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41.

Background

Ventral hernias are a common, challenging, and expensive problem for both the general and reconstructive surgeons; therefore, the aim of this study is to critically assess perioperative factors related to cost in abdominal wall reconstructions (AWR).

Methods

A retrospective review of AWR patients from 2007 and 2012 was performed. Analysis of perioperative factors associated with total cost of reconstruction was performed. Linear regression analyses were used to assess independent predictors of total cost.

Results

134 consecutive AWR performed by a single surgeon over a 5-year period at an academic teaching center were included. The average total cost of AWR was $61,251 ± 55,624. Linear regression analysis demonstrated that diabetes (P = 0.026), increased American Society of Anesthesiologists score (P = 0.002), preoperative anemia (P = 0.001), and hernias derived from trauma (P = 0.015) were independently associated with added cost in AWR when controlling for confounding variables. In addition, patients requiring intra-abdominal procedures (P = 0.012) and those receiving an AWR using Acellular Dermal Matrix (P = 0.015) accrued significantly greater cost. Interestingly, preoperative placement of an epidural (P = 0.011) was independently associated with significant cost savings and reduced medical morbidity. Major surgical complications (P < 0.001) and length of stay (P < 0.001) were independently associated with increased cost following AWR.

Conclusion

We present a critical assessment of cost in AWR at a major academic teaching hospital and quantify the impact of reconstruction in the setting of medical morbidities and reconstructive complexities. The data from this study can be used to adjust reimbursement schemes and to critically assess the cost–benefit of performing AWR.  相似文献   
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Intravascular ultrasound (IVUS) was used to study 104 lesions in 98 patients after excimer laser coronary angioplasty (ELCA). Lesion site external elastic membrane (EEM) and lumen cross-sectional areas (CSA) were measured; plaque + media (P + M = EEM − lumen) CSA and percentage of cross-sectional narrowing (CSN = P + M CSA/EEM CSA) were calculated; and the results were compared to a reference site. The lumen CSA (2.6 ± 1.0 mm2) averaged 24% larger than the cross-sectional area of the largest laser catheter used, and 64 lesions (62%) fit the definition of arterial expansion (lesion EEM CSA > reference site EEM CSA). The residual percentage of cross-sectional narrowing averaged 83.8 ± 8.8%. Dissections were present in 44% of lesions, and were more common in lesions with superficial calcium (59%) than in lesions with only deep calcium (31%) or no calcium (20%, P = 0.0102). Dissections of superficial calcified plaque had an unusual “shattered” or “fragmented” appearance. These findings suggest that excimer laser angioplasty causes forced vessel expansion with dissection, but limited atheroablation. © 1996 Wiley-Liss, Inc.  相似文献   
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In order to evaluate the biological function of the Brucella abortus high-temperature-requirement A (HtrA) stress response protein homolog, the majority of the htrA gene was deleted from the chromosome of B. abortus 2308 via gene replacement. In contrast to the parental strain, the resulting htrA deletion mutant, designated PHE1, failed to grow on solid medium at 40 degrees C and demonstrated increased sensitivity to killing by H2O2 and O2- in disk sensitivity assays. BALB/c mice were infected with strains 2308 and PHE1 to assess the effect of the htrA mutation on virulence, and significantly fewer brucellae were recovered from the spleens of mice infected with PHE1 than from those of mice infected with 2308 at 1 week postinfection. Genetic complementation studies were performed to confirm the relationship between the htrA mutation and the phenotype observed for PHE1. Plasmid pRIE1 was constructed by inserting a 1.9-kb EcoRI fragment encoding the B. abortus htrA gene into the broad-host-range plasmid pBBR1MCS. Introduction of pRIE1 into PHE1 relieved the temperature- and H2O2-sensitive phenotypes of this mutant in vitro, and PHE1(pRIE1) colonized the spleens of BALB/c mice at levels equivalent to those of the parental 2308 strain at 1 week postinfection. These results support our previous proposal that the B. abortus htrA gene product functions as a stress response protein and further suggest that this protein contributes to virulence. These studies also demonstrate the utility of the broad-host-range plasmid pBBR1MCS for genetic complementation studies in Brucella spp., establishing a key reagent for more detailed genetic analysis of this important zoonotic pathogen.  相似文献   
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Fludarabine was used to treat 68 patients with previously treated chronic lymphocytic leukemia (CLL). Nine (13%) patients achieved a complete remission and 30 (44%) a partial remission. The response rates for Rai stages 0 to 2, 3, and 4 were 64%, 58%, and 50% respectively. Seventeen (43%) of the 40 Rai stage 1 to 3 patients and four (19%) of the Rai stage 4 patients returned to Rai stage 0. Survival was strongly correlated with the final Rai stage achieved. The survival of the 11 partial responders with residual disease consisting only of residual bone-marrow nodules was similar to the complete responders (36+ months) and superior to the other partial response patients (16 months). The response to fludarabine was rapid, with 36 (92%) of the 39 responders having achieved at least a partial response following the first three courses. Complete responses occurred in the blood, liver, spleen, and lymph nodes in 48% to 69% of the patients. Eradication of all disease in the bone marrow occurred in only 13% of the cases. Neutropenia and thrombocytopenia occurred in 56% and 25% of evaluable courses. Major infections occurred in 9% of evaluable courses and fevers of unknown origin or minor infections in 12% of courses respectively. Myelosuppression and infection were more common in patients with initial Rai stages 3 and 4 and in nonresponding patients. Other toxicity was mild. No CNS toxicity was noted.  相似文献   
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