Trauma service cost: the real story.

OBJECTIVE: The objective was to define and characterize the costs associated with trauma care at a level I trauma center. Once the costs were identified, attending physician-led teams were designed to reduce costs within each cost center. SUMMARY BACKGROUND DATA: The location and magnitude of the costs on a trauma service remain largely unknown. Focused cost-containment strategies remain difficult to implement because the expected return on these interventions is unknown. METHODS: Cost center data were reviewed for the 40 major DRGs admitted for the first 6 months of the fiscal years 1996 and 1997. Data were obtained from the hospital finance department using the Transition Systems Inc. accounting system. We focused on variable direct costs, those that vary with patient volume (e.g., staff nursing expense and medical/surgical supplies). To address issues of inflation, pay raises, and changing costs, a proxy value was created for 1996 and costs were held constant for the 1997 calculation. The major services that constitute cost centers identified in the system were nursing, surgical, pharmacy, laboratory, radiology, and emergency services. Attendings were assigned to develop and oversee customized cost-reduction modalities specific to each cost center. The cost-reduction modalities used to achieve significant savings were as follows: nursing, case management approach focusing on early discharge; surgical, meeting with operating room (OR) purchasing to modify expensive behavior patterns; pharmacy, integrating clinical pharmacist with direct attending support; laboratory, enforcing protocol for lab draws; radiology, increasing the use of emergency room ultrasound and accepting outside x-rays; and emergency services, 24-hour in-house attending staff to reduce emergency room time. The surgical and emergency services cost centers predominately generate costs by the length of time care is delivered in that area. RESULTS: For each period, data from 363 patients were compared. Mean length of stay decreased between the study periods from 8.72 to 7.06 days, while the average injury severity score was unchanged. Together, these cost centers constituted 87.4% of the total cost of care delivered. Significant cost reduction was achieved in all six variable cost centers: nursing (24%), surgical (5%), pharmacy (57%), laboratory (27), radiology (7%), and emergency (36). The mean cost per case was reduced by 25%. CONCLUSIONS: Identification of the true cost centers and directed attending surgeon involvement are essential to the development and implementation of a successful cost-reduction process.     

Leishmania major heat shock protein 70 (HSP70) is not protective in murine models of cutaneous leishmaniasis and stimulates strong humoral responses in cutaneous and visceral leishmaniasis patients

Heat shock proteins (HSP) are highly conserved molecules that play important roles in protein folding, assembly of protein complexes and translocation of proteins across cellular compartments, as well as in several immunological processes. In this study, we first immunized susceptible BALB/c and resistant C57BL/6 mice with the complete open-reading frame of Leishmania HSP-70 (pcDNA-HSP70) and boosted mice with rHSP-70 (amino acid 221-604 cloned in pQE-HSP70 and referred to as rHSP70) mixed with Montanide 720. When we evaluated the effects of HSP70 in both mouse strains, we found that the entire fragment (amino acids 221-604) and rCT-HSP70 (amino acids 491-604 cloned in pQE-CT), but not rNT-HSP70 (amino acids 221-291 cloned pQE-NT), contained the highest immunogenicity. However, after infectious challenge with Leishmania major, no efficient protective responses were observed in either mouse strain. The humoral immune responses against the different truncated forms of HSP70 suggested a mixed TH1/TH2 response in vivo. We then assessed infected susceptible and resistant mice for lymphoproliferative and cytokine responses against the truncated forms of HSP70. At 9-week post-infection, we observed no differences in those responses between vaccinated and control mice. Next, we initiated comparative studies in human patient samples, finding no significant proliferation against all three truncated forms of HSP70 in the cellular immune responses of 16 cured cutaneous leishmaniasis patients and 5 normal individuals. Sera from active cutaneous and visceral leishmaniasis patients, however, were reactive to all three forms of HSP70. This study demonstrates the potential of HSP70 in stimulating humoral responses in humans and mice and indicates there is a need to further explore and examine the value of this important molecule in the control of leishmaniasis.     

Myoangiogenesis after cell patch cardiomyoplasty and omentopexy in a patient with ischemic cardiomyopathy

We describe a procedure to promote angiogenesis and impregnation of skeletal myoblast into infarcted myocardium. At the completion of coronary artery bypass surgery, the midline sternotomy incision was extended to open the abdomen, and the greater omentum was tailored to reach the myocardium. Four pieces of autologous rectus muscle were applied to the infarcted left ventricle. This implantation was reinforced by the greater omentum. Incisions were closed in the usual manner. Postoperatively, the patient showed significant improvements in left ventricular ejection fraction (from 0.15 to 0.40) and in exercise tolerance (from 3 METs to 6 METs, or 100%). Computed tomographic angiography and positron emission tomography demonstrated improved myocardial viability and vascularity in the ischemic segments of the left ventricle. Omentopexy and cell patch cardiomyoplasty in conjunction with coronary artery bypass surgery may stimulate myogenesis and angiogenesis in avascular, dyskinetic scar tissue of left ventricle; in this preliminary study, this procedure appeared to improve the functional capacity of the left ventricle.     

Acute renal failure as an initial manifestation of multiple endocrine neoplasia (MEN) type 1

Multiple endocrine neoplasia (MEN) is a group of heritable syndromes characterized by aberrant growth of benign or malignant tumors in a subset of endocrine tissues. There are three major syndromes: MEN1, 2A and 2B. We describe a 60-year-old woman who initially manifested acute renal failure due to hypercalcemia and dehydration and, finally, was diagnosed as a sporadic MEN1 case.     

Intestinal fungal and parasitic infections in kidney transplant recipients: a multi-center study

Kidney transplant recipients are susceptible to various infections due to the use of immunosuppressive drugs. The present study was performed as studies on the prevalence of intestinal fungal and parasitic infections in kidney transplant recipients are limited. A total of 150 kidney transplant recipients and 225 matched immunocompetent outpatients, who were referred to the laboratory of Noor Hospital, Isfahan, were studied. After recording demographic characteristics, direct test and specific laboratory cultures were carried out on the stool specimens. Patients were instructed on sanitary rules and, during each medical visit, they were reminded of the same. The overall prevalence of intestinal parasitic and fungal infections was 33.3% and 58.7%, respectively, in transplant recipients and 20% and 51%, respectively, in the control group; the difference was not statistically significant. The most prevalent intestinal parasite was Entameba coli, which was seen in 9.3% of the study patients and 6.7% of the controls. The most prevalent fungus was Candida sp., which was seen in 22% of the study patients and 24.4% of the control group. Co-existing infection with two or more fungi was seen in 14.8% and 3.4% in the case and control groups, respectively; P <0.001. Interestingly, there was no significant difference in the prevalence of infection by a single organism between the two groups. However, co-existing infection with two or more species was more prevalent in transplant recipients. We conclude that further investigations are needed to evaluate the pathogenesis of infection with these microorganisms.