Direct hospital cost of outcome pathways in implant-based reconstruction with acellular dermal matrices

BACKGROUND: Current cost data on tissue expansion followed by exchange for permanent implant (TE/I) reconstruction lack a necessary assessment of the experience of a heterogenous breast cancer patient population and their multiple outcome pathways. We extend our previous analysis to that of direct hospital cost as bundling of payments is likely to follow the changing centralization of cancer care at the hospital level. METHODS: We performed a retrospective analysis (2003–2009) of TE/I reconstructions with or without an acellular dermal matrix (ADM), namely Alloderm RTM. Postreconstructive events were analyzed and organized into outcome pathways as previously described. Aggregated and normalized inpatient and outpatient hospital direct costs and physician reimbursement were generated for each outcome pathway with or without ADM. RESULTS: Three hundred sixty-seven patients were analyzed. The average 2-year hospital direct cost per TE/I breast reconstruction patient was $11,862 in the +ADM and$12,319 in the −ADM groups (P > 0.05). Initial reconstructions were costlier in the +ADM ($6,868) than in the −ADM ($5,615) group, but the average cost of subsequent postreconstructive events within 2 years was significantly lower in +ADM ($5,176) than −ADM ($6,704) patients (P < 0.05). When a complication occurred, but reconstruction was still completed within 2 years, greater costs were incurred in the −ADM than in the +ADM group for most scenarios, leading to a net equalization of cost between study groups. CONCLUSION: Although direct hospital cost is an important factor for resource and fund allocation, it should not remain the sole factor when deciding to use ADM in TE/I reconstruction

The effects of Ramadan fasting on clinical and biochemical markers among hemodialysis patients: A prospective cohort study.

Ramadan fasting is compulsory for all healthy adult Muslims. Although sick people are exempted from Ramadan fasting, some patients such as hemodialysis patients prefer to fast during Ramadan. The effect of Ramadan fasting on clinical outcomes and biochemical markers among hemodialysis patients is not clear. The aim of this study was to examine the effects of daily Ramadan fasting and partial Ramadan fasting on key biochemical and clinical markers among hemodialysis patients as compared to hemodialysis patients who chose not to fast during Ramadan. A prospective cohort study of 269 end stage renal disease patients were recruited from the hemodialysis unit in An-Najah National University Hospital, Nablus, Palestine. The participants were divided into three cohorts based on their plans for fasting during Ramadan in May 2018; Ramadan fasting group (RFG), Ramadan partial fasting group (RPFG) and Ramadan not-fasting group (RNFG). Key clinical and biochemical markers were measured before, during and after Ramadan. After adjustment for diabetic and hypertension status and other sociodemographic variables, RFG had higher mean inter-dialytic weight gain (IDWG) by 0.62 kg than RNFG (95% confidence interval (CI) 0.26, 0.99). RPFG also had slight increase in mean IDWG than RNFG by 0.35 kg (95% CI 0.11, 0.60). Additionally, RFG and RPFG had significant increase in mean serum potassium as compared to RNFG. Diabetes was independently associated with increased IDWG by 0.48 kg (0.25, 0.72). Diabetes and hypertension were associated with some independent changes in biochemical markers, but these were clinically negligible. Our findings suggest that Ramadan fasting (fully or partially) is tolerable by hemodialysis patients and is not associated with important clinical complications. However, these patients should be made aware of the potential risk of fluid overload and hyperkalemia, if they decide to fast during Ramadan. Thus, they should be closely monitored and instructed to adhere to their dietary and fluid intake allowances. Further prospective cohort studies with comprehensive dietary measures and information on adverse clinical outcomes may provide more evidence about the tolerability and safety of Ramadan fasting by hemodialysis patients.The publication of this article was funded by the Qatar National Library. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Systematic review of the stage of innovation of biological mesh for complex or contaminated abdominal wall closure

Background Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterize the stage of innovation for biological mesh devices used during complex abdominal wall reconstruction and to evaluate the quality of current evidence. Methods A systematic review was performed of published and ongoing studies between January 2000 and September 2017. Eligible studies were those where a biological mesh was used to support fascial closure, either prophylactically after midline laparotomy, or for reinforcement after repair of incisional hernia with midline incision. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measure was the GRADE criteria for study quality. Results Thirty‐five studies including 2681 patients were included. Four studies considered mesh prophylaxis, 23 considered hernia repair, and eight reported on both. There was one published randomized trial (IDEAL stage 3), none of which was of high quality; the others were non‐randomized studies (IDEAL stage 2a). A detailed description of surgical technique was provided in most studies (27 of 35); however, no study reported outcomes according to the European Hernia Society consensus statement and only two described quality control of surgical technique during the study. From 21 ongoing randomized trials and observational studies, 11 considered repair of incisional hernia and 10 considered prophylaxis (seven in elective settings). Conclusion The evidence base for biological mesh is limited, and better reporting and quality control of surgical techniques are needed. Although results of ongoing trials over the next decade will improve the evidence base, further study is required in the emergency and contaminated settings