The Cost of Ambulatory Breast Reduction: Hospital Reimbursement Versus Surgeon Payments.

Introduction: Reduction mammoplasty (RM) is one of the most common operations performed in plastic surgery. While US national surgical expenditures have risen in recent years, studies have reported decreasing reimbursement rates for plastic surgeons. The purpose of this study is to characterize the trends in charges and payments for a common plastic surgery operation, ambulatory RM, for facilities and physicians. Methods: A Medicare patient records database was used to capture hospital, surgeon, and anesthesiologist charges and payments for ambulatory RM from 2005 to 2014. Values were adjusted for inflation. A ratio of hospital to surgeon charges and payments were calculated: charge multiplier (CM) and payment multiplier (PM), respectively. Charges, payments, Charlson comorbidity index, CM, and PM values were analyzed for trends. Results: This study included 1001 patients. During the study period, the facility charge for RM per patient increased from $8477 to $11,102 (31% increase; p < .0005), and the surgeon charge increased from $7088 to $7199 (2% increase; p = .0009). Facility payments increased from $3661 to $3930 (7% increase; p < .0005), and surgeon payments decreased from $1178 to $1002 (15% decrease; p < .0005). CM increased from 1.2 to 1.54, and PM increased from 3.11 to 3.92. Conclusions: Charges and payments to facilities for ambulatory RM increased disproportionately to that of surgeons, likely due in part to rising administrative costs in health care delivery. This may disincentivize plastic surgeons from offering RM at hospital-based surgical centers, limiting patient access to this operation.

Introduction: La mammoplastie de réduction (MR) est l'une des interventions les plus courantes pratiquées en chirurgie plastique. Alors que les dépenses chirurgicales aux États-Unis ont augmenté au niveau national au cours des dernières années, les études ont signalé une diminution des taux de remboursement pour les chirurgiens plasticiens. L'objectif de cette étude est de définir les tendances dans les frais et paiements pour une intervention courante de chirurgie plastique, une MR ambulatoire, pour les établissements et pour les médecins. Méthodes: Une base de données des dossiers de patients Medicare a été utilisée pour collecter les frais pour les hôpitaux, les chirurgiens et les anesthésiologistes ainsi que les paiements pour MR ambulatoires de 2005 à 2014. Les valeurs ont été ajustées pour tenir compte de l'inflation. Des ratios des frais hôpital/chirurgien et des paiements ont été calculés : respectivement, un facteur de multiplication des frais (MF) et des paiements (MP). Les tendances de la valeur des frais, des paiements, de l'indice de comorbidité de Charlson, du MF et du MP ont été analysées. Résultats: Cette étude a inclus 1001 patients. Au cours de la période de l'étude, les frais pour MR par patient à la charge de l'établissement ont augmenté de 8 477 $ à 11 102 $, soit une augmentation de 31 % (P < 0,0005) et les frais du chirurgien sont passés de 7 088 $ à 7 199 $, soit une augmentation de 2 % (P = 0,0009). Les paiements de l'établissement ont augmenté de 3 661 $ à 3 930 $, soit une augmentation de 7 % (P < 0,0005) et les paiements du chirurgien ont diminué de 1 178 $ à 1 002 $, soit une diminution de 15 % (P < 0,0005). Le facteur MF est passé de 1,2 à 1,54 et le facteur MP est passé de 3,11 à 3,92. Conclusions: Les frais et paiements aux établissements pour MR ambulatoire ont augmenté de manière disproportionnée par rapport à ceux des chirurgiens, probablement en partie à cause de l'augmentation des coûts administratifs croissants de l'administration des soins. Cela pourrait inciter les chirurgiens plasticiens à ne plus offrir de MR dans les centres chirurgicaux hospitaliers et pourrait donc limiter l'accès des patients à cette opération.

Loops, topologically associating domains, compartments, and territories are elastic and robust to dramatic nuclear volume swelling.

Layers of genome organization are becoming increasingly better characterized, but less is known about how these structures respond to perturbation or shape changes. Low-salt swelling of isolated chromatin fibers or nuclei has been used for decades to investigate the structural properties of chromatin. But, visible changes in chromatin appearance have not been linked to known building blocks of genome structure or features along the genome sequence. We combine low-salt swelling of isolated nuclei with genome-wide chromosome conformation capture (Hi-C) and imaging approaches to probe the effects of chromatin extension genome-wide. Photoconverted patterns on nuclei during expansion and contraction indicate that global genome structure is preserved after dramatic nuclear volume swelling, suggesting a highly elastic chromosome topology. Hi-C experiments before, during, and after nuclear swelling show changes in average contact probabilities at short length scales, reflecting the extension of the local chromatin fiber. But, surprisingly, during this large increase in nuclear volume, there is a striking maintenance of loops, TADs, active and inactive compartments, and chromosome territories. Subtle differences after expansion are observed, suggesting that the local chromatin state, protein interactions, and location in the nucleus can affect how strongly a given structure is maintained under stress. From these observations, we propose that genome topology is robust to extension of the chromatin fiber and isotropic shape change, and that this elasticity may be beneficial in physiological circumstances of changes in nuclear size and volume.

Memantine for the Treatment of Behavioral Disturbance in Unspecified Major Neurocognitive Disorder.

In this case report, we aimed to examine how the use of memantine in an elderly gentleman with unspecified major neurocognitive disorder (NCD) led to significant clinical improvement in his behavioral disturbances. After presenting to the psychiatric ward due to aggressive behavior at his assisted living facility, the patient continued to exhibit numerous disruptive and confrontational behaviors while hospitalized. Memantine was started at 5 mg daily with gradual titration up to 10 mg twice daily over the course of four weeks, with marked improvement in behavior as well as an increase in Montreal Cognitive Assessment (MoCA) score by five points after seven weeks of treatment. Given our experience and the safety profile of memantine, we conclude that memantine may have a role in the treatment of behavioral disturbances in patients with unspecified major NCD, though further research will be necessary to define this role.