Effect of digestive health care services integration on resource use and outcomes in patients with digestive disorders.

BACKGROUND & AIMS: Academic medical centers are under pressure to contain resources. The University of Virginia Digestive Health Service Center (DHSC) is a fully integrated inpatient service combining gastroenterology, hepatology, surgery, pathology, radiology, and nutritional services. The aim of this study was to evaluate whether integration of digestive health services can contain resource use among gastrointestinal (GI) inpatient admissions. METHODS: This is a cohort study of 2934 inpatient cases admitted to a referral academic medical center between January 1, 1998, and June 30, 2000, with a primary diagnosis of an esophageal disorder, appendicitis, abdominal hernia, intestinal obstruction, diverticulitis, biliary tract disease, liver disease, a pancreatic disorder, or GI hemorrhage. Cases were grouped by admitting service (DHSC vs. other nonintegrated inpatient services). Total cost, length of stay, and 30-day readmission rate were adjusted for differences in baseline patient characteristics and compared. RESULTS: DHSC admission was associated with significant cost savings (P = 0.0363) and reduced length of stay (P < 0.0001). Cost savings were attributable to patients admitted for liver disease (P = 0.0077), GI hemorrhage (P = 0.0031), and diverticulitis (P = 0.0497); reductions in length of stay were seen for patients with liver disease (P = 0.0314), GI hemorrhage (P = 0.0212), diverticulitis (P = 0.0017), esophageal disorders (P = 0.0006), and abdominal hernia (P = 0.0458). DHSC patients with pancreatic disorders had increased total cost (P = 0.0247), but no difference in length of stay (P = 0.7504) and a lower 30-day readmission rate (P = 0.0478). CONCLUSIONS: Integration of digestive health services reduces resource use for patients with digestive diseases and may improve outcomes for patients with pancreatic disorders. A multidisciplinary service center may represent a more efficient model for health care delivery for these patients.     

Left ventricular volume reduction surgery in the middle East

Heart transplantation is not yet socially acceptable in the Middle East, and left ventricular assist facilities are not generally available in this region. Therefore, left ventricular volume reduction surgery was attempted in 41 patients with end-stage heart failure (33 males; median age, 36.3 years) in 4 Middle Eastern tertiary referral centers between February 1996 and January 2001. Heart failure was due to idiopathic cardiomyopathy in 21 patients, ischemia in 11, rheumatic valvular disease in 8, and viral myocarditis in 1. Associated procedures were aortic valve replacement in 5 patients, mitral valve repair in 25, mitral valve replacement in 7, tricuspid valve repair in 6, and coronary bypass grafting in 8. Hospital mortality was 31.7%. Five patients were lost to follow-up. The survival rate of hospital survivors at 18 months was 65.2%. Three of the surviving patients did not benefit from the operation. Although our results were somewhat disappointing, this operation remains an option for surgeons working in developing areas of the world. It is hoped that better patient selection and new techniques of left ventricular volume reduction that avoid resection of viable muscle will further improve the outcome of this operation.     

Impact of a high-density grid catheter on long-term outcomes for structural heart disease ventricular tachycardia ablation

Journal of Interventional Cardiac Electrophysiology - Substrate mapping has highlighted the importance of targeting diastolic conduction channels and late potentials during ventricular tachycardia...     

Pressure Wire Used to Measure Gradient in Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is a rare disorder in the United States. Frequently, its symptoms correlate poorly with the angiographically apparent degree of mesenteric artery stenosis. Measuring the pressure gradient with a small-caliber catheter is an established means of determining whether a particular stenosis is flow-limiting, thus guiding the interventional decision when stenoses are of indeterminate angiographic significance. Using a 0.014-in guidewire, however, is potentially more accurate because it eliminates any measurement error attributable to the use of a larger, potentially obstructive catheter. We present a case of chronic mesenteric ischemia in a 70-year-old woman who had abdominal pain with multiple possible causes. We used a 0.014-in pressure wire to calculate pressure gradients and guide our decision to stent tandem lesions in the superior mesenteric artery. After revascularization, the patient''s symptoms improved dramatically. To the best of our knowledge, this is the first published case in which a pressure wire was used to measure a pressure gradient in chronic mesenteric ischemia.Key words: Mesenteric arteries/pathology, mesenteric ischemia, chronic, mesenteric vascular occlusion/diagnosis/therapy, mesentery/blood supply, peripheral vascular diseases/therapy, pressure gradient, pressure wire, splanchnic circulationRecent technical advances in vascular imaging have led to increased recognition of pervasive atherosclerotic plaques. The resulting clinical challenge has been to correlate anatomic findings with the clinical presentation. Using angiography alone may lead one to underestimate or overestimate the significance of visually apparent stenoses.^1,2 Techniques for measuring stenosis severity physiologically have been introduced to help overcome these problems. The pressure gradient across a lesion, measured directly and in vivo, is likely to be the most helpful guide in this regard. The use of small-caliber catheters to measure intravascular gradients has been well established, but the results must be interpreted with caution because of the potential flow obstruction caused by the measuring catheter itself. For this reason, using a 0.014-in pressure wire to measure the translesional pressure gradient can provide more precise information.We present the case of a 70-year-old woman whose symptoms, although atypical, had features that suggested chronic mesenteric ischemia (CMI). We measured the pressure gradient across 2 tandem stenoses of uncertain severity in the proximal superior mesenteric artery (SMA) to guide our decision to stent. We believe that this is the first published case in which a pressure wire was used to measure translesional pressure gradients in a patient with CMI.     

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting,May 7^th , 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7 th , 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.     

Advances in Endoscopic Ultrasound-Guided Biliary Drainage: A Comprehensive Review

Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy.     

The use of linked seeds eliminates lung embolization following permanent seed implantation for prostate cancer

PURPOSE: A number of reports of (125)I seed migration to the lungs after prostate brachytherapy have been published. There are, however, very limited data available on how to reduce the risk of this event. The purpose of the present report is to determine whether seed embolization to the lungs can be minimized by using stranded seeds alone for brachytherapy. METHODS AND MATERIALS: Between December 2001 and December 2002, 238 patients with early prostate cancer were treated with prostate brachytherapy as monotherapy using (125)I stranded seeds (RAPIDStrand) exclusively. All patients had fluoroscopy during the implant and immediate postimplant radiographs of the pelvis. A sample of 100 patients had chest radiographs performed, on average, 55 days after implant. To determine the ease, or lack of ease, with which these (125)I seeds could be visualized, 4 patients who did not have prostate cancer and who were having routine chest radiographs as part of their management for other cancers consented to have posteroanterior and lateral radiographs performed with inactive (125)I seeds taped to the skin of the thorax. All radiographs were reviewed by a single radiologist. RESULTS: The number of seeds noted on the postimplant radiographs corresponded to the number of implanted seeds in all 238 cases: There was, therefore, no evidence of seed embolization immediately postimplant. On review of the 100 chest radiographs, no embolized seeds were found. CONCLUSION: No evidence of seed embolization was observed with the use of stranded (125)I seeds as used for prostate brachytherapy.