Cost-based analysis of the treatment of mandibular fractures in a tertiary care center

BACKGROUND: The objective of this study was to assess the cost effectiveness of alternative treatment algorithms for the management of isolated mandibular fractures. METHODS: This is an institutional review board-approved retrospective study consisting of a chart review of 25 patients who underwent operative repair of an isolated mandible fracture between July 1, 1999, and June 30, 2000. Patients were stratified into two groups: patients who were immediately admitted to the hospital from the emergency department (ED) versus patients who were discharged from the ED and who returned for elective scheduled operative repair. Patients' total hospital charges were compared on the basis of operating room (OR) time, operative materials, and hospital charges. RESULTS: Seventeen of the study patients were directly admitted from the ED, and eight underwent elective scheduled operative repair. Of the patients directly admitted from the ED, the mean age was 34.9 years (range, 19-57 years), and the study population consisted of 16 men and 1 woman. This group had a mean OR time of 161 minutes, a mean OR time charge of $1,978.66, a mean OR supply charge of 1,049.43 US dollars, a mean hospital floor charge of 5,041.02 US dollars, and an average hospital stay of 2.82 days. The treatment group of patients undergoing scheduled operative repair (n = 8) had a mean age of 30.3 years (range, 19-49 years), and all were men. This second treatment group had a mean OR time of 167.1 minutes, a mean OR time charge of 2,162.03 US dollars, a mean OR supply charge of 871.00 US dollars, a mean hospital floor charge of 2,759.38 US dollars, and a mean hospital stay of 0.88 days. Comparison of the two study groups demonstrated operative charges were made on the basis of time and materials and were shown to have no statistically significant difference (p = 0.753 and p = 0.289, respectively). Comparison of hospital charges revealed that patients admitted directly from the ED had a mean charge 2,276.70 US dollars higher (p = 0.019) and stayed 1.95 days longer in the hospital than patients discharged from the emergency department who returned for elective scheduled repair. There were two complications in the study patients; both occurred in the group admitted directly from the emergency room. CONCLUSION: The results of this study indicate that the most cost-effective management of an isolated mandibular fracture is initial evaluation in the ED with elective interval operative repair. This management protocol is, of course, only applicable if the patient is clinically stable and has no other injuries or comorbidities necessitating in-hospital observation.     

Sleep disorders and quality of life in renal transplant recipients

Kidney transplantation provides the best outcome for patients with end-stage renal failure both in terms of morbidity and mortality and health-related quality of life (QoL). Health-related QoL has become recognized as an important outcome measure in patients with different chronic medical conditions, including chronic kidney disease (CKD). There are several factors in kidney-transplanted patients which have a negative impact on QoL in these patients. Sleep disorders, such as insomnia, sleep apnea syndrome (SAS), and restless legs syndrome (RLS), are common in kidney-transplanted patients and clearly belong to this group of factors, although there is only limited published data available about the association between sleep problems and QoL in this patient population. The prevalence of both insomnia and RLS is reduced in kidney-transplanted patients compared to dialysis patients, and it is similar to the prevalence observed in the general population. The prevalence of sleep apnea, however, is very high, around 30%. The association between the presence of these sleep disorders and impaired QoL has been relatively well documented in dialysis patients, but there is only scarce published information about this association in the kidney transplant population. In this paper, we will summarize data from the literature describing the impact of sleep problems, which are potentially treatable, on QoL in kidney-transplanted patients. We suggest that the appropriate diagnosis and management of sleep disorders may improve QoL in kidney-transplanted patients.     

Association between serum resistin level and outcomes in kidney transplant recipients

Resistin is an adipocytokine that is associated with inflammation, coronary artery disease, and other types of cardiovascular disease among patients with normal kidney function. However, little is known about the association of resistin with outcomes in kidney transplant recipients. We collected socio‐demographic and clinical parameters, medical and transplant history, and laboratory data from 988 prevalent kidney transplant recipients enrolled in the Malnutrition‐Inflammation in Transplant—Hungary Study (MINIT‐HU study). Serum resistin levels were measured at baseline. Associations between serum resistin level and death with a functioning graft over a 6‐year follow‐up period were examined in unadjusted and adjusted models. The mean±SD age of the study population was 51 ± 13 years, among whom 57% were men and 21% were diabetics. Median serum resistin concentrations were significantly higher in patients who died with a functioning graft as compared to those who did not die during the follow‐up period (median [IQR]: 22[15–26] vs. 19[14–22] ng/ml, respectively; P < 0.001). Higher serum resistin level was associated with higher mortality risk in both unadjusted and fully adjusted models: HRs (95% CI): 1.33(1.16–1.54) and 1.21(1.01–1.46), respectively. In prevalent kidney transplant recipients, serum resistin was an independent predictor of death with a functioning graft.     

Simultaneous bilateral percutaneous nephrolithotomy in children

In the paediatric section, two papers relating to the upper urinary tract are presented. The first, from Hungary, describes simultaneous bilateral percutaneous nephrolithotomy in 13 patients, where it was deemed feasible; this is the first such report. Authors from London report on unilateral nephrectomy in patients with nephrogenic hypertension, and found that it was successful in normalising blood pressure in patients with renal hypertension with a normal contralateral kidney. OBJECTIVE: To evaluate the efficacy of removing bilateral kidney stones simultaneously from children, in one session. PATIENTS AND METHODS: Thirteen patients (three girls and 10 boys, 26 kidneys; mean age 8 years, range 3-14) underwent simultaneous bilateral percutaneous nephrolithotomy (PCNL) in the same session, under general anaesthesia, starting with ureteric catheter insertion into both kidneys and using a 26 F adult nephroscope. The mean (range) stone diameter was 2 (1-3.5) cm. Three patients had staghorn stones in one of their kidneys. Ultrasonic disintegration was used; two patients had bilateral and two others unilateral endopylotomy, and one patient had percutaneous suprapubic cystolithotomy in the same session. The mean (range) operative duration was 65 (55-90) min. RESULTS: All patients were rendered stone-free; there was no severe bleeding or any other complication. On one side in one of the patients, a second session was needed because of residual stone. The nephrostomy tubes were removed 3 and 4 days after PCNL and the hospital stay was 6 (1-11) days. CONCLUSION: The advantages of simultaneous bilateral PCNL are reduced psychological stress, one cystoscopy and anaesthesia, less medication and a shorter hospital stay and convalescence, with considerable savings in cost. In experienced hands this method can be used not only in adults but also in children. To our knowledge this is the only report of this technique in children.     

Predialysis Kidney Function and Its Rate of Decline Predict Mortality and Hospitalizations After Starting Dialysis

Objective

To determine whether kidney function level and its rate of decline in the immediate predialysis period among veterans transitioning to end-stage renal disease (ESRD) predict postdialysis mortality and hospitalization.

Elevated Complement Factor H Levels in Asthmatic Sputa

Background

The alternative pathway of the complement system is known to play a role in the generation of asthmatic airway inflammation, but its regulatory complement protein, factor H has not been investigated in this disease.

Purpose

Our aim was to determine the local bronchial complement factor H (CFH) levels in asthma, and to investigate its relationship with complement activation, systemic CFH concentrations and clinical characteristics of patients.

Methods

Induced sputum and plasma were collected from 21 healthy and 26 asthmatic subjects, and complement factor H and SC5b-9 concentrations were assessed by ELISA. Total protein concentrations were determined by biuret-reaction based microassay system from induced sputa.

Results

CFH was detectable in 81 % of healthy and 100 % of asthmatic subjects, while SC5b-9 exceeded the detection limit in 62 % of healthy subjects and 85 % of asthmatic patients. Sputum CFH concentrations and CFH/protein ratios were increased in samples from asthmatic patients, and correlated with loss of lung function, asthma control, severity and medication intensity, but not with plasma CFH concentrations. Sputum CFH/protein ratios were in positive correlation also with sputum eosinophilic cell counts in asthma. SC5b-9 concentrations were not higher in the asthmatic sputa, although they correlated with sputum CFH concentrations.

Conclusions

CFH level is elevated on asthmatic airway surface, and may be associated with uncontrolled inflammation in asthma.