Time to failure of arterial shunts in a pig hemorrhagic shock model.

Temporary vascular shunts (TVSs) are relied on frequently in the current military theater. Details of their physiology and outcome are of increasing interest and needed to further define their place in the management of trauma. This study was conducted using a porcine hemorrhagic shock model and aimed to 1) establish the time to failure of short, proximally placed vascular shunts; and 2) examine histological changes in the shunted artery. The external iliac artery of male pigs was transected and a straight shunt secured in place. Hemorrhagic shock was then induced by rapidly removing 40 per cent of blood volume and maintaining severe hypotension for 40 minutes before resuscitation. Animals were observed for up to 6 days for limb function as well as overall physiological status. At the conclusion of the experiment, status of the shunt and adjacent artery was evaluated by an independent pathologist. The presence of thrombi and inflammation within the proximal and distal artery was graded. Among the 10 animals tested, nine subjects survived the initial surgery. All shunts remained patent with mean time of 4.2±1.2 days of observation. Three-position histological analysis of the connected arterial tissues revealed minimal acute inflammation and minimal or thrombus. The results suggest that TVSs in proximal arteries remain functional for at least 48 to 72 hours in proximal arteries even without anticoagulation in the setting of brief hemorrhagic shock. This knowledge may aid combat evacuation patterns.

Straight talk--new approaches in healthcare. Want better relationships with payors? Focus on medical management.

When it comes to managing medical care for their enrollees, payors are moving towards a broader focus for medical management that includes both costs and quality. In the twelfth installment of Straight Talk, we look at how health plans, such as CIGNA, are developing incentives to reward high-quality, low-cost providers of medical care and transitioning their utilization management operations to a new model. To ensure quality, they are beginning to compare providers' performance to national standards for medical outcomes. Through these initiatives, known as "medical management," payors hope to improve not only medical care but also their relationships with providers.

Potential cost savings of erythropoietin administration in end-stage renal disease.

BACKGROUND: In a Department of Veterans Affairs randomized controlled trial, a lower dose of recombinant human erythropoietin (epoetin) was shown to attain target hematocrit levels when administered subcutaneously compared with intravenously. Since epoetin is expensive, optimizing the therapeutic effect of epoetin using a strategy that includes subcutaneous administration could lead to substantial cost savings. METHODS: We used an economic cost projection model to estimate potential savings to the Medicare End-Stage Renal Disease Program that could occur during a transition from intravenous to subcutaneous administration of epoetin among hemodialysis patients. Data included clinical results from the Department of Veterans Affairs randomized controlled trial, the 1998 Centers for Medicare and Medicaid Services' End-Stage Renal Disease Core Indicators Survey, and the 1997-1998 Medicare claims files. In sensitivity analyses, we varied the expected dose reductions (10% to 50%) and the proportion of patients (25% to 100%) who switched to subcutaneous administration. RESULTS: Medicare cost savings were estimated at $47 to $142 million annually as 25% to 75% of hemodialysis patients who received epoetin intravenously switched to subcutaneous administration while reducing the dose by 32%. A minimal reduction (10%) in epoetin dose would result in Medicare cost savings of an estimated $15 to $44 million annually. CONCLUSION: Administering epoetin subcutaneously would provide substantial cost savings to Medicare. For the transition to occur, consensus among stakeholders is needed, especially among patients whose treatment satisfaction and health-related quality of life would be most affected.