Does complexity relate to compensation? A comparison of relative value units in initial versus recurrent inguinal hernia repair.

PURPOSE: Work relative value units (wRVUs) can be used as a compensation model based on the effort required for providing a service and helps to determine adequate compensation for physicians. Thus, more complex surgical procedures that require greater technical skills and time should yield greater compensation. There are limited data comparing wRVUs and operative times within common general surgery procedures such as inguinal hernia repair. This study aims to compare mean operative times and wRVUs per minute between primary and recurrent inguinal hernia repairs, the latter being considered as a more difficult procedure to perform. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to identify all patients undergoing primary inguinal hernia repair and recurrent inguinal hernia repair by general surgeons over a 6-year period (2012-2017). Calculation and comparison of mean operative times, wRVUs, and wRVU per minute were performed. RESULTS: A total of 134,391 patients were included in the analysis. 121,235 underwent primary inguinal repair and 13,156 patients underwent repair of recurrent inguinal hernia. Patients were distributed within open/reducible, open/incarcerated and laparoscopy groups. Mean operative time and RVUs were greater for recurrent inguinal procedures (p < 0.0001). Consistently, RVU per minute was also found to be higher for recurrent procedures within the different groups analyzed. CONCLUSION: Appropriately, general surgeons are reimbursed at a higher rate per minute in recurrent cases, regardless of the technique used.

Popular pharmaceutical residues in hospital wastewater: quantification and qualification of degradation products by mass spectroscopy after treatment with membrane bioreactor.

The occurrence of drugs in wastewater has been considered an imminent risk to the population, for the treatments used are usually ineffective. The presence of four popular drug residues (metformin, paracetamol, tetracycline, and enalapril) in hospital effluents, by using ultra-fast liquid chromatography tandem mass spectrometry (UFLC-MS/MS) with electrospray (ESI) ionization, and removal/degradation by membrane bioreactor (MBR) system are investigated in this study. For analysis method, all standard calibration curves showed satisfactory linearity (R (2) ≥ 0.993) within a relatively wide range. The recovery was between 70.4 and 105.0 %, and the relative standard deviation (RSD) values were within the ranges of 8.2 and 13.5 %. The effluent samples were collected at the end of the process treated in a bench-scale MBR treatment system and preconcentrated on solid-phase extraction (SPE) cartridges. Following that procedure, the chemical analysis demonstrated that the MBR system was effective in enalapril 94.3 ± 7.63 %, tetracycline 99.4 ± 0.02 %, and paracetamol 98.8 ± 0.86 % removal. However, the polar metformin was less effectively removed (35.4 ± 12.49 %). Moreover, the degradation products were investigated using high-resolution mass spectrometry (HRMS) by quadrupole-time of flight (Q-TOF), which has been indicated a tetracycline metabolite. In order to investigate the environmental impact, the wastewater potential risk was evaluated. The risk quotient (RQ) by measure environmental concentration (MEC) and its predicted no effect concentration (PNEC) ratio (RQ = MEC/PNEC) was between 0.003 (enalapril) to 0.815 (paracetamol). Finally, this work demonstrates that UFLC-MS/MS (ESI-Q) is a sensitive and selective method for drug analysis in wastewater and with ESI-Q-TOF has the accuracy required for determining the degradation products of these compounds. Also, it indicated that membrane bioreactor systems represent a new generation of processes that have proved to outperform conventional treatment showing better effluent quality. The removal capacity studied in this work demonstrates the efficiency of this process.

Environmental engineering education for developing countries: framework for the future.

This paper presents the existing philosophy, approach, criteria and delivery of environmental engineering education (E3) for developing countries. In general, environmental engineering is being taught in almost all major universities in developing countries, mostly under civil engineering degree programmes. There is an urgent need to address specific inputs that are particularly important for developing countries with respect to the reality of urbanisation and industrialisation. The main component of E3 in the near future will remain on basic sanitation in most developing countries, with special emphasis on the consumer-demand approach. In order to substantially overcome environmental problems in developing countries, E3 should include integrated urban water management, sustainable sanitation, appropriate technology, cleaner production, wastewater minimisation and financial framework.