A financial analysis of pediatric laparoscopic versus open fundoplication

INTRODUCTION: Laparoscopic fundoplication (LF) is rapidly replacing open fundoplication (OF) for correcting symptomatic gastroesophageal reflux (GER) in infants and children. In this study, we compared various clinical and financial parameters to determine if one technique is superior. METHODS: With Institutional Review Board approval, charts and charge data for 50 consecutive patients undergoing elective LF or OF were reviewed in 2003 and 2004 (n = 100). Clinical variables evaluated included gender, age, weight, length of stay (LOS), operating time (OT), and time to initial (IF) and full (FF) feedings. Financial charges that were reviewed included anesthesia, central supply and sterilization, equipment, operating suite, hospital room and board, pharmacy, and total charges. RESULTS: The groups were equally matched in relation to gender, age, and weight. The table below illustrates the statistically significant differences (P < 0.05) between the groups. Favoring LNF LOS (1.2 vs. 2.9 days) IF (7.3 vs. 27.9 hours) FF (21.8 vs. 42.9 hours) Equipment ($1,006 vs. $1,609) Hospital Room ($1,290 vs. $2,847) Pharmacy ($180 vs. $461), Favoring OF OT (77 vs. 91 minutes) Anesthesia ($389 vs. $475) Central Supply and Sterilization ($1,367 vs. $2,515) Operating Suite ($4,058 vs. $5,142) Total charges were similar (LF, $11,449; OF, $11,632). CONCLUSIONS: Interestingly, although there were statistical differences in every charge category, total charges for LF and OF did not differ significantly. Thus, traditionally higher expenses from longer OT for LF seem to be offset by financial benefits, such as shorter LOS, reduced discomfort as evidenced by lower narcotic charges, and earlier IF/FF.     

跨步或不跨步下的前弓步和侧弓步动作中的髌股关节压力与应力(二)

结果 髌股关节的压力与应力随膝关节屈曲角度的增加而升高,随膝关节屈曲角度的减小而降低(图3～8).不同膝关节屈曲角度下弓步变化和跨步变化的髌股关节压力见表1.     

A three-dimensional biomechanical analysis of the squat during varying stance widths

PURPOSE: The purpose of this study was to quantify biomechanical parameters employing two-dimensional (2-D) and three-dimensional (3-D) analyses while performing the squat with varying stance widths. METHODS: Two 60-Hz cameras recorded 39 lifters during a national powerlifting championship. Stance width was normalized by shoulder width (SW), and three stance groups were defined: 1) narrow stance squat (NS), 107 +/- 10% SW; 2) medium stance squat (MS), 142 +/- 12% SW; and 3) wide stance squat (WS), 169 +/- 12% SW. RESULTS: Most biomechanical differences among the three stance groups and between 2-D and 3-D analyses occurred between the NS and WS. Compared with the NS at 45 degrees and 90 degrees knee flexion angle (KF), the hips flexed 6-11 degrees more and the thighs were 7-12 degrees more horizontal during the MS and WS. Compared with the NS at 90 degrees and maximum KF, the shanks were 5-9 degrees more vertical and the feet were turned out 6 degrees more during the WS. No significant differences occurred in trunk positions. Hip and thigh angles were 3-13 degrees less in 2-D compared with 3-D analyses. Ankle plantar flexor (10-51 N.m), knee extensor (359-573 N.m), and hip extensor (275-577 N.m) net muscle moments were generated for the NS, whereas ankle dorsiflexor (34-284 N.m), knee extensor (447-756 N.m), and hip extensor (382-628 N.m) net muscle moments were generated for the MS and WS. Significant differences in ankle and knee moment arms between 2-D and 3-D analyses were 7-9 cm during the NS, 12-14 cm during the MS, and 16-18 cm during the WS. CONCLUSIONS: Ankle plantar flexor net muscle moments were generated during the NS, ankle dorsiflexor net muscle moments were produced during the MS and WS, and knee and hip moments were greater during the WS compared with the NS. A 3-D biomechanical analysis of the squat is more accurate than a 2-D biomechanical analysis, especially during the WS.     

Furlong Hydroxyapatite-Coated Hip Prosthesis vs the Charnley Cemented Hip Prosthesis

We report the results of a prospective trial comparing uncemented Furlong hydroxyapatite-coated total hip arthroplasty and cemented Charnley total hip arthroplasty. One hundred ninety-one patients were allocated into 2 groups depending on their year of birth. One group received a Furlong hydroxyapatite-coated total hip arthroplasty and the other group received a cemented Charnley total hip arthroplasty. At a mean follow-up of 14 years (12-16 years), Harris hip scores showed no difference between the 2 groups. The longitudinal multilevel model analysis shows that the mean slope of the change in the Harris hip score was −0.02 for the Furlong group and −0.05 for the Charnley group; the difference is 0.03 (P = .002). The survival analysis using Kaplan-Meier regression analysis (the log-rank test λ²₁ = 0.031, P = .58) does not show a significant difference between the 2 groups. Overall survival was 93.6% in the Furlong group and 94.8% in the Charnley group.     

Cerebral hypoperfusion in immediate postoperative period following coronary artery bypass grafting, heart valve, and abdominal aortic surgery

Perioperative levels of jugular bulb oxyhaemoglobin saturation(Sj_O2) and lactate concentration (Lj), and postoperative durationof Sj_O2<50% were compared between patients undergoing coronaryartery bypass grafting (CABG) (n=86), heart valve (n=14) andabdominal aortic (n=16) surgery. Radial artery and jugular bulbblood samples were aspirated after induction of anaesthesia,during re-warming on cardiopulmonary bypass (CPB) (36°C),on arrival in the intensive care unit (ICU) and, subsequently,at 1, 2 and 6 h after ICU admission. Most patients having heartsurgery were hypocapnic at 36°C on CPB. Following CABG andheart valve surgery, many patients were hypocapnic whereas afterabdominal aortic surgery, most were hypercapnic. During CPBand postoperatively, Sj_O2 and Lj were significantly correlatedto Pa_CO2 and the arterial concentration of lactate (La) respectively(P<0.05). After correction for arterial carbon dioxide tension(Pa_CO2) and La, there were no significant changes in Sj_O2 orLj on CPB. Postoperatively, having corrected for Pa_CO2, therewere significant effects on Sj_O2 over all groups as a resultof time from surgery (P<0.001) and its interaction with operationtype (P<0.001). Following correction for La, there were nopostoperative effects on Lj. No significant differences (P=0.2)in duration of Sj_O2<50% existed between patients undergoingCABG (1054 (82) min), abdominal aortic (893 (113) min) and heartvalve (1073 (91) min) surgery. The lack of significant reciprocaleffects on Lj combined with the frequency of hypocapnia andstrong influence of Pa_CO2on Sj_O2, suggest that Sj_O2<50% duringCPB and after cardiac surgery represents hypoperfusion as aconsequence of hypocapnia rather than cerebral ischaemia. Br J Anaesth 2001; 87: 229–36     

The role of arthroscopic surgery in the evaluation of acute traumatic hemarthrosis of the knee

Eighty patients presented for evaluation with an acute traumatic hemarthrosis of the knee and negligible instability on clinical examination. All had an examination under general anesthesia followed by arthroscopy. Anatomical lesions were demonstrated in 71 of 80 knees (89%) including anterior cruciate ligament (ACL) disruption in 50 (62%). Twenty-nine of 50 patients (58%) with arthroscopically-demonstrated ACL injuries had associated meniscal tears. Fifteen (19%) demonstrated isolated meniscal tears and nine (11%) osteochondral fractures not detected by conventional roentgenograms. The frequent occurrence of injuries to other joint structures in conjunction with ACL injuries was remarkable. An acute traumatic hemarthrosis of the knee often masks significant lesions. Arthroscopy aids the orthopedic surgeon in determining the full extent of the intraarticular damage.     

Engraftment after infusion of CD34+ marrow cells in patients with breast cancer or neuroblastoma.

The CD34 antigen is expressed by 1% to 4% of human and baboon marrow cells, including virtually all hematopoietic progenitors detectable by in vitro assays. Previous work from our laboratory has shown that CD34+ marrow cells can engraft lethally irradiated baboons. Because the CD34 antigen has not been detected on most solid tumors, positive selection of CD34+ cells may be used to provide marrow cells capable of engraftment, but depleted of tumor cells. In seven patients with stage IV breast cancer and two patients with stage IV neuroblastoma, 2.5 to 17.5 x 10(9) marrow cells were separated by immunoadsorption with the anti-CD34 antibody 12-8 and 50 to 260 x 10(6) positively selected cells were recovered that were 64 +/- 16% (range 35% to 92%) CD34+. The patients received 1.0 to 5.2 x 10(6) CD34-enriched cells/kg after marrow ablative therapy. Six patients engrafted, achieving granulocyte counts of greater than 500/mm3 at 34 +/- 10 (range 21 to 47) days and platelets counts of greater than 20,000/mm3 at 46 +/- 14 (range 28 to 66) days posttransplant. Five of these patients showed durable engraftment until the time of death 82 to 386 days posttransplant. One patient failed to sustain engraftment associated with metastatic marrow disease. Three patients died at days 14, 14, and 17 posttransplant, two of whom had evidence of early engraftment. These studies suggest that CD34+ marrow cells are capable of reconstituting hematopoiesis in humans.     

Idiopathic scoliosis. An 11-year follow-up study of the role of the Milwaukee brace in curve control and trunco-pelvic alignment

One hundred and fifty-two patients with idiopathic scoliosis were treated at the Alfred I. duPont Institute with the Milwaukee brace between 1961 and 1972. This study includes 94 patients and was undertaken to evaluate the effectiveness of Milwaukee brace treatment in managing various sequelae associated with idiopathic scoliosis, such as degree of curvature and trunco-pelvic alignment, and to assess the degree of spinal stability after treatment. Good results were obtained in patients with curves less 30 degrees; in addition, there was improvement in trunco-pelvic alignment and curve correction. However, results varied considerably among patients and were unpredictable. Double major curve patterns were found to have a poor response to bracing. After bracing is stopped, rate of curve progression appears to decrease with time.