Bundled Payments Are Effective in Reducing Costs Following Bilateral Total Joint Arthroplasty

BackgroundAlternative payment models such the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative have been effective in reducing costs following unilateral total hip (THA) and knee arthroplasty (TKA), but few studies exist on bilateral arthroplasty. This study aimed to determine whether the BPCI program for bilateral THA and TKA reduced episode-of-care costs.MethodsWe retrospectively reviewed a consecutive series of patients who underwent simultaneous bilateral primary THA and TKA between 2015 and 2016. We recorded demographic variables, comorbidities, readmissions, and calculated 90-day episode-of-care costs based on Centers for Medicare and Medicaid Services claims data. We compared data from patients before and after the start of our BPCI program, and performed a multivariate analysis to identify independent risk factors for increased costs.ResultsOf 319 patients, 38 underwent bilateral THA (12%) while 287 underwent bilateral TKA (88%). There were 239 patients (74%) in the bundled payment group. Although there was no change in readmission rate (9% vs 8%), the post-BPCI group demonstrated reduced hospital costs ($21,251 vs $18,783), post–acute care costs ($15,488 vs $12,439), and overall 90-day episode-of-care costs ($39,733 vs $34,305). When controlling for demographics, procedure, and comorbidities, our BPCI model demonstrated a per-patient reduction of $5811 in overall claims costs. Additional risk factors for increased episode-of-care costs included age ($516/y increase) and cardiac disease ($5916).ConclusionOur bundled payment program for bilateral THA and TKA was successful with reduction in 90-day episode-of-care costs without placing the patient at higher risk of readmission. Older Medicare beneficiaries and those with cardiac disease should likely not undergo a simultaneous bilateral procedure due to concerns about increased costs.     

Anesthesia for radical prostatectomy

Radical prostatectomy is one of most common treatment options currently recommended for clinically localized prostate cancer. Evaluation of intraoperative and postoperative complications is important in evaluation of relative morbidity of this treatment option. Furthermore, investigation of complications of surgical treatment in correlation with not only surgical technique, but comorbidity, ASA stage and anesthetic technique enables improvements in complete perioperative treatment and decrease of incidence of complications resulting from the procedure. Improvement of anesthetic techniques and use of new anesthetic agents contributes to better outcome of surgical treatment. For radical surgery, combined epidural analgesia and general anesthesia reduces postoperative complications and mortality. Benefits can be conferred most likely by altered coagulation activation in surgery, increased blood flow, reduction of operative stress response. Modalities for reduction of intraoperative blood loss during radical prostatectomy are normovolemic haemodilution, preoperative donation of blood for autologus transfusion and use of erythropoietin for increasing red cell mass.     

The effects of amygdala lesions on conditioned stimulus-potentiated eating in rats

Both control rats and rats with neurotoxic lesions of the amygdala central nucleus ate more food during presentations of a conditioned stimulus (CS) previously paired with food than during an unpaired CS. This potentiation occurred regardless of whether the food was presented in its usual place or in a different location. By contrast, rats with neurotoxic lesions of basolateral amygdala showed no evidence for conditioned potentiation of eating. These results are considered in the context of anatomical projections from these amygdalar areas to other brain regions involved in feeding, and the role of amygdala subregions in the acquisition of motivational value in conditioning.     

Medical Cannabis in Serbia: The Survey of Knowledge and Attitudes in an Urban Adult Population

There are some indices in which legalization of medical cannabis in the Republic of Serbia might be considered. The purpose of this research was to assess knowledge and attitudes towards medical cannabis in an urban adult population. This cross-sectional study was conducted in December 2015 and January 2016. A convenience sample of study participants comprised users of the Community Health Center. A total of 360 adults were invited to participate. Data were collected through an anonymous questionnaire. Most participants (77.1%) answered correctly that cancer was indicative of medical cannabis treatment, while the remaining conditions were less frequently recognized. A total of 42% answered correctly that adverse effects of cannabis were hallucinations and dizziness. Persons who previously used cannabis were more knowledgeable on conditions for medical cannabis treatment (ρ = 0.155; p = 0.006). Study respondents expressed positive attitude towards legalization of medical cannabis (median 5 out of 5) and negative towards legalization of recreational cannabis (median 2 out of 5). In conclusion, the adult population in Belgrade had some knowledge of medical cannabis. The overall attitude of our population regarding legalization of medical cannabis was positive, while the attitude towards legalization of cannabis for recreational purposes was negative.     

Physicochemical characterization and preliminary in vivo efficacy of bioadhesive, semisolid formulations containing flurbiprofen for the treatment of gingivitis.

In this study, the physicochemical properties and preliminary in vivo clinical performance of formulations containing hydroxyethylcellulose (HEC; 3, 5, 10% w/w), poly(vinylpyrrolidone) (PVP; 3, 5% w/w), polycarbophil (PC; 1, 3, 5% w/w), and flurbiprofen (5% w/w) were examined. Flurbiprofen release into PBS pH 7.4 was performed at 37 degrees C. The mechanical properties (hardness, compressibility, adhesiveness, initial stress) and syringeability of formulations were determined using a texture analyzer in texture profile analysis (TPA) and compression modes, respectively. In general, the time required for release of 10 and 30% of the original mass of flurbiprofen (t10%, t30%) increased as the concentration of each polymeric component increased. However, in the presence of either 5 or 10% HEC and 5% PC, increased PVP concentration decreased both t10%, t30% due to excessive swelling (and disintegration) of these formulations. Increased concentrations of HEC, PVP, and PC significantly increased formulation hardness, compressibility, work of syringe expression, and initial stress due to the effects of these polymers on formulation viscoelasticity. Similarly, increased concentrations of PC (primarily), HEC, and PVP increased formulation adhesiveness due to the known bioadhesive properties of these polymers. Clinical efficacies of formulations containing 3% HEC, 3% PVP, 3% PC, and either 0% (control) or 5% (test) flurbiprofen, selected to offer optimal drug release and mechanical properties, were evaluated and clinically compared in an experimental gingivitis model. The test (flurbiprofen-containing) formulation significantly reduced gingival inflammation, as evaluated using the gingival index, and the gingival crevicular fluid volume, whereas, these clinical parameters were generally increased in volunteers who had received the control formulation. There were no observed differences in the plaque indices of the two subject groups, confirming that the observed differences in gingival inflammation could not be accredited to differences in plaque accumulation. This study has shown both the applicability of the in vitro methods used, particularly TPA, for the rational selection of formulations for clinical evaluation and, additionally, the clinical benefits of the topical application of a bioadhesive semisolid flurbiprofen-containing formulation for the treatment of experimental gingivitis.     

Clinical challenge: heparin-induced thrombocytopenia type II (HIT II) or pseudo-HIT in a patient with antiphospholipid syndrome

Treatment of patients with heparin-induced thrombocytopenia type II (HIT II) and thrombosis in some cases that represents a clinical challenge, which, if unrecognized, may lead to treatment delay or disease progression with potentially lethal outcome. We present a case of a 19-year-old patient with antiphospholipid syndrome, factor V (FV) Leiden mutation in heterozygous state, and venous thromboembolism. The patient was subjected to intravenous infusions of unfractionated heparin (UFH), and 16 days after the beginning of the treatment, his condition worsened, with thrombocytopenia and extension of thrombosis. Whereas the patient had a high clinical score for HIT II, functional and antigenic assays for the presence of HIT antibodies were negative. After repeated negative functional and antigenic assays, pseudo-HIT was suspected and nadroparin was introduced, which resulted in further worsening of the clinical presentation. Disease remission, along with complete normalization of platelet count, was finally accomplished with the introduction of lepirudin. The presence of multiple comorbid states, such as antiphospholipid syndrome, can potentially make laboratory confirmation of disease more difficult in patients with HIT II. In our opinion, it is of great importance that HIT II diagnosis be primarily clinical and that laboratory test results are carefully interpreted, especially when HIT is indicated by high clinical score values.     

Topography of projections from amygdala to bed nuclei of the stria terminalis

A collection of 125 PHAL experiments in the rat has been analyzed to characterize the organization of projections from each amygdalar cell group (except the nucleus of the lateral olfactory tract) to the bed nuclei of the stria terminalis, which surround the crossing of the anterior commissure. The results suggest three organizing principles of these connections. First, the central nucleus, and certain other amygdalar cell groups associated with the main olfactory system, innervate preferentially various parts of the lateral and medial halves of the bed nuclear anterior division, and these projections travel via both the stria terminalis and ansa peduncularis (ventral pathway). Second, in contrast, the medial nucleus, and the rest of the amygdalar cell groups associated with the accessory and main olfactory systems innervate preferentially the posterior division, and the medial half of the anterior division, of the bed nuclei. And third, the lateral and anterior basolateral nuclei of the amygdala (associated with the frontotemporal association cortical system) do not project significantly to the bed nuclei. For comparison, inputs to the bed nuclei from the ventral subiculum, infralimbic area, and endopiriform nucleus are also described. The functional significance of these projections is discussed with reference to what is known about the output of the bed nuclei.     

Effect of Phosphine on Coke Formation during Steam Cracking of Propane

In conventional steam cracking feedstocks, contaminants such as sulfur, phosphine, and heavy metal components, present in trace levels, are believed to affect coke formation on high temperature alloys. To gain an understanding of the role of phosphine coking rates on 25/35, CrNi and Al-containing reactor materials were determined in a plug flow reactor during cracking of a propane feedstock doped with ppb levels of PH₃ in the presence of DMDS. The presence of phosphine decreased the asymptotic coking rates by more than 20%, while it had a smaller influence on the catalytic coking rate. The coking rate was more severely reduced for the 25/35 CrNi alloy in comparison to the Al-containing alloy. The ppm levels of phosphine did not affect the olefin yields nor the production of undesired carbon monoxide. The morphology of the coked alloys were studied using an off-line Scanning Electron Microscope with Energy Dispersive X-ray detector (SEM with EDX) images of coked coupons. Two types of coke morphology are observed, i.e., filamentous coke with DMDS as an additive and globular coke in the presence of phosphine. The effect of phosphine on the material has a positive impact on the oxide scale homogeneity of 25/35 CrNi alloy, whereas the Al-containing alloy remained unchanged.