Current medical research and opinion
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The addition of recombinant human bone morphogenetic protein (rhBMP-2) to the standard of care, consisting of soft tissue management and intramedullary nailing, in the BMP-2 Evaluation in Surgery for Tibial Trauma (BESTT) study led to a significantly better outcome for the patient. Reductions in fracture healing time, secondary interventions for delayed fracture healing and infection rates were observed with 1.50 mg/mL rhBMP-2 compared with the standard of care alone. In Germany the approximate cost of applying one dose of recombinant human bone morphogenetic protein-2 (rhBMP-2) to an open tibial fracture is euro2970. ⋯ A sound economic model to assess the cost-effectiveness and budget impact of rhBMP-2 is required. Using medical data from the BESTT study the differences in fracture healing time, in reduction of secondary interventions for fracture healing and infection treatment can be transferred into economic savings. It is anticipated that the overall savings that can be achieved by rhBMP-2 treatment in open tibia fractures, offset the upfront price of rhBMP-2 and lead to net savings for health insurance companies.
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Delayed healing and non-union remain common problems in the treatment of open tibial shaft fractures. Additional surgical treatments may be required to facilitate healing. The efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2), as an adjunct to the standard of care, has been investigated in the BMP-2 Evaluation in Surgery for Tibial Trauma (BESTT) study. ⋯ In a subgroup analysis of 131 patients with Gustilo-Anderson grade IIIA or IIIB open tibial fractures, using data combined from the BESTT study and a study conducted at 10 level I US trauma centres, a significant reduction in the incidence of secondary autologous bone graft procedures was observed with 1.50 mg/mL rhBMP-2 compared with the standard of care (p = 0.0005). The influence of fracture gap on the re-operation rate has also been examined in the BESTT study. In the 1.50 mg/mL rhBMP-2 group, patients with a 0 mm fracture gap had significantly less re-operations compared with those patients with a greater than 2 mm gap (p = 0.048).
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While correction of hyperglycemia remains central to the management of type 2 diabetes, current management approaches address an integrated constellation of disorders that predispose patients to the risk of microvascular and macrovascular complications. ⋯ Concerted efforts are necessary to increase the proportion of patients achieving current treatment targets. Such measures must aim to educate patients and physicians, remove barriers due to health care organization and access, and improve the monitoring of cardiovascular disease risk indicators. The poly-pharmacy 'pill burden' may be alleviated through the use of drugs that are effective against multiple aspects of the metabolic syndrome, and by co-formulation of agents with established efficacy.
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Review
Impact of long-term use of opioids on quality of life in patients with chronic, non-malignant pain.
The use of opioids in the management of non-malignant pain remains controversial. For many physicians, pain relief stemming from opioid use is not enough unless there is also a noticeable change in quality of life (QoL) and patient functioning. The impact of long-term opioid treatment on patients' QoL has been investigated in a limited number of trials, and these studies differ considerably with respect to their design and principal findings. This systematic review presents the results of these studies. ⋯ There is both moderate/high- and low-quality evidence suggesting that long-term treatment with opioids can lead to significant improvements in functional outcomes, including QoL, in patients with chronic, non-malignant pain. However, further methodologically rigorous investigations are required to confirm the long-term QoL benefit of opioid treatment in these patients, and to elucidate the effect of physical tolerance, withdrawal and addiction, which are all associated with long-term use of opioids, on patients' functional status.
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Stress urinary incontinence is the most prevalent form of urinary incontinence. In spite of its significant negative impact on quality of life less than one-third of patients in the UK present with symptoms to their GP. The current mainstay treatment is pelvic floor exercises. ⋯ This article profiles current treatments and the place of an oral agent in stress urinary incontinence. This review article includes papers that were retrieved through PubMed using search criteria 'stress urinary incontinence', 'management' and the specific therapy area, e.g. tension-free vaginal tape. The main guidance of the Department of Health (London, UK) and associated bodies was also used.