[Study of the quality of codification of diagnoses and procedures under DRG conditions]. / Untersuchung zur Qualität der Kodierungen von Diagnosen und Prozeduren unter DRG-Bedingungen.

UNLABELLED: A system based on Diagnosis Related Groups was introduced in Germany and is mandatory for hospitals from 2004. Hospitals, health care providers and the Medical Service of Social Security-Health Insurance (MDK) face a common effort. Proper codification of diagnoses and procedures is essential. The Medical Service in the State of Hessen, the Techniker Krankenkasse and the Burgerhospital Frankfurt am Main combined forces to assess codification under the DRG system. GOALS: The partners cooperated to assess actual codification and to identify starting points for improvement. METHODS: A random sample was taken from all in-patient cases (all departments) over a 6-month-period (n = 309). Codification or coding was checked according to German Coding Rules (Deutsche Kodierrichtlinien) from the complete hospital records. Different codification, or coding, was discussed between MDK and Hospital doctors. RESULTS: The actual data revealed overcoding in 34 per cent of diagnoses and in 15 per cent of procedures. Undercoding was present in 9 per cent of diagnoses and in 2 per cent of procedures. The DRG grouping changed in 68 cases (22 per cent) after scrutiny by the Medical Service (MDK). The case-mix index (CMI) calculated from relative weights as coded by the hospital was 0.84. The case-mix index calculated from coding by MDK was 0.81. The CMI calculated from effective weights was 0.77 (hospital) and 0.75 (MDK). DISCUSSION: Causes of faulty coding and possible remedies are presented. CONCLUSIONS: Further systematic reviews are required to develop the DRG System and identify faulty trends.

A cluster of childhood leukaemias near two neighbouring nuclear installations in Northern Germany: prevalence of chromosomal aberrations in peripheral blood lymphocytes.

PURPOSE: Between 1990 and 1991 a leukaemia cluster was observed in children living close to the combined site of a nuclear power plant and a nuclear research facility in Elbmarsch, a region in Lower Saxony (Germany). We aim to investigate the prevalence of presumably radiation-induced chromosomal aberrations in peripheral blood lymphocytes of children in Elbmarsch and children of a control region in order to find out whether there was an uncontrolled release of radioactive material which resulted in a substantial exposure. MATERIALS AND METHODS: The frequency of dicentric and ring chromosomes in lymphocytes of the peripheral blood in 42 children in Elbmarsch and 30 children in Plön was investigated. Children in both groups had been permanent residents of the study area. RESULTS: The mean frequency of dicentric and ring chromosomes in Elbmarsch was 14/32580 cells (=0.430 x 10(-3); 95% CI 0.24-0.70 x 10(-3) cells), and in Plön it was 17/24065 cells (=0.706 x 10(-3); 95% CI 0.42-1.10 x 10(-3) cells). CONCLUSIONS: No difference in the frequency of dicentric and ring chromosomes was observed between children in Elbmarsch living close to a combined site of a nuclear power plant and a nuclear research facility and children living in the control area Plön. The power of the study to detect a threefold or higher increase in the aberration frequency was at least 0.86.

Cytogenetic investigations in employees from waste disposal sites.

In connection with extensive health studies of employees from two big central waste disposal sites, cytogenetic investigations were performed. The subject of these special analyses was to examine whether the complex mixture of pollutants from waste disposal sites comprises a genotoxic hazardous potential. Cytogenetic analyses were performed on peripheral blood lymphocytes of 82 exposed and 71 control persons as a coded study. For chromosome analysis, 1000 cells and for sister chromatid exchange (SCE) analysis, 50 cells had been scored per person. Compared with the matched control group, a highly significant increase of the frequencies of chromosomal aberrations was detected, especially in dicentric chromosomes (4.1 +/- 0.2 vs 1.5 +/- 0.1 per 1000 cells) and acentric fragments (6.9 +/- 0.3 vs 2.8 +/- 0.2 per 1000 cells), whereas no difference was found in SCE analysis. The occurrence of multiaberrant cells with more than two dicentric chromosomes was a striking feature in waste disposal site workers (23 vs 1 in control group). Frequencies of chromosomal aberrations were similar in exposed non-smokers and smokers. Only in the control group, a significant difference was observed in the incidence of dicentric chromosomes and SCE between non-smokers and smokers. The results of the first cytogenetic investigations on employees of two waste disposal sites indicate a genotoxic hazardous potential. Further research is urgently required.

Comparative biomonitoring study of workers at a waste disposal site using cytogenetic tests and the comet (single-cell gel) assay.

Workers exposed to environmental pollutants at a waste disposal site were studied for genotoxic effects with cytogenetic tests and the comet (alkaline single-cell gel) assay. Analyses were performed on peripheral blood samples of 44 workers at a waste disposal site (DM) and 47 subjects of a control group (VE) matched for gender, age, and smoking habits. Chromosomal aberrations were evaluated in 1,000 lymphocytes per individual, sister chromatid exchanges in 50 cells, and DNA migration (tail moment) was determined in 100 leukocytes. Structural chromosome aberrations were more frequent in DM than in VE, but only the frequency of acentric fragments and the percentage of aberrant cells (excluding gaps) was significantly increased. No significant difference was found for the mean frequency of SCE. A statistically significant difference was also seen with the comet assay. The mean tail moment was higher in DM than in VE. However, no correlation was found between cytogenetic data and the effects in the comet assay. The results of our study indicate that DNA effects in the comet assay represent an independent endpoint which might be useful for the biomonitoring of genotoxic effects in addition to established tests.

Changes in the repair capacity of blood cells as a biomarker for chronic low-dose exposure to ionizing radiation.

The purpose of this study was to examine whether changes in the repair capacity of blood cells could be used as a valuable biomarker for radiation exposure. To characterize the repair kinetics in nonirradiated and irradiated cells we first performed in vitro split dose experiments. DNA damage and DNA repair capacity were analysed using the comet assay. Our results showed that the first in vitro irradiation affects the repair system of the cells, resulting in a decreased repair capacity after the second irradiation. Furthermore, the second irradiation results in a large amount of DNA damage in the blood cells. To test whether the analysis of the DNA repair capacity after in vitro irradiation is also a valuable method for in vivo studies of donors exposed to radiation, we analysed the repair capacity of blood cells of two exposed groups: patients subjected to a radioiodine therapy and chronically irradiated volunteers from the Chernobyl region. Both groups also showed a significantly impaired repair capacity indicating a stress on the hematopoietic system. In addition, in the group of the Ukrainians DNA damage after in vitro irradiation was significantly higher than in a control group. These results lead to the presumption that the repair capacity and the DNA damage after in vitro irradiation might be a very useful biological marker for radiation exposure in population monitoring.

Experience with malignant tumors of the thyroid gland in a private surgical practice.

A review of malignant tumors of the thyroid encountered in a noninstitutional, private surgical practice has been presented. Clinical judgment, coupled with radioactive iodine scanning, has given effective diagnostic direction. Subtotal thyroidectomy, as used by our group, has achieved satisfactory results in this relatively small number of malignant tumors of the thyroid gland. Hopefully, this experience has held up satisfactorily under scrutiny and will be meaningful to other surgeons in similar settings.

Elective hepatic resection.

Significant salvage of patients with a wide variety of cysts and benign tumors of the liver and of some patients with biliary strictures can be achieved by hepatic resection in carefully selected clinical situations with a low operative mortality rate and an acceptable postoperative complication rate. Still to be determined is the role of hepatic resection in metastatic carcinoma and sarcoma of the liver, where survival is modest but measurable, but important palliation can be achieved. Hepatomas should be resected when possible, but hepatic resection for aid in resection of bile duct carcinoma has proved generally unrewarding.

Emergency diagnosis of upper gastrointestinal bleeding by fiberoptic endoscopy.

Emergency esophagogastroduodenoscopy has been performed in 192 consecutive patients admitted with massive gastrointestinal bleeding. Accurate endoscopic diagnosis was made in 184 or 96%; 58 patients underwent emergency operations to control bleeding with an overall operative mortality of 26%. Excluding 16 patients who underwent emergency portacaval shunting, the operative mortality was 7%. In 6 patients, the bleeding was controlled by endoscopic electrocoagulation. There were no complications. Emergency endoscopy should be done routinely as the primary diagnostic approach in the diagnosis of upper gastrointestinal bleeding.

Catabolism of secretin by the liver and kidney.

We have investigated the roles of the liver and the kidney in the catabolism of secretin, using a specific and sensitive radioimmunoassay. Dogs were prepared with sampling catheters in the aorta, hepatic vein, portal vein, and renal vein and with electromagnetic flow probes on the portal vein, hepatic artery, and renal artery. Secretin levels in the vessels entering and leaving the liver and kidney were determined by radioimmunoassay and the total mass of secretin [concentration (picograms per milliliter) X plasma flow rate (milliliter per minute)] was calculated during an intravenous infusion of exogenous secretin and during release of endogenous secretin by acidification of the proximal intestine. The total masses of secretin entering and leaving the liver were the same during secretin infusion and during the release of endogenous secretin. Under conditions of elevation of plasma secretin, however, the kidney extracted 30 percent of arterial secretin during secretin infusion and 45 percent during release of endogenous secretin. Clearly the kidney is a major site of secretin catabolism.

Disappearance half-time of endogenous and exogenous secretin in dogs.

We have used a sensitive and specific radioimmunoassay to measurespectively. the disappearance half-times of exogenous porcine secretin and endogenous canine secretin in the dog and found them to be 2-45 and 2-85 minutes, respectively.

Suppression of gastrin release and gastric secretion by gastric inhibitory polypeptide (GIP) and vasoactive intestinal polypeptide (VIP).

Five dogs prepared with Heidenhain pouches received infusions of saline, GIP and VIP before and after a standard meat meal. Blood samples were obtained under basal conditions and at subsequent intervals for measurement of gastrin, insulin, GIP and VIP by radioimmunoassay. GIP and VIP infusions had no effect on basal levels of gastrin. GIP and VIP (in common with secretin and glucagon) were found to suppress food-stimulated release of gastrin and gastrin-stimulated acid secretion from the Heidenhain pouch. Insulin levels were significantly elevated during GIP and VIP infusions. Food released GIP (and perhaps VIP.

The effects on gastrin and gastric secretion of five current operations for duodenal ulcer.

We have measured serum gastrin and gastric acid secretion in 66 duodenal ulcer patients before and after vagotomy and pyloroplasty (V + P--15 patients), selective proximal vagotomy without drainage (SPV - D--11 patients), and with drainage (SPV + D--19 patients), and vagotomy, antrectomy, and either gastroduodenostomy (V + BI--15 patients) or gastrojejunostomy (V + BII--6 patients). Basal and peak postprandial gastrin levels were increased in postoperative V + P, SPV - D, and SPV + D patients. Basal and peak postprandial levels of gastrin were unchanged after V + BII, indicative of duodenal release of gastrin. Gastrin response to food was abolished in V + BII patients. Acid output was reliably reduced after all five operations; reduction was greatest in patients after antrectomy and least in patients after SPV. No beneficial results were found with drainage in SPV patients. Acid secretion increased with time in SPV patients, especially those with drainage.

Direct influence of blood viscosity on pulmonary vascular resistance.

When cardiac output is maintained constant in the intact animal, changes in blood viscosity exert a direct and rapid effect on pulmonary vascular resistance. The presence of intact cardiopulmonary reflex mechanisms does not alter the direct influence of blood viscosity on pulmonary vascular resistance.

Cholecystokinin metabolism in man and dogs.

We have developed a sensitive, specific and reproducible radioimmunoassay for cholecystokinin (CCK) with which basal levels of CCK of between 400-800 pg/ml have been measured in normal man, in patients with diabetes and with duodenal ulcer disease, and in normal dogs. After a meal, circulating levels of CCK rose to 1000-1200 pg/ml in human subjects. Release of CCK was more rapid in diabetic and duodenal ulcer patients than in normal subjects, but elevated postprandial levels persisted much longer in normal subjects. Patients with the Zollinger-Ellison syndrome had elevated values of cholecystokinin which rose after a meal. Lack of correlation between elevated basal levels of gastrin and CCK in patients with the Zollinger-Ellison syndrome suggest that the hypercholecystokininemia may be absolute. The disappearance half-time of exogenous CCK was about 21/2 minutes in normal subjects as well as in diabetic and duodenal ulcer patients. Studies in dogs demonstrated no uptake of basal levels of cholecystokinin by the kidney; on infusion of exogenous CCK-33, the kidney extracted 43% of the total CCK presented and 56% of the integrated CCK. We conclude that: 1) circulating basal and postprandial levels of CCK may be measured in a reproducible fashion; 2) postprandial release of CCK is more rapid in diabetic and duodenal ulcer patients than in normal man; 3) the disappearance half-time of exogenous CCK in man and dogs is about 21/2 minutes; 4) the kidney is a major site for uptake of CCK.

Natural history and experience with diagnosis and treatment of the Zollinger-Ellison syndrome.

With better methods of diagnosis, patients will be identified earlier in the course of their disease and will often have atypical and borderline manifestations of the syndrome. Serum gastrin measurements with calcium and especially with secretin challenge will be the most important method of diagnosis. Any patient with acid hypersecretion who has a high serum gastrin level that does higher on secretin infusion should be considered to have the Zollinger-Ellison syndrome. A firm diagnosis of the Zollinger-Ellison syndrome should be made, if at all possible, prior to operation. At operation, a thorough search of the pancreas, duodenum, stomach, greater and lesser omentum and liver should be made for primary and secondary gastrinomas. If the preoperative data firmly establish the diagnosis of the Zollinger-Ellison syndrome, a total gastrectomy should be carried out even if no primary tumor is found. Similarly, a total gastrectomy should be done even if there are massive hepatic metastases. If total gastrectomy is not performed, the patient is apt to die of complications of acid hypersecretion. The only possible exceptions to the rule of always performing a total gastrectomy are in asymptomatic patients with easily excisable tumors or patients with tumors of the duodenum that are easily excisable, providing that in both instances after the excision of the tumor the output of gastric acid as measured at operation is immediately halted. All possible metastatic tumor tissue should be removed. The more tumor tissue removed, the longer the patient will survive. Metastases should be treated aggressively. They do not disappear after total gastrectomy in our experience, and they may kill patients. Patients should be followed after operation with serial measurements of serum gastrin concentrations and by hepatic scintillation scans and hepatic angiography. If hepatic metastases develop, intrahepatic artery infusions of 5-fluorouracil may slow tumor growth.