Perimesencephalic nonaneurysmal subarachnoid hemorrhage in the pediatric population: case report and review of the literature

In approximately 15% of children with atraumatic subarachnoid hemorrhage (SAH), the cause of the hemorrhage cannot be determined despite detailed imaging studies. Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH) is well recognized as a distinct type of SAH in the adult population and may account for up to two thirds of these SAHs of unknown cause. PNSH in the pediatric population, however, is not well recognized. In this report, we confirm the existence of PNSH in the pediatric population by describing a 4-year-old boy who presented with acute SAH in the perimesencephalic cisterns and subsequently had two negative angiograms with a benign clinical course. Recognition of PNSH in the pediatric population is important, especially in view of its benign nature.     

Prenatal resection of a fetal pericardial teratoma

OBJECTIVE: Pericardial teratomas are rare congenital tumors which invade the developing mediastinum, compressing the venous return to the heart, leading to hydrops. Tumors, with large cystic components, have been treated previously with in utero pericardiocentesis with some success. We present the first reported case of in utero open resection of a fetal pericardial teratoma. METHODS: A 31-year-old G1P0 woman was found to have a fetus with a pericardial teratoma. Hydrops developed at 24 weeks' gestation. After counseling, open fetal resection was performed via a fetal median sternotomy. RESULTS: Although the tumor was successfully removed, the hydrops did not resolve. In addition, over the course of 3 weeks, the mother developed maternal mirror syndrome which prompted an emergent cesarean section. Neonatal death ensued shortly after birth. CONCLUSIONS: The fetus with a pericardial teratoma complicated by hydrops is compromised. Treatment options include early delivery, aspiration of the pericardial effusion, and in utero operative resection.     

Hospital community benefits other than charity care: implications for tax exemption and public policy

Recent policy initiatives attempt to link the tax treatment of nonprofit hospitals more closely with the provision of social benefits. A key issue in defining these benefits is the treatment of "community benefit" programs and services. While their costs are often unreimbursed, these programs differ from traditional charity care in terms of the populations whom they benefit and the motivation for their provision. Community benefit programs are typically targeted to the general population, rather than the poor or other underserved groups, and often serve a marketing function.     

Does utilization review reduce unnecessary hospital care and contain costs?

Research indicates that approximately one in five hospital admissions is unnecessary or inappropriate, based on accepted clinical criteria. Various cost-containment approaches have been initiated to reduce unnecessary hospital care. Among these approaches, hospital utilization review (UR) has shown promise as a cost-containment strategy. Although third party payers are increasingly relying on UR and similar approaches to contain health care expenditures, little is known about the effects of these efforts. This study analyzes insurance claims data on 223 insured groups for 1984 through 1986 to determine the effects of a UR program instituted by a commercial insurance company. It was found that UR had a significant negative effect on both utilization and expenditures, even after controlling for a large number of factors. Specifically, UR reduced admissions by 13%, inpatient days by 11%, expenditures on routine hospital inpatient services by 7%, expenditures on hospital ancillary services by 9%, and total medical expenditures by 6%. Even though UR reduced the level of utilization and expenditures, it did not appear to influence the rate of change in these areas over time. These findings suggest that hospital UR programs can reduce utilization and expenditures and generate cost savings, thereby helping to improve the efficiency of medical care resources consumption.