Insurance reimbursement for surgical facilities.

Insurance reimbursement for ambulatory surgical facilities can be accomplished by following specific rules. Unlike billing for office visits and surgical fees, facility claims are submitted on Health Care Financing Administration forms. The author provides guidelines to assist with submitting and appealing facility fees.(Aesthetic Surg J 2001;21:467-468.).

Moisture and healing: beyond the jargon.

Moist wound healing is one of the most frequently used, but least understood terms in wound care. Although no reliable operational definitions exist of too little or too much wound surface moisture, a low dressing water vapor transmission rate (WVTR) has proven to be a reliable measure of a dressing's capacity to retain moisture and provide an environment that supports healing. Dressing WVTR is a powerful linear predictor of both full- and partial-thickness healing of standardized acute wounds in vivo (alpha < 0.0001). Moreover, differences in the ability to produce an optimal moist wound environment within a dressing category, such as hydrocolloid dressings, are strongly correlated with dressing WVTR, suggesting that dressings in the same product categories may be associated with significantly different environments for healing. Even though the correlation between dressing WVTR and healing rates is more difficult to ascertain, clinical healing percentages during similar time-frames and healing times of similar wounds also follow patterns predicted by dressing moisture retention. These results suggest that, when other variables are held constant, use of more moisture-retentive dressings generally achieves environments supportive of earlier healing outcomes when compared to less moisture-retentive dressings. Maceration, an unwelcome occurrence with moisture-retentive dressing use on highly exuding wounds, is not consistently associated with increased adverse events. Evidence further suggests that greater dressing moisture retention is associated with fewer clinical infections, greater patient comfort, and reduced scarring.

Leg ulceration in the sickle cell patient.

BACKGROUND: The purpose of this study was to determine cost of care for leg ulcers in sickle cell patients and suggest an improved modality in ulcer care. STUDY DESIGN: We performed a retrospective study of a group of sickle cell disease patients with leg ulcers. RESULTS: Eighteen patients with a leg ulcer (duration: mean, 53.7 months), sickle cell disease, and a mean of 20.7 years of age had various modalities of treatment with the only consistency in healing being a commercial moist-wound dressing. CONCLUSIONS: There is no consistency in the treatment of the sickle cell patient with a leg ulcer. Treatment with a moist dressing had the best results.

Options for diabetic patients with chronic heel ulcers.

The presence of a heel ulcer in the diabetic patient is usually due to neuropathy, vasculopathy, or both. Diagnostic testing including noninvasive assessment by nerve conduction velocity and Doppler pressure measurements can provide the basis for subsequent treatment. The diagnosis of osteomyelitis is assisted by plain radiographs, isotope definition, and/or magnetic resonance imaging (MRI). The loss of the calcaneus may mean loss of the functioning foot. Reconstructive arterial surgery for heel lesions in the diabetic patient has limited success. Prevention and local wound care, along with patient education, will result in limb salvage and the prevention of disability.

Quality wound care equals cost-effective wound care: a clinical model.

The cost of wound care frequently is defined as the cost of materials and labor, ignoring the effect of both variables on outcome. As a result, money-saving measures actually may increase cost while reducing the quality of care. Definitions and tools to enable professionals to understand, evaluate, and compare the cost-effectiveness of wound care practices and treatment modalities are given.

Quality wound care equals cost-effective wound care: a clinical model.

The cost of wound care is often defined as the cost of materials and labor, ignoring the effect of both variables on outcome. As a result, money-saving measures may actually increase cost while reducing the quality of care. Definitions and tools to enable professionals to understand, evaluate and compare the cost-effectiveness of wound care practices and treatment modalities are given.

The influence of dressings on the costs of wound treatment.

To calculate cost effectiveness of wound care, it is incorrect to calculate the costs of just a dressing. All aspects influencing the costs of treatment should be calculated. These include costs for the actual materials, labor, and nonmedical costs to society.

Prospective, multicenter study of managing lower extremity venous ulcers.

Seventy patients with 90 venous ulcers were randomly assigned to hydrocolloid or conventional dressing and compression therapy at four study centers. The ulcers had been present for a mean of 47.8 in the control and 46.2 weeks in the treatment group and 42% of all patients had recurrent ulcers. Ulcers treated with hydrocolloid dressings reduced 71% and control treated wounds reduced 43% in area after 7.2 weeks of treatment. Thirty-four percent of all ulcers healed. Mean time to healing was 7 weeks for the hydrocolloid dressing group and 8 weeks for the control group. Most ulcers were less painful at final evaluation, but reduction in pain was more pronounced in hydrocolloid-dressed ulcers (p = 0.03). At baseline as well as during follow-up, significant differences between study centers were observed. Ulcers in patients in the United Kingdom were larger and less likely to heal (p = 0.001). Size of the ulcer at baseline was associated with treatment response and time to healing (p = 0.002). Percent reduction in ulcer area after 2 weeks was also correlated with treatment outcome (p = 0.004) and time to healing (p = 0.002). When all treatment outcome predictors were analyzed together, only percent reduction in area after 2 weeks remained statistically significant (p = 0.002), with percent reduction during the first 2 weeks of treatment > 30% predicting healing.

Microbiology and healing of the occluded skin-graft donor site.

Delayed healing of skin-graft donor sites may be costly and life-threatening, especially in patients with large body surface area burns. A donor site dressing should maximize the ability of the wound to heal without increasing the risk of local infection, systemic infection, or both. Specifically, the possibility of a secondary infection may either slow the healing process or ultimately convert the donor site into a full-thickness skin loss. A number of materials ranging from gauze to biologicals have been investigated for use as donor site dressings. The use of hydrocolloids for donor sites has been widely studied and has shown improved healing rates over the rates reported for conventional dressings. Our recent study using hydrocolloids confirmed earlier research that showed fewer infections and more rapid donor site healing.

Mast cells in human ulcers.

The distributions of mast cells in decubitus, venous stasis, and arteriosclerotic human skin ulcers were studied. Mast cells were found primarily in the papillary dermis but were also numerous in the reticular dermis of the three types of ulcers. There were mast cells inside the epidermis and many more in granulation tissue. Intraepidermal mast cells were more numerous in venous stasis ulcers than in decubitus or arteriosclerotic ulcers. Many of the mast cells in these areas appeared to be intact. There were also some free and intracellular granules that stained like those in mast cells, in necrotic and granulation tissue. These findings raise questions about the role of mast cells in the epidermis and in necrosis and repair of skin ulcers.

Air exposure versus occlusion: merits and disadvantages of different dressings.

A review of the literature on occlusive and non-occlusive conventional dressings for the treatment of acute wounds and chronic lesions.

Effect of calcium alginate dressings on partial-thickness wounds in swine.

The epithelization of partial-thickness wounds (PTW) has been shown to be enhanced with the use of moisture-retentive dressings (MRD), and not with nonmoisture-retentive dressings (NMRD) like gauze. This study was designed to explore this effect using two different alginate products with and without MRDs. We evaluated these alginate dressings under a polyurethane film dressing (FMRD) and under an NMRD gauze. They were compared to hydrocolloid moisture-retentive dressings (HMRD). Twelve PTW measuring 22 x 22 x 0.5 mm were made on the dorsum of six swine with a Castroviejo dermatome. Return of the epithelial barrier function was measured with an EP1 ServoMed evaporimeter. On postoperative day 4, the first alginate product under the NMRD and under the FMRD had a significantly slower healing rate than the HMRDs. By postoperative day 7, the second alginate product under the NMRD had a poorer rate of epidermal wound healing than the HMRD. Our results indicate that these alginate products have a satisfactory partial-thickness wound healing capability when used under MRDs. When used under MRDs, the return of the epithelial barrier function is delayed, indicating that these dressings should not be used on dry wounds or under gauze dressings.

Massive subgaleal hematoma resulting in skin compromise and airway obstruction.

Subgaleal hematomas following minimal trauma, haircombing, and hair pulling by playground swings have been described. Recently a case was reported that progressed to otic hemorrhage and upper facial edema. We present a case (of a previously unreported nature) of a subgaleal hematoma that resulted in airway obstruction, massive edema of the entire face and neck, and limited epidermolysis of facial skin.

Forehead expansion and total nasal reconstruction.

Forehead flaps are the method of choice for total nasal reconstruction. However, if adequate skin is unavailable, tissue expansion of this donor site for subtotal nasal reconstruction seems logical, as has been described elsewhere. The literature, however, appears devoid of reports of using this technique when all the nasal structures are absent. We report on 3 patients for whom expanded forehead flaps provided poor long-term results because of late shrinkage.

Radionuclide-labeled red blood cell imaging of vascular malformations in children.

Vascular malformations, particularly in the absence of cutaneous changes, can be difficult to distinguish from other soft tissue masses in children. We have used technetium-99m-labeled red blood cell scintigraphy to study 47 lesions in 43 children. Thirty-nine lesions showed increased flow and were, therefore, diagnosed as vascular malformations. Subsequent biopsy of 10 of these lesions confirmed that diagnosis. The other 29 lesions with increased flow were followed for 10 months to 5 years and the clinical course was consistent with vascular malformation in every case. Eight lesions showed no increased flow on technetium scan. One of these subsequently proved to be a hemangioma. The others have turned out not to be vascular malformations. Therefore, in our experience, the technetium-99m-labeled red blood cell scan has had 98% sensitivity and 100% specificity in diagnosing vascular malformations in children.

Bony and soft tissue reconstruction and rehabilitation following traumatic hemipelvectomy, exsanguination and cardiac arrest.

Survival following traumatic hemipelvectomy in the child with subsequent local flap coverage of wounds has been previously described. The use of axial skin flaps and thigh and rectus abdominis musculocutaneous flaps for coverage of hemipelvectomy defects following tumor extirpation has also been noted in the literature. The use of muscle flaps to salvage otherwise nonvital bone and to eradicate osteomyelitis with subsequent wound closure has also been thoroughly demonstrated both clinically and experimentally. The use of musculocutaneous flaps to revascularize otherwise nonviable bone of the pelvis and thus maintain the pelvic girdle integrity, however, has not to our knowledge been previously reported. We recently had an opportunity to treat such a case, which we herein describe.

The kinetics of ornithine decarboxylase activity as a function of wounding in guinea pig ear epidermis.

Guinea pig ear stratum corneum was removed to increasing depths by 1, 3, 6 or 9 strippings with adhesive tape. Increasing ornithine decarboxylase (ODC) activity responses were observed in the epidermis 4.5 hr after wounding with 3, 6 or 9 tape strippings. The kinetics of this ODC response were investigated at intervals including, 2, 4.5, 12, 18, 24 and 72 hr after tape stripping. ODC activity was significantly elevated for 12 hr after 3 or 6 tape strippings and for at least 72 hr after 9 tape strippings. These effects were independent of hair plucking or depilation prior to wounding. This model is potentially useful for comparing the effects of chemical, mechanical and physical stimuli on ODC activity and subsequent polyamine synthesis.

Lysine deficiency and voluntary exercise in the albino rat.

The relationship between low dietary protein and voluntary wheel running was investigated by feeding weanling male white rats a natural diet deficient in lysine, by bioassay criterion. Lysine deficient rats ran more than those pair-fed or ad libitum fed the same diet with lysine added. Body composition of active and inactive rats on the three dietary regimens was compared. Of the carcass components, total and percent protein reduction correlated most strongly with running. Control animals matched in growth to the lysine deficient rats showed hyperactivity earlier, but to the same extent as the lysine deficient rats.