Treatment of sternal nonunion with the Dall-Miles cable system.

We have used this technique in two patients. One had early sternal dehiscence with presternal infection, and the other had late sternal nonunion. Uncomplicated sternal union was achieved in both patients. The cables were nonpalpable in both patients, but they were removed in one patient at that patient's request. This method of using Dall-Miles cerclage cables is a straightforward and efficacious method of open reduction and internal fixation of the sternum. It is indicated for patients with chronic sternal nonunion or early postoperative separation of the sternal fragments and may be used even in the presence of an infection limited to the presternal space after adequate debridement and irrigation have been performed. Any recurrent superficial infection, although unlikely, can be cured by hardware removal after osseous union has been obtained. For sternal separation without fractures, four cables may simply be placed around the sternal halves and their tension increased. In the case of sternal fractures, the cables may be placed in figures of eight or in other woven configurations as needed for each individual case.

Microsurgery costs and outcome.

Reliable information on cost and value in microsurgery is not readily available in the literature. Driving factors for cost, determinants of complications, and cost-reduction strategies have not been elucidated in this population, despite such progress in other areas of medicine. Clearly, the time-consuming and costly nature of this endeavor demands that appropriate indications and patient management be delineated; to operate proactively in this cost-conscious time, financial and outcome determinations are critical. One hundred seven consecutive free-tissue transfers performed from 1991 to 1994 by a single microsurgeon were studied. Retrospective chart review for clinical parameters was combined with analysis of hospital costs and professional charges. Operating room and anesthesia costs were based on a microcost analysis of actual operating room time, materials, labor, and overhead. Other patient level costs were generated by Transition 1, a hospital cost-accounting system. The following issues were addressed: (1) flap survival; (2) total costs and length of stay for all free flaps; (3) payments received from various insurers; (4) breakdown of operating room costs by labor, supplies, and overhead; (5) breakdown of inpatient costs by category; (6) additional costs of complications and takebacks; (7) factors associated with complications and flap takebacks; and (8) cost-reduction strategies. Mean free flap operating room costs (exclusive of professional fees) ranged among case types from $4439 to $6856 and were primarily a function of operating room times. Elective patient cases lasted a mean 440 minutes. There was a large disparity in reimbursement: private insurers covered hospital costs (not charges) completely, whereas Medicare paid 79 percent and Medicaid only 64 percent. Length of stay, operative procedures, and complications had the greatest influence on inpatient costs in this group of free flap patients. Potential cost savings as a result of possible practice changes (e.g., shortening intensive care unit stays and avoiding staged operations) can be predicted. This analysis has caused a revision in these institutions' practice patterns and lays the foundation for planned outcome studies in this population.

Development and implementation of an extremity free-tissue-transfer database.

Rigorous clinical outcomes research requires accurate, complete, and standardized data. No such system is currently being used by reconstructive microsurgeons to evaluate free-tissue-transfer procedures. To facilitate collection of relevant and complete data, the authors propose a standardized format for data collection regarding these procedures. Data are collected via computer entry or scannable forms. The database includes sociodemographic, clinical, health/functional status, patient satisfaction, and resource utilization variables--the necessary components of a well-constructed clinical outcome study. Such studies will give rise to meaningful treatment algorithms for managing reconstructive problems. In addition, widespread use of a standardized databse will facilitate comparisons between practices and allow for meta-analyses. Resultant practice guidelines and microsurgery care maps will ultimately improve patient care and minimize unnecessary costs.

Efficacy of MR vs CT in epilepsy.

We studied 59 seizure patients with CT, MR, and EEG to determine the efficacy of each in the detection of an epileptogenic focus. EEG was most sensitive (67%), MR was next (53%), and CT was least sensitive (42%). MR detected an abnormality in five patients (8%) in whom CT was negative. EEG was positive in each of these patients. CT failed to demonstrate any focal lesion not detected by MR. MR and CT detected focal abnormalities in seven patients (12%) who had negative EEGs. Five of the seven patients had brain tumors. Eighteen of the 26 patients who underwent surgery had positive CT and MR; 14 of these patients had tumors. The remaining eight patients who had surgery all had temporal lobectomies for intractable seizures; none had tumors. In the complex partial seizure subgroup of 34 patients, MR was positive in 44%, CT was positive in 29%, and EEG was positive in 80%. We consider MR to be the imaging procedure of choice for the detection of an epileptogenic focus in seizure patients. When indicated, CT may be performed as a second procedure to try to distinguish neoplasm from thrombosed vascular malformations and other lesions.

Thromboxane release from irradiated perfused rat lungs: role of oncotic agents.

Isolated lungs from 20 Gray (Gy) whole body irradiated rats were perfused with Krebs-Ringer bicarbonate plus 3% bovine serum albumin (KRB-BSA). The pulmonary effluent showed a 99% (p less than .05) increase in immunoassayable thromboxane B2 (iTXB2) release compared with non-irradiated lungs. Since both arachidonic acid and cyclooxygenase products bind to albumin, studies were performed to determine if omission or substitution of this protein oncotic agent would alter the radiation-induced increase in pulmonary iTXB2 release. Irradiated, isolated lungs perfused with media from which the BSA was omitted (KRB) did not demonstrate the radiation-induced increase in pulmonary iTXB2 release. Similarly, irradiated lungs perfused with media in which Dextran 70 (KRB plus 3% Dextran 70, KRB-Dextran 70) was substituted for BSA also did not show the radiation-induced increase in pulmonary effluent iTXB2 levels. These studies demonstrate the importance of including albumin as the oncotic agent in perfused organ systems when studying cyclooxygenase product release.