The Relationship between the Bevel of the Radial Head Epiphysis and the Posterior Synovial Fringe During Rotation of the Elbow: An Ultrasonography Study with Possible Implications Regarding the Pathophysiology of Nursemaid's Elbow

BACKGROUND

Nursemaid's elbow is the most common upper extremity injury in children under 5 years of age. However, the exact pathomechanism underlying the nursemaid's elbow remains elusive, and approximate one-third of patients present with a nonclassical history. Using a high-frequency ultrasound probe, we attempted to determine the relationship between the anterior edge of the posterior synovial fringe and the peripheral rim of the radial head epiphysis during rotation. It is possible that the primary reason for the nursemaid's elbow is due to the pronator position.

METHODS

Twenty-one patients had a history of nursemaid's elbow and had a successful reduction before enrollment in this study. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small morphologic changes in the peripheral rim of the radial head epiphysis and the posterior synovial fringe during rotation of the capitellum-radial joint.

RESULTS

In complete pronation, the anterior edge of the posterior synovial fringe contacts the beveled articular surface of the radial head peripheral rim in all 21 patients. In neutral and complete supination, the anterior edge of the posterior synovial fringe contacts the convexly nonarticular surface of the radial head peripheral rim and extends deep into the foveal radius. The posterior synovial fringe and the capsule-aponeurotic membrane were tightened in passive pronation in all 21 cases. The posterior synovial fringe and the capsule-aponeurosis membrane were all loose in the neutral and supination positions.

CONCLUSION

The anterior edge of the posterior synovial fringe touches the beveled peripheral rim of the radial head epiphysis during complete pronation, and the tension of the lateral collateral ligament complex during pronation may further cause unstable conditions of the anterior edge of the posterior synovial fringe. We hypothesized that the beveled peripheral rim of the radial epiphysis and its relationship with the anterior edge of the posterior synovial fringe could be the reason why nursemaid's elbow only occurs while the elbow is in the pronator position.

The Usefulness of Dynamic Ultrasonography in Nursemaid's Elbow: A Prospective Case Series of 13 Patients Reconsideration of the Pathophysiology of Nursemaid's Elbow

BACKGROUND

Nursemaid's elbow is a common musculoskeletal disorder among children under 5 years of age. However, diagnostic imaging to confirm a nursemaid's elbow diagnosis is still unavailable. Through the use of a high-frequency ultrasound probe, we determined the etiology and possible pathophysiology of nursemaid's elbow.

METHODS

Thirteen consecutive patients with the clinical suspicion of nursemaid's elbows were examined. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small changes (partial eclipse signs) of the radial head in the axial view before and after manipulation.

RESULTS

All patients in this study had a successful reduction. A partial eclipse sign was found in all patients before reduction and disappeared after successful reduction.

CONCLUSION

These pathologic features detected through high-frequency ultrasonography suggest the role of the escaped posterior synovial fringe in the pathogenesis of the nursemaid's elbow. The specific finding of a "partial eclipse sign" could be a useful additional clue leading to the correct diagnosis of the nursemaid's elbow and may help avoid the unnecessary reduction in patients who do not have a "partial eclipse sign".

LEVEL OF EVIDENCE

Level II, diagnostic studies.

Effects of backhand stroke styles on bone mineral content and density in postmenopausal recreational tennis players: a cross-sectional pilot investigation

Background

One-handed backhand (OB) and two-handed backhand (TB) styles are commonly used in tennis, but only TB generates loadings on the non-dominant arm and a greater extension torque on the rear leg, leading to a greater axial torque involving rotation of the hip and trunk. The current study investigated whether those effects can further affect bone area (BA), bone mineral content (BMC) and density (BMD) in postmenopausal recreational tennis players.

Methods

BA, BMC and BMD of the lumbar spine, hip and distal radius were assessed using dual-energy X-ray absorptiometry in TB, OB, and swimmers’ group as a control (SG) (all participants self-reported for at least 5 years of exercise history, n = 14 per group). Muscular strength was assessed with a hand dynamometer. Among these three groups, the BA, BMC and BMD of distal radius and muscle strength were assessed using one-way ANOVA, and those of the lumbar region and the hip joint were tested by one-way ANCOVA.

Results

TB showed higher BMC and BMD for both lumbar spine and femoral neck than SG (all, p < 0.05). Both OB and TB showed greater BMD inter-trochanter than SG (both, p < 0.05). OB demonstrated greater inter-arm differences in the distal radius, which involved 1/3 distal for BMC and mid-distal radius for BMD compared to the TB and SG (all, p < 0.05). In addition, greater inter-arm asymmetry of grip strength was found in OB compared to TB and SG (both, p < 0.05).

Conclusion

For postmenopausal women, performing two-handed backhand strokes, leads to higher BMC and BMD in the non-dominant arm, the lumbar region, and hips, indicating potential benefit to maintain bone health and strength. Whether this result leads to reducing the risk of osteoporosis needs to be investigated in further research.

Comparison of the corticosteroid injection and hyaluronate in the treatment of chronic subacromial bursitis: A randomized controlled trial

OBJECTIVE

To analyse the effectiveness of corticosteroid (CS) and hyaluronic acid (HA) subacromial - subdeltoid (SASD) injection compared with normal saline (NS) in patients with chronic subacromial bursitis (CSB).

DESIGN

A prospective three-arm double-blinded randomised controlled trial.

SETTING

Rehabilitation department of two teaching hospitals.

SUBJECTS

Patients with CSB (N = 186) divided into CS (N = 68), HA (N = 60), and NS (N = 58) groups.

INTERVENTIONS

Three SASD injections under ultrasound guidance: group A, 20 mg of triamcinolone; group B, 2.5 mL of HA; and group C, 2.5 mL of NS.

OUTCOME MEASURES

The primary outcome measures were the pain visual analogue scale (VAS) score at eight weeks. The secondary outcomes were scores on the Shoulder Pain and Disability Index (SPADI) and Shoulder Disability Questionnaire.

RESULTS

At eight weeks, the pain VAS scores during activity were 2.56 ± 2.29, 3.65 ± 2.50, and 4.71 ± 2.83 in the CS, HA, and NS groups, respectively (CS vs NS, P < 0.001; HA vs NS, P = 0.013; CS vs HA, P = 0.010). SPADI scores were 40.83 ± 21.75, 36.92 ± 22.78, and 33.35 ± 23.38 in the CS, HA, and NS groups, respectively (CS vs NS, P < 0.001; HA vs NS, P = 0.197; CS vs HA, P = 0.004).

CONCLUSION

Ultrasound-guided corticosteroid injection into the subacromial - subdeltoid bursa was proven to be effective and superior to hyaluronic acid and normal saline injection for treating CSB. Hyaluronic acid injection was only marginally more effective than normal saline injection.Trial Registration: ClinicalTrials.gov: NCT02702206.

Ultrasound-Guided Nerve Hydrodissection for Pain Management: Rationale, Methods, Current Literature, and Theoretical Mechanisms

Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.

Surface electromyography analysis of blepharoptosis correction by transconjunctival incisions

Upper eyelid movement depends on the antagonistic actions of orbicularis oculi muscle and levator aponeurosis. Blepharoptosis is an abnormal drooping of upper eyelid margin with the eye in primary position of gaze. Transconjunctival incisions for upper eyelid ptosis correction have been a well-developed technique. Conventional prognosis however depends on clinical observations and lacks of quantitatively analysis for the eyelid muscle controlling. This study examines the possibility of using the assessments of temporal correlation in surface electromyography (SEMG) as a quantitative description for the change of muscle controlling after operation. Eyelid SEMG was measured from patients with blepharoptosis preoperatively and postoperatively, as well as, for comparative study, from young and aged normal subjects. The data were analyzed using the detrended fluctuation analysis method. The results show that the temporal correlation of the SEMG signals can be characterized by two indices associated with the correlation properties in short and long time scales demarcated at 3ms, corresponding to the time scale of neural response. Aging causes degradation of the correlation properties at both time scales, and patient group likely possess more serious correlation degradation in long-time regime which was improved moderately by the ptosis corrections. We propose that the temporal correlation in SEMG signals may be regarded as an indicator for evaluating the performance of eyelid muscle controlling in postoperative recovery.

PEDF-derived peptide promotes skeletal muscle regeneration through its mitogenic effect on muscle progenitor cells

In response injury, intrinsic repair mechanisms are activated in skeletal muscle to replace the damaged muscle fibers with new muscle fibers. The regeneration process starts with the proliferation of satellite cells to give rise to myoblasts, which subsequently differentiate terminally into myofibers. Here, we investigated the promotion effect of pigment epithelial-derived factor (PEDF) on muscle regeneration. We report that PEDF and a synthetic PEDF-derived short peptide (PSP; residues Ser(93)-Leu(112)) induce satellite cell proliferation in vitro and promote muscle regeneration in vivo. Extensively, soleus muscle necrosis was induced in rats by bupivacaine, and an injectable alginate gel was used to release the PSP in the injured muscle. PSP delivery was found to stimulate satellite cell proliferation in damaged muscle and enhance the growth of regenerating myofibers, with complete regeneration of normal muscle mass by 2 wk. In cell culture, PEDF/PSP stimulated C2C12 myoblast proliferation, together with a rise in cyclin D1 expression. PEDF induced the phosphorylation of ERK1/2, Akt, and STAT3 in C2C12 myoblasts. Blocking the activity of ERK, Akt, or STAT3 with pharmacological inhibitors attenuated the effects of PEDF/PSP on the induction of C2C12 cell proliferation and cyclin D1 expression. Moreover, 5-bromo-2'-deoxyuridine pulse-labeling demonstrated that PEDF/PSP stimulated primary rat satellite cell proliferation in myofibers in vitro. In summary, we report for the first time that PSP is capable of promoting the regeneration of skeletal muscle. The signaling mechanism involves the ERK, AKT, and STAT3 pathways. These results show the potential utility of this PEDF peptide for muscle regeneration.

Ultrasonographic appearance of subungual glomus tumors

BACKGROUND

To describe the sonographic (US) features of pathologically confirmed subungual glomus tumors.

METHODS

We retrospectively analyzed cases of pathologically confirmed subungual glomus tumors in patients presenting between December 1, 2008 and October 31, 2012, selected from cases in the musculoskeletal US database of a single institution.

RESULTS

Data on 14 patients with pathologically proven glomus tumors were retrieved from the US database. The tumor size ranged from 1.9 to 10.0 mm (mean ± SD, 5.3 ± 2.3 mm). Well-circumscribed tumors with clear margins were identified on US in 12 cases (86%): 11 (92%) tumors were hypoechoic and 1 (8%) was isoechoic. On power or color Doppler US, 11 of these 12 tumors (92%) appeared hypervascular. Two of the 14 tumors did not show a clearly circumscribed mass on gray-scale US, and bony erosion was the only US finding in one of the two cases. Seven of the 14 patients (50%) showed focal bony erosion in the underlying phalangeal bone.

CONCLUSIONS

A hypervascular mass in the nail bed was the most common US finding associated with subungual glomus tumors. We found that focal hypervascularity supports the diagnosis, and bony erosion is commonly associated with digital glomus tumors.

Enhanced data consistency of a portable gait measurement system

A gait measurement system is a useful tool for rehabilitation applications. Such a system is used to conduct gait experiments in large workplaces such as laboratories where gait measurement equipment can be permanently installed. However, a gait measurement system should be portable if it is to be used in clinics or community centers for aged people. In a portable gait measurement system, the workspace is limited and landmarks on a subject may not be visible to the cameras during experiments. Thus, we propose a virtual-marker function to obtain positions of unseen landmarks for maintaining data consistency. This work develops a portable clinical gait measurement system consisting of lightweight motion capture devices, force plates, and a walkway assembled from plywood boards. We evaluated the portable clinic gait system with 11 normal subjects in three consecutive days in a limited experimental space. Results of gait analysis based on the verification of within-day and between-day coefficients of multiple correlations show that the proposed portable gait system is reliable.

Sonographic diagnosis of a medial talar avulsion fracture

Occult talus fractures can be easily misdiagnosed as simple ankle sprains, resulting in painful nonunion, arthrosis, avascular necrosis, and long-term disability. We present a case of ankle injury with medial talar fracture that was negative on plain radiography but was diagnosed with sonography. Sonography is a valuable tool in screening ankle sprains and may assist clinicians in diagnosing the nature of ankle injury, thus guiding the most appropriate therapeutic strategy.

Reciprocal regulatory interaction between human herpesvirus 8 and human immunodeficiency virus type 1

Human herpesvirus 8 (HHV8) is the primary viral etiologic agent in Kaposi's sarcoma (KS). However, individuals dually infected with both HHV8 and human immunodeficiency virus type 1 (HIV-1) show an enhanced prevalence of KS when compared with those singularly infected with HHV8. Host immune suppression conferred by HIV infection cannot wholly explain this increased presentation of KS. To better understand how HHV8 and HIV-1 might interact directly in the pathogenesis of KS, we queried for potential regulatory interactions between the two viruses. Here, we report that HHV8 and HIV-1 reciprocally up-regulate the gene expression of each other. We found that the KIE2 immediate-early gene product of HHV8 interacted synergistically with Tat in activating expression from the HIV-1 long terminal repeat. On the other hand, HIV-1 encoded Tat and Vpr proteins increased intracellular HHV8-specific expression. These results provide molecular insights correlating coinfection with HHV8 and HIV-1 with an unusually high incidence of KS.

Economic analysis of lung volume reduction surgery as part of the National Emphysema Treatment Trial. NETT Research Group

BACKGROUND

In today's cost-conscious health care environment, obtaining timely and accurate economic information regarding new medical technologies has become extremely important. The National Emphysema Treatment Trial, a multicenter, randomized controlled trial of lung volume reduction surgery (LVRS) plus medical therapy, versus medical therapy for patients with severe emphysema, includes a parallel cost-effectiveness analysis.

METHODS

The analysis is designed to determine the cost-effectiveness of LVRS versus medical therapy for those who are eligible for the procedure. After describing theoretical foundations of cost-effectiveness analysis as they apply to this study, we describe the economic and quality of life data that are being collected alongside the clinical trial, methods of analysis, and approach to presenting the results.

RESULTS

The cost-effectiveness of LVRS relative to medical therapy will be presented as costs per quality-adjusted life years gained.

CONCLUSIONS

This analysis will provide timely economic data that can be considered alongside the clinical results of the National Emphysema Treatment Trial. As one of the largest clinical trials to include a parallel, prospective cost-effectiveness analyses, this study will also provide valuable practical information about conducting an economic analysis alongside a multicenter clinical trial.

Measurement of health outcomes in treatment effectiveness evaluations: conceptual and methodological challenges

Major challenges in the evaluation of the "end results" of health services include ensuring that concepts are correctly defined and measured, that the validity of measures used in different applications and populations is well documented, and that observed effects can be clearly interpreted. Health status is the most widely interpretable concept to apply in the context of health services. Quality of life connotes inclusion of the environment outside the context of the person and of health care and may or may not be health related, depending on the evaluation context and the impact of disease and treatment. All concepts and constructs must be defined in reference to their theoretical origin and to a model of relationships among different concepts. Modern test theory offers the potential for individualized, comparable assessments and for the careful examination and application of different measurement models. Selection and critique of measures should be based on the intended application and accumulated evidence for that application. Thus, there are no valid instruments per se. Validity in use, including responsiveness, interpretation of effects, and generalizability to diverse populations, is the most important measurement characteristic for treatment effectiveness. An evaluation of the validity of preference-based measures is particularly important for the interpretation and comparability of outcomes in cost-effectiveness evaluations. The successful translation of research into policy and practice is limited by the extent to which these critical issues are addressed in actual treatment evaluations.

Health status of Medicare enrollees in HMOs and fee-for-service in 1994

We compared the health status of 863 health maintenance organization (HMO) enrollees with that of 4,576 non-enrollees, controlling for demographics and area of residence, using 1994 data from the Medicare Current Beneficiary Survey (MCBS). HMO respondents were less likely to report fair or poor health, functional impairment, or heart disease. Average predicted costs based on various health-status measures were substantially lower for HMO respondents than for respondents in fee-for-service (FFS) arrangements. The Medicare payment formula for HMOs does not adequately adjust for the better health and consequent lower expected costs of HMO enrollees. The addition of health-status measures would improvement payment accuracy and reduce average HMO payments significantly below current levels.

Seroepidemiology of measles in southern Taiwan: two years after implementation of the measles elimination program

The seroprevalence of the measles antibody in southern Taiwan 2 years after the launch of the two-dose measles elimination program was studied using serological surveillance. Sera from 868 healthy inhabitants were collected from January to December 1993. Measles IgG antibody was detected by enzyme-linked immunosorbent assay. Measles antibody was found in 82% of infants under 3 months of age, 26% of those between 4 and 9 months and 54% of those between 10 and 15 months of age. The most common reason for postponement of vaccination was due to concomitant illness during the scheduled vaccination period. The presence of measles antibody rose sharply in children over 15 months of age, reached 90% among preschool-aged children and was 93% in school-aged children. These data suggest that a high immunization coverage rate was achieved in children over 15 months of age (92%) and that a third measles immunization at age 12 is not necessary. Future strategies for measles control should aim at increasing the immunization coverage for children between 9 and 15 months of age.

Office visits to ophthalmologists and other physicians for eye care among the U.S. population, 1990

Despite growth in the use of ophthalmologic care in the last decade, little is known about the use of eye care services and patterns of physician contact across population subgroups. As the U.S. population grows older, such information is crucial in planning strategies for treatment and prevention of eye disorders as well as in identifying potential problems in access and use of eye care. Using the 1990 National Ambulatory Medical Care Survey data, a descriptive statistical analysis was employed to profile the possible variations in eye care-related office visits to ophthalmologists and other physicians across demographic groups. In 1990, a total of 49.3 million visits that were related primarily to an ocular disorder were made to physicians' offices; 43.8 million (89 percent) of these were visits to ophthalmologists and 5.4 million (11 percent) to other physicians. Use of ambulatory eye care varied across demographic subgroups. Those ages 65 or older had a substantially higher rate of eye care related outpatient visits per 1,000 persons per year compared with the rest of the population (743.6 per 1,000 versus 118.5 per 1,000, P < 0.001). Women had a higher rate than men (216.0 per 1,000 versus 177.0 per 1,000, 0.01; P < 0.05). Blacks had a substantially lower rate than whites (143.2 per 1,000 versus 194.6 per 1,000, 0.001; P < 0.01). Those who visited ophthalmologists' offices also differed from those who visited other physicians' offices in terms of their age, sex, race, health insurance status, and disease characteristics. It is important to devote increased attention to the prevention of vision loss among the population groups that have a higher risk of developing eye diseases and that also may have underused or have less access to care. Results from this analysis, in combination with data on the prevalence of ocular disorders for different population groups, provide useful information to identify these high-risk groups.

The socioeconomic aspects of laser refractive surgery

Excimer laser photorefractive keratectomy (PRK) has shown promising results in preliminary studies. However, even if long-term safety and efficacy are demonstrated, questions have been raised about its viability from a cost-effectiveness perspective. We analyzed the economic investment of elective excimer laser PRK both from the societal and individual perspectives. When the present value of likely expenses associated with excimer laser PRK and follow-up care are compared with those entailed in wearing soft contact lenses, PRK is roughly equivalent to daily wear soft contact lenses over a 10-year horizon and considerably less expensive than extended-wear soft contact lenses. When the analytic perspective is extended to 20 years, excimer laser PRK is a less expensive investment than both daily wear and extended-wear soft contact lenses.

Health insurance coverage and medical care utilization among working-age Americans with visual impairment

As access and cost of medical care emerge as the fundamental issues in the discussion of reforming the nation's health care system, more attention needs to be devoted to the understanding of how visual impairment and functional disability in general affects an individual's access to health insurance as well as medical care utilization. Based on the 1984 Survey of Income and Program Participation (SIPP), we estimate that only 57.5% of 7.0 million working-age (15-64 years old) visually impaired Americans, compared with 79.0% of those not visually impaired, have private health insurance coverage. Moreover, an estimated 1.5 million visually impaired working-age Americans are not covered by any form of health insurance, public or private. This 20.7% uninsurance rate is significantly higher than the 14.1% reported among those who are not visually impaired (p < 0.001). Multivariate logistic regression also supports the inverse association between visual impairment and insurance coverage. On the other hand, multivariate logistic regression suggests a positive association between visual impairment and utilization of outpatient medical services. Although there is a trend toward higher utilization of inpatient services as well among the visually impaired, the finding is not statistically significant. These findings suggest that visual impairment poses a barrier to accessing health insurance, even when controlling for income, education, and employment status. On the other hand, regardless of the health insurance status, visually impaired Americans are likely to have utilized more physician services, but not the hospital services, than the non-visually impaired.

Practice patterns of the office-based ophthalmologist

Practice patterns of office-based ophthalmologists were characterized using data collected from the National Ambulatory Medical Care Survey (NAMCS) of 1989, a national probability sample survey conducted by the National Center for Health Statistics. The sample includes office visits made between 1989 and 1990 to nonfederally-employed physicians primarily engaged in office-based practice. Over 38 million office-based patient visits documented in the NAMCS were analyzed. Fifty-two percent of patients (20.4 million) were over 65 years old; 90% (34.9 million) were white, with blacks and Asians accounting for 5% (1.9 million) and 3% (1.1 million) of visits, respectively. The leading primary diagnoses and professional activity associated with the visits were cataract/cataract surgery 23% (8.9 million), disorders of refraction 19.5% (7.5 million), and glaucoma 13% (4.9 million). Over 40% (16.1 million) of visits were for visual dysfunction, abnormal appearance, or abnormal sensation. Nearly 33% (12.5 million) were related to either a diagnostic/screening session or some form of treatment. The duration of visits ranged from 6 to 10 minutes (22.9%), 11 to 15 minutes (29.8%), and 31 minutes or longer (6.7%); 74% (28.1 million) of the patients were asked to return for a follow-up visit at a specified time, and 13% to return if needed. The major sources of reimbursement for office visits were Medicare (41%, 15.6 million); Blue Cross/Blue Shield (13%, 5 million); and other commercial insurance (15.5%, 5.8 million).

Lessening the burden of diabetes. Intervention strategies

OBJECTIVE

To evaluate the impact of primary and secondary interventions on the development of complications from diabetes, we modeled the effects of primary and secondary interventions for diabetes on a single well-studied complication, diabetic retinopathy.

RESEARCH DESIGN AND METHODS

A model was developed to predict cumulative incidence of retinopathy in IDDM and NIDDM. Risk functions are based on duration of diabetes. The effects of intervention strategies were simulated by altering the retinopathy risk. The effects of the simulations were assessed using cumulative incidence.

RESULTS

Simulations of delaying the onset of IDDM from 2 to 8 yr and decreasing the retinopathy rates by 20-80% were performed for each type of retinopathy. Simulating primary prevention shifted the cumulative incidence curves to the right, and simulating secondary intervention shifted the curves downward. Primary prevention was less effective than secondary prevention. This difference was more apparent for IDDM than for NIDDM, where disease duration and exposure to retinopathy risk were shorter. All interventions shifted the development of retinopathy to later in life.

CONCLUSIONS

The greatest effect on cumulative incidence of all forms of retinopathy occurs when primary and secondary interventions are combined.

Cost-effectiveness of screening and cryotherapy for threshold retinopathy of prematurity

BACKGROUND

Retinopathy of prematurity (ROP) is the leading cause of blindness among premature infants. A recent National Eye Institute-sponsored prospective, multicenter trial investigating the use of cryotherapy for treatment of ROP demonstrates a significant reduction in blindness and low vision for patients with sight-threatening (stage 3+) ROP.

METHOD

A microsimulation model is presented to determine the cost-effectiveness of cryotherapy for ROP. Simulations are performed for three subpopulations of premature infants with birth weights 500 through 749 g, 750 through 999 g, and 1000 through 1249 g, and for three screening strategies--weekly, biweekly, and monthly.

RESULTS

Appropriately timed screening for and treatment of ROP is predicted to result in a gain of 3899 to 4648 quality-adjusted-life-years and a net governmental budgetary savings of $38.3 to $64.9 million for each annual US birth cohort of 28,321 premature infants (500 through 1249 g). The cost per quality-adjusted-life-year gained is $2488 to $6045, depending on different screening strategies.

CONCLUSIONS

Of greatest importance is the finding that properly timed screening and treatment for ROP is not only cost saving but may save approximately 320 infants per year from a lifetime of blindness.

Cost-effectiveness of the screening and treatment of diabetic retinopathy. What are the costs of underutilization?

Diabetic retinal disease remains a leading cause of visual disability among those of working age. Controlled trials have demonstrated that timely diagnosis and photocoagulation treatment can reduce significantly the likelihood of visual impairment in affected diabetic patients. Using a prospective simulation model, we show that an annual screening and treatment program saves thousands of years of vision and reduces medical expenditures over the lifetime of a cohort of Swedish Type I diabetic patients.

Detecting and treating retinopathy in patients with type I diabetes mellitus. Savings associated with improved implementation of current guidelines. American Academy of Ophthalmology

Diabetic retinopathy is the leading cause of acquired blindness among Americans of working age. The resulting economic and societal burdens are of profound magnitude. Epidemiologic and clinical trials data were used to analyze the impact of improved recruitment of patients with Type I diabetes mellitus into screening and treatment programs. The analysis predicted annual savings of $101.0 million and 47,374 person-years-sight at the currently estimated 60% screening and treatment implementation level. If all patients received appropriate eye care, the predicted savings exceed 167.0 million and 79,236 person-years-sight. Approximately two thirds of all savings result from treatment of proliferative diabetic retinopathy, while nearly one third arises from treatment of clinically significant macular edema. Additional savings of $9571 are realized with each recruitment of a newly diagnosed patient with diabetes. Initiating screening immediately upon diagnosis of diabetes, rather than the currently recommended 5-year deferral, would be cost effective if 1 additional individual in 56 were recruited. This model suggests that improved delivery of ophthalmic care to patients with diabetes would yield substantial financial and visual savings, thus making major recruitment programs such as the National Eye Institute's National Eye Health Education Program and the American Academy of Ophthalmology's Diabetes 2000, both economically and clinically effective.