Comparative effectiveness of surgeon-performed transversus abdominis plane blocks and epidural catheters following open hernia repair with transversus abdominis release.

PURPOSE: Recovery protocols aim to limit narcotic administration following ventral hernia repair (VHR). However, little is known about the contribution of a protocol's individual components on patient outcomes. We previously reported that surgeon-performed transversus abdominis plane block (TAP-block) is more effective than ultrasound-guided TAP-block following VHR. This study evaluates the effectiveness of two postoperative analgesia modalities: epidural catheter and surgeon-performed TAP-block following VHR performed with transversus abdominis release (TAR). METHODS: A retrospective analysis was performed on data prospectively collected between 2012 and 2019. All patients undergoing open VHR with TAR performed by a single surgeon were identified. Parastomal hernia repairs and any patients receiving ultrasound-guided TAP blocks or paraspinal blocks were excluded. Primary outcome was length of stay (LOS) with secondary outcomes including pain scores, opioid requirements, and 30-day morbidity. Linear regression was used to model LOS. RESULTS: One hundred thirty-five patients met inclusion criteria (63 epidural, 72 TAP-block). The majority (67.4%) of patients were modified ventral hernia working group grade 2. The only statistically significant difference in postoperative pain scores between the groups was on postoperative day 2 (TAP block 3.19 versus epidural 4.11, p = 0.0126). LOS was significantly shorter in the TAP block group (4.7 versus 6.2 days, p = 0.0023) as was time to regular diet (3.2 versus 4.7 days, p < 0.0001). After controlling for confounders, epidural was associated with increased LOS by 1.3 days (p = 0.0004). CONCLUSION: Epidural use following VHR with TAR is associated with increased LOS and increased time to regular diet without reducing pain or opioid use when compared to surgeon-performed TAP block.

RISK FACTORS FOR READMISSION AND LENGTH OF INPATIENT STAY IN RURAL GHANA FOLLOWING EXPLORATORY LAPAROTOMY.

BACKGROUND: Increased inpatient length of stay (LOS) and readmission represent significant economic burden on patients and families faced with surgical disease in low-middle income countries given limited surgical access, infrastructure, and variable insurance status. STUDY AIM: Identify risk factors for readmission and inpatient LOS in postoperative care in the Eastern Regional Hospital, Ghana. STUDY DESIGN: Retrospective case series. SETTING: Eastern Regional Hospital, Koforidua, Ghana. METHODS: Data for exploratory laparotomy procedures were obtained from surgical case logs collected at the regional referral hospital in Koforidua, Eastern Region, Ghana from July 2017 to June 2018. This information was combined with the hospital electronic medical records to collect demographic data, laboratory values, and outcomes. Multivariable analyses were used to model LOS and readmission. RESULTS: The study included 346 exploratory laparotomy procedures (286 adult, 60 pediatric) for various surgical diseases. The overall 30-day readmission rate was 9.2%. Average LOS was 12.0±20.4 days for readmitted patients and 6.7±5.5 days for patients without readmission. Readmitted patients were more likely to have had preoperative anemia (p=0.009), surgical site infection (P=0.001), or a re-laparotomy (p=0.005). Preoperative anemia (OR=3.5 [95% CI 1.54-7.96], p=0.003) and surgical site infection (OR=3.68 [95% CI 1.36-10.00], p=0.011) were associated with increased odds of readmission. Preoperative anemia was also associated with about 3.0 additional inpatient days (p=0.001). CONCLUSION: Preoperative anemia and surgical site infections represent risk factors for readmission in rural Ghana. Anemia is also associated with longer LOS. Future interventions aimed at treating anemia and preventing surgical site infections may reduce some of the post-operative burden placed on patients and their families.

Impact of smoking on the surgical outcome of Crohn's disease: a propensity-score matched National Surgical Quality Improvement Program analysis.

AIM: Smoking is known to have a deleterious effect on Crohn's disease (CD). The present study addressed the specific impact of smoking on the outcome of surgery for CD. METHOD: A review of the National Surgical Quality Improvement Program (NSQIP) database (2005-2012) identified 7631 patients with CD who underwent surgical resection. Patients were stratified based on smoking status and were compared with univariate statistical tests. Generalized linear regression and multiple logistic regressions were used to model the impact of smoking on the surgical outcome [length of stay (LOS), mortality, postoperative complications and readmission]. To confirm the validity of the regression models and to evaluate the influence of smoking in comparable patient cohorts, a propensity score match was also performed. RESULTS: There were 2047 (26.8%) patients with CD identified as current smokers, and 5584 (74.2%) identified as non- or ex-smokers. Smokers were more likely to have a pulmonary comorbidity, preoperative weight loss and a higher American Society of Anesthesiologists classification. No differences in mortality were observed between smokers and non- or ex-smokers in univariate analysis. In multivariate analysis, smoking status was not significantly associated with LOS. Morbidity (OR 1.20, P = 0.003), particularly infectious (OR 1.30, P < 0.001) and pulmonary (OR 1.87, P < 0.001) complications, and readmission (OR 1.58, P = 0.004) were significantly associated with smoking status. These findings were validated on propensity-score matching analysis. CONCLUSION: In patients with CD, the detrimental effects of smoking on surgical outcomes are driven by infectious and pulmonary complications, and by an increased likelihood of readmission.

Laparoscopic colectomy is associated with a lower incidence of postoperative complications than open colectomy: a propensity score-matched cohort analysis.

AIM: Elective laparoscopic colectomy (LC) has been shown to provide short-term results comparable with open colectomy (OC), but there is potential selection bias whereby LC patients may be healthier and therefore more likely to have a superior outcome. The aim of this study was to compare the incidence of postoperative complications between matched laparoscopic and open colectomy cohorts, while controlling for differences in comorbidity. METHOD: A retrospective cohort study (2005-2010) using National Surgical Quality Improvement Program data was performed, identifying laparoscopic and open partial colectomy patients through common procedural terminology codes. Patient having rectal resection were excluded. The cohorts were matched 1:1 on a propensity score to control for observable selection bias due to patient characteristics, comparing overall complication rates, length of hospital stay (LOS), the incidence of superficial (S-SSI) surgical site infection, urinary tract infection (UTI) and deep-venous thrombosis (DVT). RESULTS: We analysed 37 249 patients. After propensity score matching the LC group had a significantly lower overall incidence of postoperative complications (29.1 vs 21.2%; P < 0.0001), S-SSI (9.0 vs 5.9%; P = 0.003) and DVT (1.2 vs 0.3%; P = 0.001). The LC group had a shorter LOS (8.7 vs 6.4 days; P < 0.0001), while mortality was comparable between the two groups (4.0 vs 4.1%; P = 0.578). CONCLUSION: LC is associated with a lower incidence of S-SSI and DVT than OC. Previously suggested advantages for laparoscopy, such as shorter length of stay and overall rate of complications, were observed even after controlling for differences in comorbidity.

Is colectomy for fulminant Clostridium difficile colitis life saving? A systematic review.

AIM: It is unclear whether colectomy for fulminant Clostridium difficile colitis (FCDC) leads to a improvement in survival compared with continued medical therapy for this moribund population. METHOD: Selected studies from 1994-2010 were identified through a comprehensive search theme applied to MEDLINE (OvidSP and PubMed), EMBASE and by hand searching. Data regarding mortality rates between medically and surgically treated patients were extracted. Risk of bias was assessed using a Newcastle-Ottawa Scale score. A meta-analysis of the odds ratios for mortality between surgical and medical treatment for FCDC was conducted using the Mantel-Haenszel method and fixed-effects modelling. RESULTS: Five hundred and ten patients with FCDC were identified in six studies. The pooled adjusted odds ratio of mortality comparing surgery with medical therapy was 0.70 (0.49-0.99), suggesting that surgery provided a survival benefit. CONCLUSION: Emergent colectomy for patients with FCDC provides a survival advantage compared with continuing antibiotics. Though there is selection bias of patients having surgery, the results of this systematic review suggest that colectomy has a therapeutic role in treating severe forms of C. difficile colitis.

Impact of Clostridium difficile colitis following closure of a diverting loop ileostomy: results of a matched cohort study.

AIM: Previous reports describing Clostridium difficile colitis (CDC) developing after the closure of a loop ileostomy suggest it is severe. In this study the incidence of CDC following ileostomy closure and its effect on the postoperative outcome have been studied. METHOD: Patients undergoing closure of loop ileostomy from 2004 to 2008 were analysed using the Nationwide Inpatient Sample. Patients who developed postoperative CDC (n = 217) were matched 10:1 to a propensity-score-matched cohort of patients without CDC (n = 13 245). Linear and logistic regression were used to examine the effect of CDC on hospital cost (US dollars), length of stay and mortality rates. Population resampling was performed using nearest neighbour bootstrapping to confirm the validity of the results. RESULTS: The incidence of CDC following ileostomy closure was 16 per 1000 patients. The mean length of stay was 11.5 days longer among CDC patients (P < 0.0001), with a greater cost of hospitalization of US$21 240 (P < 0.0001). There was no difference in mortality between the cohorts. CONCLUSION: CDC following ileostomy closure is an uncommon, costly and morbid complication. Patients undergoing stoma closure are at high risk for an adverse outcome if they have CDC. Should it develop they should be aggressively treated.

Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders.

AIM: Eating disorders (ED) in children and younger adolescents are becoming more evident, but there is a small evidence base for their management in this population. We hypothesized that a new family-centered partial hospital program for young patients would be effective in promoting weight gain, as well as improvement in psychiatric symptoms. METHODS: A retrospective chart review of 56 patients treated in the program between August 2008 and November 2009 was performed. Historical data, anthropometric variables and scores from psychological instruments [Children's Eating Attitudes Test (ChEAT), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS)] were collected on admission and at discharge. After exclusion, 30 patients were available for statistical analysis, using paired t-tests. The primary outcome variables were improvement in weight and change in total ChEAT score. Secondary outcomes included improvements in the CDI and RCMAS scores. Multivariate analysis included linear regression models that controlled for patient-specific fixed effects. RESULTS: The cohort was 87% female with a mean age of 12.8±2 years; 60% were diagnosed with ED not otherwise specified. Two-thirds had a co-morbid depressive and/or anxiety disorder. Change in weight was significant (p<0.0001), as were improvements on total ChEAT (p<0.0001), CDI (p=0.0002), and RCMAS (p<0.0001) scores. No historical factors were correlated with improvement, nor was use of psychotropic medications. Length of stay in weeks significantly predicted greater weight gain (p=0.004, R2=0.26). CONCLUSIONS: Patients treated in a family-centered partial hospital program had significant improvements in weight and psychological parameters. This approach holds significant promise for the management of young ED patients.

Liver transplantation for hepatitis C from donation after cardiac death donors: an analysis of OPTN/UNOS data.

Donation after cardiac death (DCD) liver transplantation is increasing largely because of a shortage of organs. However, there are almost no data that have specifically assessed the impact of using DCD livers for HCV patients. We retrospectively studied adult primary DCD liver transplantation (630 HCV, 1164 non-HCV) and 54 129 donation after brain death (DBD) liver transplantation between 2002 and 2009 using the UNOS/OPTN database. With donation after brain death (DBD) livers, HCV recipients had significantly inferior graft survival compared to non-HCV recipients (p < 0.0001). Contrary to DBD donors, DCD livers used in HCV patients showed no difference in graft survival compared to non-HCV patients (p = 0.5170). Cox models showed DCD livers and HCV disease had poorer graft survival (HR = 1.80 and 1.28, p < 0.0001, respectively). However, the hazard ratio of DCD and HCV interaction was 0.80 (p = 0.02) and these results suggest that DCD livers on HCV disease do not fare worse than DCD livers on non-HCV disease. The graft survival of recent years (2006-2009) was significantly better than that in former years (2002-2005) (p = 0.0482). In conclusion, DCD liver transplantation for HCV disease showed satisfactory outcomes. DCD liver transplantation can be valuable option for HCV related end-stage liver disease.

Reduced fracture risk with early corticosteroid withdrawal after kidney transplant.

Corticosteroid use after kidney transplantation results in severe bone loss and high fracture risk. Although corticosteroid withdrawal in the early posttransplant period has been associated with bone mass preservation, there are no published data regarding corticosteroid withdrawal and risk of fracture. We hypothesized lower fracture incidence in patients discharged from the hospital without than with corticosteroids after transplantation. From the United States Renal Data System (USRDS), 77, 430 patients were identified who received their first kidney transplant from 2000 to 2006. Fracture incidence leading to hospitalization was determined from 2000 to 2007; discharge immunosuppression was determined from United Networks for Organ Sharing forms. Time-to-event analyses were used to evaluate fracture risk. Median (interquartile range) follow-up was 1448 (808-2061) days. There were 2395 fractures during follow-up; fracture incidence rates were 0.008 and 0.0058 per patient-year for recipients discharged with and without corticosteroid, respectively. Corticosteroid withdrawal was associated with a 31% fracture risk reduction (HR 0.69; 95% CI 0.59-0.81). Fractures associated with hospitalization are significantly lower with regimens that withdraw corticosteroid. As this study likely underestimates overall fracture incidence, prospective studies are needed to determine differences in overall fracture risk in patients managed with and without corticosteroids after kidney transplantation.

A new assay to screen for head and neck squamous cell carcinoma using the tumor marker metallopanstimulin.

OBJECTIVE: To date, no serologic marker has proven effective as a diagnostic test for head and neck squamous cell carcinoma (HNSCC). Levels of metallopanstimulin (MPS), as measured by a difficult to reproduce radioimmunoassay, are significantly elevated in untreated HNSCC patients. Our objective was to develop a simpler MPS assay. METHODS: Serum was obtained from HNSCC patients through Institutional Review Board approved protocols at the Penn State University College of Medicine and healthy volunteers donating blood at the hospital blood bank from 2000 to present. Serum MPS was immunoprecipitated, slot blotted, and Western blotted. MPS levels were quantified by densitometry. RESULTS: Forty-eight blood donors and 45 known HNSCC patients were studied. The MPS level was 14 ng/mL +/- 1 (SEM) for blood donors and 36 ng/mL +/- 3 (SEM) for known HNSCC patients. The difference was statistically significant (P < 0.0001). CONCLUSION: Slot blot analysis of MPS is a safe, effective, and reproducible assay that may be used to screen for HNSCC in high-risk populations.

Development of diabetes mellitus post-renal transplantation is associated with poor short-term clinical outcomes.

BACKGROUND: Although posttransplant diabetes mellitus (PTDM) is associated with poor long-term outcomes short-term outcomes are not well studied in renal transplant recipients (RTRs). METHODS: RTRs between January 1999 and December 2000 (n = 181) stratified according to the occurrence of diabetes mellitus (DM), namely, non-DM (n = 72), previous DM (n = 88), and PTDM (n = 21) were compared for infections, hospital readmissions, and graft rejections during the first 6 months posttransplantation. RESULTS: PTDM showed patients affected by a significantly higher rate of infections (57.1% vs 29.2%) and recurrent infections (28.5% vs 11.1%) compared to non-DM and a trend toward an increase compared to previous DM. PTDM patients had a significantly higher incidence of multiple readmissions compared to both previous DM (52.4% vs 20.5%) and non-DM (52.4% vs 23.6%). Subjects with PTDM showed a significantly higher occurrence of rejection (28.6% vs 9.1%) and recurrent rejection (14.3% vs 2.3%) than previous DM and a greater trend compared to non-DM. CONCLUSION: PTDM is associated with poorer short-term outcomes than either non-DM or previous DM.

Surgical site infections following pediatric liver transplantation: risks and costs.

PURPOSE: Infectious complications following orthotopic liver transplantation (OLT) represent a significant cause of morbidity and mortality in both adults and children. In adults, surgical site infections complicating OLT have been shown to significantly increase resource utilization, but their impact in children has not been studied. In this study we identify risk factors for surgical site infections in children undergoing primary OLT for end-stage liver disease and estimate their impact on patient survival, graft survival, length of stay, and charges. METHODS: All pediatric liver transplants (n = 77) less than 16 years of age from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database were included in the analysis. Surgical site infections (n = 25) were defined as wound infections, abdominal abscesses, and bacterial or fungal infections of the liver, intestine, or peritoneum during the initial transplant admission. Risk of infection was estimated using logistic regression, survival rates were estimated using the Kaplan-Meier method, and length of stay and charges were compared using Student's t-test. Multivariate analysis of charges was performed using linear regression. RESULTS: Of the 77 patients, 25 (32.5%) developed a surgical site infection. Several factors were associated with increased risk of infections, including a leak at the biliary anastomosis (odds ratio [OR] 115, P = 0.003), preoperative white blood cell count (OR = 1.28, P = 0.009), surgery > 7 h (OR = 15.0, P = 0.011), HLA mismatches (OR = 6.0, P = 0.03), and female gender (OR = 8.0, P = 0.038). Surgical site infections did not significantly decrease either patient survival or graft survival, and increased hospital stay by an average of 21 days (P = 0.14). After controlling for other factors, patients who developed surgical site infections incurred on average $132,507 (P = 0.03) more in charges than patients who did not develop infections. CONCLUSIONS: Surgical site infections in pediatric patients following liver transplantation are significantly influenced by surgical technique and endogenous patient characteristics. Though survival outcomes are not different, the development of such infections has significant implications for resource utilization in the care of these patients.

The cost-effectiveness of fluorodeoxyglucose 18-F positron emission tomography in the N0 neck.

BACKGROUND: Although surgery and radiation are effective treatments of regional lymphatics for classification N0 head and neck squamous cell carcinoma (HNSCC) patients, both have morbidities that could be avoided in approximately 70% of patients without lymph node disease with better diagnostic information. 18-F fluoro-2-deoxyglucose positron emission tomography (FDG-PET) has shown promise in detecting subclinical lymph node disease, but its cost and availability have limited its use. Here, we sought to determine whether the use of FDG-PET was cost-effective as part of a treatment strategy for classification N0 HNSCC patients. METHODS: The cost-effectiveness of proceeding from classification of N0 by computed tomography to a PET scan was estimated using standard methods of economic evaluation. Costs were for a large, Midwestern university medical center. Probabilities were computed from a review of the literature. Utilities were obtained by a time-tradeoff method, and life expectancy was estimated using the Surveillance, Epidemiology, and End Results database. Outcomes measures were cost per year of life saved and cost per quality-adjusted life-year. RESULTS: Modified radical neck dissection was associated with the lowest morbidity (utility [u] = 0.93), and radical neck dissection plus radiation was associated with the highest (u = 0.68). Life expectancy was estimated to be 5.9 and 11.5 years for patients with and without lymph node disease, respectively. The incremental cost-effectiveness ratio for the PET strategy was $8718 per year of life saved, or $2505 per quality-adjusted life-year. CONCLUSIONS: A diagnostic and treatment strategy that proceeds from classification of N0 to a PET scan is cost-effective. Prospective studies that evaluate this strategy are important to assure that these simulation results are realized in clinical practice.

Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial.

BACKGROUND: Facial laser resurfacing and chemodenervation with botulinum toxin type A are used independently as means of nonsurgical facial rejuvenation. Recent reports in the literature have described combining these 2 therapies, claiming improved and longer-lasting laser resurfacing results. To date, no scientific investigation has been undertaken to prove or disprove this theory. DESIGN: Institutional review board-approved, prospective, randomized, blinded study at university-affiliated outpatient cosmetic surgery offices. INTERVENTION: Patients had one side of their face injected, at specific anatomic subsites (crow's feet, horizontal forehead furrows, and glabellar frown lines), with botulinum toxin 1 week before laser resurfacing. After receiving an injection, patients underwent cutaneous laser exfoliation on both sides of the face with either a carbon dioxide or an erbium dual-mode laser. MAIN OUTCOME MEASURES: Patients' injected (experimental) and noninjected (control) sides were compared after laser resurfacing. Follow-up was documented at 6 weeks, 3 months, and 6 months after laser resurfacing. Subjective evaluation, based on a visual analog scale, was performed in person by a blinded observer. Furthermore, a blinded panel of 3 expert judges (1 facial plastic surgeon, 1 oculoplastic surgeon, and 1 cosmetic dermatologist) graded 35-mm photographs taken during postoperative follow-up visits. RESULTS: Ten female patients were enrolled in the study. A 2-tailed t test showed that all sites that were pretreated with botulinum toxin showed statistically significant improvement (P< or =.05) over the nontreated side, with the crow's feet region showing the greatest improvement. Comparing results between the carbon dioxide and erbium lasers did not result in any statistically significant differences. CONCLUSIONS: Hyperdynamic facial lines, pretreated with botulinum toxin before laser resurfacing, heal in a smoother rhytid-diminished fashion. These results were clinically most significant in the crow's feet region. We recommend pretreatment of movement-associated rhytides with botulinum toxin before laser resurfacing. For optimum results, we further recommend continued maintenance therapy with botulinum toxin postoperatively.

The effect of surgical site infections on outcomes and resource utilization after liver transplantation.

BACKGROUND: Although postoperative infections have a significant impact on morbidity and mortality after orthotopic liver transplantation (OLT), less is known about their economic implications. In this study, we sought to identify risk factors and estimate the impact of surgical site infections on 1-year mortality, graft survival, and resource utilization after OLT. METHODS: We studied 777 first, single-organ liver transplant recipients from the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. Surgical site infections (n = 292, 37.8%) were defined as bacterial or fungal infections of the liver, intestine, biliary tract, surgical wound, or peritoneum within 1 year of transplantation. A subset of these (n = 159) occurred during the transplant hospitalization and were used to estimate excess charges associated with surgical site infections. RESULTS: Leaks in the choledochojejunostomy (odds ratio [OR] = 7.1, P =.001) and choledochocholedochostomy (OR = 2.5, P =.002), extended operation duration in hours (OR = 1.2, P =.002), serum albumin levels in grams per liters (OR = 0.71, P =.009), ascites (OR = 1.43, P =.037), and administration of OKT3 within 7 days (OR = 1.49, P =.039) significantly increased risk of infection. Surgical site infections did not significantly increase 1-year mortality (88.5% vs 91.5%, P =.19) but significantly increased 1-year graft loss (79.8% vs 86.5%, P =.022). Patients with surgical site infections incurred approximately 24 extra hospital days and $159,967 in excess charges (P =.0001). Multivariate analysis reduced the estimate of excess charges to $131,276 (P =.0001). CONCLUSIONS: Liver transplant recipients who develop surgical site infection have significantly higher resource utilization requirements than those who do not. These results imply substantial returns to preventative efforts directed at surgical site infections in patients undergoing OLT.

The minimum speech test battery in profound unilateral hearing loss.

OBJECTIVE: Individuals with monaural hearing experience disadvantages compared with normal hearing counterparts because of the loss of the head shadow effect, the squelch effect, and binaural summation. In this study the Minimum Speech Test Battery (MSTB), a battery designed to document word recognition in bilaterally hearing impaired cochlear implant candidates, was administered to unilaterally hearing-impaired and normal hearing subjects to study its possible use in measuring hearing difficulty in monaural subjects. STUDY DESIGN: Repeated measures design with the MSTB administered in sound-field in a sound-isolated booth in 1) quiet; 2) speech toward good ear, noise (+10 dB S/N) toward impaired ear; 3) speech toward impaired ear, noise toward good ear; and 4) bilateral speech and noise. SETTING: Academic otologic practice. PATIENTS: Ten adults with normal hearing and 10 adults with normal or near-normal hearing in one ear and profound hearing loss in the contralateral ear. MAIN OUTCOME MEASURES: The MSTB, composed of the Consonant-Nucleus-Consonant (CNC) test and the Hearing In Noise Test (HINT). RESULTS: As expected, performance differences between the groups were not found in quiet conditions. Analysis of variance and regression analysis confirmed that the impaired group performed significantly worse than control subjects on HINT testing when noise was directed toward the good ear. Analysis of variance and regression analysis confirmed that the impaired group performed significantly worse than control subjects on CNC testing when noise was directed toward the good ear and in bilateral noise. CONCLUSIONS: The MSTB may be useful in measuring the hearing difficulty of patients with monaural hearing.

Mastoid oscillation in canalith repositioning for paroxysmal positional vertigo.

OBJECTIVE: The canalith repositioning procedure (CRP) was developed to treat paroxysmal positional vertigo (PPV). Successful CRP results in cessation of PPV and positional nystagmus. Mastoid oscillation (MO) has been advocated to enhance the efficacy of CRP. The authors sought to objectively determine the effect of MO on CRP. STUDY DESIGN: Retrospective review. SETTING: Ambulatory referral center. PATIENTS: Patients with PPV seen from 1993 through 1999 (N = 168). INTERVENTIONS: Canalith repositioning procedure performed without MO (n = 104) and performed with MO (n = 64). MAIN OUTCOME MEASURE: Presence or absence of nystagmus on Dix-Hallpike testing 6 weeks after CRP. RESULTS: Eighty-four percent of patients treated with MO had resolution, and 16% had persistent nystagmus. Seventy-three percent of patients without MO had resolution, and 27% had persistent nystagmus. Although suggesting a trend, the difference did not reach the level of significance (p = 0.151). CONCLUSIONS: Mastoid oscillation does not significantly enhance the efficacy of the CRP.

Comparison of Scientific Calipers and Computer-Enabled CT Review for the Measurement of Skull Base and Craniomaxillofacial Dimensions.

Traditionally, cadaveric studies and plain-film cephalometrics provided information about craniomaxillofacial proportions and measurements; however, advances in computer technology now permit software-based review of computed tomography (CT)-based models. Distances between standardized anatomic points were measured on five dried human skulls with standard scientific calipers (Geneva Gauge, Albany, NY) and through computer workstation (StealthStation 2.6.4, Medtronic Surgical Navigation Technology, Louisville, CO) review of corresponding CT scans. Differences in measurements between the caliper and CT model were not statistically significant for each parameter. Measurements obtained by computer workstation CT review of the cranial skull base are an accurate representation of actual bony anatomy. Such information has important implications for surgical planning and clinical research.

The economic benefit of allocation of kidneys based on cross-reactive group matching.

BACKGROUND: Recently the United Network for Organ Sharing (UNOS) began a pilot study to evaluate prospectively the merits of an allocation of cadaveric kidneys based on broader classes of HLA antigens, called cross-reactive groups (CREG). The objectives of the pilot study consider patient outcomes, but not the potential economic impact of a CREG-based allocation. This study predicts the impact of a CREG-based local allocation of cadaveric kidneys on 3-year Medicare payments and graft survival. METHODS: The UNOS renal transplant registry was merged to Medicare claims data for 1991-1997 by the United States Renal Data System. Average accumulated Medicare payments and graft survival up to 3 years posttransplant for first cadaveric renal transplant recipients were stratified by cross-reactive group mismatch categories. The economic impact was defined as the difference in average 3-year costs per transplant between the current and proposed allocation algorithms. Average 3-year costs were computed as a weighted average of costs, where the weights were the actual and predicted distributions of transplants across cross-reactive group categories. RESULTS: Results suggest that an organ allocation based on cross-reactive group matching criteria would result in a 3-year cost savings of $1,231 (2%) per transplant, and an average 3-year graft survival improvement of 0.6%. CONCLUSIONS: Cost savings and graft survival improvements can be expected if CREG criteria were to replace current criteria in the current allocation policy for cadaveric kidneys, although the savings appear to be smaller than may be achievable through expanded HLA matching.

Cost considerations of converting to digital photography.

OBJECTIVES: To provide the practicing surgeon with data to make an informed economic decision regarding conversion from analog to digital photography. METHODS: A cost analysis of photography based on 35-mm vs digital platforms (low-, medium-, and high-cost hardware). RESULTS: Break-even thresholds for the investment in a digital platform of low, medium, and high costs were 3674, 15,789, and 34,000 images, respectively. CONCLUSION: Given the current excellent image quality and ongoing refinements in digital photography, a digital photography platform may be cost-effective for a busy facial plastic surgery practice.