The economic impact of incorporating flexible endoscopy into a community general surgery practice.

BACKGROUND: Flexible endoscopy is a vital component of gastrointestinal surgery. It has and will replace many of the surgical procedures now commonly performed. Flexible endoscopy, unfortunately, is not an integral part of surgical residency training based on resident operative experience as reported by the Residency Review Committee. Moreover, general surgeons have deferred the practice of flexible endoscopy to the gastroenterologists because of concerns over turf battles and referral patterns. The purpose of this study was to assess the overall case load and the economic impact of flexible endoscopy on the practice of general surgery in a community hospital setting. METHODS: This retrospective review was performed over a 6-month period. The total cases and the total billings of inpatient and outpatient procedures for a group practice of five general surgeons in a community hospital were evaluated. The billings were the actual charges based on current procedural terminology (CPT) codes for these procedures using the Medicare fee schedule. RESULTS: Of the 2,159 procedures performed, 1,154 involved flexible endoscopy cases accounting for 54% of all cases (1,154 of 2,159) performed from February 1, 2003 to July 31, 2003. Flexible endocopy accounted for 43% of the total charges. A. total of 46 surgical procedures and 216 future endoscopies were generated from the flexible endoscopic procedures. Future endoscopic cases were for surveillance of colonic neoplasia and Barrett's esophagus. CONCLUSIONS: Flexible endoscopy contributed to a major portion of the caseload and revenue generated by the general surgery group studied. The overall impact of flexible endoscopy is even greater than reported because of the future endoscopic surveillance cases or surgical interventions generated on the basis of endoscopic findings.

On the relationship between matrix free Mg2+ concentration and total Mg2+ in heart mitochondria.

The matrix free magnesium ion concentration, [Mg2+]m, estimated using the fluorescent probe furaptra, averaged 0.67 mM in 15 preparations of beef heart mitochondria containing an average of 21 nmol total Mg2+ per mg protein. [Mg2+]m was compared with total Mg2+ during respiration-dependent uptake and efflux of Mg2+ and during osmotic swelling. In the absence of external Pi these mitochondria contain about 32 nmol/mg non-diffusible Mg-binding sites with an apparent Kd of 0.34 mM. [Mg2+]m depends on both the size of the total Mg2+ pool and the ability of matrix anions to provide Mg-ligands. Pi interacts strongly with Mg2+ to decrease [Mg2+]m and, in the absence of external Mg2+, promotes respiration-dependent Mg2+ efflux and a decrease in [Mg2+]m to very low levels. The uptake of Pi by respiring mitochondria converts delta pH to membrane potential (delta psi) and provides additional Mg-binding sites. This permits large accumulations of Mg2+ and Pi with little change in [Mg2+]m. Nigericin also converts delta pH to delta psi in respiring mitochondria and induces a large and rapid increase in both total Mg2+ and [Mg2+]m. Mersalyl increases the permeability of the mitochondrial membrane to cations and this also induces a marked increase in both total Mg2+ and [Mg2+]m. These results suggest that mitochondria take up Mg2+ by electrophoretic flux through membrane leak pathways, rather than via a specific Mg2+ transporter. Mitochondria swollen by respiration dependent uptake of potassium phosphate show decreased [Mg2+]m, whereas those swollen to the same extent in potassium acetate do not. This suggests that [Mg2+]m is well-buffered during osmotic volume changes unless there is also a change in ligand availability.

Regulation of mitochondrial K+/H+ antiport activity by hydrogen ions.

The effect of matrix pH (pHi) on the activity of the mitochondrial K+/H+ antiport has been studied using the fluorescence of 2,7-biscarboxyethyl-5(6)-carboxyfluorescein (BCECF) to monitor pHi and passive swelling in K+ acetate to follow antiport activity. Heart mitochondria suspended in hypotonic K+ acetate in the absence of respiration show an initial delta pH of -0.4 (interior acid) that decays slowly. Addition of A23187 to deplete matrix Mg2+ results in a further acid shift in pHi followed by equilibration of delta pH. This equilibration appears to depend on K+/H+ antiport and is slow at acid pHi but very rapid when the matrix is alkaline. Swelling of Mg(2+)-depleted mitochondria in K+ acetate is multiphasic with a slow initial rate, a period of maximum swelling, and a final period in which the rate declines. At constant external pH (pH0), the initial rate of swelling is faster with increasing pHi and the time to the onset of the maximum swelling rate decreases. The maximum swelling rate is initiated at pHi 7.4 when pH0 is 7.8 and at pHi 7.1 when pH0 is 7.4. The maximum rate of swelling increases linearly with increasing pH0 in the range from 7.0 to 8.2. This rate also shows a linear relationship to the value of pHi at the time the maximum rate is attained. Dixon plots of the reciprocal of the maximum swelling rate vs [H+]0 suggest that external [H+] is a noncompetitive inhibitor of K+ entry on the antiport. It is concluded that K+/H+ antiport in Mg(2+)-depleted heart mitochondria can be regulated by matrix [H+] (see Beavis, A. D., and Garlid, K. D. (1990) J. Biol. Chem. 265, 2538-2545), but that this antiport is also sensitive to external [H+] or to delta pH when it acts in the direction of K+ uptake.