Clinical coding of ICD-10 and OPCS in elective local anaesthetic and IV sedation cases.

Treatments facilitated by healthcare trusts are transformed into codes through which payments are organised. Accurate coding is essential for correct payment, inaccurate clinical coding results in significant loss of income. Our OMFS unit performs regular day-case procedures with data recorded in a standardised proforma. An audit was performed to determine the accuracy of ICD and OPCS codes generated by the OMFS department to identify factors contributing to inaccuracies leading to loss of income. All local anaesthetic and IV sedation cases were reviewed at two separate 3 monthly time frames within the OMFS department with 100 cases per cycle. A gold standard of 100% coding information recorded and accuracy were set. The first data cycle demonstrated a number of factors to improve the clinical coding process including implementing a new clinical coding form. This was utilised in the second audit cycle. Regarding ICD-10 the first audit cycle yielded a 65% accuracy of primary diagnoses. Following recommendations this improved to 72%. Coding accuracy in the first cycle was recorded as 62% with improvement to 78% in the second cycle. OPCS data accuracy was 80% in the first cycle improving to 90% in the second cycle. Secondary or bilateral procedures also showed improvement from 83% to 89% accuracy in the second cycle. Across the audit cycle £20,000 of revenue was generated. Inaccuracies in clinical coding reduces income, improved understanding of error sources can ensure income is commensurate with clinical activity.

Investigating the correlation between bone density and fracture frequency in the mandibular condyle with micro-computed tomography.

Fractures of the mandibular condyle are common and include diacapitular fractures that affect the condylar head. The medial part of the condylar head is least commonly fractured, possibly due to decreased propensity for lines of force to run in the region. Micro-computed tomography (X-ray microtomography) of five temporomandibular joint specimens was conducted to explore whether trabecular bone structure correlates positively with fracture prevalence, which could reflect adaptation in response to lower exposure to physiological loads throughout life. Models of trabecular bone, and graphic representation of bone density indicated least dense bone medially, but a statistically significant ANOVA result was not obtained. Further study is required to verify whether a relationship between bone microstructure and fracture frequency exists, and whether or not this is the product of association between the directions of physiological and traumatic forces.

Computed tomographic indications for occult skull fractures in paediatric head trauma diagnosed at the time of wound closure under general anaesthesia.

Children with head injuries commonly present to the emergency department with forehead lacerations, and are frequently referred to the oral and maxillofacial team. Assessing the Glasgow coma scale (GCS) and neurological status of these patients is particularly challenging and there remains marked ambiguity regarding the use of computed tomographic (CT) imaging in children who have no obvious signs of traumatic brain injury. We present a case series of three patients who presented to our unit with forehead lacerations following a fall. All had a normal GCS, no obvious neurological signs, and all were listed for wound closure under general anaesthesia. Intraoperatively they were found to have underlying skull fractures that necessitated emergency CT whilst under general anaesthesia. Retrospective analysis was performed. Current guidelines and the literature were reviewed to identify factors that may help to identify occult skull fractures in the context of paediatric head trauma. Despite the subsequent discovery of skull fractures under general anaesthesia, none of our patients would have satisfied the present absolute indications for CT in the current guidelines. A number of helpful factors are not common in the UK guidelines but are present in others, including the presence of an appreciable haematoma and lacerations greater than 5 cm, amongst others. The assessment of paediatric patients with head trauma often remains a challenge when assessing for features such as headache, focal neurology, and amnesia. A high index of suspicion, formal examination under anaesthesia, and communication with the radiology department, are imperative if we are to avoid missing an occult injury that could potentially result in brain injury.

The prevalence of iron deficiency anaemia in patients undergoing bariatric surgery.

As bariatric surgery rates continue to climb, anaemia will become an increasing concern. We assessed the prevalence of anaemia and length of hospital stay in patients undergoing bariatric surgery. Prospective data (anaemia [haemoglobin <12 g/dL], haematinics and length of hospital stay) was analysed on 400 hundred patients undergoing elective laparoscopic bariatric surgery. Results from a prospective database of 1530 patients undergoing elective general surgery were used as a baseline. Fifty-seven patients (14%) were anaemic pre-operatively, of which 98% were females. Median MCV (fL) and overall median ferritin (µg/L) was lower in anaemic patients (83 vs. 86, p=0.001) and (28 vs. 61, p<0.0001) respectively. In the elective general surgery patients, prevalence of anaemia was similar (14% vs. 16%) but absolute iron deficiency was more common in those undergoing bariatric surgery; microcytosis p<0.0001, ferritin <30 p<0.0001. Mean length of stay (days) was increased in the anaemic compared to in the non-anaemic group (2.7 vs. 1.9) and patients who were anaemic immediately post-operatively, also had an increased length of stay (2.7 vs. 1.9), p<0.05. Absolute iron deficiency was more common in patients undergoing bariatric surgery. In bariatric patients with anaemia there was an overall increased length of hospital stay.

Assessing the role of peripheral CD8 T cells in neurocognitive impairment in HIV-infected men who have sex with men: data from the MSM Neurocog Study.

Studies have suggested CD8 lymphocytes may be a possible marker for inflammation, which is believed to be a contributing factor to neurocognitive impairment. Individuals enrolled in the MSM Neurocog Study were analysed. Those with depression, anxiety or mood disorders were excluded. Individuals with neurocognitive impairment were identified using the Brief NeuroCognitive Screen and compared to those with normal scores. CD4 and CD8 T cell values and CD4:CD8 ratios were compared between groups. In all, 144 men, aged 18-50 years, were included in the analysis. Twenty were diagnosed with neurocognitive impairment. We were unable to identify any significant difference between current, nadir or peak CD4 and CD8 counts. CD4:CD8 ratios and CD4:CD8 ratio inversion (<1) were also found to be similar between both groups. However, neurocognitive impairment subjects were 8% more likely to have inversion of CD4:CD8 ratio and higher median peak CD8 cell counts reported compared to non-impaired subjects. Analysis of data from the MSM Neurocog Study, demonstrated trends in peripheral CD8 counts and CD4:CD8 ratios. However, we are unable to demonstrate any significant benefit. Plasma biomarkers of neurocognitive impairment in HIV-infected subjects would be of great benefit over current methods of invasive CSF analysis and technical neuroimaging used in the diagnosis of neurocognitive impairment. Future, prospective, longitudinal work with large numbers of neurocognitive impairment subjects is required to further investigate the role of peripheral CD8 T cells as markers of neurocognitive impairment.

Improved blood pressure, nitric oxide and asymmetric dimethylarginine are independent after bariatric surgery.

BACKGROUND: Obesity is associated with hypertension, but the exact mechanism is not fully understood. Bariatric surgery significantly decreases weight and blood pressure (BP). Low plasma nitric oxide (NO) and raised asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO, concentrations are associated with both obesity and hypertension. Correlations between the changes in these parameters were studied after bariatric surgery. METHODS: Weight, BP, plasma ADMA and NO were measured in 29 obese patients (24 female, 5 male) before and six weeks after bariatric surgery. RESULTS: Patients were 39.2 ± 1.2 (mean ± SEM) years old and weighed 126 ± 3 kg. Six weeks after the surgery, patients had lost 10 ± 0.7 kg (P < 0.0001) and mean arterial pressure (MAP) decreased by 11 ± 1.0 mmHg (P < 0.0001). The plasma ADMA concentration decreased by 24 ± 2% from 5 ± 0.4 to 4.0 ± 0.3 µmol/L (P < 0.0001). The plasma total nitrite concentration increased by 15 ± 1% from 51.4 ± 2.6 to 60 ± 3 µmol/L (P < 0.0001). The correlation between the decrease of ADMA and increase of NO subsequent to weight loss was significant (P < 0.0001). However, MAP was not correlated to the changes in ADMA or NO. CONCLUSIONS: After bariatric surgery, beneficial changes in BP, NO and ADMA occur, but our findings suggest that these BP changes are independent of changes in the NO-ADMA axis. Other causes for the changes in BP should therefore be considered.

Renal cytokines improve early after bariatric surgery.

BACKGROUND: Bariatric surgery has been suggested to improve arterial hypertension and renal function. This prospective controlled observational study aimed to investigate changes in renal inflammation, renal function and arterial blood pressure before and after bariatric surgery. METHODS: Blood pressure was measured, and urine and blood samples were collected from 34 morbidly obese patients before and 4 weeks after bariatric surgery. Serum levels of cystatin C, creatinine, albumin, cholesterol and C-reactive protein (CRP) were measured, along with urinary cytokine/creatinine ratios for macrophage migration inhibitory factor (MIF), monocyte chemotactic protein (MCP) 1, chemokine ligand (CCL) 18 and CCL-15. RESULTS: Mean(s.e.m.) bodyweight dropped from 124·1(2·6) to 114·8(2·4) kg (P < 0·001) and mean arterial blood pressure decreased from 105·7(1·8) to 95·5(1·2) mmHg (P < 0·001) in 4 weeks. Systemic and urinary inflammatory markers improved, with a reduction in serum CRP level (P < 0·001), and decreased urinary MIF/creatinine (P < 0·001), MCP-1/creatinine (P < 0·001) and CCL-18/creatinine (P = 0·003) ratios. In contrast, urinary CCL-15/creatinine ratios did not change and the glomerular filtration rate, measured by serum cystatin C, was unchanged (P = 0·615). CONCLUSION: Surgically induced weight loss contributed to a decrease in blood pressure and markers of renal inflammation. The reduced levels of CRP and urinary cytokines suggest that bariatric surgery attenuates systemic and renal inflammatory status.