"A" for Agency, "B" for Basal cell, "C" for Corticotulle, "D" for Danger

Without any proof, a governmental agency has decreed that Corticotulle was not enough efficient to be reimbursed by National Health Security. Dealing with treatment of basal cell carcinoma, another governmental agency has published recommendations which even do not follow basic rules of logic. This paper points out that economical and political methods are not scientific or medical ones.     

Caring for non-combatants, refugees, and detainees

The recently reported abuses at Abu Ghraib prison have brought the issue of medical care for displaced persons (DPs) to greater prominence. Natural disasters in the United States (eg, Hurricane Katrina) and elsewhere also require significant medical resources in situations that lack basic infrastructure. Intimate knowledge of the basic tenets of international law is crucial to the care of DPsin any capacity. This article provides an introduction to the Geneva Conventions and the medical and administrative issues that form a framework on which to base DP care.     

Identification of risk factors for increased cost, charges, and length of stay for cardiac patients

BACKGROUND: In this study we explored different risk model options to provide clinicians with predictions for resource utilization. The hypotheses were that predictors of mortality are not predictive of resource consumption, and that there is a correlation between cost estimates derived using a cost-to-charge ratio or a product-line costing approach. METHODS: From March 1992 to June 1995, 2,481 University of Colorado Hospital patients admitted for ischemic heart disease were classified by diagnosis-related group code as having undergone or experienced coronary bypass procedures (CBP), percutaneous cardiovascular procedures (PCVP), acute myocardial infarction (AMI), and other cardiac-related discharges (Other). For each diagnosis-related group, Cox proportional hazards models were developed to determine predictors of cost, charges, and length of stay. RESULTS: The diagnosis groups differed in the clinical factors that predicted resource use. As the two costing methods were highly correlated, either approach may be used to assess relative resource consumption provided costs are reconciled to audited financial statements. CONCLUSIONS: To develop valid prediction models for costs of care, the clinical risk factors that are traditionally used to predict risk-adjusted mortality may need to be expanded.     

Quest for Science,Spirit, and Skills

The 96th Annual Meeting of the Japanese Orthopedic Association will be held from May 11 to 14, 2023, at Yokohama in Japan. I decided to set the theme for this meeting as “Quest for Science, Spirit, and Skills.” We believe that the “quest” to master these elements is the basic principle of those responsible for well-balanced musculoskeletal medicine and is also essential to further developments of orthopedic surgery.The poster for the meeting incorporates Okayama Castle and an ukiyo-e painting of Miyamoto Musashi who was also famous for his nito-ryu or double-bladed swordsmanship. The idea behind using the ukiyo-e of Miyamoto Musashi on the poster is to draw an orthopaedic surgeon with “science” on one hand, “skills” on the other hand, and “spirit” in the heart. Moreover, novel perspectives and innovations may develop through working on more than two specialties. We believe that our interests to various clinical fields and science constitute the nito-ryu working style, which would accelerate the development orthopaedic science.It is important to challenge the unknown both in medicine and in life. Anyone would agree that it is fundamental to strive for new discoveries and technological developments in medicine. Sometimes we work hard because we cannot see the future, but there are times when we need to work hard even if we can anticipate the future. I think that your destiny may change depending on whether you make an effort or not. I would like young people to keep this in mind and continue to challenge the unknown. Finally, I would like to introduce the words of Shoin Yoshida in the Edo era: “Those without dreams have no success.”     

Proposed definitions for diagnosis,severity scoring,stratification, and outcome for trials on intraabdominal infection

Analysis of the experience with scientific studies on patients with secondary intraabdominal infection has revealed that problems of interpretation and comparability between studies exist as they relate to variable diagnostic criteria, unmeasured severity of disease, and unclear outcome measures. A consistent system of definitions has been developed to address these deficiencies. Intraabdominal infection is defined as clinical peritonitis requiring both operative and microbiological confirmation for proof of infection. The APACHE II system is proposed for grading the severity of the infection and for stratification of patient risk of mortality. Mortality and time until death, on one hand, and recovery and time until recovery, on the other, are proposed as the main outcome measures, both being independently and positively defined. It is anticipated that this system of minimum rules will produce studies that can be compared, hence, accelerating knowledge and understanding about intraabdominal infection and its best treatment.

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Resumen El análisis de los resultados de investigaciones científicas en pacientes con infección intraabdominal secundaria ha revelado que los problemas de interpretación y comparabilidad entre los diversos estudios se relacionan con criterios diagnósticos variables, con gravedad no definida de la enfermedad, y con parámetras indeterminados de desenlace. Se ha establecido un Sistema consistente de definiciones con el objeto de eliminar tales deficiencias. La infección intraabdominal es definida como una peritonitis clfnica que requiere confirmación, tanto operatoria como microbiológica como prueba de la infección. Se propone el sistema APACHE II para determinar el grado de gravedad de la infección y para la estratificación del riesgo de mortalidad. La mortalidad y el período hasta la muerte del paciente por un lado, y la recuperación y el perfodo hasta la recuperación por otro, son propuestos como los parámetras principales de desenlace, ambos definidos en forma independiente y positiva. Se espera que este sistema de reglas mínimas habrá de producir estudios que sean comparables, lo cual acelere la adquisición de nuevos conocimientos y la mejor comprensión de la infección intraabdominal y de su tratamiento.

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Résumé L'analyse des différentes études scientifiques sur les infections intra-abdominales a montré que les problèmes d'interprétation et de comparabilité relèvent de critiques diagnostiques variables, et de l'absence d'évaluation de la sévérité de la maladie, et de son évolution. Un système de définitions a été développé pour pallier ces déficiences. L'infection intra-abdominale se définit comme péritonite clinique exigeant la confirmation opératoire et microbiologique de l'infection. Le score APACHE II est proposé pour classer l'infection selon sa sévérité et prévoir le risque de mortalité. Mortalité et délai avant la mort, guérison st délai avant la guérison sont proposés comme critères d'évolution. On espére que le fait d'adopter ces règles permettra de comparer les études et fera progresser notre compréhension de l'infection intra-abdominale et son traitement.

     

Comparison of atracurium, pipecuronium, and vecuronium for tracheal intubation

In order to compare tracheal intubation conditions, 34 adult patients about to undergo elective surgery received at random atracurium 0.5 mg X kg-1, pipecuronium 0.1 mg X kg-1 or vecuronium 0.1 mg X kg-1, intravenously. Intubation was attempted when only the first of the train-of-four finger contractions, arising from ulnar nerve stimulation, remained. The three relaxants provided effective conditions for intubation. The time required to suppress all but the first train-of-four response was shortest in the group given atracurium (P less than 0.05). Compound muscle action potentials (emg) were continuously filmed from just before induction of anesthesia until the trachea was intubated. The degree of neuromuscular blockade was similar in the three study groups.     

Books received for reviewSurgery,Creighton University School of Medicine,

The eighth reported case of choledochocele is described. This lesion is a cyst communicating with the terminal portion of the common bile duct. It is characteristically lined with duodenal mucosa and is probably a form of duplication of the duodenum. The surgical treatment is marsupialization of the cyst to the interior of the duodenum.