Initial neck exploration for untreated hyperparathyroidism

This study represents the experience of the Department of Surgery at the University of Louisville over a 21-year interval. Many aspects of surgical management of hyperparathyroidism have changed over the last 2 decades; controversies regarding the extent of exploration and the value of preoperative localization studies remain unresolved. One hundred ninety-three patients underwent neck exploration for hyperparathyroidism from 1976 to 1997. Data were collected from four University of Louisville-affiliated hospitals by independent evaluators. One hundred sixty patients with untreated hyperparathyroidism underwent neck exploration. Preoperative localization was carried out in 52 per cent (83 of 160). The exact location of the abnormal gland was indicated in 55 per cent (46 of 83), and the correct side of the neck was identified in 74 per cent (61 of 83). Technetium sestamibi scan was most reliable and identified the abnormality in 83 per cent (24 of 29). The average operative time with preoperative localization was 118 minutes compared with 137 minutes without preoperative localization. Intraoperative methylene blue was used in 42 of 160 neck explorations. Average operative time with methylene blue was 102 minutes compared with 124 minutes without methylene blue. Thirty-seven per cent (59 of 160) of patients underwent unilateral neck exploration. Sixty-three per cent (101 of 160) underwent bilateral exploration. Successful exploration was conducted in 98 per cent of the unilateral group and 91 per cent of the bilateral group. Postoperative local complications were essentially the same in both groups (3%), whereas temporary hypocalcemia occurred in 24 per cent (24 of 101) of the bilateral group compared with 3 per cent (2 of 59) of the unilateral group. We conclude that neck exploration for hyperparathyroidism is a highly successful, safe treatment with no mortality and minimal morbidity. Preoperative localization studies modestly reduced the duration of surgery without improving outcome.     

Management of colorectal cancers

The management of colorectal cancers, published in a recent issue of Effective Health Care, is reviewed.     

Financial impact of tertiary care in an academic medical center

OBJECTIVE: To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements. SUMMARY BACKGROUND DATA: The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers. METHODS: Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU ($33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed. RESULTS: Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department. CONCLUSIONS: Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.     

Pre and postnatal diagnosis of fetus‐in‐fetu

Differentiation of abdominal masses detected on prenatal ultrasound is difficult and requires careful characterization of the mass and precise localization. Differentiation is required in order to distinguish benign from potentially malignant conditions. We describe a case of fetus‐in‐fetu with pre and postnatal imaging.     

Risk–benefit analysis of micronutrients

Traditionally, different approaches have been used to determine the recommended dietary allowances for micronutrients, above which there is a low risk of deficiency, and safe upper levels, below which there is a negligible risk of toxicity. The advice given to risk managers has been in the form of point estimates, such as the recommended dietary allowance (RDA) and the tolerable upper level (UL). In future, the gap between the two intake–response curves may become narrower, as more sensitive indicators of deficiency and toxicity are used, and as health benefits above the recommended daily allowance are taken into account. This paper reviews the traditional approaches and proposes a novel approach to compare beneficial and adverse effects across intake levels. This model can provide advice for risk managers in a form that will allow the risk of deficiency or the risk of not experiencing the benefit to be weighed against the risk of toxicity. The model extends the approach used to estimate recommended dietary allowances to make it applicable to both beneficial and adverse effects and to extend the intake–incidence data to provide a range of estimates that can be considered by the risk manager. The data-requirements of the model are the incidence of a response at one or more levels of intake, and a suitable coefficient of variation to represent the person-to-person variations within the human population. A coefficient of variation of 10% or 15% has been used for established recommended dietary allowances and a value of 15% is proposed as default for considerations of benefit. A coefficient of variation of 45% is proposed as default for considerations of toxicity, based on analyses of human variability in the fate and effects of therapeutic drugs. Using this approach risk managers, working closely with risk assessors, will be able to define ranges of intake based on a balance between the risks of deficiency (or lack of benefit) and toxicity.     

An assessment of the construct validity of the CHU9D in the Australian adolescent general population

Purpose  

To assess the construct validity of the CHU9D in an adolescent general population sample. The CHU9D is a new generic preference-based measure of health-related quality of life developed specifically for application in the economic evaluation of health care treatments and interventions for young people.     

Quality of Life and Long-Term Therapy in Patients with Chronic Myeloid Leukemia

Since the development of imatinib and other tyrosine kinase inhibitors (TKIs), the prognosis for patients with chronic myeloid leukemia (CML) has markedly improved, such that most patients diagnosed with CML can now expect to live with their disease rather than die from it. However, most patients will require long-term treatment, which has deleterious effects on health-related quality of life. We review recent literature on drug-related adverse effects, long-term medication adherence, limitations to fertility and pregnancy, effects on cognitive function, ability to work, financial toxicity, pediatric populations, and treatment discontinuation. While patients with CML are fortunate to have excellent therapies available to control their disease, many are unable to lead normal lives, which challenges the notion that research is no longer needed in CML. Curing CML, i.e., no detectable disease and no need for daily medications, should remain the ultimate goal.     

Retrospective study of treatment outcome for individuals with aphasia

Abstract

Measurement of outcomes subsequent to treatment and documentation of the efficiency with which outcomes are achieved is critical information for healthcare policy makers and third-party payers. This study employed the ASHA Functional Communication Measure (FCM) scales to retrospectively analyse charts of 20 aphasic patients. By discharge, both severe and moderate groups gained a median (across modalities) of 1 FCM level. The severe group remained dependent for communication, while the moderately impaired group typically achieved independent communication levels. Efficiency (amount of FCM level gain relative to number of treatment sessions) was greater for the moderate group; average number of treatment sessions was 40 for the severe group and 22 for the moderate group.