Evaluation of cost and length of stay, linked to complications associated with major surgical procedures

INTRODUCTION

A lot of studies have demonstrated the possibility of reducing the number of post-operative complications in the domain of major surgical procedures with the use of medical preventive techniques. However, complications following surgical procedures are unfortunately frequent and are a major problem, not only because of the impact for the patient, but also because of economic consequences that they provoke. The aim of the present study is to evaluate the extra length of stay and the extra cost, born by the hospital and the social security, linked to complications, incurring after major surgical procedures.

MATERIAL AND METHODS

Study based on the data from 13 Belgian hospitals for the year 2012. Complications were extracted through medical discharge summaries. The cost born by the social security was assessed on the basis of the billing data, hospital cost are taken from cost accounting studies.

RESULTS

The rate of complication for all the hospitals is 6.6%. About 30.3% of inpatient stays having a major or extreme severity of index had a complication during the stay, 1.8% of stays with a minor or moderate severity of index had a complication. The extra length of stay is 19.38 days when the stay has had a complication (p < 0.001). The additional mean cost borne from the hospital perspective is €21 353.07 and €8 026.65 for the social security. This additional mean cost varies greatly from one hospital to another.

DISCUSSION/CONCLUSION

The present study has shown that the actual financing do not cover real hospital costs in the field of major surgical procedures having caused complications. Results should encourage Belgian authorities to propose and finance preventive measures in order to reduce these complications, which represent major economic impacts, not only for authorities but also for hospitals.

[Cost evaluation of organ harvesting in a Belgian academic hospital]

INTRODUCTION

The aim of this study is (1) to describe the characteristics of the organ harvesting activity conducted in 2012 at the Erasme's Hospital, Brussels University Hospital, (2) to highlight the different combinations " type of donor/types of organ's retrieved " in relation to organ harvestings carried out within the hospital, and (3) to calculate the organ harvesting's cost of acts.

METHODS

The study is conducted according to the hospital perspective. It assesses the consumption of medical and nursing staff resources, disposable material costs, medical device costs, drugs costs, sterile instruments and biomedical equipment costs, of the 34 organ harvesting procedures that has been conducted this year. Costs are calculated by procedure, by donor's type, by organ and by combinations.

RESULTS

Total cost is 99.442 €, with an average cost per donor of 3.016 €, 3.292 € for DBD postmortem donor (Donor Brain Death) and 2.456 € for DCD type (Donor Cardio-Circulatory Death). The average cost per organ leading to a transplantation is 1.842 € for DCD type and 1.297 € for DBD.

CONCLUSION

The results show that there is as many costs as the number of organ harvesting's combinations. Integrate the revenue generated by organ harvestings could establish whether funding sources cover the costs generated by this activity or if a reform of the nomenclature should be considered.

Endovanilloid control of pain modulation by the rostroventromedial medulla in an animal model of diabetic neuropathy

The involvement of transient receptor vanilloid type-1 (TRPV1) channels in pain modulation by the brain remains understudied. The rostroventromedial medulla (RVM) plays a key role in conveying to the spinal cord pain modulatory influences triggered in higher brain centres, with co-existence of inhibitory (antinociceptive) and facilitatory (pronociceptive) effects. In spite of some reports of TRPV1 expression in the RVM, it remains unknown if endovanilloid signalling plays a direct role in local pain modulation. Here we used a model of diabetic neuropathy, the streptozotocin (STZ)-diabetic rat, to study the role of endovanilloid signalling in RVM-mediated pain modulation during chronic pain. Four weeks after diabetes induction, the levels of TRPV1 mRNA and fatty acid amide hydrolase (FAAH), a crucial enzyme for endovanilloid catabolism, in the RVM of STZ-diabetic rats were higher than control. The RVM of STZ-diabetic rats presented decreased levels of several TRPV1 endogenous ligands, namely anandamide (AEA), palmitoylethanolamide (PEA) and oleoylethanolamide (OEA). Administration of capsaicin (a TRPV1 agonist) into the RVM decreased nociceptive behavioural responses in the inflammatory phase of the formalin test (phase 2). These findings suggest that diabetic neuropathy induces plastic changes of RVM endovanilloid signalling, indicating that TRPV1 may be a putative target for pain modulation in this chronic pain condition.

Inhibition of spinal 5-HT3R reverted diabetes-induced mechanical hypersensitivity in a GABAAR-mediated neurotransmission-dependent manner

Spinal 5-HT3 receptor (5-HT3R) has been implicated in chronic pain development. The extent to which 5-HT3R contributes to spinal sensitization and diabetic neuropathic pain (DNP) remains elusive and the mechanisms subserving the effects of 5-HT3R activation on spinal pain processing during chronic pain are still unclear. In this study, we evaluated the contribution of spinal 5-HT3R to pain facilitation and spinal sensitization during DNP, exploiting the role of GABAAR-mediated neurotransmission and glial activation in the effects elicited by intrathecal administration of a 5-HT3R antagonist. Mechanical nociception was evaluated by paw pressure test in streptozotocin (STZ)-diabetic and control rats after intrathecal (i.t.) administration of a 5-HT3R antagonist (Y25130). The spinal activation of extracellular signal-regulated kinases (ERKs) pathway and the expression of 5-HT3R, glial fibrillary acidic protein (GFAP; marker of astroglia activation) and ionized calcium binding adaptor molecule 1 (IBA-1; marker of microglia activation) were evaluated at the peak maximum effect of Y25130. The involvement of GABAAR-mediated neurotransmission in the behavioral pain effect of Y25130, was assessed in STZ-diabetic animals receiving i.t. administrations of muscimol (GABAAR agonist). Intrathecal administration of Y25130 reverted mechanical hyperalgesia and decreased the activation of ERKs in STZ-diabetic rats, while no effects were observed in control animals. The spinal activation of GABAAR by i.t. administration of muscimol abolished Y25130-driven antinociception. The expression of IBA-1, GFAP and 5-HT3R was unaltered by treatment. These findings point to a GABA-mediated pronociceptive role of spinal 5-HT3R during DNP.

Estimating surface NO2 and SO2 mixing ratios from fast-response total column observations and potential application to geostationary missions

Total-column nitrogen dioxide (NO₂) data collected by a ground-based sun-tracking spectrometer system (Pandora) and an photolytic-converter-based in-situ instrument collocated at NASA's Langley Research Center in Hampton, Virginia were analyzed to study the relationship between total-column and surface NO₂ measurements. The measurements span more than a year and cover all seasons. Surface mixing ratios are estimated via application of a planetary boundary-layer (PBL) height correction factor. This PBL correction factor effectively corrects for boundary-layer variability throughout the day, and accounts for up to ≈75 % of the variability between the NO₂ data sets. Previous studies have made monthly and seasonal comparisons of column/surface data, which has shown generally good agreement over these long average times. In the current analysis comparisons of column densities averaged over 90 s and 1 h are made. Applicability of this technique to sulfur dioxide (SO₂) is briefly explored. The SO₂ correlation is improved by excluding conditions where surface levels are considered background. The analysis is extended to data from the July 2011 DISCOVER-AQ mission over the greater Baltimore, MD area to examine the method's performance in more-polluted urban conditions where NO₂ concentrations are typically much higher.

"Hotheaded": the role OF TRPV1 in brain functions

The TRPV1 (vanilloid 1) channel is best known for its role in sensory transmission in the nociceptive neurons of the peripheral nervous system. Although first studied in the dorsal root ganglia as the receptor for capsaicin, TRPV1 has been recently recognized to have a broader distribution in the central nervous system, where it is likely to constitute an atypical neurotransmission system involved in several functions through modulation of both neuronal and glial activities. The endovanilloid-activated brain TRPV1 channels seem to be involved in somatosensory, motor and visceral functions. Recent studies suggested that TRPV1 channels also account for more complex functions, as addiction, anxiety, mood and cognition/learning. However, more studies are needed before the relevance of TRPV1 in brain activity can be clearly stated. This review highlights the increasing importance of TRPV1 as a regulator of brain function and discusses possible bases for the future development of new therapeutic approaches that by targeting brain TRPV1 receptors might be used for the treatment of several neurological disorders.

Metastatic breast cancer: mechanisms and opportunities for cytology

Despite significant advances in diagnosis, surgical techniques, general patient care, and local and systemic adjuvant therapies, metastatic disease remains the most critical condition limiting the survival of patients with breast cancer. Therefore, the development of effective treatment against late-arising metastasis has become the centre of clinical attention and is one of the current challenges in cancer research. A deeper understanding of the metastatic cascade is fundamental, and the need for repetitive tumour assessments for the evaluation of tumour evolution is a relatively new practice in routine medical care. As such, fine needle aspiration cytology (FNAC) is ideally placed to monitor biological changes in metastasis that may affect treatment and response. As FNAC is a minimally invasive method, it can be performed repeatedly with relatively little trauma, and selective ancillary tests can be applied to FNAC specimens, including for tumour whose primary nature is known. Herein, we review how the linear and parallel models explain metastatic dissemination, thus influencing therapeutic and clinical decisions, and how cytology, together with immunocytochemistry and molecular analysis, can be a tool for routine clinical practice and clinical trials aimed at metastatic disease with a special emphasis on breast cancer.

Abstract P6-08-01: Analysis of patient-reported outcomes following nipple-sparing mastectomy and implant reconstruction

Background: Nipple-sparing mastectomy (NSM) is gaining popularity among women undergoing prophylactic and therapeutic mastectomy. Using the BREAST-Q, a validated condition-specific patient-reported outcome instrument which measures postsurgical patient satisfaction and health-related quality of life (HR-QoL), we sought to determine whether satisfaction and HR-QoL differ between patients undergoing NSM and skin-sparing mastectomy (SSM) with immediate implant reconstruction.

Methods: From 2005 to 2012, a total of 572 patients underwent mastectomy; of these 261 patients (46%) had NSM. All mastectomy patients were mailed the BREAST-Q reconstruction questionnaire consisting of 3 scales (scored 0-100): Satisfaction with Breasts, Satisfaction with Outcome, and Psychosocial Well-Being. Excluded from this analysis were males, autologous tissue reconstruction, and conversion from NSM to SSM. Comparisons were made between NSM and SSM groups using univariable analysis and multivariable linear regression models (MVA).

Results: The BREAST-Q completion rate was 27% with a median time from surgery to survey of 36 months (range 4 to 86). Women undergoing NSM, compared to SSM, were younger (mean 46 v 50 years; p = 0.01), more likely to be married (80% v 52%; p = 0.001), have bilateral mastectomies (79% v 59%; p = 0.01), and had less time between surgery and BREAST-Q completion (median 25 v 49 months; p&lt;0.001). 19 NSM patients (25%) and 7 SSM patients (13%) underwent prophylactic mastectomy (p = 0.07). There were no differences regarding tumor characteristics or treatment. Patients undergoing NSM, compared to SSM, had a higher unadjusted mean score for Satisfaction with Breasts (71 v 60; p&lt;0.001), Satisfaction with Outcome (80 v 69; p = 0.003), and Psychosocial Well-Being (84 v 74; p = 0.006). On MVA analysis, NSM (compared to SSM) was associated with greater Satisfaction with Breasts (adjusted mean difference: +13, 95% Confidence Interval[CI]: 6-21, p = 0.001), Satisfaction with Outcome (adjusted mean difference: +17, 95% CI: 7-27, p = 0.001), and Psychosocial Well-Being (adjusted mean difference: +12, 95% CI: 3-22, p = 0.013), after controlling for age at mastectomy, marital status, laterality, cancer vs. non-cancer diagnosis, post-mastectomy radiation treatment, and time from mastectomy to BREAST-Q completion. Not being married (adjusted mean difference: +8, 95% CI: 2-15, p = 0.014) and having a bilateral mastectomy (adjusted mean difference: +8, 95% CI: 1-14, p = 0.029) were also significant predictors of increased Satisfaction with Breasts.

Conclusion: These findings suggest that, in the setting of implant reconstruction, NSM is associated with higher patient satisfaction with their breasts, overall outcome, and improved emotional/social well being.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-01.

Translocação dos herbicidas glyphosate e imazamox em plantas de aguapé

Entre as diversas plantas daninhas encontradas em ambientes aquáticos, a Eichhornia crassipes é uma das principais, sendo espécie indesejável para muitas atividades. O objetivo deste trabalho foi avaliar a translocação de glyphosate e imazamox em plantas de E. crassipes. Foram estudados oito intervalos de tempo para o corte das folhas que receberam os herbicidas: 2, 4, 6, 8, 12 e 24 horas após a aplicação (HAA) dos produtos, além de um tratamento sem corte das plantas (testemunha). Utilizaram-se glyphosate na dose de 2.160 g e.a. ha-1 (produto comercial - Rodeo) + 0,5% v v-1 do espalhante adesivo aterbane e imazamox na dose de 290,4 g i.a. ha-1 (produto comercial - Clearcast). Os tratamentos foram instalados em um delineamento experimental inteiramente casualizado com quatro repetições. O glyphosate apresentou um controle insatisfatório quando realizado os cortes das folhas em todos os períodos avaliados. O herbicida imazamox não proporcionou controle em até 12 HAA, enquanto que a partir de 24 HAA do herbicida o controle foi eficiente. Não houve uma grande mobilidade da molécula de glyphosate nas plantas de aguapé, sendo necessário um período superior a 24 horas para uma translocação satisfatória. Já para o imazamox um tempo de mínimo de 24 horas após a aplicação do herbicida foi suficiente para que ocorresse a translocação e um posterior controle.

Eficácia do glyphosate e 2,4-D no controle de Commelina villosa

O objetivo do presente trabalho foi avaliar a eficácia de glyphosate e 2,4-D, isolados e em mistura, no controle de Commelina villosa. Foram estudadas duas metodologias de avaliação de absorção de herbicidas em oito intervalos de tempo para a lavagem (simulando chuva após a aplicação) e corte (simulando abortamento, como estratégia de defesa) das folhas: 2, 4, 6, 8, 12, 24 e 48 horas após a aplicação dos herbicidas, além de um tratamento sem lavagem ou corte das folhas, em delineamento experimental inteiramente casualizado com quatro repetições, dispostos em um esquema fatorial 3 x 7 + 1 (três herbicidas x sete períodos - horas após a aplicação). Os herbicidas e doses testados foram: glyphosate (1.440 g ha-1), 2,4-D (720 g ha-1) e a mistura glyphosate + 2,4-D (1.080 + 720 g ha-1). A simulação de chuva interferiu de forma negativa no controle das plantas com o herbicida glyphosate. O controle com o herbicida 2,4-D foi influenciado apenas no período de 2 horas. Os períodos de simulação de chuva não influenciaram no controle das plantas com a mistura de glyphosate + 2,4-D. Para o estudo com corte das folhas tratadas, todos os tratamentos independente do período para corte das folhas foram influenciados de forma negativa no controle, sendo que as plantas apresentaram rebrotas quando tratadas com o herbicida 2,4-D isolado.

What can we learn from international comparisons of costs by DRG?

OBJECTIVES

The objective of this study was to compare costs data by diagnosis related group (DRG) between Belgium and Switzerland. Our hypotheses were that differences between countries can probably be explained by methodological differences in cost calculations, by differences in medical practices and by differences in cost structures within the two countries.

METHODS

Classifications of DRG used in the two countries differ (AP-DRGs version 1.7 in Switzerland and APR-DRGs version 15.0 in Belgium). The first step of this study was to transform Belgian summaries into Swiss AP-DRGs. Belgian and Swiss data were calculated with a clinical costing methodology (full costing). Belgian and Swiss costs were converted into US$ PPP (purchasing power parity) in order to neutralize differences in purchasing power between countries.

RESULTS

The results of this study showed higher costs in Switzerland despite standardization of cost data according to PPP. The difference is not explained by the case-mix index because this was similar for inliers between the two countries. The length of stay (LOS) was also quite similar for inliers between the two countries. The case-mix index was, however, higher for high outliers in Belgium, as reflected in a higher LOS for these patients. Higher costs in Switzerland are thus probably explained mainly by the higher number of agency staff by service in this country or because of differences in medical practices.

CONCLUSIONS

It is possible to make international comparisons but only if there is standardization of the case-mix between countries and only if comparable accountancy methodologies are used. Harmonization of DRGs groups, nomenclature and accountancy is thus required.