Reengineering a radiology department in an academic institution

OBJECTIVE: A 1-year program was undertaken in conjunction with an outside consultant to cut nonphysician labor expenses by 15%, cut nonlabor expenses by 10%, and improve all service parameters in an academic radiology department. MATERIALS AND METHODS: A steering committee decided on five major goal teams: improve report turnaround time and improve patient throughput, increase the efficiency of performance and improve the quality of radiologic examinations, decrease the cost of each examination, improve charge capture, and improve the perception of the department. The goal teams met at least every 2 weeks, made presentations to the steering committee at midyear, and were then disbanded. The steering committee implemented changes in the second half of the year and continues to meet every 2 weeks. Data were obtained from the radiology information system, financial statements, and surveys. RESULTS: In the first year, report turnaround time decreased from 157 hr to 83 hr (and to 46 hr at 2 years), the efficiency of performing examinations (according to our criteria) improved from 64% to 80%, the quality of examinations improved, labor costs were reduced by 5% (and by 11% at 2 years), nonlabor costs were reduced by 14% (and by 31% at 2 years), cost per examination was reduced by 10% (and by 16% at 2 years), increased charge capture resulted in an annual increase in professional fees of at least $110,000, and the perception of the department by referring clinicians improved. CONCLUSION: It is possible to simultaneously cut expenses and improve service. To gauge progress, objective parameters that can be measured easily are necessary.     

Hand-assisted laparoscopic splenectomy for hydatid cyst

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the "helping hand."     

Elective laparoscopic splenectomy for hematologic disorders

Laparoscopic splenectomy has been reported to be the procedure of choice in selected patients with hematologic disorders. The purpose of this study is to review our experience with laparoscopic splenectomy in this patient population. The charts of all patients with hematologic disorders who presented for laparoscopic splenectomy over a 17-month period were reviewed. Fifteen patients, nine males and six females, aged 12 to 80 years (mean, 49 years) presented for laparoscopic splenectomy. Surgical indications included 13 cases of idiopathic thrombocytopenic purpura and one each of hemolytic anemia and Hodgkin's disease. Splenectomy was performed utilizing a four- or five-puncture laparoscopic technique. For completed laparoscopic splenectomies, the mean operative time was 129 minutes, and the mean estimated blood loss was 232 cc. Mean splenic weight was 210 g. There were no operative deaths. There was a single intraoperative complication, a 1700-cc hemorrhage, and two postoperative complications: pneumonitis and deep venous thrombosis. Overall morbidity was 20 per cent. A single patient (7%) required conversion to laparotomy for completion due to hemorrhage. For patients completed laparoscopically, the mean hospitalization was 1.5 days, and none required parenteral narcotics for pain control after the first 36 hours. Laparoscopic splenectomy for patients with hematologic disorders is a safe and technically feasible procedure. Decreased hospitalization and discomfort are the primary benefits. This technique should be added to the repertoire of surgeons treating patients with hematologic disorders.     

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.     

Portal thrombosis. A rare complication of laparoscopic splenectomy

Portal thrombosis is a rare complication of splenectomy. We performed 12 laparoscopic splenectomies and observed this complication only in one patient with idiopathic thrombocytopenia (ITP). The right branch of the portal vein presented a partial thrombosis, while the left branch was completely obstructed by thrombi. Abdominal ultrasonography and an ultrasound doppler exam allowed us to diagnose this event and a retrograde angiography performed afterward confirmed our diagnosis. A 48-h intravenous heparin treatment was promptly begun, followed by anticoagulant drugs (dicumarol). The patient was dismissed 5 days afterward, presenting a steady-state ultrasound doppler pattern and a complete normalization of liver parameters. An ultrasound doppler exam performed 1 month after anticoagulant therapy showed a complete resolution of portal thrombosis. We believe that early diagnosis of this rare complication, prompt beginning of anticoagulant therapy, and care in surgical procedures may reduce patient life-threatening risks and assure complete remission.     

The learning curve associated with laparoscopic antireflux surgery in infants and children

Laparoscopic fundoplication is an effective method for treating gastroesophageal reflux in infants and children. Some surgeons prefer the traditional open technique and have concerns regarding complications associated with laparoscopic surgery as well as the time length of operation. This report addresses these concerns in a retrospective review of the first 160 consecutive pediatric patients who underwent laparoscopic fundoplication. "Learning Curves" as a function of surgical experience are presented highlighting some of the lessons learned while developing the laparoscopic fundoplication technique.     

A case controlled comparison of open and laparoscopic splenectomy in children

BACKGROUND: This case controlled study compares the efficacy, safety, and cost of laparoscopic splenectomy (LS) and open splenectomy (OS) for hematologic disorders in children. METHODS: The records of 82 consecutive children and adolescents undergoing splenectomy for hematologic disorders between August 1994 and September 1997 were reviewed retrospectively. RESULTS: Fifty patients underwent LS by a lateral approach and 32 underwent OS through a left subcostal incision. Mean age was 7.76 years for LS and 6.9 years for OS. Patient weights were similar: (LS, mean 30.5 kg; OS, mean 27.6 kg). Hematologic indications included hereditary spherocytosis in 43 children (LS 26, OS 17), sickle cell anemia with sequestration in 13 (LS 7, OS 6), immune thrombocytopenic purpura in 14 (LS 8, OS 6), and 12 with other disorders (LS 9, OS 3). Concomitant cholecystectomy was performed in 10 of 50 LS and 6 of 32 OS cases. Accessory spleens were identified in 8 of 32 (25%) OS and 9 of 50 (18%) LS cases (P = .578). No LS procedures required conversion to OS. The mean estimated blood loss was 54.4 mL for LS and 49.0 mL for OS (P = .233). LS required a longer operative time (115 vs 83 minutes, P = .002), less need for postoperative intravenous narcotic (51% vs 100%, P < .0001), lower total narcotic doses (0.239 vs 0.480 mg/kg morphine, P = .006), shorter length of hospital stay (1.4 +/- 0.97 vs 2.5 +/- 1.43 days, P = .0001), and lower average total hospital charges ($5713 vs $6564) than OS. There were no deaths or major complications in either group. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration, shorter length of stay, and lower total hospital charge.     

The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies

BACKGROUND: Laparoscopic-assisted colectomy is an emerging technology for patients with cancer, polyps, inflammation, and other types of pathologic conditions. While previous studies have shown better outcomes for laparoscopic cholecystectomies when surgeons perform more procedures, there is no information on the relationship between surgeon volume and outcomes for laparoscopic-assisted colectomy. OBJECTIVE: To evaluate whether better clinical outcomes are found for surgeons who perform higher numbers of laparoscopic-assisted colectomies and whether such a relationship, if it exists, applies to both intraoperative and postoperative outcomes. DESIGN: Analysis of a data set of 1194 patients, operated on by 114 surgeons, from a prospective registry sponsored by the American Society of Colon and Rectal Surgeons, from May 1991 to October 1994. MAIN OUTCOME MEASURES: Completion rate, intraoperative and postoperative complications, and length of hospital stay. RESULTS: In 75% of cases, surgery was completed laparoscopically, with no difference between high-volume surgeons (> or = 40 cases) and low-volume surgeons. Length of stay (average, 6 days) did not vary according to surgeon volume. Postoperative complications occurred in 15% of cases, with a significantly lower rate for high-volume surgeons (10% vs 19%; P < .001). Intraoperative complications occurred in 5% of cases, with a nonsignificant trend toward a lower rate for high-volume surgeons (3.7% vs 6.3%). A multivariate regression analysis, adjusting for type of disease (cancer vs inflammation vs polyps) and for level of difficulty of the procedure (high vs low) showed that for high-volume surgeons there is a lower probability of both intraoperative complications (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.97; P = .04) and postoperative complications (adjusted odds ratio, 0.48; 95% confidence interval, 0.34-0.68; P < .001). CONCLUSIONS: There is a learning curve for laparoscopic-assisted colectomy with respect to intraoperative and postoperative outcomes. As with other laparoscopic procedures, surgeons who perform higher volumes of laparoscopic-assisted colectomy have lower rates of intraoperative and postoperative complications.     

A social cognitive view of self-regulated academic learning.

Researchers interested in academic self-regulated learning have begun to study processes that students use to initiate and direct their efforts to acquire knowledge and skill. The social cognitive conception of self-regulated learning presented here involves a triadic analysis of component processes and an assumption of reciprocal causality among personal, behavioral, and environmental triadic influences. This theoretical account also posits a central role for the construct of academic self-efficacy beliefs and three self-regulatory processes: self-observation, self-judgment, and self-reactions. Research support for this social cognitive formulation is discussed, as is its usefulness for improving student learning and academic achievement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development of an outcomes management program at an academic medical center

Donor CD4+ and CD8+ T cells mediate graft-vs.-leukemia (GVL) responses in the allogeneic bone marrow transplantation (alloBMT) setting. To evaluate the role of functional T cell subsets in the mediation of GVL, alloreactive donor CD4+ (Th1/Th2) and CD8+ (Tc1/Tc2) T cells of defined cytokine phenotype were generated by in vitro culture. A leukemia/transplantation model (B6 into B6C3F1; 1050 cGy host irradiation) was established using the bcr/abl-transfected myeloid leukemia line, 32Dp210 (P210; H-2k). Leukemia control mice (1X10(4) P210 cells per recipient) died at day 12.0 post-BMT. Recipients of the CD4+, Th1-type or CD8+, Tc1-type populations were conferred a survival advantage (death at 20.7 and 23.5 days post-BMT, respectively). In contrast, the CD4+, Th2-type population did not mediate GVL (death at 12.3 days). Furthermore, cell mixing experiments demonstrated that the Th2 subset abrogated both Th1- and Tc1-mediated GVL. The CD8+, Tc2 population, which secreted type II cytokines and lysed the P210 leukemia target in vitro, mediated GVL in some experiments; interestingly, the magnitude of Tc2-mediated GVL was inversely related to the level of interleukin-10 (IL-10) secreted in vitro by the Tc2 population. These studies therefore indicate that alloreactive T cells of type I phenotype maximally generate GVL, and that type I/type II interactions are an important consideration for allogeneic transplantation in the setting of leukemic hosts.     

Present status of laparoscopic splenectomy for hematologic diseases: certitudes and unresolved issues

Laparoscopic splenectomy is considered to be the "gold-standard" treatment of benign hematologic diseases, with normal or slightly enlarged spleens. Laparoscopic treatment of malignant diseases and splenomegalies remains more controversial. The procedure requires a great surgeon's laparoscopic expertise, appropriate positioning of the patient and trocar insertion, and gentle and meticulous dissection of the spleen. The technique is feasible in 91% of the patients with a 0.9% operative mortality and a postoperative complications rate of 12%. When compared with open splenectomy in retrospective case-controlled studies, the laparoscopic approach includes a longer operative time and higher operative room costs. However, advantages include reduced postoperative hospital stay and faster return to normal activities. Despite scarce reported data, long-term hematologic cure rate seems to be equivalent in patients with idiopathic thrombocytopenic purpura. The accuracy of laparoscopic exploration to detect all accessory spleens is however questioned, and residual postoperative accessory splenic tissues have been observed. Prospective randomized controlled trials comparing short- and long-term results of open and laparoscopic splenectomies are required to confirm definitely the role of laparoscopy in the management of hematologic disorders.     

Learning as accumulation: A reexamination of the learning curve.

Theories of learning that predict a negative exponential growth curve are based on the assumption that learning is a process of replacement—incorrect response tendencies are replaced with correct ones. In the present article, an alternate model is presented that describes learning as a process of accumulation where incorrect response tendencies remain constant and correct response tendencies increase with practice. These 2 approaches were compared in their ability to describe the shapes of the learning curves for several experiments in free recall and perceptual and motor learning. In nearly every case, the predictions of the accumulation model were superior, and the predictions of the best fitting replacement equations failed in systematic ways. The relationship between the accumulation model and a reinforcement theory of steady-state responding is discussed. It is argued that the accumulation model should be given greater consideration as a viable model of the learning process. (68 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-motivational characteristics and academic achievement of learning disabled children: A longitudinal study.

Academic self-concept, academic locus of control, and achievement expectations were investigated over a 2-year period for 78 children identified as learning disabled (LD) and 71 non learning disabled, normally achieving children (NLD). The LD children had no remedial program for their learning problems and had not been classified by the schools as LD. The data were collected while the sample was in junior high school. Five schools participated in the project. The results indicated that in comparison with NLD students, the LD children had lower self-perceptions of ability, showed signs of learned helplessness, and reported lower achievement expectations. These differences were well established at the start of Year 1 of the project and remained consistent through to the end of Year 2. The hypothesis that LD children not receiving remedial help would develop increasingly negative affective characteristics was therefore not supported. Correlation and regression data show that academic self-concept scores were the single best predictor of achievement levels. I suggest that negative school-related attitudes develop early in the school lives of LD children and remain negative but consistent through high school. Some consequences for future learning and remedial programming are considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A technic for laparoscopic gastrostomy

The authors describe the technique of laparoscopic gastrostomy and laparoscopic assisted gastrostomy. It is an alternative method for patients, when PEG (percutaneous endoscopic gastronomy) or other more physiologic way of food administration is not possible to perform.     

Perceptions of self-managed learning opportunities and academic locus of control: A causal interpretation.

566 students in Grades 5, 6, and 7 were assessed at the beginning and the end of a school year on their perception of opportunities for self-management of their instruction and on their academic locus of control (Attitude Toward Learning Processes instrument and the Intellectual Achievement Responsibility Questionnaire, respectively). Data were analyzed by a cross-lagged panel correlation technique. Perceptions of opportunity for self-management of instruction were causally prior to perceptions of academic locus of control. It is suggested that if students perceive the classroom as a place where they can in part manage their own instruction, then they are likely to accept responsibility for their academic successes and especially for their academic failures. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Investigating the academic achievement of adolescents with learning disabilities: A structural modeling approach.

Although academic performance is a primary component of the federal definition of learning disabilities (LD), there have been few investigations of factors that influence academic growth among adolescents with LD. The focus of the present study is parental attitudes, their effects on adolescents with and without LD and on the academic achievement of those students. The estimated model accounted for 72% and 74% of the variance in academic achievement for the groups of students with and without LD, respectively. The findings support the position that parental expectations and perceptions of parental expectations are instrumental in raising the academic expectations and the achievement of adolescents with and without LD. The comparison between the students with and without LD showed that the most important factors were the same for both groups, suggesting the model worked in the same way for the two populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Bayesian model for growth curve analysis

An experiment involves K subjects where for subject i, ni, values yi1, yi2, ..., y(ini) of a random variable Y are observed at times ti1 ti2, ..., t(ini). Assume that yij = F(tij) +eij where eij are independently and identically distributed (i.i.d.) N(0, sigma2). We consider the estimation of the function F and the testing of the homogeneity hypothesis that, for [formula, see text] does not depend on t. The function F(i,t) is modelled as a Gaussian process which seeks to quantify the notions that for each i, F(i, t) is a slowly changing function of t and that for i is not equal to j, F(i, t), and F(j, T) are in some sense similar. We propose to estimate F (i, t) by its posterior mean given all of the data. This Bayes estimate is shown to be equivalent to a particular form of penalised likelihood estimation. We consider data-based methods for setting the parameters of the Gaussian process prior, develop a test of the homogeneity hypothesis, report the results of a Monte Carlo study illustrating the effectiveness of the proposed methodology, and apply the methods to a study of variations in temperature and blood pressure over the course of the menstrual cycle.