follow-up year's IPD cases, and 27% of community-treated pneumonia cases. These outcomes were compared with international guidelines for risk for pneumococcal diseases that accurately identified only 35% of hospitalized pneumonia, 41% of IPD cases and 21% of community-treated pneumonia. Conclusions We demonstrate that a customized model for vaccine targeting performs better than international guidelines, and therefore, risk modeling may allow for more precise vaccine targeting and resource allocation than current national and international guidelines. Health care managers and policy-makers may consider the strategic potential of utilizing clinical and administrative databases for creating population-specific risk prediction models to inform vaccination campaigns.

Objective The purpose of this case report was to describe the chiropractic management of a patient with neck-tongue syndrome (NTS). Clinical Features A 34-year-old female patient sought treatment at a chiropractic clinic for symptoms involving neck pain associated with left-sided paresthesia of the tongue that had persisted for >2 years. A diagnosis of NTS was made. Intervention and Outcome The patient was treated with spinal manipulation, myofascial release, and home exercises. After 2 weeks, she was symptom free. At the 2-year follow-up, the patient remained free of symptoms. Conclusion This patient with NTS responded favorably to a course of chiropractic care.

Currently, 13-valent pneumococcal conjugate vaccine (PCV); and ten-valent PCV vaccine are marketed. Neither vaccine obtained regulatory approval based on efficacy trials, but instead were approved based on a surrogate end point: immunogenicity data measuring effective antibody levels. Therefore, direct measures of efficacy were unavailable at the time economic analyses were conducted. The authors systematically reviewed cost-effectiveness studies of ten-valent PCV and 13-valent PCV from the literature to analyze the methodologies and compare the assumptions made about vaccine effectiveness. The following three inputs were found the most variant across analyses: efficacy against acute otitis media; inclusion of indirect effects; and cross protection. These assumptions are discussed with regard to the validity of supporting data and implications on decision-making.

The purpose of this systematic review was to analyse the available evidence regarding nonunions of the fibula. We focussed on the incidence, risk factors, evaluation, and treatment modalities for fibular nonunions as evident in the current literature and propose a treatment algorithm.This was an Institutional Review Board (IRB) exempt study performed at a level one trauma centre. We systematically reviewed the published evidence on fibular nonunion or delayed union from 1950 to February, 2011.Twelve articles were included in this systematic review. In summary, nonunion of the fibula is becoming increasingly more common in association with intramedullary nailing of concomitant tibial shaft fractures. A treatment algorithm for nonunion of the fibula has been proposed.The suspicion for nonunion of the fibula should be heightened in lower leg fractures if the patient is symptomatic, and the progression of healing is not as expected. Ideally, prospective, multicentre studies would be performed to provide more rigorous data on the incidence, risk factors, and optimum treatment.

The purpose of this study was to systematically review the available evidence on lumbar paraspinal compartment syndrome with specific reference to patient demographics, aetiology, types, diagnosis, clinical features, and treatment. This was an Institutional Review Board-exempt study performed at a Level 1 trauma center. A PubMed search was conducted with the title query: lumbar paraspinal compartment syndrome. Eleven articles met our search criteria. Three of the patients with acute paraspinal compartmental syndrome treated with fasciotomy had a full recovery and were able to resume skiing after four months. The aetiology of the onset of lumbar paraspinal compartment syndrome is broadly divided into acute and chronic. Lumbar paraspinal compartment syndrome is one of the causes of back pain with diagnostic clinical features which should be considered in the differential diagnosis of a patient with low back pain. Prospective multicentre trials may provide the surgeon with more insight into the diagnosis and management of lumbar paraspinal compartment syndrome.

Compartment syndrome is an urgent clinical entity characterised by an increase in the interstitial pressure within a closed osseofascial compartment. Although well recognised as a potential complication after orthopaedic trauma, it is very rarely presented after elective orthopaedic surgery and especially joint arthroplasty. In these rare cases a number of variables are associated with it (positioning, coagulopathy, extensive soft tissue dissection, previous scarring, and epidural analgesia). In this study we present the current evidence with regard to incidence and causation of compartment syndrome after lower limb joint arthroplasty and make recommendations on how to avoid the development of this devastating complication.

Trauma centers are limited resources, particularly in rural areas, and availability of emergency care in some parts of the United States may be inadequate. The declining number of orthopedic surgeons willing to care for injured patients has limited access to fracture repair in some communities. We studied the management of closed midshaft femur fractures in both trauma centers (TCs) and nontrauma centers (NTCs) to evaluate outcome for this common orthopedic injury and determine if these issues have affected fracture care in Kentucky. All patients 16-years-old and older who suffered femur fractures in Kentucky from 2004 and 2005 were identified. There were 334 TC patients and 341 NTC patients with closed, midshaft femur fractures. The mean age of TC patients (33 ± 17 years) was significantly lower than that of NTC patients (59 ± 25 years). TC patients were more likely men (71% vs 44%), had more associated injuries (2.4 ± 2.1 vs 0.5 ± 1.2), and had longer lengths of stay (8.3 ± 9.8 vs 6.4 ± 7.1 days) (TCs vs NTCs, all P < 0.005). Although both groups ultimately underwent internal fixation (97% vs 99%, TCs vs NTCs), TC patients were more likely (2.7% vs 0.3%) to receive external fixation than the NTC patients ( P < 0.05). There was no significant difference in the percentage of patients that received only a closed reduction. There was no significant difference in hospital mortality (0.3% vs 0.9%, TCs vs NTCs, P = 0.62). Although differences in patient populations exist between TCs and NTCs, both TCs and NTCs manage substantial numbers of patients with closed, midshaft femur fractures with low mortality in this state database.

Intramedullary nailing is the accepted treatment of femoral and tibial shaft fractures. Improvements in surgical techniques and implant designs have extended indications for nailing to metaphyseal fractures of the proximal tibia, distal tibia and the distal femur. Malalignment can still occur with intramedullary nailing of these fractures. Among many techniques that have been described, the use of a 'poller screw' or 'blocking screw' is one of the methods that may be used to aid in satisfactory fracture reduction and biomechanical stability. To our knowledge, the use of a Steinman pin as the initial step in poller screw insertion has not been reported in the English literature. Were port a new technique of poller screw using Steinman pin localisation with tibial and femoral nailing of metaphyseal fractures.

Background Fluconazole is a standard first-line therapy for candidemia/invasive candidiasis (C/IC), based on its efficacy, safety profile, and comparatively low acquisition cost. However, little is known about the total costs associated with fluconazole treatment for this indication, particularly in cases of clinical failure. Objective The aim of this study was to examine overall costs, resource use, and treatment outcomes associated with fluconazole as first-line therapy for invasive Candida infections in the United States. Methods A retrospective analysis of data from a US hospital-based (>500 hospitals), service-level database was performed. All patients aged >16 years with primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification codes for IC or septicemia, receiving intravenous fluconazole treatment, and discharged between October 1, 2004 and September 30, 2005 were selected. Costs and resource use were calculated from the start of antifungal therapy until discharge. Two groups were analyzed: patients who received fluconazole only and those who required a second-line antifungal. Separate analyses for the survivor subpopulations were also conducted. Results A total of 7170 patients met the inclusion criteria; 21.2% required an additional antifungal agent. Overall mortality was 27.1%, and total mean treatment cost for all patients was $44,482 (in 2005 US dollars). Patients treated with fluconazole alone incurred mean costs of $36,319. Mean hospital and intensive care unit stays in the fluconazole monotherapy group were 17.9 days and 7.1 days, respectively. Patients requiring additional therapy had a mortality rate of 34.5% and a mean treatment cost of $76,329; in this group, the mean hospital and intensive care unit stays were 31.7 days and 14.8 days, respectively. Conclusions The overall resource use associated with fluconazole as first-line treatment for C/IC was high, especially in patients who required additional antifungal therapy. Future studies should examine the patterns of care and costs associated with alternative treatment options as first-line C/IC therapy.

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.

Objective We sought to compare the cost-effectiveness of different interventions that have been shown to improve adherence with antihypertensive and lipid-lowering therapy, by combining a burden of nonadherence model framework with literature-based data on adherence-improving interventions. Methods MEDLINE was reviewed for studies that evaluated ≥1 adherence intervention compared with a control, used an adherence measure other than self-report, and followed patients for ≥6 months. Effectiveness was assessed as Relative Improvement, ratio of adherence with an intervention versus control. Costs, standardized to 12 months and adjusted to 2007 US$, and effectiveness estimates for each intervention were entered into a previously published model designed to measure the burden of nonadherence with antihypertensive and lipid-lowering medications, in a hypertensive population. Outputs included direct medical costs and incremental costs per quality-adjusted life-year (QALY) gained. Results After screening, 23 eligible adherence-improving interventions were identified from 18 studies. Relative Improvement ranged from 1.13 to 3.60. After eliminating more costly/less effective interventions, two remained. Self-monitoring, reminders, and educational materials incurred total health-care costs of $17,520, and compared with no adherence intervention, had an incremental cost-effectiveness ratio (ICER) of $4984 per QALY gained. Pharmacist/nurse management incurred total health-care costs of $17,896, and versus self-monitoring, reminders, and education had an ICER of $6358 per QALY gained. Conclusions Of published interventions shown to improve adherence, reminders and educational materials, and a pharmacist/nurse management program, appear to be cost-effective and should be considered before other interventions. Understanding relative cost-effectiveness of adherence interventions may guide design and implementation of efficient adherence-improving programs

A systematic review of the literature was performed in order to evaluate the role of reduction and internal fixation in the management of Lisfranc joint fracture–dislocations. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Eleven articles were eligible for the final analysis, reporting data for the management of 257 patients. Injuries of the first three metatarsal rays were treated by closed reduction and internal fixation with screws in 16.3% of the patients, open reduction and internal fixation with screws in 66.5% and open reduction and internal fixation with Kirschner wires (K-wires) in 17.1% of the patients. The preferred method for the stabilisation of the fourth and fifth metatarsal rays was K-wires. Screw-related complications were common and were reported in 16.1% of the cases. The mean American Orthopaedic Foot and Ankle Society midfoot score was 78.1 points. Post-traumatic radiographic arthritis was reported in 49.6% of the patients, but only in 7.8% of them it was severe enough to warrant an arthrodesis. We conclude that open reduction and internal fixation of the first three metatarsal rays with screws is a reliable method for the management of Lisfranc injuries. This can be complemented by K-wires application in the fourth and fifth metatarsal rays if needed.

Nonunion and delayed union of patella fractures are rare conditions that are fraught with challenges. There exists limited evidence in the literature to guide the clinician in the management of these complications. Therefore, the purpose of this study was to perform a systematic review of the available evidence on the management of nonunion and delayed union of patella fractures. A total of five publications which met our criteria were identified and formed the basis of this study. The decision making in the treatment of this condition is based on the functional demands of the patient, the factors that led to the development of the nonunion, the potential impact of the biomechanical effects of a total patellectomy, and the presence of an intact extensor mechanism of the knee for a later reconstructive procedure. Patients with low functional demands may be managed with nonoperative methods; however, those who perform heavy physical work or participate in sports usually require open reduction and internal fixation. Tension band wiring is the treatment of choice for patients suitable for a reconstructive procedure. Partial or total patellectomy is also an option for small distal fragments or an inability to satisfactorily perform internal fixation.

Knowledge of the bony thickness of the acetabular columns is one requisite for safe execution of percutaneous fixation of acetabular fractures. We performed a cadaveric study to determine anatomical dimensions of the columns of acetabulum with reference to percutaneous screw fixation. Twenty-two hemipelves (11 pairs) from 6 male and 5 female cadavers were measured and statistically analysed. In the anterior column, the psoas groove displayed the least vertical thickness of 15.1 mm (range, 12.1–18.2 mm), followed by the obturator canal with 15.9 mm (range, 12.2–20.6 mm). The mean thickness of the posterior column wall of the acetabulum along the screw path displayed 21.3 mm (range, 16.5–30.3 mm). This study provides a clinical map for safe passage of both antegrade and retrograde percutaneous screws. Anatomic data suggests that 7.3 mm cannulated screws can be safely accommodated by the anterior and posterior columns of the acetabulum.

Traumatic dislocations of the hip appear to be on the rise in North America. Multidetector CT, hip arthroscopy, and high field MRI have further defined the pathoanatomy of hip dislocations. They can be divided into simple and complex dislocations. At the University of Louisville, an algorithm has been developed to facilitate rapid and accurate diagnosis and treatment of simple hip dislocations. In contrast to the treatment of simple hip dislocations, the treatment of complex hip dislocations (fracture-dislocations) is generally predicated on specific treatments of the associated fracture (e.g., femoral head fracture, femoral neck fracture, acetabular fracture, etc.). This review includes the mechanism of injury, epidemiology, associated injuries, evaluation, treatment, and functional outcomes of simple hip dislocations.

To improve the understanding of relationships among United States Medical Licensing Examination (USMLE Step I), Orthopedic In-Training Examination (OITE), Subjective Clinical Performance Evaluations, and American Board of Orthopedic Surgery Examination Part I (Abos-I) and Part II (Abos-II), which would help residency programs better achieve their educational mission.A 12-year descriptive study of retrospectively collected data.One residency program with 47 resident participants.Residents that failed Abos-I and Abos-II had lower program mean OITE year-in-training (YIT) percentile rank scores. The program mean OITE YIT percentile rank score had a moderate relationship with Abos-I (% correct) score (r = 0.68, p0.0001) and an insignificant relationship with USMLE Step I (3-digit) score (r = 0.22, p = 0.13). Residents with upper quartile (or=220) USMLE Step I (3-digit) scores for our program had higher program mean OITE YIT percentile rank scores and Abos-I (% correct) scores than residents with lower quartile scores (or=202). Residents who scored in the upper quartile (or=55) for the program mean OITE YIT percentile rank score had higher Abos-I (% correct) scores than residents who did not. Residents who scored in the lower quartile for the third postgraduate year (PGY-3) program OITE YIT percentile rank score or for the program mean OITE YIT percentile rank score had a 5.2 and 5.8 time greater Abos-I failure risk, respectively. The program PGY-3 OITE YIT percentile rank score was the strongest Abos-I (% correct) score discriminator. Resident Abos-I (% correct), program mean OITE YIT, and program PGY-3 OITE YIT percentile rank scores were the strongest discriminators for Abos-II passage. Residents with a program mean OITE YIT percentile rank scoreor=28, program PGY-3 OITE YIT percentile rank scoreor=39, and USMLE Step I (3-digit) scoreor=207 were more likely to pass Abos-I and II. Residents that had lower quartile USMLE Step I (3-digit) scores for our program had a 2.3 time greater Abos-I failure risk. Program residents withor=2 below-average subjective clinical performance evaluations had lower Abos-I (% correct) scores but had similar Abos-I and II pass rates.Our program uses the USMLE Step I (3-digit) score as a preacceptance estimate of likely supplemental guided mentoring needs. Program mean OITE YIT percentile rank and PGY-3 OITE YIT percentile rank scores help identify educational deficiencies and predict eventual Abos-I and II passage. Subjective clinical performance evaluations provide important supplemental information regarding professionalism, communication, and patient care skills.

Introduction Thigh compartment syndrome is a surgical emergency with risk of high morbidity and mortality rates. The purpose of this study was to review the available evidence regarding the causes of thigh compartment syndrome, techniques of fasciotomy (specifically, one versus two incisions), methods of wound closure, and complications. Methods This institutional review board-exempt study was performed at a level-one trauma centre. PubMed and Medline OVID databases in the English language were searched for case series of two or more cases of compartment syndrome of the thigh. Cases were reviewed and analysed for causes of thigh compartment syndrome, number of fasciotomy incisions, methods of wound closure, and complications. Results A total of 9 papers met our criteria. All were retrospective case studies comprising a total of 89 patients. The most common cause was blunt trauma (90%). Motor vehicle accidents accounted for 36% of cases whilst motorcycle accidents were involved in 9%. Associated injuries included femur fractures in 48%, other limb fractures, renal, cardiovascular and head insults. Eighty-six percent of fasciotomies were performed through a single incision. Fifty-nine percent of fasciotomy wounds were closed by delayed primary closure, 26% had split-thickness skin grafts, and 15% had primary wound closure. Neurological deficits were the most common complications. Conclusion There are limited data on thigh compartment syndrome with respect to cause, use of one versus two incisions for fasciotomy, methods of wound closure, and complication rates. Prospective studies are required to better define these variables in order to optimise the management of this problem.