Is an authorization for care necessary for the incapacitated adult?

We report the case of a 30-year-old mentally disabled patient who presented for diagnostic colonoscopy. This patient raised the problem of authorization for such a procedure and the related anaesthetic. The French law of 1968 on the protection of severely incapacitated persons does not clearly solve the problem of the consent for procedures with a therapeutic finality. The distinction relies usually on the extent of the planned act, for asking for an agreement of the guardian, judge of guardianship or the family board. In such cases the problem of the practice of an anaesthetic remains unsolved. For scheduled procedures it is recommended to obtain the written consent of the guardian before any medical act.     

Does cost containment create conflict in the care of the elderly patient?

Ethical aspects of care of geriatric patients with orthopaedic disorders include patient autonomy, beneficence, and nonmaleficence. Advance directives and surrogate decision-makers are required if the patient has lost decisional capacity. Investor-owned health plans have captured the major share of the United States medical market, but have been shown to deliver lower quality of care than competing methods. A deeply imbedded fear of a government-run health plan with good intentions expressed as bad policy exists. Ageism is one example of how ethical principles may be trampled. The orthopaedic surgeon has a responsibility to maintain and fight for these ethical standards.     

Is kyphoplasty the standard of care for compression fractures in the spine, especially in the elderly?

Vertebral fractures, particularly if they are nonsymptomatic, are old, and have not produced kyphotic deformity, should be treated with conservative care, including appropriate medical management. Those fractures that are symptomatic, produce pain that persists over several weeks (4 out of 10 on the visual analog score), and have resulted in some kyphotic deformity should be treated with a vertebroplasty or kyphoplasty. Patients with kyphotic deformity of less than 20% can obtain pain relief from vertebroplasty that is comparable to pain relief from kyphoplasty. For patients with a greater degree of kyphosis, only kyphoplasty can offer the predictable restoration of height and realignment of the spine. Currently we treat all Colles' fractures, all hip fractures, and all tibia plateau fractures. The time has come to treat all symptomatic vertebral fractures.     

Is early operative fixation of unstable ankle fractures cost effective? Comparison of the cost of early versus late surgery

Introduction

A retrospective study of all patients who sustained an ankle fracture requiring operative treatment was performed. 98 patients were admitted over a 14-month time period. All fractures treated conservatively were excluded.

Materials and methods

The inpatient length of stay and the cost of operating less than and more than 24 and 48 h from admission was determined.

Results

There was a significant difference (p value <0.001) in cost and length of stay in patients operated less than and more than 24 h, and less than and more than 48 h from admission. There was no difference in cost and length of stay between the 2 groups of less than 24 and 48 h. However, length of stay and cost rose significantly if the operation was delayed more than 48 h.

Conclusion

The results show that the length of stay and cost is significantly reduced by operating on ankle fractures early. There is no significant difference in the length of stay or cost if the operation is performed earlier than 24 or 48 h from admission.     

Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?

Background

Identifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution.

Is the use of albumin in colloid prime solution of cardiopulmonary bypass circuit justified?

BACKGROUND: Albumin in the priming solution precoats the surface of the cardiopulmonary bypass circuit, supposedly causing delayed adsorption of fibrinogen and reduced activation and adhesion of platelets. This action may result in lower transoxygenator resistance. Because our institution uses a colloidal prime solution (Gelofusine), questions were raised about the value of albumin in the prime solution. We decided to focus on the clinical effects of transoxygenator resistance. METHODS: Sixty adults undergoing elective cardiac operations were randomly divided into three groups: a group with 20-g albumin (n = 20), a group with 2-g albumin (n = 20), and a group with no albumin (n = 20) in the 1,600-mL colloidal prime. Patients older than 75 years and patients with a preoperative serum albumin level of 30 g/L or less were excluded. The transoxygenator resistance was measured throughout cardiopulmonary bypass. Beta-thromboglobulin levels were used to study contact activation of platelets. Measures of prothrombin F1,2 fragments were used as a marker of thrombin generation. Body surface area, age, preoperative albumin, hematocrit, hemoglobin, fibrinogen, platelet count, and colloid osmotic pressure levels were compared between groups. RESULTS: Base line characteristics and chosen control measurements were similar for all three populations. When comparing the observed transoxygenator resistance among the three different groups, no significant differences were noted. Prothrombin F1.2 fragments remained low for all the groups without significant differences. In the no-albumin group the level of beta-thromboglobulin appeared to be higher, but the difference was not statistically significant. CONCLUSIONS: Addition of albumin to prime solution in a cardiopulmonary bypass circuit that already contains colloids does not affect the transoxygenator resistance of the COBE Duo flat sheet oxygenator and does not affect prothrombin F1.2 and beta-thromboglobulin levels. Therefore additional costs for the albumin are not justified. Measurement of transoxygenator resistance is a reliable, simple method to determine the effects of a prime solution on the oxygenator surface in vivo.     

Is mastectomy overtreatment for Paget's disease of the nipple?

The standard local management for Paget's disease of the nipple is currently mastectomy although this may well represent overtreatment. The place of breast conserving surgery is somewhat uncertain. We have reviewed the casenotes of 146 patients with Paget's disease of the nipple, and compared the mortality and recurrence rates between 74 women who had undergone mastectomy and 31 women who had breast conserving surgery. There was no significant difference in either local or overall treatment failure rates between these two treatment groups. We conclude that breast conserving treatment maybe an appropriate alternative to mastectomy for the management of Paget's disease, where clear margins of excision can be achieved. However, a randomized prospective study is needed to confirm this.     

Is this the end of the line for the moderate dyskaryotic smear?

OBJECTIVE: The British Society for Clinical Cytology has recently proposed that the terminology for cervical smear reporting is to be changed from a 3-tier system (mild, moderate, severe dyskaryosis) to a 2-tier system of low-grade and high-grade dyskaryosis. This modification eliminates the central category of moderate dyskaryosis which would be incorporated into the high-grade group. The aim of this study was to investigate the role of the moderate dyskaryotic smear in clinical practice. MATERIALS AND METHODS: A retrospective review of all women who were referred for colposcopy because of a moderate dyskaryotic smear was carried out for a 6-month period. Data collected included colposcopic impression, procedure performed and final histopathology. Two cytologists who were unaware of the original smear report were asked to reclassify these smears using the new 2-tier system. Their findings were compared with the documented colposcopic and histopathology results. RESULTS: One hundred women with moderate dyskaryotic smears were referred for colposcopy during the study period. Most of these were reclassified as high-grade dyskaryosis using the new system. Fifty-six (72%) of the moderate dyskaryotic smears which were correctly regraded as high grade by cytologist 1 were found to have cervical intraepithelial neoplasia 2/3 on final histopathology, whereas for cytologist 2, 66 (68%) were found to have high-grade cervical intraepithelial neoplasia. CONCLUSION: There is no clinical benefit in retaining the term moderate dyskaryosis. This study emphasizes the need for a uniform 2-tier system.     

Is thoracoscopic decortication sufficient for the treatment of empyema?

Before thoracoscopy became popular in the 1990s, thoracotomy and decortication was the treatment of choice for empyema thoracis not responding to tube thoracostomy. An Institutional Review Board-approved, retrospective review of all patients treated for empyema between September 1, 2006, and August 31, 2009, at Kern Medical Center was conducted. A total of 37 patients (male=33; female=4) with a mean age of 43.7 years were treated. Empyema developed after community-acquired pneumonia (CAP) in 27, traumatic hemothorax (TH) in nine, and other cause in one. For 34 of 36 patients (91%), a thoracoscopic approach was successful. Two of 36 patients required conversion to thoracotomy, whereas one patient required an initial thoracotomy in each case as a result of tenacious adhesions. Mean duration of the chest tube was 4.1 days in patients with CAP and 4.6 days in patients with TH. Mean length of stay after surgery was 6 days for patients with CAP and 9.1 days for patients with TH. Five of 37(13.5%) had complications and one patient died (2.7%). Follow-up was complete for 81.1 per cent of patients, none of whom required a subsequent intervention. Compared with the literature, it appears that the conversion rate to thoracotomy, length of chest tube duration, and postoperative length of stay have decreased as experience has increased.     

Blood conservation for myocardial revascularization. Is it cost effective?

A total of 284 patients undergoing myocardial revascularization were prospectively studied to determine if the use of intraoperative autotransfusion or intraoperative autotransfusion plus postoperative reinfusion of shed mediastinal blood decreased transfusion requirements and the use of one or both techniques was cost effective. The Haemonetics Cell Saver System was used for intraoperative autotransfusion and the Sorenson Receptaseal autotransfusion system for postoperative reinfusion of shed mediastinal blood. During Phase 1, the Cell Saver System was used for 57 patients and 93 patients served as a control group. During Phase 2, the Cell Saver System plus the autotransfusion system were used in 43 patients and 91 patients were in the control group. Separate parallel analyses to compare the blood conservation groups to control groups were conducted for each phase of the study. The patient groups were comparable with regard to age, sex, preoperative red cell mass, preoperative hematocrit value, number of bypasses, and use of internal mammary grafts. Blood conservation techniques resulted in significant reductions in the use of bank blood. During Phase 1, Cell Saver System patients received an average of 2.8 units of packed cells versus 4.7 units for control patients. Transfusion was avoided entirely in 14% of Cell Saver System patients compared to 3% of control patients. During Phase 2, patients subjected to both the Cell Saver System and the autotransfusion system received an average of 1 unit of packed red cells versus 3 units for control patients. Transfusion was required in only 42% of patients subjected to both the Cell Saver System and the autotransfusion system compared to 85% of control patients. Multiple logistic regression analysis confirmed that the use of the Cell Saver System in Phase 1 and the Cell Saver System and autotransfusion system in Phase 2 were each independently predictive of decreased transfusion requirements. The total "blood-related costs" (including cost for all bank blood products plus Receptaseal and Cell Saver System equipment) was slightly lower for the blood conservation patients in both Phase 1 ($555.00 versus $615.00, no significant difference) and Phase 2 ($373.00 versus $426.00, no significant difference). Intraoperative use of the Cell Saver System is associated with substantial savings of bank blood, and the addition of postoperative reinfusion of shed mediastinal blood results in further bank blood savings. The use of blood conservation techniques is cost effective; that is, the costs incurred for the blood conservation equipment are more than offset by the resultant dollar savings for blood products.     

Is there still a place for dopamine in the modern intensive care unit?

For many years, dopamine was considered an essential drug in the intensive care unit (ICU) for its cardiovascular effects and, even more, for its supposedly protective effects on renal function and splanchnic mucosal perfusion. There is now ample scientific evidence that low dose dopamine is ineffective for prevention and treatment of acute renal failure and for protection of the gut. Until recently, low-dose dopamine was considered to be relatively free of side effects. However, it is now clear that low-dose dopamine, besides not achieving the preset goal of organ protection, may also be deleterious because it can induce renal failure in normo- and hypovolemic patients. Furthermore, dopamine may cause harm by impairing mucosal blood flow and by aggravating reduced gastric motility. Dopamine also suppresses the secretion and function of anterior pituitary hormones, thereby aggravating catabolism and cellular immune dysfunction and inducing central hypothyroidism. In addition, dopamine blunts the ventilatory drive, increasing the risk of respiratory failure in patients who are being weaned from mechanical ventilation. We conclude that there is no longer a place for low-dose dopamine in the ICU and that, in view of its side effects, its extended use as a vasopressor may also be questioned.