Prevalence of heart disease and its risk factors related to age in Asians, Pacific Islanders, and Whites in Hawai'i

OBJECTIVE

To examine disparities in disease prevalence related to age and race/ethnicity. Study design. Retrospective observational study.

METHODS

Eligible population included enrollees with largest insurer in Hawai'i. Chronic diseases were identified from claims data (1999-2009) based on algorithms including diagnostic codes and pharmaceutical utilization. Relative risk of heart disease and its risk factors were calculated for Native Hawaiians and Asian sub-groups by age.

RESULTS

Prevalence of heart disease and its risk factors differed substantially by age and race/ethnicity. Native Hawaiians and Filipinos had higher rates of hypertension and diabetes; Asians had highest rates of hyperlipidemia. Whites had the lowest prevalence of risk factors yet their risk of heart disease equaled other groups.

CONCLUSION

Prevalence curves began diverging at age 30 for risk factors and age 40 for heart disease. This suggests approaches to reduce the burden of disease for vulnerable groups need to begin in early adulthood if not sooner.

The Relationship of Hospital Quality and Cost per Case in Hawaii

One of the leading questions of our time is whether high-quality care leads to lower health care costs. Using data from Hawaii hospitals, this paper addresses the relationship of overall cost per case to a composite measure of the quality of inpatient care and a 30-day readmission rate. We found that low-cost hospitals tend to have the highest quality but the worst readmission performance. Change in quality and change in cost were also negatively correlated, but not statistically significant. We conclude that high-quality hospital care does not have to cost more, but that the dynamics of the readmission rate differ substantially from other quality dimensions.

Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Disparities in health, obesity and access to care among an insured population of Asian and Pacific Islander Americans in Hawai'i

OBJECTIVE

To examine differences in health status, obesity and access among Asian and Pacific Islander Americans in Hawai'i using data from a 2007 health plan survey, including Caucasians, Puerto Ricans, American Indian and Alaska Natives, Chinese, Filipinos, Japanese, Koreans, Native Hawai'ians, Samoans, and Other Pacific Islanders.

METHODS

Data were collected through a stratified random sample of adult members of a health plan in Hawai'i (n = 119,563) who saw a physician in the past 12 months. Multivariable logistic and ordinary least squares regression analyses were used to examine racial/ethnic differences in health status, access, and obesity and the impact of obesity and access on health status, after controlling for age, gender, and education.

RESULTS

The highest obesity rates were found among Samoans (50%), Puerto Ricans (37%), Native Hawai'ians (36%), and Other Pacific Islanders (35%). Puerto Ricans and Samoans reported the highestnumber of poor physical health days (5.4). Samoans reported the highest number of poor mental health days (4.4). Obesity had a stronger impact than access on self-reported health status.

CONCLUSION

Samoans had the highest rate of obesity, low health ratings, and a high number of days of poor health. Targeted interventions may be needed for this group.

The effect of a PPO pay-for-performance program on patients with diabetes

OBJECTIVES

To investigate the effectiveness of a pay-for-performance program (P4P) to increase the receipt of quality care and to decrease hospitalization rates among patients with diabetes mellitus.

STUDY DESIGN

Longitudinal study of patients with diabetes enrolled in a preferred provider organization (PPO) between January 1, 1999, and December 31, 2006.

METHODS

We used multivariate analyses to assess the effect of seeing P4P-participating physicians on the receipt of quality care (ie, glycosylated hemoglobin and low-density lipoprotein cholesterol testing) and on hospitalization rates, controlling for patient characteristics.

RESULTS

Patients with diabetes who saw P4P-participating physicians were more likely to receive quality care than those who did not (odds ratio, 1.16; 95% confidence interval, 1.11-1.22; P <.001). Patients with diabetes who received quality care were less likely to be hospitalized than those who did not (incident rate ratio, 0.80; 95% confidence interval, 0.80-0.85; P <.001). During 1 year, there was no difference in hospitalization rates between patients with diabetes who saw P4P-participating physicians versus those who did not. However, patients with diabetes who saw P4P-participating physicians in 3 consecutive years were less likely to be hospitalized than those who did not (incident rate ratio, 0.75; 95% confidence interval, 0.61-0.93; P <.01).

CONCLUSIONS

A P4P can significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes in a PPO setting. Although it is possible that the differences observed between P4P-participating physicians and non-P4P-participating physicians were due to selection bias, we found no significant difference in the receipt of quality care between patients with diabetes who saw new P4P-participating physicians versus non-P4P-participating physicians during the baseline year. Further research should focus on defining the effect of P4Ps on intermediate outcomes such as glycosylated hemoglobin and low-density lipoprotein cholesterol levels.

Patient outcomes and evidence-based medicine in a preferred provider organization setting: a six-year evaluation of a physician pay-for-performance program

OBJECTIVE

To determine whether health plan members who saw physicians participating in a quality-based incentive program in a preferred provider organization (PPO) setting received recommended care over time compared with patients who saw physicians who did not participate in the incentive program, as per 11 evidence-based quality indicators.

DATA SOURCES/STUDY SETTING

Administrative claims data for PPO members of a large nonprofit health plan in Hawaii collected over a 6-year period after the program was first implemented.

STUDY DESIGN

An observational study allowing for multiple member records within and across years. Levels of recommended care received by members who visited physicians who did or did not participate in a quality incentive program were compared, after controlling for other member characteristics and the member's total number of annual office visits.

DATA COLLECTION

Data for all PPO enrollees eligible for at least one of the 11 quality indicators in at least 1 year were collected.

PRINCIPAL FINDINGS

We found a consistent, positive association between having seen only program-participating providers and receiving recommended care for all 6 years with odds ratios ranging from 1.06 to 1.27 (95 percent confidence interval: 1.03-1.08, 1.09-1.40).

CONCLUSIONS

Physician reimbursement models built upon evidence-based quality of care metrics may positively affect whether or not a patient receives high quality, recommended care.

New insight into the molecular pathways of metallothionein-mediated neuroprotection and regeneration

There is a large body of evidence demonstrating that metallothioneins (MTs) expressed in astrocytes following CNS injury, exhibit both neuroprotective and neuroregenerative properties and are critical for recovery outcomes. As these proteins lack signal peptides, and have well characterized free radical scavenging and heavy metal binding properties, the neuroprotective functions of MTs have been attributed to these intracellular roles. However, there is an increasing realization that the neuroprotective functions of MTs may also involve an extracellular component. In this issue of Journal of Neurochemistry, Ambjørn et al. reveal considerable insight into this novel function of MTs. In this review, we examine the seminal work of Ambjørn et al. in the context of our current understanding of the role of MT in astrocyte-neuron interactions in the injured brain, and also discuss the significant therapeutic potential of their work.

Excitotoxicity mediated by non-NMDA receptors causes distal axonopathy in long-term cultured spinal motor neurons

Excitotoxicity has been implicated as a potential cause of neuronal degeneration in amyotrophic lateral sclerosis (ALS). It has not been clear how excitotoxic injury leads to the hallmark pathological changes of ALS, such as the abnormal accumulation of filamentous proteins in axons. We have investigated the effects of overactivation of excitatory receptors in rodent neurons maintained in long-term culture. Excitotoxicity, mediated principally via non-N-methyl-D-aspartate (NMDA) receptors, caused axonal swelling and accumulation of cytoskeletal proteins in the distal segments of the axons of cultured spinal, but not cortical, neurons. Axonopathy only occurred in spinal neurons maintained for 3 weeks in vitro, indicating that susceptibility to axonal pathology may be related to relative maturity of the neuron. Excitotoxic axonopathy was associated with the aberrant colocalization of phosphorylated and dephosphorylated neurofilament proteins, indicating that disruption to the regulation of phosphorylation of neurofilaments may lead to their abnormal accumulation. These data provide a strong link between excitotoxicity and the selective pattern of axonopathy of lower motor neurons that underlies neuronal dysfunction in ALS.

Metallothionein expression by NG2 glial cells following CNS injury

Metallothionein (MT) expression is rapidly up-regulated following CNS injury, and there is a strong correlation between the presence or absence of MTand improved or impaired (respectively) recovery from such trauma.We now report that a distinct subset of NG2-positive, GFAP-negative glial cells bordering the injury tract express MT following focal injury to the adult rat neocortex. To confirm the ability of these NG2 glial cells to express MT, we have isolated and cultured them and identified that they can express MT following stimulation with zinc. To investigate the functional importance of MT expression by NG2 glial cells, we plated cortical neurons onto these cells and found that expression of MT enhanced the permissivity of NG2 glial cells to neurite outgrowth. Our data suggest that expression of MT by NG2 glial cells may contribute to the overall permissiveness of these cells to axon regeneration.

Follow-up services after an emergency department visit for substance abuse

OBJECTIVE

The recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED).

STUDY DESIGN

Retrospective claims analysis.

METHODS

Claims were abstracted for all members who used an ED in 2004 for a diagnosis of substance abuse in a large commercial MCO. General linear models were used to estimate the association between receiving follow-up care within 14 and 60 days and sex, age, type of primary diagnosis, substance abused, and level of use.

RESULTS

Of the 1235 patients who visited an ED with a diagnosis of substance abuse, 13% received follow-up substance abuse services within 14 days of their ED visit. An additional 36% of patients had an outpatient service that did not code a substance abuse diagnosis within 2 weeks of an ED visit. The diagnosis breakdown of patients' primary diagnoses was 28% substance use, 13% mental health issues, and 59% nonpsychiatric (medical) disorders. The multivariable regression analyses revealed having a nonpsychiatric (medical) primary diagnosis was the strongest predictor of not receiving follow-up care (relative risk = 0.51) at 14 days compared with patients who had a mental health diagnosis.

CONCLUSIONS

Training ED staff and nonbehavioral health outpatient providers in treatment follow-up for substance abuse may improve the quality of care for patients. Encouraging providers to code for substance abuse when treatment or counseling is delivered would improve health plan HEDIS scores. Interventions may be needed for frequent ED users with substance abuse.

Health disparities in 30 indicators of recommended clinical care

This article examines variations in clinical practice for 30 clinical indicators. Patients' age, gender, and morbidity and certain characteristics of their physicians affected whether they received recommended care. Recommended care increased with patient age for 13 significant clinical indicators and decreased with age for 7 others. Males received recommended care more often for 12 of 13 clinical indicators. Recommended care varied by physician specialties for health screenings, disease management, and medication use. Patients seeing physicians who treated a high volume of patients generally received better care. The variations in recommended care suggest potential targets for healthcare quality improvements.

Antihypertensive adherence and drug class among Asian Pacific Americans

OBJECTIVE

Research on adherence has emphasized the need to consider patient ethnicity when developing adherence plans. The objective of this study is to identify predictors of adherence for specific groups, particularly Asian Americans and Pacific Islanders.

METHODS

We examined the factors, including drug class, associated with antihypertensive adherence for 28,395 adults in Hawaii (July 1999-June 2003) using health plan administrative data. The population included Japanese (n=13,836), Filipino (n=3,812), Chinese (n=2,280), Korean (n=450), part-Hawaiian (n=3,746) and white (n=3,920) patients. Members with antihypertensive medication in their possession >or=80% of the time were considered adherent. Multivariable logistic regression models were used to identify factors associated with adherence.

RESULTS

Overall adherence rates were less than 65% among all racial/ethnic groups. After adjustment for patient age, gender, morbidity level, health plan type, isle of residence, comorbidities and year of treatment, Japanese were more likely than whites to adhere to antihypertensive therapy [OR=1.21 (1.14-1.29)], whereas Filipino [OR=0.69 (0.64-0.74)], Korean [OR=0.79 (0.67-0.93)] and Hawaiian [OR=0.84 (0.78-0.91)] patients were less likely to adhere. These results were consistent across therapeutic class. Other patient factors associated with lower adherence included younger age, higher morbidity and history of heart disease. Patient factors were also significantly related to adherence, including gender and seeing a sub-specialist. Seeing a physician of the same ethnicity did not appear to improve adherence.

CONCLUSIONS

Our findings of substantial disparities among Asian Pacific American subgroups highlight the need to examine subgroups separately. Future qualitative research is needed to determine appropriate interventions, particularly for Filipino, Korean and Hawaiian patients.

Cyclosporin-A treatment attenuates delayed cytoskeletal alterations and secondary axotomy following mild axonal stretch injury

Following central nervous system trauma, diffuse axonal injury and secondary axotomy result from a cascade of cellular alterations including cytoskeletal and mitochondrial disruption. We have examined the link between intracellular changes following mild/moderate axonal stretch injury and secondary axotomy in rat cortical neurons cultured to relative maturity (21 days in vitro). Axon bundles were transiently stretched to a strain level between 103% and 106% using controlled pressurized fluid. Double-immunohistochemical analysis of neurofilaments, neuronal spectrin, alpha-internexin, cytochrome-c, and ubiquitin was conducted at 24-, 48-, 72-, and 96-h postinjury. Stretch injury resulted in delayed cytoskeletal damage, maximal at 48-h postinjury. Accumulation of cytochrome-c and ubiquitin was also evident at 48 h following injury and colocalized to axonal regions of cytoskeletal disruption. Pretreatment of cultures with cyclosporin-A, an inhibitor of calcineurin and the mitochondrial membrane transitional pore, reduced the degree of cytoskeletal damage in stretch-injured axonal bundles. At 48-h postinjury, 20% of untreated cultures demonstrated secondary axotomy, whereas cyclosporin A-treated axon bundles remained intact. By 72-h postinjury, 50% of control preparations and 7% of cyclosporin A-treated axonal bundles had progressed to secondary axotomy, respectively. Statistical analyses demonstrated a significant (p < 0.05) reduction in secondary axotomy between treated and untreated cultures. In summary, these results suggest that cyclosporin-A reduces progressive cytoskeletal damage and secondary axotomy following transient axonal stretch injury in vitro.

Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care

OBJECTIVE

To measure the impact of medication copayment level and other predictors on compliance with antihypertensive medications, as measured by the medication possession ratio.

STUDY DESIGN

Retrospective observational analysis.

METHODS

We used claims data from a large managed care organization. The identification of subjects was based on a diagnosis of hypertension and a filled prescription for antihypertensive medication between January 1999 and June 2004. Multivariate logistic regression models were used to evaluate copayment level and patient characteristics as predictors of medication compliance.

RESULTS

Analysis of data for 114,232 patients filling prescriptions for antihypertensive medications revealed that compliance was lower for drugs in less preferred tiers. Relative to medications with a 5 dollars copayment, the odds ratio (95% confidence interval) for compliance with drugs having a 20 dollars copayment was 0.76 (0.75, 0.78); for drugs requiring a 20 dollars to 165 dollars copayment, the odds ratio for compliance was 0.48 (0.47, 0.49). Medication compliance also differed by patient age, morbidity level, and ethnicity, as well as by medication therapeutic class--with the best compliance observed for angiotensin receptor blockers, followed by calcium channel blockers, beta-adrenergic receptor antagonists (beta-blockers), angiotensin-converting enzyme inhibitors, and last, thiazide diuretics.

CONCLUSIONS

Copayment level, independent of other determinants, was found to be a strong predictor of compliance with antihypertensive medications, with greater compliance seen among patients filing pharmacy claims for drugs that required lower copayments. This finding suggests that patient use is sensitive to price. The potential impact on compliance should be considered when making pricing and policy decisions.

Variations in clinical practice among the Hawaiian islands

State health surveys and hospital discharge data suggest aspects of health care may vary by island in the state of Hawai'i. This study further examines the issue comparing O'ahu, Maui, Hawai'i, and Kaua'i on 15 indicators of recommended clinical care using data from a large insurer in Hawaii. The Hawaiian Islands differed to a statistically significant extent on 14 of the 15 indicators. O'ahu had the highest percentage of recommended care for six indicators, Maui for four, Kaua'i for three, and Hawai'i for two. In analyses adjusted for age, gender, morbidity, and health plan--and comparing the outer islands individually to O'ahu--O'ahu had more favorable care in 16 of 18 statistically significant comparisons. More focused geographic studies may be warranted to clarify where and why the variations in health care occur.

Are physician reimbursement strategies associated with processes of care and patient satisfaction for patients with diabetes in managed care?

OBJECTIVE

To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model.

DATA SOURCES

Primary data collected during 2000-2001 in 10 managed care plans.

STUDY DESIGN

Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive.

DATA COLLECTION

Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes.

PRINCIPAL FINDINGS

Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model.

CONCLUSIONS

Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.

Aligning Financial Incentives with Quality of Care in the Hospital Setting

This article describes the structure, implementation, and early results of a performance-based hospital incentive program designed by a large nonprofit health plan. The Hospital Quality Service and Recognition program, developed by the Hawaii Medical Service Association, was launched in 2001 to reward high-quality medical care at the hospital level. This pay-for-performance program used administrative claims data, survey data, and hospital-reported information to assess hospital performance in risk-adjusted complications and risk-adjusted length of stay (LOS), patient satisfaction, and hospital processes of care measures. Financial incentives were provided to participating hospitals based on their performance on these measures. Preliminary outcomes of the program evaluated over a 4-year period after implementation revealed improvements in aggregated rates of risk-adjusted surgical complications and efficiency of care as evidenced by a substantial decrease in risk-adjusted average LOS for several surgical procedures. Quality improvement was demonstrated in several other program components including emergency department satisfaction. This quality incentive program offers an innovative approach for encouraging delivery of high-quality and service-oriented care in a statewide network of participating hospitals.

Localization of glutamate receptors in developing cortical neurons in culture and relationship to susceptibility to excitotoxicity

Overactivation of glutamate receptors leading to excitotoxicity has been implicated in the neurodegenerative alterations of a range of central nervous system (CNS) disorders. We have investigated the cell-type-specific changes in glutamate receptor localization in developing cortical neurons in culture, as well as the relationship between glutamate receptor subunit distribution with synapse formation and susceptibility to excitotoxicity. Glutamate receptor subunit clustering was present prior to the formation of synapses. However, different receptor types showed distinctive temporal patterns of subunit clustering, localization to spines, and apposition to presynaptic terminals. N-methyl-D-aspartate (NMDA) receptor subunit immunolabelling was present in puncta along dendrites prior to the formation of synapses, with relatively little localization to spines. Vulnerability to NMDA receptor-mediated excitotoxicity occurred before receptor subunits became localized in apposition to presynaptic terminals. Clustering of alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors occurred concurrently with development of vulnerability to excitotoxicity and was related to localization of AMPA receptors at synapses and in spines. Different AMPA receptor subunits demonstrated cell-type-specific localization as well as distribution to spines, dendrites, and extrasynaptic subunit clusters. A subclass of neurons demonstrated substantial perineuronal synaptic innervation, and these neurons expressed relatively high levels of GluR1 and/or GluR4 at receptor puncta, indicating the presence of calcium-permeable AMPA receptors and suggesting alternative synaptic signalling mechanisms and vulnerability to excitotoxicity. These data demonstrate the relationship between glutamate receptor subunit expression and localization with synaptogenesis and development of neuronal susceptibility to excitotoxicity. These data also suggest that excitotoxicity can be mediated through extrasynaptic receptor subunit complexes along dendrites.

Remote Physiological Monitoring: Clinical, Financial, and Behavioral Outcomes in a Heart Failure Population

This article reports on the outcomes associated with remote physiological monitoring (RPM) conducted as part of a heart failure disease management program. Claims data, medical records, data transmission records, and survey results for 91 individuals ages 50-92 (mean 74 years) successfully completing a heart failure RPM program were analyzed for time periods before, during, and after the monitoring intervention. The program was associated with significant reductions in per member per month costs and emergency room and hospital utilization. More detailed analyses were performed for specific gender and age subgroups. Participant surveys indicated high levels of satisfaction, and improvements in self-perceived health status, self-efficacy, and self-management behaviors. This study is the first to assess the impact of a RPM program following removal of the monitoring equipment. The results indicate that RPM, as a component of a traditional disease management program, has a sustained, beneficial effect on participants' lifestyles after the monitoring period has ended.

Metallothionein biology in the ageing and neurodegenerative brain

In recent years metallothionein (MT) biology has moved from investigation of its ability to protect against environmental heavy metals to a wider appreciation of its role in responding to cellular stress, whether as a consequence of normal function, or following injury and disease. This is exemplified by recent investigation of MT in the mammalian brain where plausible roles for MT action have been described, including zinc metabolism, free radical scavenging, and protection and regeneration following neurological injury. Along with other laboratories we have used several models of central nervous system (CNS) injury to investigate possible parallels between injury-dependent changes in MT expression and those observed in the ageing and/or degenerating brain. Therefore, this brief review aims to summarise existing information on MT expression during CNS ageing, and to examine the possible involvement of this protein in the course of human neurodegenerative disease, as exemplified by Alzheimer's disease.

Olfactory ensheathing cells promote neurite sprouting of injured axons in vitro by direct cellular contact and secretion of soluble factors

Olfactory ensheathing cells (OECs) represent an exciting possibility for promoting axonal regeneration within the injured spinal cord. A number of studies have indicated the ability of these cells to promote significant reactive sprouting of injured axons within the injured spinal cord, and in some cases restoration of functional abilities. However, the cellular and/or molecular mechanisms OECs use to achieve this are unclear. To investigate such mechanisms, we report for the first time the ability of OECs to promote post-injury neurite sprouting in an in vitro model of axonal injury. Using this model, we were able to differentiate between the direct and indirect mechanisms underlying the ability of OECs to promote neuronal recovery from injury. We noted that OECs appeared to act as a physical substrate for the growth of post-injury neurite sprouts. We also found that while post-injury sprouting was promoted most when OECs were allowed to directly contact injured neurons, physical separation using tissue culture inserts (1 mm pore size, permeable to diffusible factors but not cells) did not completely block the promoting properties of OECs, suggesting that they also secrete soluble factors which aid post-injury neurite sprouting. Furthermore, this in vitro model allowed direct observation of the cellular interactions between OECs and sprouting neurites using live-cell-imaging techniques. In summary, we found that OECs separately promote neurite sprouting by providing a physical substrate for growth and through the expression of soluble factors. Our findings provide new insight into the ability of OECs to promote axonal regeneration, and also indicate potential targets for manipulation of these cells to enhance their restorative ability.

A role for extracellular metallothioneins in CNS injury and repair

For many years, research focus on metallothioneins, small zinc binding proteins found predominantly within astrocytes in the brain, has centred on their ability to indirectly protect neurons from oxygen free radicals and heavy metal-induced neurotoxicity. However, in recent years it has been demonstrated that these proteins have previously unsuspected roles within the cellular response to brain injury. The aim of this commentary is to provide an overview of the exciting recent experimental evidence from several laboratories including our own suggesting a possible extracellular role for these proteins, and to present a hypothetical model explaining the newly identified function of extracellular metallothioneins in CNS injury and repair.

Olfactory ensheathing cells promote collateral axonal branching in the injured adult rat spinal cord

In recent years, injection of olfactory ensheathing cells (ECs) into the spinal cord has been used as an experimental strategy to promote regeneration of injured axons. In this study, we have compared the effects of transplanting encapsulated ECs with those injected directly into the spinal cord. The dorsal columns of adult rats were cut at T(8-9) and rats in experimental groups received either EC-filled porous polymer capsules or culture medium (CM)-filled capsules with ECs injected at the injury site. Control rats were in three groups: (1) uninjured, (2) lesion with transplantation of CM-filled capsules and (3) lesion with transplantation of CM-filled capsules and injections of CM. Three weeks after injury, Fluororuby was injected into the hindlimb motor and somatosensory cortex to label corticospinal neurons. Observations indicated that there were a few regenerating fibres, up to 10, in the EC-treated groups. In rats that received encapsulated ECs, regenerating fibres were present in close association with the capsule. Rats that received EC injections demonstrated a significant increase in the number of collateral branches from the intact ventral corticospinal tract (vCST) compared with the corresponding control, CM-injected group (P=0.003), while a trend for increased collateral branches was observed in rats that received encapsulated ECs (P=0.07).

A Quality-Driven Physician Compensation Model: Four-Year Follow-up Study

This case report describes a qualitative and preliminary quantitative assessment of a quality-based physician compensation program. The Hawaii Medical Service Association's Physician Quality and Service Recognition program offers an innovative and effective approach for improving delivery of high-quality and cost-effective care to patients enrolled in preferred provider organizations. Support for the program is demonstrated through increasing numbers of voluntarily participating physicians. Preliminary assessment of population outcomes reveals sustained improvements in many clinical areas and mixed findings in others. This study contributes to the body of knowledge available to payers and policy makers considering alternative payment methods to reward improved performance.

Alternate financial incentives in multi-tiered formulary systems to improve accountability for outcomes

BACKGROUND

Drug manufacturer rebates paid to health plans and pharmacy benefit management companies have come under increased public scrutiny. Over the past several years, numerous articles have appeared in the literature encouraging a shift to a more quality-based decision-making process for health plan drug formularies.

OBJECTIVE

To propose a new basis for formulary placement decisions that would include consideration of health-plan-specific measures (clinical outcomes, total cost, adherence, and appropriateness of care) and align incentives for health plans, physicians, pharmacists, and pharmaceutical companies to promote high-quality care.

SUMMARY

The proposed approach builds on key components of the Pharmacy's Framework for Drug Therapy Management in the 21st Century and the Academy of Managed Care Pharmacy's Format for Formulary Submission, including a focus on patient outcomes and evidence-based decision making. The proposed approach would lessen the influence of drug manufacturer rebates on formulary placement by shifting the focus to appropriateness of care, clinical outcomes, patient adherence, and total cost of care. Pharmaceutical manufacturers would benefit from the focus on adherence to drug therapy and total cost of care. Health plans and pharmacy benefit management companies would gain in that they may be able to reduce efforts in drug utilization review as pharmaceutical manufacturers are given incentives to market their drugs more appropriately. Physicians and pharmacists would benefit because the rebate money would be used to provide quality-based financial incentives related to adherence and appropriate use of drugs.

CONCLUSION

The implementation of this approach would be difficult and require cooperation from employers, pharmacists, pharmaceutical manufacturers, health plans, and pharmacy benefit management companies. Aspects of this approach could be incorporated into existing pharmacy benefit management processes to encourage the delivery of high-quality health care.

Prescription drugs: elderly enrollee reports of financial access, receipt of free samples, and discussion of generic equivalents related to type of coverage

OBJECTIVE

To compare elderly health plan enrollee's survey responses regarding access to prescription drugs, receipt of samples, and discussion of generic equivalents across healthcare delivery systems and to examine the extent to which member characteristics are related to responses.

STUDY DESIGN

Cross-sectional, observational study.

PATIENTS AND METHODS

Elderly enrollees (aged 65 and over) in the Preferred Provider Organization (PPO in = 10,2201) and Medicare cost contract (n = 14,635) of a single health insurer responded to a 2001 member satisfaction survey. Multivariable logistic regression was used to estimate the relationship between outcomes (eg, not filling prescriptions) and patient characteristics.

RESULTS

Elderly enrollees in a PPO had more comprehensive drug coverage and better access to pharmaceuticals than Medicare enrollees, with 14% of Medicare enrollees reporting that they "occasionally" or "always" skipped filling prescriptions due to cost, compared with 6% of PPO members (P < .001). Similarly, 14% of Medicare enrollees reported taking less medication than prescribed to save money, compared with 7% of PPO members. Ethnicity was one of the strongest predictors of financial access to pharmaceuticals among elderly enrollees, with the predicted probability of "occasionally" or "never" filling medications ranging from 0.06 for Japanese to 0.16 for Filipinos. A majority of members in both health plans reported receiving free samples of pharmaceuticals from their physicians.

CONCLUSIONS

Further research is needed to determine which medications are not being filled, the impact of sampling on subsequent drug utilization, and specific chronic conditions for which more extensive coverage is cost effective.

The decline of training in open biliary surgery: effect on the residents' attitude toward bile duct surgery

BACKGROUND

After more than a decade of growth for laparoscopic cholecystectomy and decline in open cholecystectomy, the impact on the training of resident's in other open biliary operations can be analyzed quantitatively.

METHODS

The national operative statistics for residents' operations from 1988 to 2001 (data in the public domain) were analyzed by regression analysis to establish trends and to calculate the rate of change. For laparoscopic biliary operations, the changes in laparoscopic and open operations over time and the number of operations per trainee each year were used to measure the growth of a laparoscopic operation and to predict future trends. A survey of attitude, management algorithm, and self-confidence for coping with unexpected events in laparoscopic cholecystectomy also was conducted for senior residents and recent graduates.

RESULTS

In 2001, open cholecystectomy decreased to 28%, open common duct exploration to 27%, sphincteroplasty to 20%, of 1988 (baseline year) levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. The decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. Many of the recent graduates surveyed in one program indicated a preference for a nonsurgical, mainly endoscopic, approach for all bile duct conditions, but also for the assistance of senior surgeons in the operative management of unexpected events.

CONCLUSION

The popularity of noninvasive therapy in biliary surgery significantly reduced the resident's exposure to open biliary surgery, adversely affecting their confidence in the management of unexpected events encountered during laparoscopic operations. Supplemental and remedial education measures must be instituted in training programs.

Metallothionein-III inhibits initial neurite formation in developing neurons as well as postinjury, regenerative neurite sprouting

Human metallothionein-III (MT-III) is an inhibitory factor deficient in the Alzheimer's disease (AD) brain. MT-III has been identified as an inhibitor of neurite sprouting, and its deficiency has been proposed to be involved in the formation of neurofibrillary tangles (NFT) in the neuropathology of AD. However, there has been limited investigation of the proposed neurite growth inhibitory properties of MT-III. We have applied recombinant human MT-III to both single cell embryonic cortical neurons (to investigate initial neurite formation), as well as mature (21 days postplating) clusters of cortical neurons (to investigate the regenerative sprouting response following injury). We report that MT-III inhibited the initial formation of neurites by rat embryonic (E18) cortical neurons. This was based on both the percentage of neurite positive neurons and the number of neurites per neuron (45 and 30% inhibition, respectively). Neurite inhibition was only observed in the presence of adult rat brain extract, and was also reversible following replacement of MT-III-containing medium. MT-III inhibited the formation and growth of both axons and dendrites. Of more physiological significance, MT-III also inhibited the regenerative neurite sprouting response following axonal transection. The morphology of sprouting neurites was also altered, with the distal tip often ending in bulb-like structures. Based on these results, we propose that MT-III, in the presence of brain extract, is a potent inhibitor of neurite sprouting, and may be involved in abnormal sprouting potentially underlying both AD and epilepsy.

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan

OBJECTIVE

To evaluate the effectiveness and possible cost savings of influenza vaccination.

SUBJECTS

Members age 65 and older in a Medicare managed care plan during the 1994-1995, 1995-1996, and 1996-1997 influenza seasons.

RESEARCH DESIGN

The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF).

RESULTS

Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about $80 per vaccinated subject.

CONCLUSIONS

Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

Carbon dioxide flux density in cultivated rice paddy field

The carbon dioxide flux density in a subtropical cultivated rice paddy field were determined over four crop seasons (two consecutive years) at five stages of rice plant development, transplanting, active tillering, booting, flowering and ripening, and an idle period between crops. During 24 h sampling periods at those stages, the CO2 flux densities were measured and found to be -2,000 to 55,000 mg CO2/m2/day in the first year and 600 to 29,000 mg CO2/m2/day in the second year in acrylic chambers covering rice plants. The CO2 flux densities in glass domes without plants but with soil were -700 to 6,000 mg CO2/m2/day in the first year and 147 to 4,500 mg CO2/m2/day in the second year. The data for the CO2 flux density over an entire year are extrapolated. Although our non-controlled environment experiments have inherent drawbacks, the collected data indicate that continuous rice cultivation has a tendency to result in increased CO2 emissions.

The clinical diagnosis of chronic acalculous cholecystitis

BACKGROUND

Chronic acalculous cholecystitis (CAC), a diagnosis of exclusion, appears to be more common than was previously thought. We correlated the pathology with test results and response to treatment in a prospective study to obtain data for evidence-based management.

METHODS

The study subjects were patients with chronic biliary symptoms but had normal sonogram results. They were further investigated with esophagogastroduodenoscopy, multidiscipline evaluations, and cholecystokinin-stimulated scintigraphy (CCK-HIDA). They were offered laparoscopic cholecystectomy (LC) when the symptoms were intransigent, and the main abnormality was a low ejection fraction (EF) as determined by CCK-HIDA. We analyzed the histologic findings of the gallbladder, CCK-HIDA EF, and clinical outcomes during the control period with a concurrent series of LC for calculus from the same surgeons.

RESULTS

Of 176 cholecystectomies for biliary pain without stones, 152 had pathologically verified CAC. EF by CCK-HIDA was low in patients with CAC (18%) and low in normal gallbladders (26%). In the same period, 497 patients had cholecystectomies for cholelithiasis. Lasting symptom relief for CAC after LC was not different from that for calculous disease (85% vs 90%).

CONCLUSIONS

The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease.

Correlating physical and mental health status with satisfaction in a health plan

Managed care organizations strive to prevent illness where possible and improve patient outcomes for enrollees. The objective of this study was to examine how data from the Medical Outcomes Study Short Form-12 from more than 45,000 health plan enrollees can be used to: compare enrollee health status with national norms, examine the relationship between health status and member characteristics, and determine the extent to which health status is related to member satisfaction. The member survey measured physical and mental health and the following aspects of satisfaction: access, communication, and medical services. The researchers found that physical and mental health status were significantly associated with age, education, and ethnicity, whereas satisfaction was positively correlated with mental health status. Monitoring the health status of enrollees through the administration of a short, well-validated questionnaire can provide useful information in comparison with national norms as well as important insights regarding potential areas to target for quality improvement initiatives.

Pretarsal fat compartment in the lower eyelid

It is generally accepted that there are three infraorbital fat regions in the lower eyelid; medial, central, and lateral compartments. However, removing only the fat in the lateral compartment does not remove the bulge just below the eyelashes, which is caused by another fat pad. The aim of this study was to describe the anatomy of the pretarsal fat compartment and to demonstrate its clinical implications in lower lid blepharoplasty. Ten cadavers (total 20 lower eyelids) were studied. A skin-muscle flap was reflected to expose the soft pretarsal structures. A small stab incision was made on the lateral portion of the sac containing fat on the tarsus. Methylene blue dye was injected into the sac. Specimens were fixed and sagittal sections in four different planes were prepared for histological analysis. The injected dye remained within the sac and demarcated it as a pear or cone shaped structure. This encapsulated fat compartment sits on the lateral half of the tarsal plate above the lateral compartment fat. Auxillary or submuscular fat is well known. This study, however, designates the pretarsal fat as "encapsulated" in a compartment instead of being unbound. We have named it the "pretarsal fat compartment." Histologically, orbital septal fibers separate "pretarsal fat" from lateral infraorbital fat. It is recommended that fat in the pretarsal fat compartment be removed during lower lid blepharoplasty in order to alleviate the bulge or knoll of the skin just below the lower eyelashes.

Histomorphometry of parietal bones versus age and race

Surgeons are used to obtaining bone grafts of calvaria, which are abundant and available. The outer table of the parietal bone can be split, usually at the level of the diploic interstice, with an osteotome. Inadvertently violating the inner table and the dura leads some surgeons to avoid using the outer table in the elderly. Sullivan and Smith measured the thickness of the outer tables, diploe, and inner table of 37 cadavers (average age, 59 years) and found each layer to be well preserved distinctly. However, they suggested that calvaria become brittle in patients older than 50 years of age. The current authors hypothesized that diploic composition is not changed, even in the elderly. The thickest part of the parietal bone of 49 Koreans and 30 whites were acquired, and undecalcified slides were made. Via light microscopy, using the National Institutes of Health image, the following measurements were made: the thickness of the parietal bone (PT), outer table (OT), diploe (DT), and inner table (IT); trabecular bone volume percent (TBV); trabecular thickness (TT); and trabecular separation (TS). There was no significant difference in the thickness of the OT, DT, and IT of the PT, TBV, TT, and TS among different ages. The PTs of women were thicker than men's. The PTs of whites were significantly thicker than Koreans'. This study disclosed that the DT is not different among varying age groups and is not sclerosed in the persons older than 80 years, and the OT of these individuals is not brittle. Thus, surgeons do not need to hesitate when taking the OT of the PT in older patients. However, the selection of the site is attentive to PT. The thickest posteromedial part of the PT is favorable and safe as a donor.

Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs

BACKGROUND

Despite randomized controlled trials, the merits of laparoscopic hernia repair remain poorly defined. A meta-analysis may provide a timely overview.

METHODS

An electronic MEDLINE search, supplemented by a manual search, yielded 14 randomized controlled trials with usable statistical data, involving 2,471 patients. The trials were grouped for separate meta-analyses according to the control operation, either a tension-free or sutured repair, used for comparison. The effect sizes for operating time, postoperative pain, return to normal activity, and early recurrence were calculated, using a random-effects model when the effect sizes were heterogeneous and without subcategories.

RESULTS

In all meta-analyses, the laparoscopic operation was significantly longer. When compared with tension-free repairs, the laparoscopic operation showed no advantage in terms of postoperative pain, but resulted in a shorter recovery (marginal significance). As compared with sutured repair, both postoperative pain and recovery were in favor of the laparoscopic operation. When all 14 trials were analyzed together, laparoscopic repairs still had moderately reduced postoperative pain and recovery time.

CONCLUSIONS

Laparoscopic hernia repair has a modest advantage over conventional repairs. This advantage is more apparent when laparoscopic repairs are compared with sutured repairs rather than tension-free repairs.

Impact of a dedicated trauma service on the quality and cost of care provided to injured patients at an urban teaching hospital

BACKGROUND

To determine the impact of a dedicated trauma service on cost and quality of care in an urban teaching hospital, a before-and-after study was designed. The key elements of the trauma service were dedicated in-house trauma attending surgeons and residents, and continuity and integration of trauma care.

METHODS

Injury Severity Scores and probabilities of survival for each patient were calculated from the hospital International Classification of Diseases, Ninth Revision, codes, and individual patient costs were estimated from charges using the Medicare Cost Report.

RESULTS

The trauma service resulted in a significant increase in the severity of injuries. There was a highly significant (p<0.001) increase in the mean probability of death (from 0.16 to 0.21). There was no change in actual mortality. Although the mean cost of care increased by 16.6%, there were small reductions in the cost of care of the most severely injured patients.

CONCLUSION

A dedicated trauma service has a positive impact on the quality of care.

A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy

BACKGROUND

Despite many randomized controlled trials, the merits of laparoscopic appendectomy remain unclear. A meta-analysis may provide insights not evident from any individual studies.

DATA SOURCES

Systematic literature search yielded 17 trials (1,962 subjects) of true randomized design with usable statistical data comparing laparoscopic and conventional appendectomy in adults. The effect sizes for operating time, hospitalization, postoperative pain, return to normal activity, wound infection, and intra-abdominal abscess were calculated, using the random effects model to allow for heterogeneity. An estimate of the robustness of all positive findings was also calculated.

RESULTS

Modest but statistically significant effect sizes were found for four of the six outcome measures. Laparoscopic appendectomy takes 31% longer to perform, but results in less postoperative pain, faster recovery (by 35%), and lower wound infection rates (by 60%).

CONCLUSION

Laparoscopic appendectomy offers significant improvement in postoperative outcomes at the cost of a longer operation.

An anatomical study of the junction of the orbital septum and the levator aponeurosis in Orientals

The anatomical relationships of the orbital septum and levator aponeurosis has been studied in 40 eyelids subjected to blepharoplasty and corrective ptosis surgery by dissection in 10 cadavers and in histological sections. The orbital septum originates from the arcus marginalis of the frontal bone and consists of two layers. The whitish outer (superficial) layer, containing vertically running vessels, descends just inside the orbicularis oculi muscle to interdigitate with the levator aponeurosis with loose connective tissue, then disperses inferiorly. The inner (deep) layer follows the superficial one initially, then reflects at the levator aponeurosis and continues posteriorly with the levator sheath. We reconfirmed Whitnall's original description that the levator sheath thickens to form the superior transverse ligament runs continuously inferiorly anterior to the levator aponeurosis and forms the inner layer of the orbital septum. This detailed anatomical analysis should assist in performing upper eyelid surgery such as the Oriental double fold operation or levator resection.

Unsuspected choledocholithiasis first diagnosed at laparoscopic cholecystectomy: treatment by trans-cystic duct stenting and elective stent-guided sphincterotomy

BACKGROUND

Despite advances in laparoscopic surgery, management of unsuspected choledocholithiasis diagnosed at laparoscopic cholecystectomy is controversial. We propose a simple maneuver of laparoscopic trans-cystic duct stenting of the papilla during cholecystectomy, followed by elective stent-guided sphincterotomy, as an expedient option.

METHODS

We studied retrospectively 16 patients with choledocholithiasis first diagnosed in the course of laparoscopic cholecystectomy, treated with laparoscopic stenting of the papilla via the cystic duct using a short Cotton-Leung stent before completion of cholecystectomy. Elective stent-guided, needle-knife sphincterotomy and stone clearance was performed 2 to 3 weeks postoperatively.

RESULTS

Of 16 patients attempted, the procedure failed in one due to an impacted stone that prevented passage of the guidewire. Stenting time was 13 +/- 5 minutes (n = 15). Two stented patients had no stones at endoscopic retrograde cholangiography. Thirteen patients had successful elective stent-guided sphincterotomy with stone clearance without complications.

CONCLUSIONS

Laparoscopic biliary stenting combined with stent-guided sphincterotomy is a simple, safe, and cost-effective option for the management of uncomplicated choledocholithiasis.

Efficacy of routine laparoscopy for the acute abdomen

BACKGROUND

Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen.

METHODS

After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls.

RESULTS

The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest.

CONCLUSIONS

Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time.

Laparoscopy-assisted jejunal resection for bleeding leiomyoma

We report a case of successful resection of a jejunal leiomyoma using a minimally invasive technique. By combining the procedures of push enteroscopy and laparoscopy, jejunal resection can be performed expeditiously without laparotomy.

In vitro effects of simulated gastric juice on swallowed metal objects: implications for practical management

BACKGROUND

Swallowed metal objects often pose a technical challenge for the endoscopist. We studied in vitro the effects of simulated gastric juice on metal objects commonly encountered in endoscopic practice and measured the physical-chemical changes.

METHOD

Razor blades, disc batteries, and pennies were incubated in simulated gastric juice at 37 degrees C. The weights of the objects were recorded hourly. When no change could be detected, the solution was subjected to mass spectrometry to verify absence of effect. The findings were correlated with clinical observation in one patient who swallowed razor blades repeatedly.

RESULTS

Dissolution of the razor blade was proportional to the duration of acid immersion. At 24 hours, the blades weighed 63% of the original weight. Double-edged razor blades could be broken with a snare at 15 hours. The thickened back of the single-edged blade totally dissolved in 2 hours. No leak of contents could be detected with disk batteries. Pennies were unaffected.

CONCLUSION

Corrosion of razor blades occurs rapidly in the normal stomach. Within 24 hours double-edged blades become fragile and can be broken with a snare. This observation may guide the timing of endoscopic removal. Modern disk batteries are acid resistant for 24 hours.

Client satisfaction data and quality improvement planning in managed mental health care organizations

Quality improvement (QI) planning is enhanced when TQM administrators ensure appropriate analysis of client satisfaction (CS) survey data. A cost-effective QI strategy is to shift "moderately satisfied" into "maximally satisfied" clients. Use of a categorical variable derived from CS data and development of a predictive model with Chi Square Automatic Interaction Detection (CHAID) produces recommendations for quality improvement.

Palliative gastrojejunostomy. A minimally invasive approach

Palliative bypass for neoplastic gastric outlet obstruction should be minimally invasive. We designed a laparoscopically assisted approach that appears to meet the need. The proximal jejunum is exteriorized by laparoscopy via an epigastric trocar-site incision. An EEA anvil is installed in the exteriorized jejunum, which is returned to the abdomen. Through this mini-incision, the anterior wall of the stomach is opened for insertion of the EEA stapler, which penetrates the posterior gastric wall. When snapped to the anvil and fired, an antecolic gastrojejunostomy is created. No mortality or anastomotic leak occurred in two cases. The operation and recovery appeared to be faster than historic controls. This operation is minimally invasive and expeditious, ideal for patients requiring palliative bypass.