Development and initiation of computer generated documentation for burn patient care.

Burn care is costly, complex, and poorly reimbursed. Capturing evaluation and management codes is an essential step in obtaining reimbursement for services rendered. For surgeons used to billing on the basis of Current Procedural Terminology codes, this represents a significant paradigm shift. In an effort to document the care provided and increase compliance with billing standards, we created computerized history and physical examination notes and progress notes specifically for burn patients. Drop down menus are included to answer directed queries, which allows the majority of the documentation to be completed with a point and click of the mouse. The note is completed by the house staff except for the "assessment and plan," which are entered by the attending physician who reviews and then electronically signs the note. A log of electronically signed notes is generated weekly for billing purposes. The use of these computerized documents has been reviewed and approved by the coding and quality assurance specialists within our billing organization. We believe these tools maximize the efficiency of documenting burn patient care, while minimizing the effort necessary to comply with evaluation and management guidelines. The aim of this study was to test the new computerized method at our institution to see whether it would improve documentation for evaluation and management services provided to burn patients. The results prove that this new system accomplished the goal we had set.

Lateral thoracic expansion for Jeune's syndrome: midterm results.

BACKGROUND: In 1995, we reported the use of lateral thoracic expansion in a patient with symptomatic Jeune's asphyxiating thoracic dystrophy. We have subsequently used lateral thoracic expansion 16 times on 10 patients during 7 years. This article reports our outcomes and provides surgical details. METHODS: Charts of all patients undergoing lateral thoracic expansion were reviewed. Eight of the 10 patients had symptomatic Jeune's syndrome. The other 2 had similar thoracic deformities limiting thoracic capacity. In half of the patients the procedures were performed bilaterally. RESULTS: All patients older than 1 year of age were symptomatically benefited by lateral thoracic expansion. Functional and anatomic measurements documented thoracic enlargement in several patients who had comparable preoperative and postoperative studies. However, 2 infants with significant underlying airway disease did not improve and went on to succumb to that aspect of their disease despite enlargement of the thorax. Fracture of the titanium ministruts has been a recurrent problem, and we now use larger struts. CONCLUSIONS: Lateral thoracic expansion is a safe and effective procedure in selected patients with Jeune's syndrome older than 1 year of age as judged by short-term and midterm follow-up. More experience and longer follow-up are required to discern the place of the lateral thoracic expansion in the overall management of these patients.

A prosthetic breast implant infected with Mycobacterium fortuitum.

Augmentation mammaplasty is a common operation performed in the United States. Postoperative wound infections are rare, but can be devastating. Most often, bacteria from the normal skin flora cause these infections, but more atypical organisms can lead to similar situations. The authors present a case of a prosthetic breast implant infected with Mycobacterium fortuitum after augmentation mammaplasty. The patient, diagnosis, and treatment are discussed so that others may recognize and treat this entity successfully before encountering major complications. Although it is an infrequent occurrence, plastic surgeons, infectious disease specialists, and primary care doctors who may see postoperative wound infections should be aware of this potential pathogen. It is important in any postimplant infection and especially crucial in cases of unresolving or recurrent infections with unusual or even clear drainage. With proper identification through acid-fast smear and culture, multiagent therapy can be initiated early. Additional complications, including implant removal, may thus be avoided.

Muscarinic transmission decreases the number of SIF cells demonstrating catecholamine histofluorescence in rat superior cervical ganglia.

Preganglionic electrical stimulation of the cervical sympathetic trunk to the rat superior cervical ganglia produced a mean reduction in the number of visible small intensely fluorescent (SIF) cells demonstrating catecholamine histofluorescence to 32% of the unstimulated contralateral control. The reduction in the number of catecholamine-positive SIF cells required the presence of specific blockers of catecholamine uptake and synthesis and was dependent on normal synaptic transmission. No change in the number of catecholamine-positive SIF cells was observed when ganglionic transmission occurred in solutions containing both hexamethonium and atropine or with atropine alone (97% of the unstimulated control). Furthermore, preganglionic stimulation in the presence of high magnesium/low calcium solutions, which effectively blocked synaptic transmission, prevented the stimulation-induced decrease in the number of catecholamine-positive SIF cells. Prolonged antidromic stimulation of the internal carotid nerve only reduced the number of catecholamine-positive SIF cells to 75% of the unstimulated contralateral control. These results suggest that preganglionic synaptic impulses can induce the release of catecholamines from SIF cells via muscarinic receptor activation. Furthermore, the necessity for pharmacological intervention of uptake and synthesis blockers of catecholamines in order to detect the synaptically-induced reduction in the number of catecholamine-positive SIF cells, suggests that synaptic transmission also modulates the synthesis of catecholamines in SIF cells within the rat superior cervical ganglia.