Prakash Laud

Economics of managed care in spinal cord injury

OBJECTIVE To determine and describe trends in economic variables related to the care of individuals with spinal cord injury (SCI) and significant changes in these trends coincident with major developments in medical care cost control. DATA SOURCES Data from the National Spinal Cord Injury Statistical Center (NSCISC) database were used to review the economic trends in SCI management from 1973 to 1998 and their relation to managed care and other health care cost-containment measures. A panel of SCI health care specialists was interviewed to determine the appropriate data variables to be reviewed. The Shepherd Center Care Health Management Program, Atlanta, GA, is presented as an example of a fiscally successful managed care program for patients with SCI. DATA EXTRACTION Data from the NSCISC database for the years studied were extracted and converted to a form suitable for analysis by means of the statistical software SAS. DATA SYNTHESIS Statistical techniques included multiple regression analysis, logistic regression analysis, and model selection methods. CONCLUSIONS Trends in economic variables, in the care of individuals with SCI show changes coincident with the introduction of Diagnostic Related Groups (DRGs) and managed care as models for provider reimbursement. Significant changes occurred in acute care charges, rehabilitation charges, length of stay, rehospitalization 1 year postinjury, time from injury to admission to a Model System, and discharges to a nursing home.

Objective testing and quality-of-life evaluation in surgical candidates with chronic rhinosinusitis.

Background Discordance has been reported between patient symptoms and objective measures of disease in chronic sinusitis, such as radiographic evaluation. The objective of this study was to evaluate the association between presurgical objective studies and presurgical quality of life (QOL). This work was designed as a cross-sectional study of 90 consecutive patients presenting to a tertiary rhinology practice for surgical management of sinonasal disease. Methods QOL assessment was performed using disease-specific instruments (Chronic Sinusitis Survey and Rhinosinusitis Disability Index). Computed tomography (CT) scans were scored according to the Lund-Mackay CT scoring system and endoscopy evaluation was scored by the system proposed by Lund and Kennedy. Results Ninety surgical candidates were enrolled and included in the analysis. Correlation between the QOL total scores and subscale scores was excellent (r = 0.39; p = 0.0001) as was the correlation between CT and endoscopy scores (r = 0.59; p = 0.0001). In contrast, correlation between QOL and objective measures was poor. These results were not significantly influenced by subgroup analysis by diagnosis, comorbidity, and other patient factors. Conclusion Preoperative objective measures of CRS disease show little, if any, correlation with disease-specific QOL measures in surgical candidates. It is likely that CT and endoscopy are measuring a different aspect of CRS disease than the QOL measures. In addition, it is possible that preoperative QOL, either alone or in combination with CT and endoscopy, may prove important in selecting patients most likely to benefit from surgery.

Does breast tumor location influence success of sentinel lymph node biopsy

BACKGROUND Controversy exists regarding the influence of sentinel lymph node (SLN) mapping technique or patient variables on the success rate of SLN mapping. We undertook a prospective study in a single institution series to evaluate multiple variables that could adversely affect SLN identification rates. STUDY DESIGN Data were collected on 174 patients who underwent 177 SLN mapping procedures followed by axillary dissection from October 1996 through January 2000. Patient demographics, body mass index (BMI), biopsy method, tumor size, palpability, and location were recorded. SLNs were identified by blue dye only (n = 31), Tc-99m sulfur colloid only (n = 34), or combined techniques (n = 112). Data were analyzed by logistic regression analysis and expressed as the probability of failure to map the SLN. RESULTS SLNs were identified successfully in 150 of 177 procedures (85%) with a false negative rate of 3.7%. Mapping success reached 93% using combination blue dye and isotope. Variables found to adversely affect SLN mapping success and the odds ratio of failure (OR) included lower inner quadrant (LIQ) location (OR 35.6), blue dye only (OR 42.4), BMI >30 and upper outer quadrant (UOQ) location (OR 14.6), and nonpalpable UIQ location (OR 25). LIQ location adversely affects mapping success independent of technique, tumor size, or obesity. Obesity and nonpalpability were adverse factors when tumors were located in the UOQ and UIQ, respectively. Age, biopsy technique, and tumor diameter did not affect SLN mapping success. CONCLUSIONS SLN mapping success is influenced by technique and tumor location, with best results achieved using combined techniques and for lesions located in quadrants other than the LIQ. Obesity and tumor palpability influence success in the context of tumor location.

Severe-to-fatal head injuries in motor vehicle impacts

Severe-to-fatal head injuries in motor vehicle environments were analyzed using the United States Crash Injury Research and Engineering Network database for the years 1997-2006. Medical evaluations included details and photographs of injury, and on-scene, trauma bay, emergency room, intensive care unit, radiological, operating room, in-patient, and rehabilitation records. Data were synthesized on a case-by-case basis. X-rays, computed tomography scans, and magnetic resonance images were reviewed along with field evaluations of scene and photographs for the analyses of brain injuries and skull fractures. Injuries to the parenchyma, arteries, brainstem, cerebellum, cerebrum, and loss of consciousness were included. In addition to the analyses of severe-to-fatal (AIS4+) injuries, cervical spine, face, and scalp trauma were used to determine the potential for head contact. Fatalities and survivors were compared using nonparametric tests and confidence intervals for medians. Results were categorized based on the mode of impact with a focus on head contact. Out of the 3178 medical cases and 169 occupants sustaining head injuries, 132 adults were in frontal (54), side (75), and rear (3) crashes. Head contact locations are presented for each mode. A majority of cases clustered around the mid-size anthropometry and normal body mass index (BMI). Injuries occurred at change in velocities (DeltaV) representative of US regulations. Statistically significant differences in DeltaV between fatalities and survivors were found for side but not for frontal impacts. Independent of the impact mode and survivorship, contact locations were found to be superior to the center of gravity of the head, suggesting a greater role for angular than translational head kinematics. However, contact locations were biased to the impact mode: anterior aspects of the frontal bone and face were involved in frontal impacts while temporal-parietal regions were involved in side impacts. Because head injuries occur at regulatory DeltaV in modern vehicles and angular accelerations are not directly incorporated in crashworthiness standards, these findings from the largest dataset in literature, offer a field-based rationale for including rotational kinematics in injury assessments. In addition, it may be necessary to develop injury criteria and evaluate dummy biofidelity based on contact locations as this parameter depended on the impact mode. The current field-based analysis has identified the importance of both angular acceleration and contact location in head injury assessment and mitigation.

THE NORMAL KIDNEY GROWTH RATE DURING YEAR 1 OF LIFE IS VARIABLE AND AGE DEPENDENT

AbstractPurpose: The concept of normal contralateral kidney growth rate was introduced as a parameter to consider in conjunction with others in the evaluation of unilateral hydronephrosis in asymptomatic neonates and infants. Historically measurements of renal size obtained at different times from different patients have been relied on to construct normal renal growth charts. We report normal kidney growth rates in year 1 of life derived from interval ultrasound measurements of renal size in the same newborns and infants longitudinally with time.Materials and Methods: We reviewed 333 normal renal ultrasound studies performed between 1991 and 1995 in 55 patients during year 1 of life. These longitudinal measurements were made bilaterally 2 to 8 times (median 3) per patient. Growth curve models that consider random patient effects were used to estimate the mean growth curve and ascertain its form. We also reviewed an additional 91 ultrasound studies in 10 patients with myelomeningocele without hydronephrosi...

Perceived Barriers to Employment in Individuals with Spinal Cord Injury

This study assessed the factors influencing employment for individuals with spinal cord injury (SCI). Employment status and the perceived barriers to employment were assessed in a home interview with 97 community-based individuals, mean time 6.6 years postinjury. More than half of the unemployed individuals with SCI, with stated motivation to work, remain unemployed. The perception of barriers and of factors helpful to employment differs significantly between employed and unemployed individuals. Lack of transportation was ranked as the number one barrier among the unemployed. Lack of Social Security benefits was ranked as the number two perceived barrier among the employed and seventh in the unemployed.

DISCUSSION: THE NORMAL KIDNEY GROWTH RATE DURING YEAR 1 OF LIFE IS VARIABLE AND AGE DEPENDENT

PURPOSE The concept of normal contralateral kidney growth rate was introduced as a parameter to consider in conjunction with others in the evaluation of unilateral hydronephrosis in asymptomatic neonates and infants. Historically measurements of renal size obtained at different times from different patients have been relied on to construct normal renal growth charts. We report normal kidney growth rates in year 1 of life derived from interval ultrasound measurements of renal size in the same newborns and infants longitudinally with time. MATERIALS AND METHODS We reviewed 333 normal renal ultrasound studies performed between 1991 and 1995 in 55 patients during year 1 of life. These longitudinal measurements were made bilaterally 2 to 8 times (median 3) per patient. Growth curve models that consider random patient effects were used to estimate the mean growth curve and ascertain its form. We also reviewed an additional 91 ultrasound studies in 10 patients with myelomeningocele without hydronephrosis or reflux. We analyzed the kidney growth rate in a similar manner and compared the results with those in the normal patients. RESULTS Analysis of the normal cases revealed a changing growth rate during year 1 of life estimated to be 3.1 mm. per month at birth, decreasing gradually during the first 7 months of life to 0.25 mm. per month and remaining constant thereafter (p = 0.0064). Mean kidney size at birth was estimated to be 42.8 mm. (95% confidence limits 27.0 to 58.5). At age 7 months mean size was 60.7 mm. (95% confidence limits 40.1 to 81.3). CONCLUSIONS These data demonstrate that normal kidney growth is age dependent. A rapid but slowly decreasing growth rate during the first 7 months of life is followed by a more constant and lower rate. The data also suggest that unusually rapid growth, such as that which may occur in the normal contralateral kidney in unilateral obstruction, may also be age dependent, exceeding 5.0 mm. per month during the first 7 months of life and 2.0 mm. per month thereafter.