[Healthcare cost reimbursement without application-Experiences of a German bariatric service]. / Kostenübernahme bariatrischer Operationen ohne Antragstellung ­ Erfahrungen in einem deutschen Adipositaszentrum.

BACKGROUND: Only a small proportion of patients with morbid obesity in Germany have access to the currently most effective treatment, bariatric surgery. A major reason for this is the restrictive attitude of health insurance companies regarding the reimbursement of costs. OBJECTIVE: To record the postoperative rate of cost coverage by health insurance companies without the currently common preoperative application for morbidly obese patients who received a guideline-indicated bariatric surgery. METHODS: The process of postoperative reimbursement was evaluated through a prospective database over a 2-year period. Cases of primary reimbursement were correlated with respect to age, BMI, comorbidities and membership of a specific health insurance company. Rejected coverage cases were followed up for further advocacy and social court process. RESULTS: A total of 188 patients underwent bariatric surgery as indicated in the guidelines without prior application. Primary cost coverage was achieved in 76.6% (n = 144). There was no correlation with BMI, comorbidities or health insurance affiliation. Patients over 40 years of age were significantly more likely to be covered for costs. For patients without postoperative cost coverage, an out of court settlement was reached in 7 cases, 8 cases were heard by the social courts and 29 cases were still being processed by lawyers. CONCLUSION: Despite the relatively high rate of primary cost coverage, this analysis also shows the restrictive attitude of the health insurance companies regarding bariatric surgery with corresponding economic pressure on the service providers. The consistent implementation of application-free surgery seems necessary to increase the political pressure on health insurers and social courts.

[Malnutrition after biliopancreatic diversion--postoperative management and complications]. / Malnutrition nach biliopankreatischer Teilung--postoperative Maßnahmen und Komplikationen.

The biliopancreatic diversion is currently the maximum variant of bariatric surgery. It presents several opportunities of typical surgical complications, beside the risks generally prevailing in bariatric surgery. In addition, there is the procedure-immanent risk of development of nutritional deficiencies in the long-term process, at significant percentages. These deficiencies can, to a great extent, be avoided by consistent supplementation within the scope of a structured follow-up program; they can also be corrected by a substitution therapy. In the future, the risk of malnutrition can possibly be lowered by technically modified procedures with equal bariatric effectiveness. Considering the very good long-term results with regard to stable weight reduction in connection with a high recovery rate of the comorbidities, combined with a consistent postal-surgical management, the problem of malnutrition appears to be of minor importance. However, an appropriate compliance of the patient is also required.

Time-resolved contrast-enhanced MR angiography of the thorax in adults with congenital heart disease.

OBJECTIVE: The aim of this study was to evaluate the diagnostic value of time-resolved contrast-enhanced MR angiography in adults with congenital heart disease. SUBJECTS AND METHODS: Twenty patients with congenital heart disease (mean age, 38 +/- 14 years; range, 16-73 years) underwent contrast-enhanced turbo fast low-angle shot MR angiography. Thirty consecutive coronal 3D slabs with a frame rate of 1-second duration were acquired. The mask defined as the first data set was subtracted from subsequent images. Image quality was evaluated using a 5-point scale (from 1, not assessable, to 5, excellent image quality). Twelve diagnostic parameters yielded 1 point each in case of correct diagnosis (binary analysis into normal or abnormal) and were summarized into three categories: anatomy of the main thoracic vessels (maximum, 5 points), sequential cardiac anatomy (maximum, 5 points), and shunt detection (maximum, 2 points). The results were compared with a combined clinical reference comprising medical or surgical reports and other imaging studies. Diagnostic accuracies were calculated for each of the parameters as well as for the three categories. RESULTS: The mean image quality was 3.7 +/- 1.0. Using a binary approach, 220 (92%) of the 240 single diagnostic parameters could be analyzed. The percentage of maximum diagnostic points, the sensitivity, the specificity, and the positive and the negative predictive values were all 100% for the anatomy of the main thoracic vessels; 97%, 87%, 100%, 100%, and 96% for sequential cardiac anatomy; and 93%, 93%, 92%, 88%, and 96% for shunt detection. CONCLUSION: Time-resolved contrast-enhanced MR angiography provides, in one breath-hold, anatomic and qualitative functional information in adult patients with congenital heart disease. The high diagnostic accuracy allows the investigator to tailor subsequent specific MR sequences within the same session.

Evaluation of the stereotactic 8G vacuum-assisted breast biopsy in the histologic evaluation of suspicious mammography findings (BI-RADS IV).

PURPOSE: The purpose of this study was to evaluate the potential of the new 8G stereotactic vacuum-assisted breast biopsy (ST-driver, Mammotome; Ethicon Endosurgery) in the histologic evaluation of BI-RADS IV microcalcifications. MATERIALS AND METHODS: Fifty-eight patients with 61 mammographic BI-RADS IV microcalcifications underwent stereotactic vacuum-assisted breast biopsy (SVAB). The new 8G system was mounted on the ST driver, which was formerly used only with the hand-held version under sonographic guidance. The evaluation criteria for each biopsy were minimally invasive and operative histologies, the time needed for biopsy, the amount of bleeding, number of rotations and specimen, the degree of resection, and the complications. RESULTS: Fifty-eight of 61 biopsies were technically successful because > or = 50% were resected (29 x 100%, 8 x 90%, 5 x 80%, 6 x 70%, 3 x 50%, 3 x 0%). In 7 cases with representative biopsies of segmental suspicious microcalcifications, the degree of resection could not be exactly measured. All but 2 biopsies were performed without clinically relevant complications and after gaining enough specimens (Ø 12.6 specimen, 1.85 rotations). Those 2 patients showed evidence of severe bleeding into the breast tissue and operative revision had to be performed (3.5%). The size of intramammary hematoma was measurable in 27 biopsies and showed a range from 0.5 to 5 cm (Ø 2.7 cm). The average external bleeding was still low with 16 mL (5-80 mL). In 3 of 61 lesions, it was not possible to gain representative tissue as a result of displacement of the lesion after introducing or shooting the needle. The average time needed for all biopsies was 28.2 minutes for all but 5 very complicated biopsies, which took 16.1 minutes. The histologic findings with further operative workup were: 10 ductal carcinomas in situ (DCIS), 4 atypical ductal hyperplasias, 1 atypical lobular hyperplasias (ALH), 3 lobular carcinomas in situ (LCIS), and 6 invasive ductal carcinomas. In 7 of 12 of the initial DCIS histologies, the operative histology was also DCIS, whereas in 4 of 12, no residual malignant tumor was found. In 1 of 12 patients with an initial DCIS histology, operative histology revealed invasive ductal cancer (8.3%). The cases with lobular lesions (ALH, LCIS) did not show any evidence for residual tissue in the operative workup. Most frequent benign histologies were mastopathy (13), ductal hyperplasia (9), fibroadenoma (8), and sclerosing adenosis (5). The control examinations (maximum 1 year) did not show any signs for a false-negative biopsy. CONCLUSION: The 11-G SVAB has proven to be a perfect adjunct to the existing breast biopsy methods. The new 8G SVAB speeds up the method when used for the same size of lesions and enables the user to representatively biopsy lesions up to 3 cm in diameter. The method is still minimally invasive; however, the amount of hematomas as well as clinically relevant complications is increased.

Value of electrical impedance scanning (EIS) in the evaluation of BI-RADS III/IV/V-lesions.

Two hundred and fifty-six (256) patients (72% preoperative, 28% pre-Mammotome) were prospectively examined with EIS using the TS 2000 (TransScan Research and Development Center, Israel; temporarily distributed by Siemens, Erlangen) with the "LOS"-software (level of suspicion). All exams were performed with the targeted scan probe, the observer knowing all clinical and imaging facts. The area of the lesions was examined with EIS at least with 5 single scans. The evaluation included a scaling of lesions from 1 (surely benign) up to 5 (highly suggestive for malignancy) as well as the additional notification of spots. Results of EIS were based upon the automatic scaling which is provided by the software and were compared with mammography and histology. Furthermore the influence of the histology, size of lesions, and presence/absence of spots on the EIS results were analyzed. Histology revealed benign results in 138 lesions and malignant results in 118 lesions (DCIS=61, ID-Ca=51, IL-Ca=5, mucinous Ca=1). Mammography as expected yielded high values with 91% sensitivity and 62% specificity. Overall sensitivity of EIS was 75.4%, specificity 42.03%, negative predictive value 66.7% and positive predictive value 52.7% (89 TP, 58 TN, 80 FP, 29 FN). EIS was false negative in 20 ID-Ca, 3 IL-Ca, 1 IDL-Ca, 4 DCIS, and 1 mucinous carcinoma. Sensitivity and specificity of EIS did not differ for the different histological differentiations neither for the degree of invasion. Also the additional notification of "spots" didn't show a correlation to malignancy. There were significant differences of the sensitivity of EIS regarding the tumor size. While EIS correctly diagnosed 85% of lesions <10 mm in size, only 64% of lesions >10 mm were detected. Most frequent lesion types for false positives were mastopathy (55/80 FP) and fibroadenoma (21/80 FP). Patient acceptance of EIS was perfect and there were no drop outs because of movement artifacts. In conclusion the "LOS"-software clearly improved the clinical performance of the TS 2000 as compared to the initial software. The high sensitivity of EIS in small cancers which was found in our study may indicate an advantage of this method. However, the overall sensitivity and specificity with this setup of EIS is still far too low. Further improvements especially including the measurement of higher frequencies should be realized.

Treatment planning in patients with PAOD:Comparison of CE-MRA employing a dedicated peripheral MRA coil and high dose single volume contrast material application with i.a. DSA.

AIM: To evaluate whether contrast enhanced MRA (CE-MRA), including a dedicated MRA coil and a high dose of contrast material, correlates to i.a. digital subtraction angiography (DSA) when used for treatment planning in patients with peripheral arterial obstructive disease (PAOD). METHODS AND RESULTS: A retrospective CE-MRA and i.a. DSA comparison was used to evaluate 2200 vessel segments with stenosis or occlusion in the pelvic or lower extremity arteries in 100 patients. A 1.5T MR unit (Magnetom Symphony Quantum, Siemens) employing a peripheral angiography array surface coil and automatic table movement was used. The interventional approach was planned according to both CE-MRA and DSA findings. Visual material was blinded and reviewed by two experienced radiologists.In 98.95% (Observer 1) and 98.1% (Observer 2) CE-MRA revealed an exact correlation of the grade as well as length of stenosis compared to DSA. The sensitivity was 100% and 95.3% for observers 1 and 2 and its specificity 98.3% and 100%, respectively. The interobserver agreement between was 0.98 and 0.96 for observers 1 and 2, respectively. Suggested treatment and interventional approach based on the CE-MRA findings corresponded to DSA in 97%. CONCLUSION: CE-MRA is an excellent modality for treatment planning in patients with PAOD. Especially in patients with restenosis or reocclusion, CE-MRA enables an accurate, non-invasive diagnosis and facilitates treatment planning.

Extracorporeal shock wave therapy in calcific tendinitis of the shoulder.

OBJECTIVE: To investigate clinical (pain, mobility) and radiological (resolution of calcium deposits) efficacy of different energy levels of extracorporeal shock wave therapy (ESWT) in calcific tendinitis of the shoulder. DESIGN AND PATIENTS: There were 90 study subjects with radiographically verified calcific tendinitis of one shoulder, mean age 52+/-6 years (range 29-65 years; females:males=55:35), all of whom had had symptoms for at least 6 months and substantial restriction of shoulder mobility and pain that required taking anti-inflammatory drugs. Calcium deposits were of type I or type II (clearly circumscribed and dense) and ranged from 1 cm to 3 cm in diameter. Subjects were divided into three groups to receive ESWT at one of two energy levels (E1=0.15 mJ/mm2, E2=0.44 mJ/mm2) or sham treatment. Treatment was given at 6 weekly intervals until symptoms resolved, five treatments had been given or the subject dropped out of the programme. RESULTS: All subjects in groups E1 and E2 completed the programme. Those in group E1 had significantly less pain during treatment but more treatments than those in group E2, and at 6 month follow-up had residual calcification and recurrence of pain (87%). Subjects in group E2 had no residual calcification or recurrence of pain. Sham treatment had no effect. There were no side effects except a small number of haematomas (2 in E1, 6 in E2; maximum size 2 cm). CONCLUSION: ESWT in calcific tendinitis of the shoulder is very effective. It does not have significant side effects at an energy level of E=0.44 mJ/mm2, which can therefore be recommended.

Galactography: an important and highly effective procedure.

Galactography should only be performed if there is spontaneous bloody or serous discharge from a single lactiferous duct of one breast. If this is observed, only pathologic processes instead of normal breast tissue are removed upon surgery and there is a close correlation between radiologic results and pathologic findings. Galactography localizes intraductal pathologic processes precisely and thus contributes to minimal volume surgery.

Intradiploic meningoencephalocele.

We report on a 36-year-old patient who presented with coordinative problems in his right leg. The MRI study of his brain showed the extremely rare intradiploic meningoencephalocele which explained his symptoms. Most cephaloceles are inborn developmental disturbances and present with symptoms of different severity depending on the degree of associated malformations in early childhood. They usually demand immediate treatment. In the patient presented here the cephalocele belongs to the rare type of intradiploic meningoencephalocele. This is a variant of the intradiploic cerebrospinal fluid cyst and of traumatic instead of developmental origin.