La colecistectomia videolaparoscopica elettiva: i limiti di un sogno ormai realtà

La tecnica laparoscopica per la colecistectomia elettiva è il capolinea di un’evoluzione volta a ridurre ai minimi termini la via d’accesso. Abbiamo analizzato dal 1° gennaio 2004 al 31 dicembre 2006 un totale di 5515 interventi di colecistectomia, di cui 4877 laparoscopici e 635 in tecnica tradizionale. Le complicanze e le diagnosi aggiuntive sono state codificate ricercandole nel database delle SDO della Regione Lombardia. La morbilità è stata di 82 casi (12.9%) con la tecnica tradizionale e da 109 casi (2.23%) con la tecnica laparoscopica; la mortalità è stata di 11 casi (1.73%) con la tecnica tradizionale e di 1 caso (0.02%) con la tecnica laparoscopia. Le giornate di degenza media sono state 14.40 con la tecnica tradizionale e 4.75 con la tecnica laparoscopia La morbilità nella tecnica open è sei volte superiore rispetto alla tecnica laparoscopica. Questo divario tra le due tecniche è presente in tutte le casistiche mondiali ed è il risultato della mini-invasività della laparoscopia rispetto all’incisione laparotomica, condizione che spiega e giustifica anche la differenza per quanto riguarda i giorni di degenza media in favore ovviamente della tecnica laparoscopia. La mortalità così alta nella tecnica tradizionale rispetto alla laparoscopia è da attribuirsi ai casi selezionati La prima importante osservazione è che nei nostri ospedali, come in tutti i migliori del mondo, la colecistectomia laparoscopica è diventata il gold standard di trattamento della colelitiasi e la seconda è che sempre di più la tecnica open è riservata alla patologia complicata della litiasi della colecisti e questo quindi ne giustifica l’importante divario, rispetto alla tecnica laparoscopica, per quanto concerne le giornate di degenza, la morbilità e la mortalità

An Examination of Private Payer Reimbursements to Primary Care Providers for Healthcare Services Using Telehealth, United States 2009–2013

Half of telehealth-related state policies were implemented in the last five years. Although many states permit reimbursements for telehealth services, only seven states have passed statutes mandating parity with reimbursements for non-telehealth services. Despite an increasing number of telehealth policies, claims for telehealth services to private insurers are rare. Lower average reimbursements for telehealth billings may discourage adoption of telehealth technologies. Surveillance of claims data will help identify whether telehealth policies are having their intended impact on the healthcare system.https://digitalcommons.unmc.edu/coph_policy_reports/1026/thumbnail.jp

Legal Mapping Analysis of State Telehealth Reimbursement Policies

Background: There exists rapid growth and inconsistency in the telehealth policy environment, which makes it difficult to quantitatively evaluate the impact of telehealth reimbursement and other policies without the availability of a legal mapping database. Introduction: We describe the creation of a legal mapping database of state-level policies related to telehealth reimbursement of healthcare services. Trends and characteristics of these policies are presented. Materials and Methods: Information provided by the Center for Connected Health Policy was used to identify state-wide laws and regulations regarding telehealth reimbursement. Other information was retrieved using: (1) LexisNexis database, (2) Westlaw database, and (3) retrieval from legislative websites, historical documents, and contacting state officials. We examined policies for live video, store and forward, and remote patient monitoring (RPM). Results: In the United States, there are 24 states with policies regarding reimbursement for live video transmission. Fourteen states have store and forward policies and 6 states have RPM related policies. Mississippi is the only state that requires reimbursement for all three types of telehealth transmission modes. Most states (47 states) have Medicaid policies regarding live video transmission, followed by 37 states for store and forward and 20 states for RPM. Only thirteen states require that live video will be reimbursed “consistent with” or at the “same rate” as in-person services in their Medicaid program. Discussion: There are no widely accepted telehealth reimbursement policies across states. They contain diverse restrictions and requirements that present complexities in policy evaluation and determining policy effectiveness across states

Opioid abuse/dependence among those hospitalized due to periapical abscess

AimOpioid abuse/dependence (OAD) is an emerging public health crisis in the USA. The aim of the present study was to estimate the nationwide prevalence of OAD in those hospitalized due to periapical abscess in the USA.MethodsThe Nationwide Inpatient Sample for 2012‐2014 was used. All patients who were hospitalized due to periapical abscess were selected for analysis. In this cohort, OAD was identified and used as the outcome variable. A mix of patient and geographic factors were used as independent variables. The simultaneous association between outcome and independent variables was examined by a multivariable logistic regression model. Clustering of outcomes within hospitals was adjusted. Odds of OAD were computed for all independent variables.ResultsDuring the study period, 30 040 patients were hospitalized due to periapical abscess; 1.5% of these had OAD. Those aged 18‐29 years (odds ratio [OR] = 3.69, 95% confidence interval [CI] = 1.76‐7.72, P < 0.01) and 30‐44 years (OR = 3.19, 95% CI = 1.77‐5.76, P < 0.01) were associated with higher odds for OAD compared to those aged 45‐64 years. Blacks were associated with lower odds for OAD compared to whites (OR = 0.52, 95% CI = 0.28‐0.95, P = 0.03). Those covered by Medicare (OR = 4.08, 95% CI = 1.458‐11.44, P = 0.01), Medicaid (OR = 5.86, 95% CI = 2.22‐15.47, P < 0.01), and those who were uninsured (OR = 3.68, 95% CI = 1.30‐10.45, P = 0.01) were associated with higher odds for OAD compared to those covered by private insurance. The odds of OAD increased with comorbid burden (OR = 1.66, 95% CI = 1.50‐1.84, P < 0.01).ConclusionsHigh‐risk groups that are likely to have OAD were identified among those hospitalized due to periapical abscess.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146647/1/jicd12354.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146647/2/jicd12354_am.pd

Outcomes of Acute Chest Syndrome in Adult Patients with Sickle Cell Disease: Predictors of Mortality

Adults with sickle cell disease(SCD) are a growing population. Recent national estimates of outcomes in acute chest syndrome(ACS) among adults with SCD are lacking. We describe the incidence, outcomes and predictors of mortality in ACS in adults. We hypothesize that any need for mechanical ventilation is an independent predictor of mortality. Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample(2004–2010),the largest all payer inpatient database in United States, to estimate the incidence and outcomes of ACS needing mechanical ventilation(MV) and exchange transfusion(ET) in patients >21 years. The effects of MV and ET on outcomes including length of stay(LOS) and in-hospital mortality(IHM) were examined using multivariable linear and logistic regression models respectively. The effects of age, sex, race, type of sickle cell crisis, race, co-morbid burden, insurance status, type of admission, and hospital characteristics were adjusted in the regression models. Results: Of the 24,699 hospitalizations, 4.6% needed MV(2.7% for <96 hours, 1.9% for ≥96 hours), 6% had ET, with a mean length of stay(LOS) of 7.8 days and an in-hospital mortality rate(IHM) of 1.6%. There was a gradual yearly increase in ACS hospitalizations that needed MV(2.6% in 2004 to 5.8% in 2010). Hb-SS disease was the phenotype in 84.3% of all hospitalizations. After adjusting for a multitude of patient and hospital related factors, patients who had MV for <96 hours(OR = 67.53,p<0.01) or those who had MV for ≥96 hours(OR = 8.73,p<0.01) were associated with a significantly higher odds for IHM when compared to their counterparts. Patients who had MV for ≥96 hours and those who had ET had a significantly longer LOS in-hospitals(p<0.001). Conclusion: In this large cohort of hospitalized adults with SCD patients with ACS, the need for mechanical ventilation predicted higher mortality rates and increased hospital resource utilization. Identification of risk factors may enable optimization of outcomes

Hospital Based Emergency Department Visits Attributed to Child Physical Abuse in United States: Predictors of In-Hospital Mortality

Objectives: To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome. Materials and Methods We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008–2010. All ED visits and subsequent hospitalizations with a diagnosis of “Child physical abuse” (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors. Results: Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child’s parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81–0.96, p<0.0001). Females (OR = 2.39, 1.07–5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57–154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24–11.07, p<0.0001) had higher odds of mortality compared to their male counterparts. Conclusions: In this large cohort of physically abused children, younger age, females and intracranial or crushing/internal injuries were independent predictors of mortality. Identification of high risk cohorts in the ED may enable strengthening of existing screening programs and optimization of outcomes

Infection Related Never Events in Pediatric Patients Undergoing Spinal Fusion Procedures in United States: Prevalence and Predictors

OBJECTIVE: To examine the prevalence and predictors of infection related never events (NE) associated with spinal fusion procedures (SFP) in children (age < = 18 years) in the United States. METHODS: We performed a retrospective analysis of the Nationwide Inpatient Sample for the years 2004 to 2008. All pediatric hospitalizations that underwent SFP were selected for analysis. The main outcomes measures include occurrence of certain NE's. The association between the occurrence of a NE and factors (patient & hospital related) were examined using multivariable logistic regression analysis. RESULTS: Of 56,465 hospitalizations, 61.7% occurred among females. The average age was 13.7 y and two-thirds were whites. The major insurance payer was private insurance (67.4%). About 82% of all hospitalizations occurred on an elective basis. Teaching hospitals accounted for a majority of hospitalizations (87.9%). Two-thirds were posterior fusion techniques, 52.3% had underlying musculoskeletal deformities, and the most frequently present co-morbid conditions (CMC) included paralysis (10.9%), chronic pulmonary disease (9.7%), and fluid/electrolyte disorders (7.6%). Overall rate of occurrence of a NE was 4.8%. Post-operative pneumonia was the most frequently occurring NE (2.9%). Female gender (OR = 0.78) and elective admissions (OR = 0.66) were associated with lower risk of NE occurrence. Medicaid coverage (OR = 1.46), primary diagnosis of other acquired deformities (OR = 1.82), spinal cord injury (OR = 6.94), other nervous system disorders (OR = 2.84) were associated with higher risk of NE occurrence. Among CMC, those with chronic blood loss anemia (OR = 2.57), coagulopathy (OR = 1.97), depression (OR = 2), drug abuse (OR = 3.71), fluid/electrolyte disorders (OR = 2.62), neurological disorders (OR = 1.72), paralysis (OR = 1.75), renal failure (OR = 5.45), and weight loss (OR = 4.61) were risk factors for higher odds of a NE occurrence. Hospital teaching status, region, hospital size, and patient race did not influence the occurrence of NE. CONCLUSION: The never events examined in the current study occurred in 4.8% of children hospitalized with SFP. Certain predictors of NE are identified in this study

Self Inflicted Injuries among Children in United States – Estimates from a Nationwide Emergency Department Sample

OBJECTIVE: The objectives of the current study are to provide nationally representative estimates of hospital based emergency department visits (ED) attributed to self inflicted injuries and attempted suicides among children in United States; and to identify potential methods of such intentional self inflicted injuries and attempted suicides. METHODS: The Nationwide Emergency Department Sample (year 2007) was used. All ED visits occurring among children (aged ≤18 years) with an External Cause of Injury for any of self inflicted injuries were selected. Outcomes examined include hospital ED charges and hospitalization charges. All estimates were projected to national levels. RESULTS: 77,420 visits to hospital based emergency departments were attributed to self inflicted injuries among children (26,045 males and 51,370 females). The average age of the ED visits was 15.7 years. 134 patients died in ED’s (106 males and 28 females) and 93 died in hospitals following in-patient admission (75 males and 18 females). A greater proportion of male ED visits were discharged routinely as opposed to female ED visits (51.1% versus 44%). A greater proportion of male ED visits also died in the emergency departments compared to female visits (0.4% versus 0.05%). 17,965 ED visits necessitated admission into same hospital. The mean charge for each ED visit was $1,874. Self inflicted injuries by poisoning were the most frequently reported sources accounting for close to 70% of all ED visits. CONCLUSIONS: Females comprise a greater proportion of ED visits attributed to self inflicted injuries. 227 children died either in the ED’s or in hospitals. The current study results highlight the burden associated with such injuries among children

Bitcoin and Its Position on Financial Markets

Import 22/07/2015Cílem této bakalářské práce je empiricky ověřit vliv finančních a makroekonomických ukazatelů na vývoj ceny Bitcoinu. Naplnění tohoto cíle je dosaženo pomocí vědeckých metod syntézy a deskriptivní a korelační analýzy. Důvodem pro ověřování byla skutečnost, že většina autorů prováděla svoji analýzu před téměř dvěma roky, což v případě Bitcoinu představuje dávnou minulost. Vliv konkrétních finančních a makroekonomických indikátorů na cenu Bitcoinu byl nejprve ověřen v dlouhém období, které vzniklo prodloužením původního období použitého v jiné předchozí práci. V tomto období byl potvrzen vztah mezi cenou Bitcoinu a hodnotou Dow Jones indexu. Nepotvrdila se předchozí koncepce závislosti mezi cenou Bitcoinu a hodnotou směnného kurzu USD/EUR, resp. cenou ropy. V tomto období byla rovněž objevena nepřímá závislost mezi cenou Bitcoinu a cenou zlata. V samostatné podkapitole byl pak ověřen vliv všech těchto veličin na cenu Bitcoinu v krátkém období.The aim of this bachelor thesis is to empirically check the influence of financial and macroeconomic indicators on Bitcoin price. This is achieved by using synthesis and descriptive and correlation analysis as the main scientific methods. The reason for the research was that the majority of authors have done their analysis almost two years ago, which in case of Bitcoin means a very long time. First, the influence of specific financial and macroeconomic indicators on Bitcoin price has been checked in the long run (a period that was created by prolonging the period used in previous literature). In this period the relationship between Bitcoin price and Dow Jones Index value has been confirmed. The previous concept of Bitcoin price and its dependence on USD/EUR exchange rate value and oil price respectively has not been confirmed. A negative correlation between Bitcoin price and gold price has been discovered. After that the influence of all these indicators on Bitcoin price has been checked for the short run as well.156 - Katedra národohospodářskávelmi dobř