Prescribing of sick leave by surgeons: a survey based on hypothetical patient cases.

BACKGROUND: Physicians regard the tasks of sick-listing and work ability assessments problematic and among the most challenging duties in their practice. Few studies have analyzed sick leave prescribing practices, and the practices have been shown to vary among physicians. The aim of this study was to examine the prescribing of sick leave by surgeons and factors that affect these prescribing practices. METHODS: A questionnaire study with 19 hypothetical patient cases was conducted among 338 Finnish surgeons. The effects of both physician-related and local structural background variables on sick leave prescribing were studied using univariate and multiple linear regression models. The economic consequences of the variation in sick leave prescribing were estimated. RESULTS: The overall number of days of sick leave prescribed for the entire group of 19 patient cases averaged 281.4 days (range = 134-490 days). With the same diagnosis, surgeons prescribed more days of sick leave for patients who do physical work than for those who work in an office. Older surgeons with more working experience and those working in smaller municipalities or in smaller hospitals prescribed longer sick leave than others. Clinical specialists tended to prescribe longer sick leave than those still in specialty training. CONCLUSION: Structured education for surgeons on prescribing sick leave, together with defined guidelines, could produce more uniform practices and improve equality among patients.

Tight junction proteins and perineurial cells in neurofibromas.

Cutaneous neurofibromas consist of axonal processes, Schwann cells, fibroblasts, perineurial cells, mast cells, and abundant extracellular matrix. The distribution and role of perineurial cells in neurofibromas has been uncertain, partly because there has not been a specific immunohistochemical marker for perineurial cells. In this study, tight junctions (TJs) of 16 neurofibromas from 12 patients with neurofibromatosis type 1 (NF1) were analyzed using electron microscopy, immunohistochemistry, and Western transfer analysis. Cell-cell contacts with typical ultrastructural morphology of TJs were seen between adjacent perineurial cells surrounding the small nerves and between contacting perineurial cell processes embedded in tumor stroma. Immunohistochemistry showed expression of claudin-1, claudin-3, and ZO-1 in the intercellular junctions of a subpopulation of tumor cells. Occludin was present mainly in perineurium and claudin-5 localized to the blood vessels. Double immunolabelings were used to identify the cell types expressing claudin-1. The results showed that claudin-1 positive cells were also positive for type IV collagen and epithelial membrane antigen but not for S-100 protein. This labeling pattern is consistent with perineurial cell phenotype. Using claudin-1 as a marker, our results showed that clusters of perineurial cells are distributed around the rudimentary nerves within cutaneous neurofibromas and at the periphery of some neurofibromas.

Surgical workload and cost of postoperative adhesion-related intestinal obstruction: importance of previous surgery.

Postoperative intraabdominal adhesions cause morbidity of varying degree. Intestinal obstruction is the most severe complication of adhesions. This study examined the importance of previous surgery on clinical and economic workloads caused by intestinal obstruction due to postoperative intraabdominal adhesions. All emergency hospitalizations due to adhesion-related intestinal obstruction from January 1, 1999 to December 31, 1999 in a hospital district serving roughly 450,000 inhabitants was reviewed retrospectively. The patient population was divided into six groups according to the site of previous surgery, and the total as well as group-related surgical workload and direct costs of inpatient care were analyzed. There were 123 hospitalizations due to postoperative adhesion-related intestinal obstruction during the study period. A total of 101 patients had experienced 176 operations. The most prevalent operations were colorectal (with or without other operations), upper abdominal, and female reproductive system procedures. Colorectal surgery preceded 40% and 38% of inpatient episodes and inpatient days, respectively. Altogether, 40 operations were performed because of adhesion-related intestinal obstruction. No differences between groups were seen in terms of the mean operating or theater time. Total annual inpatient costs due to emergency hospitalizations for intestinal adhesion-related obstruction related to colorectal surgery in a hospital district serving roughly 450,000 inhabitants was 72,520.60 (U.S. dollars) which accounted for 35.3% of all annual costs caused by postoperative adhesion-related intestinal obstructions. There were no significant differences between groups regarding the total mean inpatient episode costs. Intestinal obstruction due to postoperative adhesions poses substantial costs for the society. Colorectal operations are the most important procedures preceding adhesion-related intestinal obstruction, accounting for 35.3% to 46.8% of the total clinical workload or costs attributable to postoperative adhesion-related obstruction.