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1.
Objectives
The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences.Methods
Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 (most) to 5 (least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas.Results
Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference.Conclusions
Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both. 相似文献2.
Eva Ma Montalvá Orón Luis Sabater Ortí Ana Ma Sánchez Romero Alberto López Delgado 《Cirugía espa?ola》2009,86(4):230-241
Introduction
In recent months we have witnessed an update of the residents training program and the regulation of important training aspects. Teaching units are an important aspect of the training process, which should be required to comply with the prerequisites adapted to changing times as a guarantee of quality.Aim
To identify areas for improvement in training, and the baseline resources of the units to deal with the implementation of the new training program.Material and methods
The study was carried out in all units with accredited educational programs in the Valencian Community with questionnaires answered by tutors and residents, and meetings held with them.Results
The participation rate was high (100% of tutors and 92% of residents). Some deficiencies in the requirements of the surgical units and in the quality of the training felt by the residents are detected, mainly in the research and educational activity fields. Huge differences between hospitals are found.Conclusions
More attention must be paid to fulfilling all the requirements needed for the accreditation of the teaching units, with an emphasis on educational and research activities. The implementation of the new training program requires monitoring to minimise the differences found between the units. 相似文献3.
Kuroda T Kitano Y Honna T Sago H Hayashi S Saeki M 《Journal of pediatric surgery》2004,39(12):1819-1822
Purpose
The aim of this study was to investigate the prenatal courses and management of abdominal surgical diseases.Methods
Of the 327 patients registered with our fetal treatment board since March 2002, 83 fetuses referred to the surgical department were enrolled for the current study. The prenatal diagnosis, sequential fetal images, and perinatal courses of these cases were reviewed retrospectively.Results
Of the 83 cases, abdominal diseases were suspected in 34, lung and thoracic diseases in 25, genitourinary diseases in 12, and other anomalies in 12. Meconium peritonitis (MP), intestinal obstruction, and abdominal wall defects accounted for approximately 65% of the abdominal diseases. Five patients with prenatally diagnosed lung diseases underwent fetal surgical intervention, and 17 of the 22 liveborn patients survived. In contrast, none of the patients with prenatally diagnosed abdominal anomalies underwent fetal surgical intervention, yet, 23 of the 24 liveborn patients survived. However, preterm labor and hydrops were seen frequently in the patients with giant cystic MP, suggesting a fetal critical condition.Conclusions
Although the clinical outcome of abdominal diseases seemed favorable with postnatal treatment, the current results suggested the occurrence of hidden mortality in utero and the potential need for fetal intervention for some abdominal conditions, such as MP. 相似文献4.
Purpose
Focused abdominal sonography for trauma (FAST) has been popularized for the initial evaluation of trauma patients. We sought to understand the scope of practice on a national level with specific attention to its use in the pediatric age group.Methods
An electronic survey was sent to all American College of Surgeons level I trauma centers and the National Association of Children's Hospitals and Related Institutions that were freestanding children's hospitals.Results
The survey was emailed to 124 centers, and 98 (79%) completed the survey. Of the surveyed centers, 23% cared for adults only, 28% were freestanding children's hospitals, and 49% managed both. At adults-only institutions, 96% use FAST and at children's hospitals, only 15%; it is used at 85% of centers that care for both. For the centers that use FAST on children, 88% have no age limit. Of all the institutions that typically use FAST, the individual performing the examination could be a surgeon (73%), an emergency department doctor (48%), or a radiologist (3%). Of the centers that perform FAST, 51% bill for the FAST examination.Conclusions
Adult hospitals are much more likely to perform FAST examinations in the trauma patient, and many adult centers routinely use FAST to examine pediatric patients. 相似文献5.
Robert P. Sticca Bree D. Dewing M.D. Joel D. Harris M.D. M.P.H. 《American journal of surgery》2009,198(6):829-833
Background
Recent literature suggests implantable central venous access ports (ICVAPs) can be placed by interventional radiologists with fewer complications and lower expenses when compared with surgeons. An analysis of outcomes and expenses of ICVAP placement by service was conducted.Methods
Three hundred sixty-eight ICVAPs were placed over 3 years at a 230-bed community teaching hospital. A retrospective review of these procedures was conducted. Data recorded for each procedure included patient demographics, reason for placement, indwelling port days, complications, billed charges, and reimbursement.Results
Two hundred seventy-six (75%) ICVAPs were placed by interventional radiologists, while surgeons placed the remaining 92 ports (25%). Short-term complications were identified in 7 interventional radiologist-placed ports (2.5%) and 1 surgically placed port (1.1%), P = .42. Billed charges were greater for interventional radiologist-placed ports ($5,301 vs $4,552, P = .0001). In contrast, reimbursement was greater for surgically placed ports: interventional radiologist 31.3% of charges, surgery 42.8%, P = .049.Conclusion
Reimbursement and charges demonstrated significant differences between surgeons and interventional radiologists. Prior assertions that ports placed by interventional radiologists are less expensive with fewer complications may no longer be valid. 相似文献6.
David H. Stone M.D. Hassan Albadawi M.D. Mark F. Conrad M.D. Fateh Entabi M.D. Michael C. Stoner M.D. Patrick J. Casey M.D. Richard P. Cambria M.D. Michael T. Watkins M.D. 《American journal of surgery》2009,198(2):250-255
Background
Visceral ischemia-reperfusion injury (VI) contributes to adverse outcomes following the repair of thoracoabdominal aneurysms. Experiments were designed to determine whether a poly-adenosine diphosphate-ribose polymerase (PARP) inhibitor modulates indexes of metabolic function (mitochondrial activity), inflammatory cell activation, and tissue inflammation (lipopolysaccharide receptor CD14 messenger ribonucleic acid) following VI.Methods
129S1/SvImj mice were subjected to thoracic aortic occlusion followed by 48 hours of reperfusion. Normal saline was administered to 25 untreated control mice and PJ34 to 21 mice before and immediately after thoracic aortic ischemia-reperfusion. Sham mice (n = 13) underwent median sternotomy alone. At 48 hours, all animals were euthanized and tissues harvested for quantitative analysis.Results
PJ34 improved intestinal (P < .05) but not hepatic mitochondrial activity following reperfusion. CD14 messenger ribonucleic acid levels in liver (P < .004), kidney (P < .003), and spinal cord (P < .03) tissue were less in PJ34-treated mice.Conclusions
PJ34 preserved the metabolic function of intestinal but not hepatic tissue during reperfusion. PJ34 uniformly decreased the expression of an important marker of inflammatory cell activation and tissue inflammation in visceral tissue following VI. PARP inhibitors may serve as a therapeutic modality to abrogate the stress response to VI. 相似文献7.
Purpose
Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care.Methods
All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated.Results
Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled $43,493. Critical care services were provided to 49 patients and yielded $8964 in payments. Six hundred thirty-nine inpatient consultations were performed with a reimbursement of $42,830. Daily care services were billed 1044 times and produced $71,579 in payments. Overall reimbursement for documented, nonoperative services was $166,866. This represented 16.2% of total, noncontracted income for the practice.Conclusion
Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial. 相似文献8.
Álvaro Campillo-Soto Víctor Soria-Aledo María José Millán Enrique Girela-Baena Andrés Carrillo-Alcaraz José Luis Aguayo-Albasini 《Cirugía espa?ola》2009,86(1):13-16
Background
The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries.Method
Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries.Results
For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.Conclusion
The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma. 相似文献9.
Rahul K. Shah Brian Nussenbaum Matthew Kienstra Michael Glenn Jean Brereton Milesh M. Patel David Nielsen David W. Roberson 《Otolaryngology--head and neck surgery》2010,143(1):37-41
Objective
To determine the scope of wrong-site sinus surgery.Study Design
Electronic mail survey.Setting
E-mailed via the American Academy of Otolaryngology-Head and Neck Surgery's weekly newsletter.Subjects and Methods
Members were asked about wrong-site sinus surgery in an 11-item survey.Results
A total of 455 members responded (response rate 19.8%). Forty-two (9.3%) have heard of a case of wrong-site sinus surgery occurring. Twenty-one cases were analyzed; of these, 10 (48%) implicated radiographic error, and the Universal Protocol was followed in one third. In seventeen reports (81%), there was disclosure to the family, one case with delayed disclosure; there was no disclosure in three cases. Sixty-one percent (n = 266) are concerned about operating on the wrong sinus or side. Forty-nine percent (n = 216) routinely use a checklist preoperatively. There is large variation in site marking for sinus surgery. Sixty-five percent (n = 282) routinely review the computed tomography scan prior to surgery.Conclusion
Approximately 10 percent of survey respondents know of a case of wrong-site sinus surgery occurring; the majority of respondents are concerned about a wrong-sinus or wrong-sided surgery occurring in their practice. Otolaryngologists should be vigilant regarding the potential for inverted computed tomography images; there should be national efforts to address this latent systems defect. Surgeons should be trained in understanding the role of and engaging in disclosure and in other techniques that are of greatest support to the patient. Consideration of sinus-specific checklists should be led by the societies representing sinus surgeons. 相似文献10.
Little DC St Peter SD Calkins CM Shah SR Murphy JP Gatti JM Gittes GK Sharp RJ Andrews WS Holcomb GW Ostlie DJ Snyder CL 《Journal of pediatric surgery》2006,41(1):234-238
Purpose
In 1992, the Congress implemented a Medicare payment system based on relative value units (RVUs). Today, RVUs are increasingly used to determine surgeon reimbursement from Medicare, Medicaid, and private third-party payers. We questioned whether current RVU assignments accurately reflect the quantity of time that surgeons spend operating.Methods
Over a 12-month period, 59 common pediatric operations were identified and classified as general surgery (n = 34), urology (n = 13), or minimally invasive (n = 10). Only operations performed as an outpatient or requiring less than one inpatient day of direct surgeon involvement were included. By regression analysis, correlation coefficients were generated comparing average operating time per procedure to the corresponding RVU generated.Results
Of 59 specific operations, a total of 744 general surgery cases, 1155 urological cases, and 370 minimally invasive cases were performed. RVU efficiency was greatest in general surgery (1 RVU = 5.18 operating minutes), followed by minimally invasive operations (1 RVU = 6.80 minutes) and urological operations (1 RVU = 8.59 minutes). Regression analysis proved minimally invasive operations to correlate best with RVUs with R2 = 0.8376, followed by urology at R2 = 0.6753, and then general surgery at R2 = 0.649.Conclusions
The RVU has emerged as the most dominant factor influencing reimbursement of practicing pediatric surgeons. Despite common surgeon bias, RVUs do correlate with current operating times. These data prove important as surgeons analyze cost, negotiate contracts, and strategically plan for fiscal success. 相似文献11.
Byrn JC Schluender S Divino CM Conrad J Gurland B Shlasko E Szold A 《American journal of surgery》2007,193(4):519-522
Background
This study was designed to evaluate the impact of 3-dimensional vision on the performance of resident and experienced surgeons using the da Vinci Robot System (Intuitive Surgical, Sunnyvale, CA).Methods
Four tasks were performed by 12 surgeons with varying experience. Performance times and errors were recorded using both 2-dimensional and 3-dimensional vision for each task.Results
Performance time and error rates for all 4 skills confirm a significant advantage using 3-dimensional vision. Performance times were reduced by 34% to 46% using 3-dimensional imaging for all participants with statistical significance. Error rates were reduced by 44% and 66%.Conclusion
Independent of the biomechanical advantages of the da Vinci Robot System, 3-dimensional vision allows for significant improvement in performance times and error rates for both inexperienced residents and advanced laparoscopic surgeons. 相似文献12.
Study design
Sheep anterior spinal fusion model with autogenous and xenogenous bone grafts.Objective
To investigate whether the relationship between cross-sectional area of the bone graft and area of the adjacent vertebral endplates has an effect on graft fracture rate.Summary of background data
Anterior spondylodesis with autogenous iliac crest transplant is a frequently performed operation to stabilize spinal motion segments but to date no precise recommendations with respect to minimum graft size are available in the literature.Methods
Anterior spondylodesis using autogenous and xenogenous grafts of constant size in combination with an angular stable plate (Macs TL®). Autogenous iliac crest graft was inserted in eight sheep and xenogenic, commercially available bovine graft (Tutobone®) in the additional eight animals.The surface areas of the endplates of the fused intervertebral space were calculated using CT scans and contact radiographs of the specimens obtained after 24 weeks. The graft itself was evaluated for fractures and osteolysis.Results
A fracture occurred in tricortical, autogenous grafts if the graft cross-sectional area was less than 21% of the area of the adjacent endplates. All xenogenic grafts fractured and therefore a comparable value could not be determined.Conclusion
The results clearly indicate that the relation between graft cross-sectional area and endplate area defines the survival or fracture of the graft in anterior spinal fusion. Although it is difficult to directly apply the results to the clinical situation it is suggested to choose a sufficiently large graft, in order to reduce the risk of autogenous graft fracture in anterior spondylodesis. 相似文献13.
Rosamond Jacklin Nick Sevdalis Ara Darzi Charles A. Vincent 《American journal of surgery》2009,197(1):76-81
Background
Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships.Methods
Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons'/medical students' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set.Results
Post-feedback, both groups' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further.Conclusions
Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making. 相似文献14.
Background
Racial disparities in access to coronary artery bypass graft (CABG) surgery are well documented. Recent evidence shows that even when patients receive CABG surgery, racial minorities are more likely to be treated by lower quality providers.Methods
New York State (NYS) hospital discharge data for 1996 and 1997 for patients undergoing CABG surgery were combined with risk-adjusted mortality rates for cardiac surgeons calculated by the NYS Department of Health. Statistical analysis was performed to determine the relationship between patients' race and the quality of the surgeon performing the CABG, as measured by the surgeon's risk-adjusted mortality rate, after controlling for patient characteristics such as comorbidities and socioeconomic status; the hospital where the surgery was performed; and the number of surgeries the surgeon performed over a 3-year period.Results
African Americans and Asian/Pacific Islanders are treated by surgeons with higher risk-adjusted mortality rates compared with whites. This association does not appear to be a result of inadequate risk adjustment. It is explained to some degree by the hospital to which these patients are admitted, and to a lesser degree by (1) the education and income level in the patient's zipcode of residence and (2) being treated by a low-volume surgeon. After controlling for these factors, race continues to be associated with treatment by a surgeon with a higher risk-adjusted mortality rate.Conclusions
Efforts to achieve the “Healthy People 2010” goals of eliminating health disparities should address not only access to care, but also access to high-quality care. 相似文献15.
Marilyn W. Butler 《Journal of pediatric surgery》2010,45(2):303-309
Introduction
Pediatric general surgeons volunteering internationally often work independently, some without prior assessment of the needs of those they wish to assist. Consequently, care may be inefficient, duplicated, or misdirected. A study was performed to assess whether a network for pediatric surgery volunteer work exists.Methods
A search of the Internet was performed to determine whether a pediatric surgery network exists. Worldwide pediatric surgery societies were identified and grouped by country according to income. Web sites for medical volunteer organizations were examined for links to a network of pediatric surgery volunteer work.Results
A search of the Internet revealed no pediatric surgery volunteer network. Ninety-seven pediatric surgery societies were identified. Fifty-one of the organizations were identified as residing in low- and middle-income countries. Searching 50 Web sites for these societies revealed no existing pediatric surgery network. Of 45 Web sites for volunteer medical work, 1 surgery networking Web site was identified. Only 4 pediatric general surgery international volunteer opportunities were cited on that Web site.Conclusions
This study demonstrated that no pediatric surgery volunteer network exists. By identifying pediatric surgery organizations in low- and middle-income countries, it is speculated that one might link the surgeons in these regions with those wishing to volunteer their services. 相似文献16.
Objectives
Research has shown that early surgical intervention for hip fractures serves to decrease mortality. In 2004 the Ministry of Health decided to condition the reimbursement regime at the time of operation. The objectives of this study were to examine whether the reform succeeded to decrease inpatient mortality of hip fracture casualties.Method
The study utilised data drawn from the Israeli Trauma Registry (ITR) for the years 1999-2006. The study population included patients aged 65 and older with an isolated diagnosis of hip fracture following trauma.Results
Two years after the reform, the inpatient mortality decreased by 34% amongst patients undergoing fixation surgery, and by 30% amongst all operated patients. Median LOS decreased by 2 days. The proportion of patients undergoing hip fracture fixation surgery within 48 h increased by 35%.Conclusions
The implementation of a payment limited by time for hip fracture fixation surgery increased the number of patients being operated within 48 h, shortened patient LOS, and decreased inpatient mortality. 相似文献17.
Clifton MS Heiss KF Keating JJ Mackay G Ricketts RR 《Journal of pediatric surgery》2011,46(2):372-377
Background/Purpose
Closure of abdominal wall defects in children poses a challenge for pediatric surgeons. We describe a technique using tissue expanders placed either intraperitoneally or in the abdominal wall to aid in the reconstruction of a variety of complex abdominal wall defects.Methods
The tissue expanders are inserted under general anesthesia. Initial expansion is done in the operating room with attention to peak airway pressure, urine output, and end-tidal carbon dioxide. The expanders are inflated in the outpatient setting via percutaneous access until the calculated inflation volume is achieved. They are then removed; and definitive closure is accomplished using a combination of native tissue flaps, abdominal component separation techniques, biomaterials, and synthetic material.Results
Six children underwent tissue expansion for treatment of abdominal wall defects (omphalocele, n = 3), trauma (n = 1), and thoracopagus twins (n = 1 pair). One to 4 expanders were used per patient, with all having a successful reconstruction of their abdominal walls. Two to 3 operations were required to restore abdominal domain and consisted of expander insertion, removal with reconstruction, and possible revision of the reconstruction.Conclusions
Tissue expanders possess a broad range of applications for abdominal wall reconstruction and can be used in patients of all ages. 相似文献18.
De Pasquale C Pistorio ML Veroux P Giuffrida G Sinagra N Ekser B Zerbo D Corona D Giaquinta A Veroux M 《Transplantation proceedings》2011,43(4):1045-1047
Objective
Enhancement of the subjective components, recognition of overall needs, and careful consideration of subjectively perceived quality of life among dialysis and/or transplanted patients appear to be key objectives to promote optimized adherence to treatment and active cooperation of the patient. This study explores the relationship between self-rated health among recipients of kidney transplantations from deceased marginal donors (age older than 55 years) in relation to gender, age, time on dialysis, years after transplantation, and donor age.Patients and Methods
Posttransplant quality of life was assessed with the Complete Form Health Survey (SF-36) in 70 recipients of kidney transplantations from marginal deceased donors.Results
Donor age did not negatively influence health status perceived by the subjects. The vitality and mental health seemed to increase with greater donor ages, but the status of perceived health, vitality, social activities, and mental health were negatively influenced by the age of the transplant.Conclusions
Our study shows that good general health and social well-functioning can be achieved also among recipients of organs from older donors. Thus, age alone should not be a barrier to organ donation, providing that the organ function is normal and that specific disease is absent in the organ. 相似文献19.
Chu SH Chiang YJ Huang CC Lee PH Hu RH Lai MK Chueh SC Tsai MK 《Transplantation proceedings》2004,36(7):2108-2109
Background
Acute rejection is a major cause of graft loss in renal transplantation. Because the highest risk for acute rejection is in the first month posttransplantation, improved prophylaxis could be most beneficial in this period. Simulect administration provides 30 to 45 days of immunoprophylaxis against acute rejection during the critical period after transplantation.Objectives
We sought to assess the incidence of acute rejection episodes and the safety and tolerability of Simulect plus Neoral immunosuppression. Patient and graft survival rates up to 3 years posttransplantation were evaluated.Method
Forty-one transplant recipients received Simulect by intravenous infusion of an initial 20-mg dose on the day of renal transplantation and a second 20-mg dose on day 4 posttransplant. All renal recipients received immunosuppression with Neoral and steroid.Results
There were eight cases (19.5%) of acute rejection within 1 year. The rejection episodes were easily reversed with steroid pulse therapy in seven patients except for graft loss. The 1-, 2-, and 3-year graft survival rates were 95%, 93%, and 88%, respectively. Overall, the 3-year patient survival rate was 100%.Conclusions
Simulect in combination with Neoral and steroid-reduced the incidence of acute rejection without an increase in adverse events. The low incidence and severity of acute rejection may have led to the superior 3-year patient and graft survival rates in renal transplantation. 相似文献20.