The economic impact of incorporating flexible endoscopy into a community general surgery practice

Background Flexible endoscopy is a vital component of gastrointestinal surgery. It has and will replace many of the surgical procedures now commonly performed. Flexible endoscopy, unfortunately, is not an integral part of surgical residency training based on resident operative experience as reported by the Residency Review Committee. Moreover, general surgeons have deferred the practice of flexible endoscopy to the gastroenterologists because of concerns over turf battles and referral patterns. The purpose of this study was to assess the overall case load and the economic impact of flexible endoscopy on the practice of general surgery in a community hospital setting.Methods This retrospective review was performed over a 6-month period. The total cases and the total billings of inpatient and outpatient procedures for a group practice of five general surgeons in a community hospital were evaluated. The billings were the actual charges based on current procedural terminology (CPT) codes for these procedures using the Medicare fee schedule.Results Of the 2,159 procedures performed, 1,154 involved flexible endoscopy cases accounting for 54% of all cases (1,154 of 2,159) performed from February 1, 2003 to July 31, 2003. Flexible endocopy accounted for 43% of the total charges. A. total of 46 surgical procedures and 216 future endoscopies were generated from the flexible endoscopic procedures. Future endoscopic cases were for surveillance of colonic neoplasia and Barrett’s esophagus.Conclusions Flexible endoscopy contributed to a major portion of the caseload and revenue generated by the general surgery group studied. The overall impact of flexible endoscopy is even greater than reported because of the future endoscopic surveillance cases or surgical interventions generated on the basis of endoscopic findings.     

A normal flow pattern in women does not exclude voiding pathology

It is a widespread assumption that normal micturition behaviour is reflected in a normal flow pattern. This would also mean that a normal flow curve would correspond with normal voiding and would even permit to exclude voiding difficulties. In our study we investigated the value of a normal flow pattern in four different groups: stress incontinent women, women with bladder overactivity, healthy middle-aged volunteers and healthy students. These women voided with a bell-shaped flow curve on pressure flow in 50, 65, 57 and 50%, respectively. Women who strained to void, a major component of dysfunctional voiding, managed to void a bell-shaped flow curve in 46, 60, 70 and 100%, respectively. Our study demonstrates that a normal bell-shaped flow curve does not exclude voiding dysfunction in women.Editorial Comment: It is assumed that normal voiding behavior is reflected in a normal flow pattern, but it is unknown whether one can assume the correlate, that is whether a normal flow curve corresponds to normal voiding. To answer this question, the authors prospectively evaluated free flow and pressure flow patterns in four groups—women with SUI, women with OAB, healthy middle-aged women and young healthy female students. They found that normal bell-shaped free-flow curves were found in 67–83% and bell-shaped pressure flow curves were found in 50–65%. They then showed that bell-shaped flow curves were found in 24 patients who had evidence of abdominal straining during micturition     

The costs for persons sick-listed more than one month because of low back or neck problems. A two-year prospective study of Swedish patients

The total costs for patients who are sick-listed due to back and neck problems have not previously been determined prospectively on an individual basis. This study aimed to determine the total cost to a society, based on individually assessed costs of health services and loss of production in people who are sick-listed 28 days or more for back or neck problems. Detailed data on individuals health-care consumption due to back or neck problems was collected through prospectively entered diaries and questionnaires, after 4 weeks, 3 months, 1 and 2 years, in a consecutively selected cohort of 1,822 employed persons aged between 18 and 59 years. Costs for health care and production losses due to work absenteeism were determined individually and combined to render total costs to society. The costs for all medical services during the 2-year study were 6.9% of total costs for back and neck problems. The single most expensive medical service was surgery. Transferred to a national level, annual total costs for back and neck problems corresponded to 1% of GNP. In conclusion, direct health-service costs were a small fraction of the total costs, consequently indirect costs offer the greatest potential for savings.     

Acute kidney injury, mortality, length of stay, and costs in hospitalized patients

The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.     

Peroxisome proliferator-activated receptor beta/delta exerts a strong protection from ischemic acute renal failure

Ischemic acute renal failure is characterized by damages to the proximal straight tubule in the outer medulla. Lesions include loss of polarity, shedding into the tubule lumen, and eventually necrotic or apoptotic death of epithelial cells. It was recently shown that peroxisome proliferator-activated receptor beta/delta (PPARbeta/delta) increases keratinocyte survival after an inflammatory reaction. Therefore, whether PPARbeta/delta could contribute also to the control of tubular epithelium death after renal ischemia/reperfusion was tested. It was found that PPARbeta/delta+/- and PPARbeta/delta-/- mutant mice exhibited much greater kidney dysfunction and injury than wild-type counterparts after a 30-min renal ischemia followed by a 36-h reperfusion. Conversely, wild-type mice that were given the specific PPARbeta/delta ligand L-165041 before renal ischemia were completely protected against renal dysfunction, as indicated by the lack of rise in serum creatinine and fractional excretion of Na+. This protective effect was accompanied by a significant reduction in medullary necrosis, apoptosis, and inflammation. On the basis of in vitro studies, PPARbeta/delta ligands seem to exert their role by activating the antiapoptotic Akt signaling pathway and, unexpectedly, by increasing the spreading of tubular epithelial cells, thus limiting potentially their shedding and anoikis. These results point to PPARbeta/delta as a remarkable new target for preconditioning strategies.     

Quality of thrombin produced from the patient's own plasma using the TPD, a new Thrombin-processing Device

Thrombin derived from bovine sources commonly is used to arrest bleeding during surgical procedures. However, complications such as postoperative hemorrhage can occur because of the development of cross-reactive anti-bovine antibodies that inhibit human coagulation factor V. It would thus be advantageous to develop techniques to generate human thrombin. This study evaluated thrombin produced from human plasma using a new Thrombin-Processing Device (TPD). Plasma was introduced into the TPD, mixed with an ethanol/ CaCl2 reagent, incubated for 1 h, and the harvested thrombin was assayed for activity and the ability to activate platelets by in vitro assays. TPD-produced thrombin activity was found to be 51.8 +/- 12.4 IU/mL (n = 145). TPD-produced thrombin also stimulated P-selectin (CD62) expression (83 +/- 13% of the platelet population) and Annexin V binding (10.3 +/- 2% of the platelet population) on platelets in a similar fashion to commercial thrombin (P-selectin expression: 88 +/- 3%; Annexin-V binding: 11.4 +/- 3%). Compared with CaCl2 and batroxobin, TPD-produced thrombin had a significantly greater ability to activate platelets. TPD-produced thrombin from human plasma has consistent activity and significantly activates platelets and, thus, may have attractive applications such as the production of autologous thrombin for surgical patients.     

Recombinant coagulation factor VIIa in major liver resection: a randomized, placebo-controlled, double-blind clinical trial

BACKGROUND: Prevention of bleeding episodes in noncirrhotic patients undergoing partial hepatectomy remains unsatisfactory in spite of improved surgical techniques. The authors conducted a randomized, placebo-controlled, double-blind trial to evaluate the hemostatic effect and safety of recombinant factor VIIa (rFVIIa) in major partial hepatectomy. METHODS: Two hundred four noncirrhotic patients were equally randomized to receive either 20 or 80 microg/kg rFVIIa or placebo. Partial hepatectomy was performed according to local practice at the participating centers. Patients were monitored for 7 days after surgery. Key efficacy parameters were perioperative erythrocyte requirements (using hematocrit as the transfusion trigger) and blood loss. Safety assessments included monitoring of coagulation-related parameters and Doppler examination of hepatic vessels and lower extremities. RESULTS: The proportion of patients who required perioperative red blood cell transfusion (the primary endpoint) was 37% (23 of 63) in the placebo group, 41% (26 of 63) in the 20-microg/kg group, and 25% (15 of 59) in the 80-microg/kg dose group (logistic regression model; P = 0.09). Mean erythrocyte requirements for patients receiving erythrocytes were 1,024 ml with placebo, 1,354 ml with 20 microg/kg rFVIIa, and 1,036 ml with 80 microg/kg rFVIIa (P = 0.78). Mean intraoperative blood loss was 1,422 ml with placebo, 1,372 ml with 20 microg/kg rFVIIa, and 1,073 ml with 80 microg/kg rFVIIa (P = 0.07). The reduction in hematocrit during surgery was smallest in the 80-microg/kg group, with a significant overall effect of treatment (P = 0.04). CONCLUSIONS: Recombinant factor VIIa dosing did not result in a statistically significant reduction in either the number of patients transfused or the volume of blood products administered. No safety issues were identified.     

Salvage of infected cartilage grafts for nasal reconstruction with a through-and-through irrigation system

Development of a wound infection after nasal reconstruction can place the entire reconstructive effort in jeopardy. The approach to management in these cases has traditionally entailed wound drainage, removal of involved graft material, and debridement of nonvital tissue. Following adequate wound healing, delayed reconstruction is then performed, with the final result often compromised in form and function.We present a case of a postoperative wound infection following reconstruction of a traumatic nasal deformity utilizing autologous cartilage grafts. Treatment consisted of hospitalization with administration of culture-specific parenteral antibiotics and continuous through-and-through antibiotic irrigation of the wound via an indwelling catheter. The infection was completely eradicated and all cartilage grafts were salvaged utilizing this technique. At 3 years postoperatively, the patient has maintained the shape and quality of her reconstruction, without evidence of recurrent infection.