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Biomedical subjects

E Birnbaum

Publications and source records attributed to E Birnbaum.

At least 19 recordsLinked to original sources
PubMed2003

Age and type of procedure influence the choice of patients for laparoscopic colectomy.

BACKGROUND: The aim of this retrospective, case-matched controlled study was to determine the benefit of laparoscopic-assisted colectomy (LC) for the elderly (>75 years of age) and the young (<75 years of age) compared to an open colectomy (OC) control group. METHODS: A retrospective review of 39 patients older than 75 years of age and 38 patients younger than 75 years of age who underwent LC for colorectal cancer between 1991 and 1999 was performed. LC patients were matched with an open control group for procedure, age, gender, year of procedure, and surgeon. Procedures included right and left colectomy, anterior resection of the rectosigmoid, and abdominoperineal resection. Measured intraoperative variables included anesthesia time, operative time, and estimated blood loss. Postoperative parameters consisted of duration of intravenous or epidural narcotic usage, return of bowel function (RBF), length of stay, and independence at discharge. These variables were compared in the entire group of 154 patients. RESULTS: Mean ages were 81.4 and 81.8 years for LC and OC age >75 and 62.9 and 62.7 for LC and OC age <75. Mean anesthesia time and operative time were significantly longer (p < 0.05) for LC compared to OC (46.8 vs 39.3 and 159.3 vs 111.7 min, respectively) for age >75 and for age <75 (47.1 vs 40.3 and 182.8 vs 135.5 min, respectively). LC achieved faster recovery in both age groups: RBF (3.9 vs 4.9 days for age >75; 6.7 vs 7.7 days for age <75) (p < 0.05). Narcotic usage was shorter for the LC group age <75 (3.3 vs 4.4 days; p < 0.05). There was no significant difference in independence at discharge between LC and OC in either age group. Faster recovery was seen with left LC in age >75 and right LC in age <75 compared to OC. CONCLUSION: The advantages of LC over OC are the same for the elderly and the young. There may be a selective benefit of laparoscopic left colectomy in the elderly and laparoscopic right colectomy in the young.

Age Factors↗
PubMed1999

Five fractions of preoperative radiotherapy for selected cases of rectal carcinoma: long-term tumor control and tolerance to treatment.

BACKGROUND: Randomized Swedish studies demonstrate the efficacy of a 5-fraction course of preoperative radiotherapy for rectal carcinoma. The present study evaluates the results in a single U.S. institution over a 20-year period with a similar regimen. METHODS AND MATERIALS: During the period of 1975-1995, 83 patients received pelvic radiotherapy of 20 Gy/5 fractions, followed by immediate surgery for rectal cancer. These patients represented 21% of cases receiving preoperative treatment; the remainder received 45-50 Gy preoperatively. The 5-fraction course was used for lesions deemed readily resectable but too bulky for conservative endocavitary treatment. Since 1990, it has been our policy to administer postoperative chemotherapy to medically fit patients who prove to have pathologic Stage II or III disease. Patient characteristics including age (mean 65 years, range 23-90), gender (45% male), and location within the rectum were comparable to our previously reported cases that received 45 Gy/25 fractions preoperatively. However, the group selected for 5 fractions preoperatively had relatively fewer lesions that were tethered (20% vs. 61%), circumferential (11% vs. 20%), or near obstructing (1% vs. 16%). RESULTS: With a post treatment follow-up of 1-15 years (mean 4.7), there have been 3 local failures and 12 distant failures, with an actuarial local control of 95%, and disease-specific survival of 77% at 5 and 10 years. Grade > or = 3 perioperative or late toxicity occurred in 11 cases (13%), including 3 (3.5%) late bowel obstructions. Stage II or III disease was found in 56% of the cases, 74% of which were free of disease at last follow-up. However, patients with Stage II or III lesions that were significantly tethered or fixed had a 40% greater likelihood of recurring than similar stage lesions that were, at most, slightly tethered. Sphincter-preserving surgery was possible in 60% of the patients. In recent years, postoperative chemotherapy has been administered to 16 patients with Stage II or III disease; this has been well tolerated, with only 1 late toxicity (cystitis managed medically). When compared with a matched group of cases receiving conventionally fractionated preoperative radiation, there were no significant differences in perioperative morbidity and nonradiotherapeutic cost generating factors (length of hospital stay, duration of postoperative antibiotics, blood loss at surgery). CONCLUSION: Patients with resectable rectal cancer who received 20 Gy/5 fractions preoperative radiotherapy to the pelvis had excellent local and distant control of disease. These patients were able to undergo sphincter-preserving surgery and postoperative chemotherapy. It would be of interest to conduct a randomized trial comparing short course with longer course (45 or 50 Gy) preoperative radiotherapy for resectable T3 lesions. The results of this study suggest that, in general, differences in toxicity, local control, and disease-free survival would probably be < 10%. However, since the results of this study suggest that patients with significantly tethered lesions may be better served with the higher dose and longer duration course of radiation, clinical degree of fixation should be included as a stratification parameter, and stopping criteria should be included for tethered lesions.

Adult↗
PubMed1997

Preliminary experience with intrasphincteric botulinum toxin for persistent constipation after pull-through for Hirschsprung's disease.

Although most children who have Hirschsprung's disease have an excellent result after pull-through surgery, some experience persistent constipation caused by "internal sphincter achalasia." Anal myectomy has been advocated for this problem, but it results in permanent injury to the sphincter and is not universally effective. Botulinum toxin has been safely used to selectively and reversibly weaken a variety of voluntary muscles and sphincters in both adults and children. Injection of botulinum toxin into the internal anal sphincter (IAS) should theoretically produce the same functional result as anal myectomy without permanent sphincter injury. Four children aged 4 to 8 years presented with persistent constipation after a pull-through procedure for Hirschsprung's disease. Two had associated encopresis, both of whom had previous myectomies. The authors performed four-quadrant intrasphincteric botulinum toxin injection (total dose, 15 U). Resting IAS pressure decreased in all children 4 to 8 weeks after injection. Patients have been followed up for 7 to 9 months. One child (with Down's syndrome) remained symptomatically unchanged. The other three families reported significant improvement in bowel function in their children. In two of these, there was a return of symptoms 6 months after injection; one child underwent reinjection with good results. Postinjection incontinence occurred in three children, but resolved after several weeks in the one who did not have encopresis before botulinum toxin injection. These preliminary results suggest that botulinum toxin may represent a less invasive alternative to anal myectomy for children who have severe constipation after surgery for Hirschsprung's disease. If myectomy is contemplated, botulinum toxin may also be useful as a means of predicting which children may benefit.

Anal Canal↗
PubMed1996

Carcinoma of the rectum. Possible cellular predictors of metastatic potential and response to radiation therapy.

BACKGROUND: Preoperative radiation therapy can markedly improve local control of rectal carcinoma. However, some tumors do not respond well to moderate doses of preoperative radiation and would be better served by more aggressive preoperative treatment (e.g., chemoradiotherapy). Cellular predictors of responsiveness to radiation can help to select lesions for more aggressive treatment. In addition, there is a need for cellular predictors of metastatic potential. This is particularly important in the setting of preoperative radiation-downstaging by preoperative treatment can obscure the true pathologic stage of a tumor and confound the usual selection criteria for postoperative chemotherapy. PURPOSE: This study was undertaken to determine if proliferating cell nuclear antigen (PCNA), p53, DNA ploidy, and S-phase fraction are associated with response to radiation and/or risk for distant metastatic disease and to determine if these cellular markers are best evaluated from preradiation biopsy specimen or the larger (but possibly altered) final surgical specimen. MATERIALS AND METHODS: Archival specimens from 23 cases of ultrasound T3 or T4 rectal carcinoma treated preoperatively with radiation therapy were reviewed. Eligible lesions had preradiation biopsy specimens of sufficient size for flow cytometric review of archival tissue. Factors considered included PCNA positivity, presence of mutant nuclear p53, more than 30 percent tumor cells in S-phase, and presence of aneuploidy. RESULTS: With a median follow-up of three years, overall freedom from relapse was 83 percent, with all but one failure being extrapelvic. PCNA positivity in the preradiation specimen was significantly (P = 0.025) associated with a greater risk of tumor recurrence. In addition, there was a trend to greater likelihood of "probable downstaging" (defined as surgical T stage less than preradiation ultrasound T stage) for lesions that were PCNA-negative or lesions with normal p53. Biomarkers measured in the postradiation surgical specimen were not associated with either freedom from relapse or response to radiation. Radiation treatment appeared to produce false-negatives in the final specimen. Thus, there were significantly more specimens converting from PCNA-positive to PCNA-negative after preoperative radiation than would be expected solely on the basis of sampling errors (P = 0.004). Similar results were found for abnormal p53 findings (P = 0.02). CONCLUSIONS: Prospective studies of biomarkers should be based on pretreatment specimens if preoperative radiation is given. For carcinoma of the rectum, PCNA and p53 may be useful predictors of both metastatic potential and responsiveness to radiation.

Adenocarcinoma↗
PubMed1995

Adjuvant radiation therapy for rectal carcinoma: predictors of outcome.

PURPOSE: To review predictors of outcome, including sequencing of modalities and pretreatment findings for adjuvantly treated rectal cancer. METHODS AND MATERIALS: From 1975 through 1990, 307 patients with adenocarcinoma of the rectum underwent adjuvant radiation therapy. In 251 cases the radiation therapy was administered preoperatively, either 40-50 Gy (median dose 45 Gy) followed in 6-7 weeks by surgery (210 cases), or 20 Gy in five fractions immediately prior to surgery (41 cases). In 56 cases, patients were referred postoperatively for radiation (median dose 50 Gy). Adjuvant chemotherapy was never given concurrently with the preoperative radiation (RT), although 43 of the cases (including 14 of the preoperative RT cases) received postoperative chemotherapy. RESULTS: Multivariate analysis (Cox model) indicated that significant predictors of better overall freedom from disease were preoperative rather than postoperative RT (p < 0.001), low surgical stage (p < 0.0001), specialist surgeon (p = 0.007), low or moderate histologic grade (p = 0.026), and proximal lesion (p = 0.033). The significant predictors for better local control included use of preoperative RT (p < 0.001), low or moderate grade (p = 0.001), and low surgical stage (p = 0.015). The 5-year local control and freedom from disease for the preoperative RT patients were 90% +/- 2% and 73% +/- 3%, respectively. The selected cases that received the short course of 20 Gy preoperatively did well. Although 24 out of 41 patients proved to have Astler Coller B2 or C disease, local control at last follow-up was 39 out of 41 (95%). A second multivariate analysis of pretreatment factors was performed on the preoperative RT cases. The significant factors for both local control and overall freedom from disease were noncircumferential vs. circumferential tumor, proximal vs. distal lesion, and background of the surgeon. Additional negative factors on univariate analysis (although not achieving independent significance on multivariate analysis) included the finding of near-obstructing lesions and elevated carcinoembryonic antigen (CEA). Grade > or = 3 sequelae occurred in 8% of cases (including 3% bowel obstruction). The only significant factor for complications was background of the surgeon (4% for colorectal specialists vs. 12% for nonspecialists, p = 0.015). CONCLUSIONS: Significant factors for better tumor control included preoperative as opposed to postoperative RT and the experience of the surgeon. In selected cases, excellent results can be obtained with a short course of preoperative radiation. Concurrent chemotherapy need not be given routinely with preoperative radiation. Subgroups of preoperative RT cases at risk for distant metastases (who might benefit from postoperative chemotherapy), and at high risk for local failure (for whom concurrent preoperative chemotherapy and radiation might be considered), are identified.

Adenocarcinoma↗
PubMed1995

Carcinoma of the anal canal.

From 1975 to 1990 65 patients with carcinoma of the anal canal received radiation therapy alone or in conjunction with other modalities. Follow-up ranged from 12 to 171 months (mean: 59 months; median: 44 months). Actuarial disease-free survival (including salvage surgery) for T1-3 N0 lesions was 88% +/- 7% at 10 years. This was independent of T stage (91% for T1, 88% for T2, and 100% for T3). Disease-free survival was significantly worse for T1-3 N+ lesions (52% +/- 23% disease-free at 10 years, P = .025) and T4 lesions (0/8 disease free by 21 months, P < .001). Of the 57 patients with T1-3 lesions, 46 received low to moderate doses of radiation (< or = 5,000 cGy) in conjunction with infusional 5FU based chemotherapy. These were reviewed for treatment related factors. Among patients treated with low to moderate dose chemoradiotherapy the local control (including salvage surgery) was excellent: 100% for T1 lesions and 88% +/- 6% for T2, 3 lesions. There was a suggestion that increasing the dose of radiation to the tumor may reduce the need for surgery for T2, 3 lesions. For T2, 3 lesions the local control excluding surgery was 63% +/- 12% with 3,000 cGy plus chemotherapy, as opposed to 77% +/- 11% with 4,000-5,000 Gy (mean 4,600 cGy) plus chemotherapy. The most important factor for posttreatment toxicity was the addition of pelvic surgery to chemotherapy and radiotherapy. Eighteen patients who received chemoradiotherapy either had a history of prior pelvic surgery (five cases) or underwent APR following chemotherapy (13 cases). There were a total of nine grade 3 or 4 complications (including all five cases of small bowel obstruction) in this group. There was a significantly lower (P = .04) incidence of complications in the remaining patients: 2/47 (4%). It should be noted that no patient required a colostomy for management of treatment sequelae, the interventions taken were all successful in managing complications, and no complication was fatal. Nonetheless these results suggest that, for some T3 and T2 lesions, measures which reduce the need for salvage surgery might improve overall quality of life by reducing complications, although it may prove difficult to demonstrate an improvement in the excellent disease-free survival. In addition, measures should be taken to reduce the volume of irradiated bowel if a patient has a history of prior pelvic surgery.

Adult↗
PubMed1991

Hospital costs, resource characteristics, and the dynamics of death for general surgery patients.

The world of health care finance and quality assessment is undergoing rapid change. We analyzed a large group of general surgical patients who died regarding hospital resource consumption. General surgical patients who died generated much greater resource consumption than survivors per DRG; increasing hospital LOS for general surgical patients who died was associated with increasing financial risk under DRGs. Patients who died after non-emergency admission generated similar financial risk to patients who died after emergency admission. General surgical patients who died who were referred from another clinical service generated, on average, similar resource consumption to non-referred patients who died. The results of this study support those of previous studies suggesting the payment inequities of DRGs for general surgical patients who die and suggest that attention should be directed at improving the DRG hospital payment system for these patients.

Aged↗
PubMed1991

Experience in managing 70 patients with ruptured abdominal aortic aneurysms.

Seventy cases of ruptured abdominal aortic aneurysms (RAAAs) repaired over a 14-year period from 1975 to 1989 were analyzed. Age, heart disease, chronic obstructive pulmonary disease (COPD), hypertension, diabetes, or specific postoperative complications did not correlate with mortality. If the time interval from arrival at the hospital to skin incision (emergency room (ER) or operating room (OR] was less than six hours, there was no correlation with survival. Mortality correlated significantly with admitting systolic blood pressure, blood pressure at the time of skin incision, a comparison of ER to OR time of less than or more than six hours, blood loss of less than compared to more than ten units, and time in the operating room of less than five hours compared to more than five hours. Both time in the operating room and blood loss correlated with technical problems. Prior to 1985, 11 general and vascular surgeons had repaired RAAAs with a mortality of 76%. Since 1985, six vascular surgeons repaired RAAAs with a significant decrease in mortality (54%). Our data indicate that patients profoundly hypotensive on admission or at the time of incision are unlikely to survive regardless of other factors; patients with a systolic blood pressure greater than 100 mm Hg have the best chance of survival; a delay of up to six hours prior to surgery in patients with a systolic blood pressure greater than 100 mm Hg does not increase mortality; and a smaller number of surgeons operating on RAAAs increases survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

The inactivation of antithrombin III by serum elastase in patients with surgical infections.

The relationship between serum elastase and antithrombin III was determined in septic surgical patients as a possible mechanism for intravascular thrombosis and hypercoagulability during sepsis. Eighteen patients with surgical infections and elevated white blood cell counts had their blood assayed daily for white blood cell count, serum elastase, and antithrombin III, until the patient's white blood cell count returned to normal. Antithrombin III was significantly lower (0.87%) when elastase was above the normal range (greater than 14.2 micrograms/ml). Elastase was significantly higher (30.6 micrograms/ml), when antithrombin III was less than normal. These data indicate that elevated serum elastase is associated with a significant reduction in circulating antithrombin III. Stimuli that increase serum elastase, i.e. surgery, trauma, or sepsis may promote intravascular thrombosis by the inhibition of antithrombin III at the blood-endothelial cell interface.

Antithrombin III↗
PubMed1989

Hospital costs and resource characteristics for cardiothoracic surgical hospital deaths.

No major changes in the federal Medicare diagnostic-related group (DRG) prospective hospital payment system have been implemented by the United States Congress. We analyzed hospital resource consumption for 1,567 cardiothoracic surgical patients by outcome (ie, survivors versus nonsurvivors). The 76 patients who died had a much greater intensity of hospital resource utilization and represented a substantial financial risk under DRG pricing schemes compared with the 1,491 survivors. Only patients who died within 1 week of admission to the hospital generated a financial surplus under DRGs. A long hospital stay for nonsurvivors produced a substantial deficit (patients with a stay greater than 60 days generated a $154,433 loss per patient). The cardiothoracic patients admitted on an emergency basis who died tended to have a shorter length of stay and represented a lower financial risk under DRGs compared with patients admitted on a nonemergency basis who died. Among nonsurvivors, patients referred for cardiothoracic surgical procedures from other clinical services had lower resource utilization and financial risk under DRGs compared with nonreferrals. These data suggest significant inequities in the current DRG prospective payment system vis-à-vis cardiothoracic surgical patients who die. Variables predictive of greater hospital resource utilization by outcome included a longer hospital stay, nonemergency admission, and admission directly to the cardiothoracic surgical service. Methods to improve the equity of DRG payment vis-à-vis cardiothoracic surgical nonsurvivors should be implemented in the future.

Adolescent↗
PubMed1989

The effect of small intestinal transplantation on intraluminal levels of serotonin and substance P.

This study was performed to examine the effect of transplantation, and thus extrinsic denervation, of the small intestine on intraluminal release of serotonin and substance P. Heterotopic 40-cm-long proximal (jejunal) small intestinal isografts were performed in six 200- to 250-g adult male Lewis rats under general anesthesia. Bowel ends were exteriorized as ostomies. Six Lewis rats with neurovascularly intact 40-cm proximal small bowel Thiry-Vella loops exteriorized as ostomies served as the control animals. On the seventh postoperative day, the intestinal loops were perfused at 0.5 ml/min for three 10-min periods with normal saline followed by an equilibrium period and then for three 10-min periods with 20% dextrose. Perfusates were collected for each period and levels of serotonin and substance P were determined by radioimmunoassay. Intraluminal serotonin levels rose from 29 +/- 9 ng/ml during saline perfusion to 115 +/- 28 ng/ml during intestinal perfusion with 20% dextrose in the innervated loops and from 21 +/- 7 ng/ml to 94 +/- 26 ng/ml in the transplanted loops. While there was a statistically significant increase in mean intraluminal serotonin levels following perfusion with 20% dextrose in both the control and transplant groups, there was no difference in the intraluminal serotonin response between controls and transplant recipients. In contrast, 20% dextrose had no effect on luminal release of substance P in either group. These results indicate that extrinsic denervation of the small intestine has no effect on the intraluminal serotonin response to stimulation and suggest that serotonin and substance P are not released into the intestinal lumen by the same regulatory mechanisms.

Animals↗
PubMed1989

Hospital costs, use of resources, and dynamics of death associated with diabetes mellitus.

The federal Medicare DRG (diagnosis-related group) system is entering its sixth year. The hospital industry contends that DRGs are under-reimbursing for the hospital care provided. Our analysis by outcome (ie, survival vs death) of 3,329 patients with insulin-dependent or non-insulin-dependent diabetes mellitus showed that the 242 diabetes-related deaths were associated with a much more intense use of hospital resources and a substantial financial risk under DRG pricing schemes, compared with the 3,087 diabetic survivors. Only deaths within one week of admission to the hospital were profitable under DRGs. Patients who died after a hospital stay of more than 60 days generated a loss of $28,377 per patient. Diabetic patients who died after emergency admission tended to have a shorter hospitalization and to pose less financial risk under DRGs than those who died after nonemergency admission. Those who died after referral from other clinical services tended to have greater use of resources and to pose greater financial risk under DRGs than those not referred. These data suggest significant inequities in the current Medicare DRG prospective payment system vis-à-vis deaths from diabetes. Long hospitalization, nonemergency admission, and referral from another clinical service were shown to be good predictors of greater use of hospital resources for diabetic patients who died. However, since hospitals are not compensated for the increased utilization, diabetic patients may suffer a decline in quality of and/or access to medical care in the future.

Adolescent↗
PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for surgical patients.

This article details data that suggest significant inequities in the current DRG prospective payment system vis-à-vis surgical mortalities. Important health policy issues, in addition to the ability of outcome data to function as a proxy for quality, involve the usefulness of stratifying DRGs vis-à-vis outcome or severity of illness in the future. Much interest has emerged in outcome data--especially with regard to its ability to function as a risk-adjusted quality-of-care screen for hospitals. A study of hospital resource consumption comparing survivors and mortalities demonstrated that surgical mortalities had a much greater intensity of hospital resource utilization and a substantial financial risk under Medicare's DRG prospective payment pricing system, as compared to surgical survivors. Hospital length of stay for mortalities proved very unprofitable. Emergency-admitted patients who died tended to have shorter hospital stays and less financial risk under DRGs than nonemergency mortalities. Mortalities referred to surgery from other clinical services tended to have greater resource utilization and financial risk under DRGs than nonreferred mortalities.

Adult↗
PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for hospitalized patients in cardiology Diagnosis-Related Groups.

A number of complex health policy questions face the nation regarding the Diagnosis-Related Group (DRG) prospective hospital payment system. An ongoing debate ensues at the federal level of the utility of improving the DRG system, given the "budget neutrality" provision of the DRG law. We analyzed hospital resource consumption for 5809 cardiology inpatients by outcome (i.e., survival vs death). Hospital resource use was greater and financial risk under DRG pricing schemes was substantial for the 312 deaths compared with the 5497 survivors. Only cases in which the patient died within 1 week of admission to the hospital were profitable under DRGs. A long hospital length of stay for patients who eventually died was very unprofitable (those who died after more than a 60-day hospital length of stay generated a $24,688 loss per patient). Patients who died after emergency admission tended to have a similar hospital length of stay and to be similar financial risk under DRGs, compared with nonemergency patients who died. Those patients who had been referred from other clinical services and who died caused greater resource use and financial risk under DRGs, compared with patients who were not referred and who died. These data suggest significant inequities in the current DRG prospective payment system for patients in cardiology DRGs who die. Variables predictive of greater hospital resource use for cardiology patients who die include longer hospital lengths of stay and referral from another clinical service. Health policy leaders should attempt to improve the equity of cardiology DRGs regarding outcome in the future.

Aged↗
PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for patients with a primary diagnosis of congestive heart failure.

Although substantial changes have been recommended in the diagnosis related group (DRG) prospective hospital payment system related to very expensive care for some patients, no major change in payment for these patients has been implemented by the US Congress. Both the Health Care Financing Administration and the Prospective Payment Assessment Commission continue to study issues related to DRG stratification along the lines of severity of illness, outcome (lived or died), or complications and/or comorbidities. We analyzed hospital resource consumption for 599 patients with a primary diagnosis of congestive heart failure (CHF) by outcome (ie, survivors vs mortalities). The 68 mortalities had a much greater intensity of hospital resource utilization, and a substantial financial risk under DRG pricing schemes, compared to the 531 survivors. Only mortalities within one week of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with a greater than 60-day LOS generated a +42,028 loss per patient). Emergency patients who died tended to have a shorter hospital LOS and less financial risk under DRGs, compared to patients who died who were not admitted as emergencies. These data suggest significant inequities in the DRG prospective payment system vis-a-vis CHF mortality. Variables predictive of greater hospital resource utilization for mortalities included longer hospital lengths of stay and urgent admission. Health policy leaders should be encouraged to further stratify DRG hospital resource consumption for appropriate variance in hospital costs.

Aged↗
PubMed1988

Hospital costs, resource characteristics, and the dynamics of death for patients with hypertension.

A great deal of interest has begun to focus on outcome data for hospitals. We analyzed hospital resource consumption for 4289 patients with hypertension by outcome (ie, survivors vs mortalities). The 211 mortalities had a much greater intensity of hospital resource utilization and a substantial financial risk under diagnosis related group (DRG) pricing schemes compared with the 4078 survivors. Only mortalities within one week of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with greater than 60-day LOS generated a $40,673 loss per patient). Patients admitted under emergency conditions who died tended to have a shorter hospital LOS and less financial risk under DRGs compared with those who were not emergency admissions and died. Mortalities referred from other clinical services tended to have greater resource utilization and financial risk under DRGs compared with nonreferred mortalities. These data suggest notable inequities in the DRG prospective payment system vis-à-vis patients who died with hypertension. They also demonstrated variables predictive of greater hospital resource utilization for patients who died with hypertension, including longer hospital LOS, nonemergency admission, and referral from another clinical service.

Aged↗
PubMed1988

A staged approach to long gap esophageal atresia employing a spiral myotomy and delayed reconstruction of the esophagus: an experimental study.

In beagle dogs, the cervical esophagus was divided 5 cm cranial to the thoracic inlet employing a stapler. The distal esophageal stump was attached to the external surface of the trachea. A spiral myotomy (2 1/2 revolutions) was made in a 3-cm long segment constituting the distal end of the proximal esophageal segment. This was twisted on a bias with the muscle edges approximated by interrupted stitches to cover the denuded submucosal layer. With moderate traction, this segment could be elongated to a length of 5 cm. A subcutaneous tunnel was created in the anterior chest to accommodate the reconstructed proximal esophageal segment (under slight traction), with its distal end forming a cutaneous esophagostomy. A gastrostomy was created using a Gauderer button (Bard Interventional Products, Billerica, MA) for feeding. After 3 weeks, the proximal esophageal segment was mobilized and removed from the subcutaneous tunnel. The distal esophageal segment was freed from the trachea and 5 to 8 cm of its proximal end was excised. The proximal (myotomized) esophagus was brought down to the stump of the remaining distal esophagus and an anastomosis formed in an end-to-end fashion. Oral feeding was reestablished within 1 week. Prolonged ingestion, observed soon after operation, gradually improved. During a period of 1 to 6 months after the operation, motility of the myotomized segment was tested by barium swallow and manometry. There was neither diverticulum formation nor stenosis. Transit of contrast material in the myotomized segment was smooth and rapid. Manometry demonstrated preservation of motility in the myotomized segment of the esophagus.(ABSTRACT TRUNCATED AT 250 WORDS)

Anastomosis, Surgical↗