[Splitting of supplemental revenues in intensive care medicine]. / Erlöszuordnung von Zusatzentgelten in der Intensivmedizin.

In patient care several clinical departments are often involved in the treatment of a single case. Due to this shared work and internal patient transfer between departments the respective departments have to share the single reimbursement sum which is granted for each hospital case in the German DRG system. The intensive care unit in particular, at least if maintained as an independent department, has a high rate of internal transfers and most of the patients will be transferred back to the original department prior to discharge from hospital. Different models have been suggested regarding the splitting of DRG reimbursement between clinical departments, however, no research has been done on the splitting of supplemental revenues. The allocation of supplemental revenues is especially complex for revenues generated over many days of hospital care or for clustered revenues. In most cases the supplemental revenues are simply allocated to the department from which the patient is ultimately discharged. This would lead to a significant economic risk for the intensive care unit, as a considerable proportion of medical services which are eligible for triggering supplemental revenues are applied there. In this study all cases treated in two intensive care units in a university hospital in 2007 were analyzed in which supplemental revenue-related medical services were performed over a longer period of time or graduated according to different amounts. In a total of 385 cases, 691 supplemental revenues were analyzed. Three different methods of supplemental revenues allocation were analyzed regarding the financial impact on the intensive care unit: allocation to the department from which the patient is discharged, allocation according to the length of stay in a particular department (in this case the intensive care unit) and allocation based on actually documented medical services eligible for supplemental revenues. The supplemental revenues take up a considerable share of the total reimbursement for intensive care. Based on the first 2 allocation methods the intensive care unit would receive 20% less supplemental revenues compared to the third allocation method, which supposedly reflects best the actual costs.

[Minimally invasive surgery and the economics of it. Can minimally invasive surgery be cost efficient from a business point of view?]. / Minimal-invasive Chirurgie und Okonomie. Rechnet sich die minimal-invasive Chirurgie aus betriebswirtschaftlicher Sicht?

Minimally invasive surgery (MIS) is now accepted as equally valid as the use of a standard access in some areas of surgery. It is not possible to decide whether this access is economically worthwhile and if so for whom without a full economic cost-benefit analysis, which must take account of the hospital's own characteristics in addition to the cost involved for surgery, staff, infrastructure and administration. In summary, the main economic advantage of MIS lies in the patient-related early postoperative results, while the main disadvantage is that the operative material costs are higher. At present, the payment made for each procedure performed under the DRG system includes 14-17% of the total cost for materials, regardless of the access route and of the technical sophistication of the operation. The actual material costs are greater by a factor of 2-50 for MIS than for a conventional procedure. The task of the hospital is thus to lower the costs for material and infrastructure; that of industry is to offer less expensive alternatives; and that of our politicians, to implement better remuneration of the material costs.

Glutamine stabilizes intestinal permeability and reduces pancreatic infection in acute experimental pancreatitis.

Intestinal barrier failure and subsequent translocation of bacteria from the gut play a decisive role in the development of systemic infections in severe acute pancreatitis. Glutamine (GLN) has been shown to stabilize gut barrier function and to reduce bacterial translocation in various experimental settings. The aim of this study was to evaluate whether GLN reduces gut permeability and bacterial infection in a model of acute necrotizing pancreatitis. Acute necrotizing pancreatitis was induced in 50 rats under sterile conditions by intraductal infusion of glycodeoxycholic acid and intravenous infusion of cerulein. Six hours after the induction of pancreatitis, animals were randomly assigned to one of two groups: standard total parental nutrition (TPN) or TPN combined with GLN (0.5 g/kg(-1)/day(-1)). After 96 hours, the animals were killed. The pancreas was prepared for bacteriologic examination, and the ascending colon was mounted in a Ussing chamber for determination of transmucosal resistance and mannitol flux as indicators of intestinal permeability. Transmucosal resistance was 31% higher in the animals treated with GLN- supplemented TPN compared to the animals given standard TPN. Mannitol flux through the epithelium was decreased by 40%. The prevalence of pancreatic infections was 33% in animals given GLN-enriched TPN as compared to 86% in animals receiving standard TPN (P < 0.05). Adding GLN to standard TPN not only reduces the permeability of the colon but decreases pancreatic infections in acute necrotizing pancreatitis in the rat. This confirms previous reports that GLN decreases bacterial translocation by stabilizing the intestinal mucosal barrier. The present findings provide the first evidence suggesting that stabilizing the intestinal barrier can reduce the prevalence of pancreatic infection in acute pancreatitis and that GLN may be useful in preventing septic complications in clinical pancreatitis.

Azathioprine combined with prednisolone or monotherapy with prednisolone in active Crohn's disease.

BACKGROUND: The role of azathioprine (AZA) in the treatment of active Crohn's disease (CD) is still controversial. This study examined whether AZA combined with standard prednisolone therapy improved the therapeutic outcome compared with monotherapy with prednisolone. METHODS: Forty-two patients with a Crohn's Disease Activity Index (CDAI) of > 150 were randomized into two groups. Both received 60 mg of prednisolone daily in a tapering regimen to a maintenance dose of 10 mg. In addition, group 1 received 2.5 mg AZA/kg body wt and group 2 received a placebo over the whole study period of 4 months. RESULTS: At the end of the trial, 16 of 21 patients (76%) in group 1 were in remission (CDAI < 150), compared with 8 of 21 (38%) in group 2 (P = 0.03). The CDAI in group 1 dropped from 290 +/- 97 (SD) to 72 +/- 84 and from 285 +/- 110 to 155 +/- 105 in group 2. The differences between activity indices in groups 1 and 2 became statistically significant after 8 weeks. The average prednisolone dose per day was 20.9 mg in group 1 and 26.7 mg in group 2 (P = 0.02). No major side effects were observed in this study. CONCLUSION: The combination of prednisolone and AZA was superior to the treatment with prednisolone alone in active CD. Patients receiving AZA showed remission more frequently, more quickly, and with lower doses of prednisolone.

Enteric protein loss as a marker of intestinal inflammatory activity in Crohn's disease: comparability of enteric clearance and stool concentration of alpha-1-antitrypsin?

Intestinal alpha 1-antitrypsin (alpha 1-AT) clearance has been shown a reliable index of intestinal inflammatory activity in Crohn's disease (CD). For reasons of practicability, it has been repeatedly suggested to replace alpha 1-AT clearance by alpha 1-AT concentration in random stool samples. In 60 controls and in 70 patients with CD, in 21 patients before and after treatment, fecal alpha 1-AT concentration and the ratio of stool and serum alpha 1-AT concentration were compared with alpha 1-AT clearance. In 11 patients alpha 1-AT clearance, fecal concentration and stool/serum alpha 1-AT concentration ratio were compared with 51Cr-albumin clearance. alpha 1-AT clearance (104 +/- 14 vs. 17.5 +/- 2 ml/d, p < 0.0001) as well as fecal alpha 1-AT concentration (155 +/- 21 vs. 30 +/- 3 mg/100 ml, p < 0.0001) and stool/serum alpha 1-AT concentration ratio (45 +/- 6 vs. 12 +/- 1) were significantly higher in CD patients than in controls. alpha 1-AT clearance (60 +/- 9 vs. 37 +/- 4 ml/d, p < 0.01), fecal alpha 1-AT concentration (113 +/- 21 vs. 59 +/- 8 mg/100 ml, p < 0.01) and the stool/serum alpha 1-AT concentration ratio (27 +/- 4 vs. 18 +/- 2) decreased after treatment, but fecal alpha 1-AT concentration and the stool/serum alpha 1-AT concentration ratio failed to parallel the course of alpha 1-AT clearance in 33% and in 24% of patients, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Increased serum alpha 1-antitrypsin does not produce a rise in fecal alpha 1-antitrypsin in patients with healthy intestines]. / Erhöhtes Serum-alpha-1-Antitrypsin verursacht bei darmgesunden Patienten keinen Anstieg des fäkalen alpha-1-Antitrypsin.

Fecal alpha-1-Antitrypsin (alpha-1-AT) was related to serum alpha-1-AT concentration in 50 healthy controls, 51 patients with extraintestinal inflammatory disease as well as in 23 patients with ulcerative colitis with mild or severe disease activity. alpha-1-AT concentrations were measured by radial immunodiffusion. Even though serum alpha-1-AT concentration was elevated above normal limits in all patients, a concomitant increase of fecal alpha-1-AT was found only in patients with ulcerative colitis. In these patients a positive correlation between fecal alpha-1-AT-clearance and -concentration and severity and extension of inflammation could be demonstrated. It is concluded that elevated blood levels of alpha-1-AT do not cause increases in fecal alpha-1-AT loss and that fecal alpha-1-AT excretion is increased specifically in patients with intestinal inflammation.