White Paper AGA: An Episode-of-Care Framework for the Management of Obesity-Moving Toward High Value, High Quality Care: A Report From the American Gastroenterological Association Institute Obesity Episode of Care and Bundle Initiative Work Group.

The American Gastroenterological Association acknowledges the need for gastroenterologists to participate in and provide value-based care for both cognitive and procedural conditions. Episodes of care are designed to engage specialists in the movement toward fee for value, while facilitating improved outcomes and patient experience and a reduction in unnecessary services and overall costs. The episode of care model puts the patient at the center of all activity related to their particular diagnosis, procedure, or health care event, rather than on a physician's specific services. It encourages and incents communication, collaboration, and coordination across the full continuum of care and creates accountability for the patient's entire experience and outcome. This paper outlines a collaborative approach involving multiple stakeholders for gastrointestinal practices to assess their ability to participate in and implement an episode of care for obesity and understand the essentials of coding and billing for these services.

Wartime burn care in Iraq: 28th Combat Support Hospital, 2003.

INTRODUCTION: The U.S. Army 28th Combat Support Hospital (CSH), an echelon III facility, deployed to Iraq at the start of military operations in 2003. Shortly after arrival, it was designated as the hospital primarily responsible for burn care for the U.S. military in Iraq. This report reviews the experience of the CSH with burn care during combat operations. METHODS: An after-action review was conducted during a 2-day period after the hospital's redeployment. RESULTS: Between April 11, 2003, and August 21, 2003, the 28th CSH treated a total of 7,920 patients, of whom 103 (1.3%) had burns. Patients included U.S. and allied service members, U.S. contractors, and Iraqi prisoners of war and civilians. Although a CSH is designed to care for patients until they can be stabilized and evacuated, usually within 1 to 3 days, the length of stay for some Iraqi patients was as long as 53 days. Definitive care, including excision and grafting of the burn wound, was thus required for some Iraqi patients. The largest graft completed comprised 40% of the total body surface area. The largest burn survived involved approximately 65% of the total body surface area. Eighteen (17%) of 103 patients returned to duty after treatment at the 28th CSH. The mortality rate for burn patients at the 28th CSH was 8%. Shortages of burn-experienced personnel and burn-specific supplies were identified during the after-action review. CONCLUSIONS: The CSH provided complex definitive care to burn patients in an austere environment. Predeployment identification of military field hospitals for such specialized missions, with early assignment of experienced personnel and materiel to these units, may improve future wartime burn care.

Burn support for Operation Iraqi Freedom and related operations, 2003 to 2004.

Thermal injury historically constitutes approximately 5% to 20% of conventional warfare casualties. This article reviews medical planning for burn care during war in Iraq and experience with burns during the war at the US Army Burn Center; aboard the USNS Comfort hospital ship; and at Combat Support Hospitals in Iraq and in Afghanistan. Two burn surgeons were deployed to the military hospital in Landstuhl, Germany, and to the Gulf Region to assist with triage and patient care. During March 2003 to May 2004, 109 burn casualties from the war have been hospitalized at the US Army Burn Center in San Antonio, Texas, and US Army Burn Flight Teams have moved 51 critically ill burn casualties to the Burn Center. Ten Iraqi burn patients underwent surgery and were hospitalized for up to 1 month aboard the Comfort, including six with massive wounds. Eighty-six burn casualties were hospitalized at the 28th Combat Support Hospital for up to 53 days. This experience highlights the importance of anticipating the burn care needs of both combatants and the local civilian population during war.

Hepatic reticuloendothelial system dysfunction after ischemia-reperfusion: role of P-selectin-mediated neutrophil accumulation.

The relationship between hepatic ischemia-reperfusion (I-R) and subsequent injury through neutrophil accumulation is well described. Although alterations in reticuloendothelial system (RES) function (specifically Kupffer cell function) after I-R have been delineated, the degree to which discrete components of RES function (phagocytosis and killing) are independently modulated under these conditions has not been quantified. A hepatic segmental I-R model was established in mice, in which blood supply to the left lateral lobe of the liver was occluded for 45 minutes, the liver was reperfused, and the laparotomy incision was closed. Experimental animals were pretreated with either vinblastin (1.5 mg/kg) to induce neutropenia or anti-P-selectin monoclonal antibody (mAb; 50 microg/mice) 4 days and 5 minutes before ischemia, respectively. We previously reported that after intravenous injection of chromium 51 ((51)Cr) and iodine 125 ((125)I) double-labeled Escherichia coli, hepatic (51)Cr levels could be used to reliably quantify hepatic phagocytic clearance (HPC) of bacteria from blood, whereas the subsequent release of (125)I from the liver accurately paralleled hepatic bacterial killing efficiency (HKE). Using this double-label bacteria clearance assay, HPC and HKE were depressed after I-R, in association with hepatic neutrophil accumulation. Segmental I-R resulted in decreased HPC and HKE activity in both ischemic and nonischemic hepatic lobes. Depressions in HPC and HKE were attenuated by either vinblastin-induced neutropenia or blocking neutrophil adhesion to the hepatic endothelium with anti-P-selectin mAb. These findings support the hypothesis that I-R induces hepatic RES dysfunction, at least in part, through P-selectin-mediated neutrophil accumulation.