Tissue expander complications in the pediatric burn patient

OBJECTIVES: The main purpose of our study was to identify the patient characteristics of women undergoing hysterectomy and to estimate the proportion of hysterectomies that could be done vaginally by recognized surgical techniques. STUDY DESIGN: The records of 500 women who underwent hysterectomy were reviewed. The characteristics of patients without an absolute contraindication to vaginal hysterectomy were analyzed. RESULTS: Overall, 96 (19.2%) of our study group underwent vaginal hysterectomy. A total of 382 (76.4%) women were judged not to have an absolute contraindication to this route. The most frequent characteristics of this group were lack of uterine prolapse (76.4%), a myomatous uterus (44.5%), and a need for oophorectomy (43.2%). We did not exclude women who did not have significant uterine prolapse or a history of pelvic surgery or pelvic tenderness and we included those requiring oophorectomy or with a uterine size up to that of 14 weeks' gestation; with these criteria more than two thirds of the entire study population could undergo vaginal surgery. CONCLUSIONS: To maximize the proportion of hysterectomies performed vaginally, gynecologists need to be familiar with surgical techniques for dealing with nonprolapsed uteri, uterine leiomyomas, and vaginal oophorectomy.     

Vaginal and abdominal hysterectomy: comparison and perspectives. Apropos of 385 consecutive cases

Hysterectomy is the most common non-pregnancy related surgical procedure. However, given the lack of final guidelines on indications, alternative therapies, surgical approach and outcomes, it is desirable to keep its use under constant monitoring. We reviewed 385 hysterectomies for benign conditions-divided according to surgical approach-performed in the Gynaecological Department of San Daniele del Friuli (Udine-Italy) in 1991-1993, and with one-year follow-up. Traditional approaches, i.e. abdominal (39.2%) and vaginal (60.2%), were used. Colporraphy was performed in 79 cases (33.8% of vaginal hysterectomies); 73.4% of colporraphies were followed by urethral suspension. We reviewed population's patterns, indications and surgical outcomes according to Dicker's suggestions. Vaginal hysterectomy with associated colporraphy concerned a population of patients with average age and parity significantly different from patients who underwent simple vaginal or abdominal hysterectomy. These last two groups, on the other hand, have similar characteristics making them comparable. In abdominal hysterectomy and simple vaginal hysterectomy we reported a complication rate respectively of 21.9% and 7.1%. The advantages of simple vaginal hysterectomy include shorter operating time, reduction in antibiotic drugs usage, earlier hospital discharge and quicker recovery, with obvious cost saving. Our experience therefore supports the view that the balance between abdominal and vaginal hysterectomy could safely be shifted in favour of the last one, the advantages of which could then be made available to a larger number of patients.     

Characteristics of epileptic seizures after ischemic stroke

BACKGROUND: Anesthesia gas delivery equipment is a potentially important source of patient injury. To better define the contribution of gas delivery equipment to professional liability in anesthesia, the authors conducted an in-depth analysis of cases from the database of the American Society of Anesthesiologists Closed Claims Project. METHODS: The database of the Closed Claims Project is composed of closed US malpractice claims that have been collected in a standardized manner. All claims resulting from the use of gas delivery equipment were reviewed for recurrent patterns of injury. RESULTS: Gas delivery equipment was associated with 72 (2%) of 3,791 claims in the database. Death and permanent brain damage accounted for almost all adverse outcomes (n = 55, 76%). Equipment misuse was defined as fault or human error associated with the preparation, maintenance, or deployment of a medical device. Equipment failure was defined as unexpected malfunction of a medical device, despite routine maintenance and previous uneventful use. Misuse of equipment (n = 54, 75%) was three times more common than equipment failure (n = 17, 24%). Misconnects and disconnects of the breathing circuit made the largest contribution to injury (n = 25, 35%). Reviewers judged that 38 of 72 claims (53%) could have been prevented by pulse oximetry, capnography, or a combination of these two monitors. Overall, 56 of 72 gas delivery claims (78%) were deemed preventable with the use or better use of monitors. The year of occurrence for claims involving gas delivery equipment ranged from 1962 to 1991 and did not differ significantly from claims involving other adverse respiratory events. CONCLUSIONS: Claims associated with gas delivery equipment are infrequent but severe and continue to occur in the 1990s. Educational and preventive strategies that focus on equipment misuse and breathing circuit configuration may have the greatest potential for enhancing the safety of anesthesia gas delivery equipment.     

How to complete a medical insurance form

The information submitted is knowledge accumulated over years of experience teaching dentists how to bill medical insurance. This is supplemented with a good number of personal expert witness testimonies in criminal and malpractice insurance cases. The objective is to prevent problems before they start with the prudent use of information. My experience in court testimony on these issues has shown me that there is an army of lawyers, insurance company fraud examiners, and dentists working for the aforementioned, just waiting for you to improperly use this method of insurance reimbursement. Use this only if you understand the nuances of what it is you are doing! For example, any procedure you bill to dental insurance using CDT-2 codes can be billed to medical insurance using medical insurance CPT-95 codes. The difference is that if the procedure is not a covered medical expense, it will not be paid by the medical insurance carrier. I strongly suggest that you do not fall into the trap of obfuscating these codes. There are a number of so-called insurance "gurus" teaching dentists how to write confusing and misleading operative reports so as to obtain reimbursement for procedures that normally would not be covered. I beseech you--please do not do it! The penalties are severe. You will experience a significant increase in payments from the medical insurance when procedures are submitted in the proper manner. More and more computerized dental insurance management programs are offering their clients the ability to automatically cross-code and submit dental/medical insurance claims. It is a recognized ability of dentists to do such. Billing responsibly is of the utmost importance.     

Southeast Asians: Asian-Pacific Americans at risk for substance misuse

Projections indicate that by the year 2000 over a million Cambodians, Laotians, and Vietnamese will be living in the United States. There is sparse information relative to the use of substances by these groups due to the absence of national prevalence data. The combined stressors that these refugee groups have faced puts them at high risk for substance misuse. Southeast Asians infrequently use substance misuse and mental health services, which has been perceived as a lack of need for services by these groups. In reality, there is a critical shortage of culturally-appropriate treatment and intervention programs as the prevalence of substance misuse increases in these populations.     

Costs of hysterectomy: does surgical approach make a difference?

We wanted to determine the direct cost of hysterectomies by surgical approach and to estimate the impact on costs if more vaginal hysterectomies were substituted for abdominal hysterectomies for women under 50 years of age. Eleven Ontario (Canada) hospitals provided 1994 cost data based on 1376 hysterectomies. These data were applied to all hysterectomies performed in the province for women under 50 to estimate the cost of subtotal, vaginal (VH), or laparoscopically assisted vaginal hysterectomy (LAVH) relative to total abdominal hysterectomy (TAH). We determined the change in costs if TAHs in Ontario in 1994-1995 had been substituted by VH or LAVH. Teaching and community hospitals were considered separately. VH was less costly than TAH, subtotal, or LAVH. The direct cost for TAH at teaching hospitals was much higher than at community hospitals. Costs relative to TAH were higher for LAVH at community but not at teaching hospitals. From the population baseline rate of 25% VH, 5% LAVH, 10% subtotal, and 60% TAH, we estimated that increasing VH to 45% would lower costs by 2.4%; increasing LAVH to 25% would increase costs by 4.4%. VH is associated with lower costs than TAH or LAVH. However, the magnitude of the substitution and the extent of cost savings should ultimately be based on evaluation of patient outcomes.     

Laparoscopy-assisted and -prepared hysterectomy. A series of 80 cases

OBJECTIVE: Our objective was to determine the interest of laparoscopic assisted vaginal hysterectomy. STUDY DESIGN: Between January 1991 to december 1994, 80 patients had laparoscopically assisted vaginal hysterectomy. We reviewed with particular emphasis characteristic indications, complications. RESULTS: Eighty were performed as laparoscopically assisted vaginal hysterectomy. 14 patients (17.5%) had laparotomy conversion; because of size of uterus in 3 cases, suspected ovarian tumor in 3 cases. Pelvic adherences in 4 cases, urinary tract injuries in 1 case, hypercapnia in 1 case, hemorrhage in 2 cases. 9 patients experienced febrile morbidity and 1 urinary infection. 1 patient received 2 units of packed red blood cells. The hospital stay was 5 days for laparoscopically assisted vaginal hysterectomy versus 5.9 for laparotomic hysterectomy. CONCLUSION: Laparoscopically assisted vaginal hysterectomy offers a technique to convert certain abdominal hysterectomies into vaginal hysterectomies with a 17.5% laparoconversion rate.     

Multiple models and mental illnesses: A rejoinder to "Failure of a moral enterprise: Attitudes of the public toward mental illness" by T. R. Sarbin and J. C. Mancuso.

Critically analyzes the T. R. Sarbin and J. D. Mancuso (see record 1971-04081-001) report. Data are presented indicating that the public is (a) generally accepting of the medical model of mental illness; (b) optimistic about prognosis; and (c) able to identify the simple schizophrenic, the alcoholic, and the juvenile character disorder as mentally ill and in need of medical care. The public does not place a sizable social distance between themselves and those labeled mentally ill. These data contradict the claims advanced for a unitary social deviancy model. It is argued that the medical model is neither rejected by the public nor discredited by current research. The need is not for the abandonment of medical and psychological models which have already demonstrated formidable heuristic value; what is needed is recognition that there are many different kinds of mental illnesses and that multiple models may consequently have value. (20 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outpatient hysterectomy: determinants of discharge and rehospitalization in 133 patients

OBJECTIVE: This study examines our continuing experience in performing vaginal hysterectomies and laparoscopy-assisted vaginal hysterectomies with an outpatient protocol. The purpose was to review factors associated with discharge and hospitalization. STUDY DESIGN: Surgical records from all women entering our previously reported outpatient hysterectomy protocol were reviewed. Demographics, surgical indications, intraoperative data, and postoperative data were studied, and their associations with patient discharge and hospitalization were determined. Specific attention was directed to complications. RESULTS: The study group consisted of 133 women. Twelve women (9.0%) were not discharged from the hospital and 5 (3.8%) required readmission. Surgical indications, the type of hysterectomy, and the requirement for pain medication revealed no association with hospitalization. The occurrence of an intraoperative complication (p < 0.000), the need for transfusion (p = 0.043), and postoperative antiemetics (p = 0.013) were statistically associated with hospitalization. In addition, low hematocrit values and elevated temperatures on the first and second postoperative days were associated with hospitalization. CONCLUSION: Long-term experience with outpatient hysterectomy reveals a hospitalization rate of 12.8%. Complications, blood loss, elevated temperatures, and postoperative nausea are the major determinants of patient discharge and hospitalization. Readmission rates continue to remain low.     

Information technology and the clinical curriculum: some predictions and their implications for the class of 2003

Information technology, medical knowledge, and medical practice are on a collision course. The consequences of the impact will change the way physicians work, the way medical knowledge is processed, packaged, and distributed, and the way patients obtain medical care and information. Today's educators need to design an information technology curriculum to prepare students for this emerging world of practice. Computer labs, based on today's complex and unreliable desktop systems, are not the answer. What is needed by students who entered medical school in 1997-98 is an informatics curriculum that is based on the real-world requirements of 2003 and beyond. The authors draw upon academic studies and their own clinical and industry experiences to outline some predictable elements of what lies ahead. Their predictions--ubiquitous, simple network computing and "power tools" for managing medical knowledge--have implications for how schools cover such educational topics as patient confidentiality, systems thinking and error management, and knowledge resource evaluation.     

Specific detection of myeloma plasma cells using anti-idiotypic single chain antibody fragments selected from a phage display library

OBJECTIVES: The authors examined how the courts have responded to public and private insurers' use of medical appropriateness criteria to establish coverage and payment policies. METHODS: A structured review of all federal and state court health insurance cases decided between 1960 and June 1994 that involved a dispute involving medical appropriateness was performed. A total of 3,215 published court decisions were analyzed, of which 203 met the criteria of relevance and 124 explicitly mentioned medical appropriateness criteria. The main outcome variable was whether the court ordered the insurer to provide coverage. RESULTS: In 185 cases, a definitive decision was rendered, and the insurer was required to pay in 57% of the decisions. Whether the insurer relied on an assessment or not, whether the assessment process was formal or informal, and who conducted the assessment did not appear to influence courts' decisions, nor did the specificity of the coverage exclusion. Significant predictors of courts ordering coverage were court jurisdiction, contract language assigning discretion to the insurer, severity of patient's condition, and whether the treatment appeared to work for the particular patient. CONCLUSIONS: For practice guidelines to be accepted by the courts, it is more important to focus on how insurance contracts are written than on how medical assessments are performed.     

Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial

OBJECTIVES: To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure. DESIGN: A multicentre, prospective, randomised, controlled study. PARTICIPANTS: One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks. INTERVENTIONS: Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery. MAIN OUTCOME MEASURES: Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment. RESULTS: After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12-week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; chi2(1) = 19.18, P < 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction. CONCLUSIONS: Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.     

Mental health care: Access, stigma, and effectiveness.

Discusses the lack of commitment by the US as a nation to ensure that high-quality mental health care will be provided to all who are in need. The mental health benefits under Medicare and Medicaid programs are meager at best. Psychologists and other nonphysician health care providers are not considered bona fide professionals. Prevention, program evaluation efforts, and the use of alternatives to traditional inpatient care, such as halfway houses and crisis intervention programs, are not treated under the current reimbursement system. An "efficacy proposal" created by US Senators D. K. Inouye and S. M. Matsunaga is described. The essence of the proposal was modeled after the current Food and Drug Administration requirements for safety and efficacy for all new drugs and medical devices. In addition to these 2 requirements, the notion of "appropriateness" or "cost-effectiveness" was added. This proposal, which was deleted in 1980, would have established an interdisciplinary commission comprised of representatives of both the scientific and clinical communities. The commission would have been charged with the responsibility for making recommendations as to what types of mental health services, and under what conditions, should be reimbursed under the Social Security Act. It is concluded that the establishment of an independent entity with the charge of seriously reviewing the "probably public benefit" of providing psychotherapy would be in the national interest of the US. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A physicist's perspectives on the complementary roles of the physical and behavioral sciences.

Discusses issues faced by scientists and by science and technology and ways in which psychologists and other social scientists can aid the process of resolving these issues. One such area is the need for greater attention to education in mathematics and sciences, by both teachers and students; psychologists must work with educators and administrators in the implementation of programs designed to meet the demands posed by a world increasingly dependent on technology. In the same way, psychologists can address a number of socially oriented scientific issues, such as increasing minority and female participation in scientific professions, and in developing socially acceptable and viable approaches to problems in energy use, environmental preservation, and other areas. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What happened to street kids? An analysis of the Mexican experience

This paper documents some possible reasons of failure of programs for street children in Mexico, and provides background information on demographic and socioeconomic trends that underlay self-employment as well as a historical perspective of the social context of street children. It also describes the strategies used to survive in the streets, trends in drug use/misuse, the felt needs of children and the social responses to this problem. It documents how underlying failure there are unrealistic goals, a fragmented perception of the problem and consequently, a fragmented response to it. It also refers to the great pressure on institutions for results, lack of continuity of the programs and disregard of the perception and felt needs of working children who should benefit from these programs.     

Perioperative nurses' roles in managing new technology

The scientific knowledge base for medical technology doubles every two years. Whether new technologies will improve health care depends on how appropriately they are used; therefore, purchasing appropriate technology is crucial. Appropriate technologies include those that are valid, adaptable, acceptable, and affordable. Perioperative nurses can facilitate acquisition and use of appropriate technology in the OR by applying the process of technology assessment--a five-step process that examines the need, safety, effectiveness and efficacy, economic appraisal, and social impact of new technology. This article details the technology assessment process and provides methods of preparing perioperative staff members to use new technology.     

Costs and charges associated with three alternative techniques of hysterectomy

BACKGROUND: Many hysterectomies are now performed by a laparoscopically assisted vaginal technique. This procedure is controversial, partly because of concern about cost. We studied hospital charges and costs for the procedure as compared with those for total abdominal hysterectomy and total vaginal hysterectomy in clinically similar groups of patients. METHODS: From hospital-discharge data and patients' charts, we identified hysterectomies performed in 1993 and 1994 by 96 surgeons at a community teaching hospital to treat benign conditions. The patients were grouped according to the surgical procedures performed in conjunction with the hysterectomy. Data on hospital charges and cost-to-charge ratios for 64 hospital cost centers were used to assess charges and costs for specific resources, as well as for the hospitalization overall. RESULTS: Of 1049 patients studied, 26 percent underwent laparoscopically assisted vaginal hysterectomy, 54 percent underwent abdominal hysterectomy, and 20 percent underwent vaginal hysterectomy. The average hospital stays were 2.6, 3.9, and 2.9 days, respectively, and the mean total charges (facility charges plus professional fees) for the hospitalizations were $6,116, $5,084, and $4,221 (P<0.001 for the comparison of the laparoscopic technique with both other techniques). The mean facility costs were $4,914, $3,954, and $3,116, respectively (P<0.001 for the same comparison), with similar findings in all subgroups. The higher charges and costs for laparoscopically assisted vaginal hysterectomy were due to higher supply costs, particularly when disposable supplies were used, and to longer operating-room time. CONCLUSIONS: Despite shorter hospital stays, in-hospital charges and costs for laparoscopically assisted vaginal hysterectomy are higher than for either alternative procedure, because of the disposable supplies that are typically used and the longer operating-room time.