Charles D. Mabry

Disease-Specific Amino Acid Infusion (F080) in Hepatic Encephalopathy: A Prospective, Randomized, Double-Blind, Controlled Trial

Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.

Advanced hidradenitis suppurativa: Review of surgical treatment in 23 patients☆

Abstract Hidradenitis suppurativa remains a poorly understood disease involving the apocrine sweat glands. Management of 23 patients with the advanced form of the disease has been reviewed. Local therapy and incision and drainage all have an unacceptable rate of recurrence. From our experience, we recommend wide and deep excision of the area involved combined with individualized closure.

Activated clotting time (ACT) monitoring of intraoperative heparinization in peripheral vascular surgery

We conclude that (1) the activated clotting time (ACT) is an accurate method of monitoring anti-coagulation during peripheral vascular surgery and can easily be performed by a technician in the operating room or at the bedside; (2) an initial heparinizing dose of 120 to 130 units/kg is adequate in 95 per cent of the patients; (3) the ACT should be maintained at greater than twice the control values (180 to 200 seconds), which required supplementation within 2 hours in 21 per cent; (4) the response to heparin is twofold: an initial sensitivity or resistance followed by an independent and variable rate of consumption; (5) the patients heparin dose-response curve should be used to calculate the amount of supplemental heparin needed to maintain the ACT at a safe level; (6) protamine should be given if the ACT at the conclusion of the operation is greater than 150 seconds (50 per cent of our patients); and (7) a final ACT 15 to 30 minutes postoperatively should be obtained to ensure adequate reversal or to detect heparin rebound or depletion of clotting factors.

The Use of Intraservice Work per Unit of Time (IWPUT) and the Building Block Method (BBM) for the Calculation of Surgical Work

Objective:We will review the contribution to the Medicare Fee Schedule (MFS) by the techniques of intensity of work per unit of time (IWPUT), the building block methodology (BBM), and the work accomplished by the American College of Surgeons General Surgery Coding & Reimbursement Committee (GSCRC) in using IWPUT/BBM to detect undervalued surgical procedures and recommend payment increases. Summary Background Data:The MFS has had a major impact on surgeons’ income since its introduction in 1992 by the Centers for Medicare and Medicaid (CMS) and additionally has been adopted for use by many commercial insurers. A major component of MFS is physician work, measured as the relative value of work (RVW), which has 2 components: time and intensity. These components are incorporated by: RVW = time × intensity. Methods:This work formula can be rearranged to give the IWPUT, which has become a powerful tool to calculate the amount of RVW performed by physicians. Most procedures are valued by the total RVW in the global surgical package, which includes pre-, intra-, and postoperative care for a time after surgery. Summing these perioperative components into RVW is called the building block methodology (BBM). Results:Using these techniques, the GSCRC increased the values for 314 surgery procedures during a recent CMS 5-year review, resulting in an increase to general surgeons of roughly

Vitamin regimens in parenteral nutrition: a dilemma.

76 million annually. Conclusions:The use of IWPUT/BBM has been instrumental to correct payment for undervalued surgical procedures. They are powerful methods to measure RVW across specialties and to solve reimbursement, compensation, and practice management problems facing surgeons.

Determining the Hospital Trauma Financial Impact in a Statewide Trauma System

Recently, a parenteral vitamin product which matches the recommended dietary allowance for parenteral vitamins set forth by the Nutrition Advisory Group (NAG) of the American Medical Association has been marketed. The release of this product calls attention once again to the NAG recommendations and their applicability. The authors point out that the NAG guidelines do not address the needs of the traumatized or hypermetagolic patient. Further, the cost of the new vitamin product is questioned in regard to the additional expense incurred in attempting to administer vitamins as per the NAG recommendations. The authors offer cost and therapeutic comparisons of existing produces on the market to the new vitamin product, and explain a therapeutic regimen utilizing multiple products administered on regular basis compared to the daily administration of the new product. The weekly cost of the plan proposed by the authors is +7.56 compared to +16.70 per week for the new vitamin product.

A Resource-Based Relative Value Scale (RBRVS) System

BACKGROUND There have been no comprehensive studies across an organized statewide trauma system using a standardized method to determine cost. STUDY DESIGN Trauma financial impact includes the following costs: verification, response, and patient care cost (PCC). We conducted a survey of participating trauma centers (TCs) for federal fiscal year 2012, including separate accounting for verification and response costs. Patient care cost was merged with their trauma registry data. Seventy-five percent of the 2012 state trauma registry had data submitted. Each TCs reasonable cost from the Medicare Cost Report was adjusted to remove embedded costs for response and verification. Cost-to-charge ratios were used to give uniform PCC across the state. RESULTS Median (mean ± SD) costs per patient for TC response and verification for Level I and II centers were

Does the Institution of a Statewide Trauma System Reduce Preventable Mortality and Yield a Positive Return on Investment for Taxpayers

1,689 (

Successful Management of a Breast Surgery Practice

1,492 ±

Appropriate payment will follow quality care.

647) and