El coste por proceso en cirugía mayor ambulatoria: aplicación a liberación del túnel carpiano / The cost per proceeding in major outpatient surgery: application in carpal tunnel syndrome

Introducción: La gestión por procesos constituye un cambio de paradigma en la forma de gestión de las organizaciones sanitarias. El síndrome del túnel carpiano constituye la causa más frecuente de consulta en cirugía de la mano. El objetivo general del presente trabajo es establecer las bases teóricas del análisis del coste medio por proceso. Como objetivo específico, calcular el coste medio de liberación del síndrome del túnel del carpo (GRD 6) y compararlo con centros de similares características, como indicador de eficiencia. Material y metodología: Análisis de la casuística correspondiente al GRD 6 intervenidos en un año mediante herramientas de gestión clínico-financiera. Se utiliza la metodología de cálculo de coste agregado descendente o top-down. Se calcula el coste medio por proceso a partir del coste total de la Unidad de Responsabilidad, su casuística y los pesos relativos de sus GRD. Resultados: Se presentan las diferencias existentes en el coste medio por proceso del GRD 6 tanto en su versión ambulatoria, con ingreso, entre diferentes servicios de un mismo hospital y entre distintos centros. Conclusión: El sistema de producción hospitalaria, especialmente de la actividad quirúrgica ambulatoria, avanza hacia una gestión por líneas de producto (gestión por procesos). Una verdadera gestión clínica debe gestionar el conocimiento, las personas, la calidad y los recursos financieros. Es necesario que, en los planes de formación de todo profesional médico y, muy especialmente de los médicos en formación, se incluyan temas económicos para que conozcan los recursos que manejan (AU)

Introduction: The management per proceeding makes up a step change in the way the healthcare organizations are managed. Carpal tunnel syndrome is the most frequent cause of consultant in hand surgery. The general objective of this study is to establish the theoretical bases for the analysis of the average cost per proceeding. The specific objective is to calculate the average cost of the Diagnosis-related group (DRG) 6 and to compare it with healthcare centers of similar characteristics, as an indicator of efficiency. Methods: Analysis of the case studies of the DRG 6 that were operated during one year with clinic and financial management tools. The top-down calculation methodology was employed. The average cost per proceeding was calculated on the basis of the total cost of the Responsibility Unit, the cases and the relative importance of the DRG. Results: We present the differences between the average cost per proceeding of the DRG 6, in outpatient and inpatient surgery, between different services of the same hospital and between different healthcare centers. Conclusions: The hospital production system, specially outpatient surgical activity, progresses towards a management per product lining (management per proceeding). A true clinic management must manage knowledge, people, quality and financial resources. It's necessary to include economical issues in the curriculum of every health professional, specially medical doctor under training, in order to allow them understand the resources that they manage (AU)

Is there a role for cervical assessment and uterine artery Doppler in the first trimester of pregnancy as a screening test for spontaneous preterm delivery?

OBJECTIVE: To evaluate the role of cervical length (CL) and uterine artery pulsatility index (UtA-PI) at 11+0 to 13+6 weeks as predictors of spontaneous preterm delivery (sPTD) in a Chilean population. METHODS: This was a prospective study of asymptomatic women with singleton pregnancies attending for a nuchal translucency scan at 11+0 to 13+6 weeks' gestation and who underwent a transvaginal scan for evaluation of CL and UtA-PI. Exclusion criteria were fetal and pregnancy complications (other than sPTD) and iatrogenic delivery at<34 weeks. Measurements of CL and UtA-PI were adjusted for fetal crown-rump length and maternal characteristics and expressed as multiples of the median (MoM) of the unaffected group. Prediction of sPTD using maternal and pregnancy characteristics was studied using logistic regression analysis. RESULTS: A total of 3480 women were recruited into the study and, after application of exclusion criteria, 3310 were included in the analysis. The rate of sPTD at<34 weeks was 0.9% (n=31). A previous PTD had occurred in 7.4% of parous women. Patients with sPTD in the index pregnancy were characterized by a significantly higher prevalence of previous PTD (12.9% vs 3.7%, P<0.05). No significant difference was found in either CL or UtA-PI between pregnancies with and without subsequent sPTD. Logistic regression analysis showed that smoking and previous PTD were significantly associated with sPTD at<34 weeks. The combination of these characteristics provided a detection rate of 26% with a false-positive rate of 8%. CONCLUSIONS: Neither UtA-PI nor CL during the first trimester was shown to be a useful predictor of early sPTD. However, a combined model that includes smoking and previous PTD predicts approximately one-quarter of those women destined to deliver at<34 weeks, with a false-positive rate of 8%.

Durability and restoring of superhydrophobic properties in silica-based coatings.

The durability and restorable properties of superhydrophobicity are a most important issue essential for utilization of superhydrophobic materials in industrial and domestic fields. In this work, we have focused on the sol-gel dip coating synthesis, durability, and restoring properties of a superhydrophobic surface composed of spherical silica particles with low energy free surface successfully achieved on the surface of glass substrates. The water contact angle (WCA) of the as-prepared superhydrophobic coatings reached as high as 170±1° (WCA=170±1°) and the sliding angle was 3±1° (WSA=3±1°). The behavior of wettability on superhydrophobic coating surface under various external disturbances including outdoor environments, heat, and mild acidic condition is investigated. It is shown in particular that degradation and repairing of surface methyl groups between two such surfaces leads to a fully restorable coating surface by the surface modification with trimethylchlorosilane (TMCS) at room temperature. The coating also holds good thermal stability; it holds superhydrophobicity up to 550 °C and gets degrade into superhydrophilicity above 600 °C without deforming surface morphology. The results confirm the durability of the silica coating under different external disturbances and sol-gel dip coating method and restoring property provide the best solution to fabricate superhydrophobic silica coating surface with extended durability at low cost.

Diagnóstico alternativo al tromboembolismo pulmonar en urgencias en pacientes oncológicos y no oncológicos / Suspected acute pulmonary embolism in patients with and without cancer: alternative diagnoses

Objetivo: Conocer los diagnósticos alternativos al tromboembolismo pulmonar (TEP)en los pacientes oncológicos y no oncológicos atendidos en un servicio de urgencias hospitalario (SUH) a los que se les solicitó una tomografía computarizada (TC).Método: Estudio retrospectivo con inclusión de todos los pacientes a los que se les practicó una TC desde un SUH por sospecha de TEP durante los años 2006 y 2007.Resultados: Se incluyeron un total de 265 pacientes, 93 oncológicos y 172 no oncológicos. El 98,5% presentaban, o bien una sospecha clínica alta de acuerdo a las escalas de Wells y de Geneva, o bien una sospecha clínica baja o intermedia con una determinación de dímero D positiva. En los pacientes oncológicos y no oncológicos, el porcentaje de diagnosticados de TEP fue del 25,8% y 39,5%, respectivamente. En los pacientes con sospecha de TEP en los que éste no se confirmó, la TC permitió determinar el diagnóstico alternativo en el 81,2% de los pacientes oncológicos y en el 67,3% de los no oncológicos. En los oncológicos el diagnóstico alternativo más frecuente fue la progresión neoplásica, que incluso fue más frecuente que el de TEP. Los diagnósticos alternativos más frecuentes en los no oncológicos, fueron la insuficiencia cardiaca aguda (ICA), la enfermedad pulmonar obstructiva crónica (EPOC) descompensada y la neumonía. Conclusiones: En los pacientes con sospecha de TEP, la TC permitió determinar el diagnóstico alternativo en un elevado porcentaje de pacientes. Los diagnósticos alternativos más frecuentes fueron la progresión neoplásica en los pacientes oncológicos yla EPOC descompensada y la ICA en los no oncológicos (AU)

Objectives: To determine the alternative diagnoses made in patients with and without cancer who undergo computed tomography (CT) to confirm or rule out a suspected diagnosis of acute pulmonary embolism in a hospital emergency department. Methods: Retrospective study of all patients who underwent CT with a suspected diagnosis of acute pulmonary embolism in 2006 and 2007. Results: A total of 265 case records (for 93 patients with cancer and 172 without cancer) were studied. In 98.5% of the patients, clinical suspicion of pulmonary embolism was high, based on the Wells or Geneva Scales, or low-intermediate clinical suspicion and positive D-dimer level. A diagnosis of pulmonary embolism was confirmed in 25.8% of the cancer patients and 39.5% of the non cancer patients. When pulmonary embolism was ruled out, an alternative diagnosis could be reached by CT in 81.2% of the cancer patients and 67.3% of the noncancer patients. The most common alternative diagnosis in cancer patients was tumor progression, which was even more common than the diagnosis of pulmonary embolism. In noncancer patients, the most common alternative diagnoses were acute heart failure, exacerbation of chronic obstructive pulmonary disease (COPD), and pneumonia. Conclusions: CT facilitates the differential diagnosis of a large percentage of patients suspected of having acute pulmonary embolism. The most common alternative diagnosis is tumor progression in patients with cancer; in noncancer patients the most common alternative diagnoses are exacerbated COPD and acute heart failure (AU)

Principios de evaluación y resultados funcionales en los reimplantes de miembro superior / Principles of evaluation and functional results in upper extremity replantation surgery

El objetivo de este trabajo es evaluar nuestros resultados funcionales y subjetivos en pacientes sometidos a reimplante de miembro superior. Medimos rango de movilidad articular, fuerza de la prensión y otros tests en 41 pacientes con edad media 44,8 años que sufrieron amputación de miembro superior y fueron sometidos a reimplante quirúrgico en nuestro hospital entre enero del 2005 y diciembre del 2009. Los resultados funcionales se midieron con la tabla de Mayo modificada para lesiones de pulgar, dedos largos y mano, distal a muñeca. Las amputaciones proximales a muñeca se evaluaron según los criterios de Chen. Los resultados subjetivos fueron documentados aplicando a todos los casos el cuestionario de Russell. La mayoría de las lesiones fueron provocadas por mecanismos de avulsión y 30 (74 %) fueron accidentes laborales. La tasa final de supervivencia fue del 85 % (35 pacientes) incluyendo 2 pacientes en los que se realizó trasplante de pie a mano para salvar la amputación. Aplicando la tabla de Mayo modificada, los resultados fueron buenos en pulgar y discretos en mano y dedos largos. En reimplantes proximales obtuvimos 1 resultado excelente y 2 discretos. Diecinueve pacientes retornaron al mundo laboral en una media de 10 meses. Veintisiete manifiestan satisfacción alta con los resultados obtenidos. Los resultados de cualquier reimplante deben superar los del cierre simple de una amputación. Aunque los resultados objetivos de la serie son moderados, muchos pacientes retornan al trabajo y la mayoría es capaz de realizar sus actividades cotidianas (AU)

The aim of this study was to evaluate functional and subjective outcome after upper limb replantation, with assessment or range of motions, grip strength, and additional functional tests. Forty-one patients, mean age 44.8 years old, with upper limb amputations were treated in our hospital with replantation between January 2005 and December 2009. Functional results were assessed by modified Mayo scoring system for thumb, fingers and hand amputations. Proximal amputations were evaluated according to the criteria of Chen. Subjective results were documented in all patients by Russell's Questionnaire. Most of the injuries were caused by avulsion forces and 30 (74 %) were work related. The final survival rate was 85 % (35 patients); we include 2 patients who have had immediate foot transplantations. Using modified Mayo score system the outcome was good in thumb patients and fair in fingers and hand amputations. According to Chen's criteria the result was excellent in 1 forearm amputation and fair in 2 patients. Nineteen patients had returned to work, their time-off work averaged was 10 months. Patient satisfaction was rated as better than expected and satisfactory in 27 patients. Outcomes of replantation must be better than revision amputation. Although functional outcomes were moderate, most of patients were able to use their hands to perform some work and daily living activities (AU)

Accuracy of physician and nurse practitioner colposcopy to effect improved surveillance of cervical cancer.

PURPOSE: To compare physician and nurse practitioner accuracy in recognizing cervical dysplasia during colposcopy. MATERIALS AND METHODS: A retrospective review was performed of cervical excisional biopsies from 2007 to 2009 performed by gynecologists and nurse practitioners in the same patient population. Cervical cone biopsy and loop electrosurgical excision procedure (LEEP) pathology were used as a gold standard compared to the previous colposcopy biopsies. RESULTS: Four hundred fifty-five patients qualified for the study. Patients were stratified according to age: under 30 years, 30-39, and 40 and above. For physicians, 77% of high-grade colposcopy biopsy results agreed with high-grade pathology on cone biopsy or LEEP. This was statistically similar to nurse practitioner results (p = 0.12). Likewise, there was no significant difference between physician and nurse practitioner accuracy within the various patient age strata. CONCLUSION: Colposcopy biopsy results compared to cone biopsy or LEEP results were statistically similar between gynecologists and nurse practitioners.

Screening for trisomy 21 during the routine second-trimester ultrasound examination in an unselected Chilean population.

OBJECTIVE: To evaluate the performance of a detailed ultrasound examination during the second trimester as a screening test for Down syndrome in an unselected Chilean population. METHODS: This was part of an ongoing longitudinal study. Included were 3071 women with singleton pregnancies who underwent routine ultrasound examination between 21 + 0 and 25 + 6 gestational weeks as a screening test for chromosomal abnormalities and major congenital structural defects, and who were diagnosed as having trisomy 21 or being chromosomally normal. Maternal age, and eight soft markers and cardiac defects associated with Down syndrome were evaluated as a screening test using logistic regression analysis. RESULTS: The incidence of Down syndrome was 0.6%, and the mean maternal age was 29.4 +/- 6.2 years. At least one of four soft markers (absent nasal bone, nuchal edema, short femur, echogenic foci) and/or cardiac defects was present in 77.8% of Down syndrome fetuses and in 3.1% of normal fetuses. Furthermore, with a false-positive rate of 1%, the detection rate using the combined model of ultrasound markers and maternal age was 72.2%. CONCLUSIONS: Second-trimester ultrasound markers are able to detect over 70% of Down syndrome fetuses with only a 1% false-positive rate.

[Value of preoperative colonoscopy in colon-rectal neoplasms]. / Valor de la colonoscopia preoperatoria en el cancer colo-rectal.

The surgical approach to treat colo-rectal carcinoma is usually based on the findings of barium enema. In 102 patients we reviewed the yield of pre-operative colonoscopy. Barium enema revealed the cancer in 76 of 84 patients (91%), whereas colonoscopy did so in 96 of 102 subjects (94%). In addition, 5 associated cancerous lesions were demonstrated by colonoscopy and none by barium enema. Associated benign lesions were seen in 14 patients. In 5 patients the surgical plan based on the barium enema was modified by the findings at colonoscopy. Eight false negatives to barium enema were correctly diagnosed by colonoscopy. We conclude that colonoscopy yields valuable information, beyond that of barium enema, in patients with colo-rectal cancer.