David M. Brogan

A systematic review and critical assessment of incentive strategies for discovery and development of novel antibiotics

Despite the growing threat of antimicrobial resistance, pharmaceutical and biotechnology firms are reluctant to develop novel antibiotics because of a host of market failures. This problem is complicated by public health goals that demand antibiotic conservation and equitable patient access. Thus, an innovative incentive strategy is needed to encourage sustainable investment in antibiotics. This systematic review consolidates, classifies and critically assesses a total of 47 proposed incentives. Given the large number of possible strategies, a decision framework is presented to assist with the selection of incentives. This framework focuses on addressing market failures that result in limited investment, public health priorities regarding antibiotic stewardship and patient access, and implementation constraints and operational realities. The flexible nature of this framework allows policy makers to tailor an antibiotic incentive package that suits a country’s health system structure and needs.

Iatrogenic Nerve Injuries During Shoulder Surgery

INTRODUCTION The current literature indicates that neurologic injuries during shoulder surgery occur infrequently and result in little if any morbidity. The purpose of this study was to review one institutions experience treating patients with iatrogenic nerve injuries after shoulder surgery. METHODS A retrospective review of the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identified twenty-six patients with iatrogenic nerve injury secondary to shoulder surgery. The records were reviewed to determine the operative procedure, time to presentation, findings on physical examination, treatment, and outcome. RESULTS The average age was forty-three years (range, seventeen to seventy-two years), and the average delay prior to referral was 5.4 months (range, one to fifteen months). Seven nerve injuries resulted from open procedures done to treat instability; nine, from arthroscopic surgery; four, from total shoulder arthroplasty; and six, from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in thirteen patients and at a terminal nerve branch in thirteen. Fifteen patients (58%) did not recover nerve function after observation and required surgical management. A structural nerve injury (laceration or suture entrapment) occurred in nine patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus. CONCLUSIONS Nerve injuries occurring during shoulder surgery can produce severe morbidity and may require surgical management. Injuries at the level of a peripheral nerve are more likely to be surgically treatable than injuries of the brachial plexus. A high index of suspicion and early referral and evaluation should be considered when evaluating patients with iatrogenic neurologic deficits after shoulder surgery.

Incentives for new antibiotics: the Options Market for Antibiotics (OMA) model

BackgroundAntimicrobial resistance is a growing threat resulting from the convergence of biological, economic and political pressures. Investment in research and development of new antimicrobials has suffered secondary to these pressures, leading to an emerging crisis in antibiotic resistance.MethodsCurrent policies to stimulate antibiotic development have proven inadequate to overcome market failures. Therefore innovative ideas utilizing market forces are necessary to stimulate new investment efforts. Employing the benefits of both the previously described Advanced Market Commitment and a refined Call Options for Vaccines model, we describe herein a novel incentive mechanism, the Options Market for Antibiotics.ResultsThis model applies the benefits of a financial call option to the investment in and purchase of new antibiotics. The goal of this new model is to provide an effective mechanism for early investment and risk sharing while maintaining a credible purchase commitment and incentives for companies to ultimately bring new antibiotics to market.ConclusionsWe believe that the Options Market for Antibiotics (OMA) may help to overcome some of the traditional market failures associated with the development of new antibiotics. Additional work must be done to develop a more robust mathematical model to pave the way for practical implementation.

Management of Neuromas of the Upper Extremity

Neuromas primarily arise from iatrogenic injury, trauma, or chronic irritation. Given the disabling symptoms of neuromas, an array of treatment strategies exist, with varied results. Successful treatment relies on accurate identification of the offending nerve, containment of the regenerating fascicles, and cessation of mechanical or other noxious stimuli over the regenerating nerve end. The choice of treatment depends in part on the nerve affected, whether it involves critical or noncritical sensation, and its location.

Applying the concepts of financial options to stimulate vaccine development

Stimulating research and development for neglected diseases (such as tuberculosis, malaria and AIDS) has proven difficult. We offer an alternative approach to stimulating research into neglected diseases based on the concept of a financial call option. Our Call Options for Vaccines (COV) model allows the purchaser to make payments during the early stages of development in exchange for reduced future prices. We conclude with a discussion of possible risks and benefits.

Pharmaceutical Pricing in Europe: Weighing up the Options

Rising healthcare costs, particularly pharmaceutical expenditures, have led to the implementation of several pharmaceutical pricing regulations and policies throughout the world. This paper undertakes a critical review of current policies, along with a discussion of alternatives for both on-patent and off-patent drug pricing mechanisms. Traditional direct and indirect price controls have failed to balance the objectives of efficiency and equity. Direct price controls do not restrain growth of costs and may not address the need for innovation. Indirect price controls fail to contain costs and do little to create a competitive off-patent pharmaceutical market. For the on-patent drug markets, we evaluate the use of profit controls, government purchase or auction of patents and Ramsey pricing. Each of these has its own merit, yet the integration of the often separate price and reimbursement decision-making processes would seem to hold the most promise for governments and purchasers to obtain value for money. This approach could send signals to the industry to help direct research towards clinically relevant areas.

Management of Severely Comminuted Distal Radius Fractures

Distal radius fractures are among the most common fractures of the upper extremity. Indications for operative and nonsurgical management have evolved over time, as have fixation techniques. Volar locking plates are commonly used in the treatment of selected distal radius fractures such as low-energy or relatively uncomplicated fractures. They have limitations, however, in the management of highly comminuted fracture patterns and in polytrauma patients. In these patients, other methods ranging from spanning fixation to fragment-specific fixation have emerged as useful alternatives in the surgeons armamentarium for treatment of these challenging fractures.

Lateral Antebrachial Cutaneous Neuropathy Following the Long Head of the Biceps Rupture

Lateral antebrachial cutaneous neuropathies present as purely sensory lesions, manifesting as elbow pain or dysesthetic pain over the lateral forearm. Classically, entrapment of the lateral antebrachial cutaneous nerve has been documented at the lateral edge of the biceps tendon as it exits the deep fascia in the antecubital fossa. We report a case of lateral antebrachial cutaneous nerve traction neuritis, rather than entrapment, resulting from a rupture of the long head of the biceps. The biceps displaced the nerve laterally, resulting in sensory loss and severe allodynia. The patients symptoms were relieved with proximal biceps tenodesis.

Metacarpophalangeal Joint Hyperextension and the Treatment of Thumb Basilar Joint Arthritis

HUMB BASILAR OR carpometacarpal arthritis is a common and often debilitating condition seen in more than half of women aged over 71 years. 1 It manifests as pain localized to the base of the thumb, as well as global hand dysfunction including weak grip and pinch, and inability to grasp large objects. 2 Eaton and Glickel 3 described the radiographic severity of basilar joint arthritis, and these stages are often used to dictate treatment. Several interventions have been described, including volar ligament reconstruction, trapeziometacarpal arthrodesis, trapeziectomy alone, trapeziectomy with ligament reconstruction, and arthroplasty. 4– 9 Despite this, comparatively little has been described about how to manage the accompanying hyperextension deformity of the metacarpophalangeal (MCP) joint that often exists. Failure to recognize and treat this deformity may lead to suboptimal results. 2 Patients with basilar joint arthritis develop radial adduction and flexion of the first metacarpal with narrowing of the first webspace. The anterior oblique (or volar beak) ligament becomes increasingly attenuated with subsequent dorsoradial subluxation of the metacarpal on the trapezium. 2,10 This leads to a relative

Distal radius fractures in the elderly.

THE PATIENT A 72-year-old, active, healthy woman fell onto her outstretched dominant right hand. The wrist was swollen and painful to move. Radiographs demonstrated a displaced intra-articular fracture of the distal radius. After hematoma block, manipulative reduction, and orthotic immobilization, radiographs demonstrate a residual radiocarpal articular stepoff of 2 mm with 10 dorsal angulation of the articular surface on the lateral radiograph.