Surgical subspecialty block utilization and capacity planning: a minimal cost analysis model

BACKGROUND: Operational inefficiencies in the use of operating rooms (ORs) are hidden by traditional measures of OR utilization. To better detect these inefficiencies, the authors defined two new terms, underutilization and overutilization, and illustrated how these measures might be used to evaluate the use of surgical subspecialty ORs. The authors also described capacity planning (optimizing surgical subspecialty block time allotments) using a minimal cost analysis (MCA) model. METHODS: The authors evaluated post hoc all surgeries performed over 6 yr at a large teaching hospital. To prepare utilization estimates, surgical records were categorized relative to budgeted OR block time for each subspecialty. Surgical cases beginning and ending during budgeted OR block time were categorized as budgeted utilization, budgeted time not used for surgery was underutilization, and cases beginning before/after budgeted block time were classified as overutilization. Cases that overlapped budgeted and nonbudgeted OR block time were parsed and the portions were assigned appropriately. Probability distributions were fitted to the historical patterns of surgical demand, and MCA block time budgets were estimated that minimized the costs of underutilization and overutilization for each subspecialty. To illustrate the potential savings if these MCA budgets were implemented, the authors compared actual operational costs to the estimated MCA budget costs and expressed the savings as a percentage of actual costs. RESULTS: The authors analyzed data from 58,251 surgical cases and 10 surgical subspecialty blocks. Classic utilization for each block-day by surgical subspecialty ranged from 44-113%. Average daily block-specific underutilization ranged from 16 to 60%, whereas overutilization ranged from 4 to 49%. CONCLUSIONS: Underutilization and overutilization are important measures because they may be used to evaluate the quality of OR schedules and the efficiency of OR utilization. Overutilization and underutilization also allow capacity planning using an MCA model This study indicated that the potential savings, if the MCA budgets were to be implemented, would be significant.     

Analysis of the symptoms of depression--a neural network approach

The purpose of this study is to determine the individual contribution, or importance number, of the symptoms to an analysis of depression, utilizing a neural network model. In addition, the presence of hopelessness and somatic complaints was examined, to determine their relevance to depression. Using Wave 1 data from Duke University's contribution in the Epidemiological Catchment Area (ECA) study, we created a mathematical model, a neural network, to map the relationship of nine symptoms of major depression, hopelessness and somatic complaints to the presence or absence of the formal diagnosis of depression, and performed a contribution analysis. The contribution analysis using the neural network revealed that the symptoms with the greatest impact on the occurrence of depression, or with the largest importance number for depression, were sadness, loss of interest, tiredness and sleeping trouble, in that order. The most frequently reported symptoms, though, were sadness, sleeping trouble, suicidal ideation, tiredness and poor concentration, in that order. Hopelessness and somatic symptoms were the lowest in their contribution to the diagnosis of depression. The study thus provides the hierarchy of the symptoms of depression and supports the DSM classification of major depression.     

Long-term results of the Spanish trial on treatment and survival of patients with predominantly mild heart failure

A randomized open-label clinical trial was conducted to determine whether mortality, readmission, or quality of life differed between heart failure patients managed with captopril plus diuretics and those with digoxin plus diuretics. A total of 345 heart failure patients in New York Heart Association functional classes 2 and 3 without atrial fibrillation, dyspnea of bronchopulmonary origin, or hypertension not controlled with diuretics was randomized for digoxin (n = 175) or captopril (n = 170) treatment and followed up for a median of 4.5 years. Socioeconomic, demographic, electrocardiographic, echocardiographic, spirometric, and chest radiograph data were obtained at the initial examination. In a random sample of half the patients, ergometric, echocardiographic, and Holter records were obtained at entry and at 3 and 18 months. Patients were followed up for > or = 3 years. The end points were mortality, hospitalization for cardiac events, deterioration in quality of life, worsening of functional class, and need for digoxin or captopril in the captopril and digoxin groups, respectively. The trial had to be terminated prematurely owing to the difficulty in finding candidates free of angiotensin-converting enzyme (ACE)-inhibitor treatment. Baseline patient characteristics were similar in both groups. From the clinical point of view, only the 48-month mortality was relevantly lower (20.9 vs. 31.9%, respectively) among patients treated with captopril than that in those receiving digoxin (log rank test, p = 0.07). No statistically or clinically relevant differences were found in other end points or adverse effects. The results suggest but do not confirm the hypothesis that captopril treatment in mild to moderate heart failure might provide better long-term survival than digoxin.     

Infarcted myxoid fibroadenoma following fine-needle aspiration

Infarction of breast fibroadenomas is very rare and is frequently associated with physiologic changes, such as pregnancy and lactation. We report a case of an infarcted fibroadenoma following fine-needle aspiration. The patient presented with an asymptomatic breast mass, which was clinically difficult to evaluate. Excisional biopsy was performed 7 days after a nondiagnostic fine-needle aspiration of the mass. Microscopically, the nodule showed features of a classic fibroadenoma of the intracanalicular type with myxoid or mucinous stromal changes, as well as extensive areas of acute infarction. This report provides another example of the changes that may be observed in biopsy specimens obtained after fine-needle aspiration of the breast.     

Chromosomal study after radioactive synoviorthesis for haemophilic haemarthrosis

Summary Twenty joints in 19 haemophiliacs were treated by radioactive synoviorthesis with gold (Au 198) to prevent recurrent haemarthrosis. Twelve knees, six elbows and two ankles were treated in two separate groups (29. 9. 76 and 9. 5. 77).In eight cases (40%) no further haemarthrosis occurred. A diminution of bleeding was obtained in nine cases (45%), a total of 85% good results with 15% failures. One failure in the first group (an elbow) had a second synoviorthesis and was included in the second group also.Prior to synoviorthesis the joint was scanned with technetium (Tc99m) to compare the inflammation of the synovium with that of six months later. The technique including the dosage of Tc99m, Au 198, and factor VIII cover is presented.A leucocyte culture was performed in 16 cases to study any chromosomal breakage, by banding and fluorescent techniques.Paper read at the SICOT meeting in Kyoto, Japan, October 1978     

Neurological manifestations in chronic mountain sickness: the burning feet-burning hands syndrome

OBJECTIVE: To characterise the clinical features and nerve biopsy findings in patients with chronic mountain sickness (CMS) living in the Peruvian Andes, with particular attention to the occurrence of the "burning feet-burning hands" syndrome. METHODS: Symptoms and signs were documented clinically in 10 patients with CMS and compared with those in five healthy subjects all living at 4338 metres altitude. Sural nerve biopsies were obtained from three patients with CMS.The nerve fibre population and endoneurial microvessels were analyzed morphometrically. RESULTS: All patients with CMS experienced burning and tingling paraesthesiae in the distal parts of their limbs. Similar but milder symptoms confined to the feet occurred in four of five controls. Three patients with CMS had a mild sensory neuropathy on examination, controls were clinically normal. Nerve biopsies showed a mild demyelinating neuropathy in all three with a reduction in the unmyelinated axon population in one. The endoneurial blood vessels showed a reduced thickness in the basal laminal zone compared with control values but were otherwise normal. CONCLUSIONS: Apart from well recognised symptoms and signs of CMS, the study has shown that such patients may also exhibit a mild sensory neuropathy. Its relation to the burning feet-burning hands syndrome, which was not confined to the patients but was also found in controls at altitude, is uncertain. The time course and pattern of the centrifugal resolution of the burning paraesthesiae complex on low altitude sojourn of high altitude natives raises the possibility that a mechanism involving altered axonal transport may be involved. The reduced thickness of the basal laminal zone of microvessels implies that adaptive structural changes to hypobaric hypoxia may also occur in peripheral nerve and are similar to those reported in other tissues of high altitude natives.     

Quantitative analysis of bcl-2 expression in normal and leukemic human B-cell differentiation.

Lack of apoptosis has been linked to prolonged survival of malignant B cells expressing bcl-2. The aim of the present study was to analyze the amount of bcl-2 protein expressed along normal human B-cell maturation and to establish the frequency of aberrant bcl-2 expression in B-cell malignancies. In normal bone marrow (n=11), bcl-2 expression obtained by quantitative multiparametric flow cytometry was highly variable: very low in both CD34(+) and CD34(-) B-cell precursors, high in mature B-lymphocytes and very high in plasma cells. Bcl-2 expression of mature B-lymphocytes from peripheral blood (n=10), spleen (n=8) and lymph node (n=5) was significantly higher (P<0.02) in CD23(-) as compared to CD23(+) B cells, independent of the type of tissue analyzed. Upon comparison with normal human B-cell maturation, bcl-2 expression in neoplastic B cells from 144 patients was found to be aberrant in 66% of the cases, usually corresponding to bcl-2 overexpression (63%). Follicular lymphoma (FL) carrying t(14;18) and MALT lymphoma were the only diagnostic groups constantly showing overexpression of bcl-2. Bcl-2 overexpression was also frequently found in precursor B-acute lymphoblastic leukemia (84%), typical (77%) and atypical (75%) B-cell chronic lymphocytic leukemia, prolymphocytic leukemia (two of three cases), mantle cell lymphoma (55%), but not in t(14;18)(-) FL, splenic marginal zone lymphoma, Burkitt lymphoma and multiple myeloma.     

Reduced levels of growth hormone, insulin-like growth factor-I and binding protein-3 in patients with shunted hydrocephalus

OBJECTIVE: Children with hydrocephalus are characterised by slow linear growth in prepuberty, accelerated physical maturation during puberty, and reduced final height. We aimed to study the possible roles of growth hormone, insulin-like growth factor-I (IGF-I), and IGF binding protein-3 (IGFBP-3) in this growth pattern. STUDY DESIGN: One hundred and fourteen patients with shunted hydrocephalus (62 males) aged 5 to 20 years, of whom 17 had spina bifida (six males), and 73 healthy controls (38 males) were studied. Anthropometric measures, body mass index, and body fat mass were assessed and the stage of puberty was determined. Serum growth hormone and plasma IGF-I and IGFBP-3 concentrations were measured. RESULTS: The patients comprised 44 (26 males) who were prepubertal and 70 (36 males) pubertal or postpubertal, while 32 of the controls (19 males) were prepubertal and 41 (19 males) pubertal or postpubertal. The prepubertal children with hydrocephalus had lower IGF-I (p = 0.002) and IGFBP-3 concentrations (p < 0.001) than the controls, and the pubertal children had four times lower basal growth hormone concentrations (p < 0.001). There was a correlation between height SD score and IGF-I levels in the total patient population (r = 0.23; p = 0.01). Peripheral IGF-I concentrations peaked at pubertal stages 2-3 in the female patients and at stage 4 in the controls. The prepubertal patients on antiepileptic treatment, carbamazepine in most cases (73%), had higher IGF-I (p = 0.01) and IGFBP-3 concentrations (p = 0.03) than those who had never been treated with antiepileptic drugs, but still lower IGFBP-3 levels than the controls (p = 0.01). CONCLUSION: Based on these findings, it can be concluded that reduced growth hormone secretion may contribute to the pattern of slow linear growth and reduced final height observed in these patients.     

Increasing breastfeeding rates to reduce infant illness at the community level

OBJECTIVE: Although breastfeeding is associated with lower rates of a variety of infant illnesses, skeptics have suggested that much of the association is attributable to confounding, even after appropriate statistical adjustment. This article utilizes a novel design to investigate changes in infant illness at the community level after a successful breastfeeding promotion program. METHODS: In this population-based cohort study, the medical records of all infants born in one Navajo community the year before a breastfeeding promotion program (n = 977) and the year during the intervention (n = 858) were reviewed. Outcomes assessed include changes after the intervention in: proportion breastfeeding and/or breastfeeding exclusively; incidence of common infant illnesses in the first year of life; and feeding-group specific incidence of illness. RESULTS: The proportion of women breastfeeding exclusively for any period of time increased from 16.4% to 54.6% after the intervention. The percent of children having pneumonia and gastroenteritis declined 32. 2% and 14.6%, respectively, after the intervention. Feeding-group specific rates of these illnesses were unchanged, indicating that the decline observed was attributable to the increased proportion of infants breastfeeding. In contrast, rates of croup and bronchiolitis increased after the intervention among those fed formula from birth, suggesting a viral epidemic which was limited to those never exclusively breastfed. Finally, sepsis declined in both formula-fed and breastfed infants after the intervention, suggesting that other factors affected this illness outcome after the intervention. CONCLUSIONS: Increasing the proportion of exclusively breastfed infants seems to be an effective means of reducing infant illness at the community level. The experimental design suggests that the increased incidence of illness among minimally breastfed infants is causally related to lack of breast milk, rather than being attributable to confounding.     

The short-term effect of a switch from glibenclamide to metformin on blood pressure and microalbuminuria in patients with type 2 diabetes mellitus

BACKGROUND: Renal hyperfiltration and albuminuria have a deleterious effect on kidney function. Therefore, we studied the effect of metformin on blood pressure, renal hemodynamics, and microalbuminuria in type 2 diabetic patients. METHODS: A clinical trial was designed in type 2 diabetic patients with incipient nephropathy. All patients were below the age of 65, normotensive, and without evidence of malignant, hepatic, or cardiovascular disorders. They were randomly allocated to receive glibenclamide or metformin. At baseline and 12 weeks thereafter we measured body mass index (BMI), serum insulin, blood glucose, lipid profile, glycosylated hemoglobin, blood pressure, glomerular filtration rate, renal plasma flow, and urine albumin. RESULTS: We studied 23 patients in the glibenclamide group and 28 in the metformin group. There was no difference in baseline variables between the groups. Metabolic control was obtained in both groups. In the metformin group, all the following variables decreased: microalbuminuria was reduced by a mean of 24.2 mg/day (p = 0.008); systolic and diastolic blood pressure by a mean of 5.3 mmHg (p = 0.002) and 3.93 mmHg (p = 0.009), respectively; insulin levels by an average of 11.8 microIU/mL (p = 0.001), and total cholesterol levels and triglycerides by an average of 0.45 and 0.18 mmol/L, respectively. Insulin resistance measured by the homeostasis model decreased more in the metformin group than in the glibenclamide group. Patients treated with glibenclamide had an increase in HDL cholesterol of 0.082 mmol/L (p = 0.01). CONCLUSIONS: Metformin significantly decreased the urine albumin excretion rate with none of the expected changes in renal hemodynamics, probably due to its favorable effects on blood pressure, lipid profile, metabolic control, and insulin resistance.