Hospital costs associated with psychiatric comorbidities: a retrospective study

BACKGROUND

Psychiatric comorbidities are relevant for the diagnostic and therapeutic regimes in somatic hospital care. The main aim of this study was to analyse the association between psychiatric comorbidities and hospital costs per inpatient episode. A further aim was to discuss and address the methodological challenges in the estimation of these outcomes based on retrospective data.

METHODS

The study included 338,162 inpatient episodes consecutively discharged between 2011 and 2014 at a German university hospital. We used detailed resource use data to calculate day-specific hospital costs. We adjusted analyses for sex, age, somatic comorbidities and main diagnoses. We addressed potential time-related bias in retrospective diagnosis data with sensitivity analyses.

RESULTS

Psychiatric comorbidities were associated with an increase in hospital costs per episode of 40% and an increase of reimbursement per episode of 28%, representing marginal effects of 1344 € and 1004 €, respectively. After controlling for length of stay, sensitivity analyses provided a lower bound increase in daily costs and reimbursement of 207 € and 151 €, respectively.

CONCLUSION

If differences in hospital costs between patient groups are not adequately accounted for in DRG-systems, perverse incentives are created that can reduce the efficiency of care. Therefore, we suggest intensifying the inclusion of psychiatric comorbidities in the German DRG system. Future research should investigate the appropriate inclusion of psychiatric comorbidities in other health care systems' payment schemes.

The Epidemiology, treatment, and complication of ameloblastoma in East-Indonesia: 6 years retrospective study

Background

Ameloblastoma is a neoplasm classified as a benign epithelial odontogenic tumor of the jaws, grow slowly and are locally invasive. The aim of the present study was to investigate the incidence, treatment, and complication of patients with ameloblastoma in East-Indonesia during six years retrospective study.

Material and Methods

This retrospective study included 84 patients who were diagnosed with ameloblastoma from 2011 to 2016. There were 56 patients with treatment data available. Data from each patient, including gender, age, histologic type, the size of the tumor, radiologic form, tumor location, type of treatment, and complication were reviewed and analyzed retrospectively.

Results

Fourteen patients were diagnosed with unicystic ameloblastoma (25%), thirty two patients with multicystic follicular ameloblastoma (57%) and ten patients with an unspecified multicystic ameloblastoma (18%). A total of about 35 patients were treated conservatively (62.5%) and 21 patients were treated radically (37.5%). Swelling was present as a pre-operative complication in all 56 cases (100%). There were no complaints concerning speech.

Conclusions

The majority findings of the histologic type were multicystic ameloblastoma and their location were in the mandible. Most ameloblastoma were treated conservatively and reconstructions were made with only titanium plates and not bone graft.

Key words:Ameloblastoma, epidemiology, east Indonesia.

3D assessment of damaged bicycle helmets and corresponding craniomaxillo-mandibular skull injuries: A feasibility study

OBJECTIVES

In the Netherlands, cyclists continue to outnumber other road users in injuries and deaths. The wearing of bicycle helmets is not mandatory in the Netherlands even though research has shown that wearing bicycle helmets can reduce head and brain injuries by up to 88%. Therefore, the aim of this study was to assess the feasibility of using 3D technology to evaluate bicycle-related head injuries and helmet protection.

METHODS

Three patients who had been involved in a bicycle accident while wearing a helmet were subjected to multi-detector row computed tomography (MDCT) imaging after trauma. The helmets were separately scanned using the same MDCT scanner with tube voltages ranging from 80kVp to 140kVp and tube currents ranging from 10mAs to 300mAs in order to determine the best image acquisition parameters for helmets. The acquired helmet images were converted into virtual 3D surface hence Standard Tessellation Language (STL) models and merged with MDCT-derived STL models of the patients' skulls. Finally, all skull fractures and corresponding helmet damage were visualized and related.

RESULTS

Imaging bicycle helmets on an MDCT scanner proved to be feasible using a tube voltage of 120kVp and a tube current of 120mAs. Merging the resulting STL models of the patients' skull and helmet allowed the overall damage sustained by both skull and helmet to be related.

CONCLUSION

Our proposed 3D method of assessing bicycle helmet damage and corresponding head injuries could offer valuable information for the development and design of safer bicycle helmets.

Work-Time Distribution of Physicians at a German University Hospital

BACKGROUND

The effective utilization of staff resources is of decisive importance for the adequate, appropriate, and economical delivery of hospital services. The goal of this study was to determine the distribution of working time among doctors in a German university hospital-in particular, in terms of type of activities and time of day.

METHODS

The distribution of working time was determined from 14-day samples taken in seven clinical departments of the Medical Center-University of Freiburg. In each 14-day sample, the activities being carried out at multiple, randomly chosen times were recorded.

RESULTS

A total of 250 doctors (participation rate: 83%) took part in the study. A total of 20 715 hours of working time was analyzed, representing twelve years of full-time employment. Overall, 46% of working time in the inpatient sector was spent in direct contact with patients, with relevant differences among the participating clinical departments: for instance, the percentage of time taken up by patient contact was 35% in pediatrics and 60% in oral and maxillofacial surgery. Patient contact was highest (over 50% overall) in the period 8 a.m. to 12 noon.

CONCLUSION

The amount of working time taken up by activities other than direct patient contact was found to be lower than in previous studies. It remains unclear what distribution of working time is best for patient care and whether it would be possible or desirable to increase the time that doctors spend in direct contact with patients.

Reliability and accuracy of three imaging software packages used for 3D analysis of the upper airway on cone beam computed tomography images

OBJECTIVES

The aim of this study was to assess the reliability and accuracy of three different imaging software packages for three-dimensional analysis of the upper airway using CBCT images.

METHODS

To assess the reliability of the software packages, 15 NewTom 5G^® (QR Systems, Verona, Italy) CBCT data sets were randomly and retrospectively selected. Two observers measured the volume, minimum cross-sectional area and the length of the upper airway using Amira^® (Visage Imaging Inc., Carlsbad, CA), 3Diagnosys^® (3diemme, Cantu, Italy) and OnDemand3D^® (CyberMed, Seoul, Republic of Korea) software packages. The intra- and inter-observer reliability of the upper airway measurements were determined using intraclass correlation coefficients and Bland & Altman agreement tests. To assess the accuracy of the software packages, one NewTom 5G^® CBCT data set was used to print a three-dimensional anthropomorphic phantom with known dimensions to be used as the "gold standard". This phantom was subsequently scanned using a NewTom 5G^® scanner. Based on the CBCT data set of the phantom, one observer measured the volume, minimum cross-sectional area, and length of the upper airway using Amira^®, 3Diagnosys^®, and OnDemand3D^®, and compared these measurements with the gold standard.

RESULTS

The intra- and inter-observer reliability of the measurements of the upper airway using the different software packages were excellent (intraclass correlation coefficient ≥0.75). There was excellent agreement between all three software packages in volume, minimum cross-sectional area and length measurements. All software packages underestimated the upper airway volume by -8.8% to -12.3%, the minimum cross-sectional area by -6.2% to -14.6%, and the length by -1.6% to -2.9%.

CONCLUSIONS

All three software packages offered reliable volume, minimum cross-sectional area and length measurements of the upper airway. The length measurements of the upper airway were the most accurate results in all software packages. All software packages underestimated the upper airway dimensions of the anthropomorphic phantom.

Finite element analysis of 6 large PMMA skull reconstructions: A multi-criteria evaluation approach

In this study 6 pre-operative designs for PMMA based reconstructions of cranial defects were evaluated for their mechanical robustness using finite element modeling. Clinical experience and engineering principles were employed to create multiple plan options, which were subsequently computationally analyzed for mechanically relevant parameters under 50N loads: stress, strain and deformation in various components of the assembly. The factors assessed were: defect size, location and shape. The major variable in the cranioplasty assembly design was the arrangement of the fixation plates. An additional study variable introduced was the location of the 50N load within the implant area. It was found that in smaller defects, it was simpler to design a symmetric distribution of plates and under limited variability in load location it was possible to design an optimal for expected loads. However, for very large defects with complex shapes, the variability in the load locations introduces complications to the intuitive design of the optimal assembly. The study shows that it can be beneficial to incorporate multi design computational analyses to decide upon the most optimal plan for a clinical case.

Impact of prone, supine and oblique patient positioning on CBCT image quality, contrast-to-noise ratio and figure of merit value in the maxillofacial region

OBJECTIVES

To assess the impact of supine, prone and oblique patient imaging positions on the image quality, contrast-to-noise ratio (CNR) and figure of merit (FOM) value in the maxillofacial region using a CBCT scanner. Furthermore, the CBCT supine images were compared with supine multislice CT (MSCT) images.

METHODS

One fresh frozen cadaver head was scanned in prone, supine and oblique imaging positions using a mobile CBCT scanner. MSCT images of the head were acquired in a supine position. Two radiologists graded the CBCT and MSCT images at ten different anatomical sites according to their image quality using a six-point scale. The CNR and FOM values were calculated at two different anatomical sites on the CBCT and MSCT images.

RESULTS

The best image quality was achieved in the prone imaging position for sinus, mandible and maxilla, followed by the supine and oblique imaging positions. 12-mA prone images presented high delineation scores for all anatomical landmarks, except for the ear region (carotid canal), which presented adequate to poor delineation scores for all studied head positions and exposure parameters. The MSCT scanner offered similar image qualities to the 7.5-mA supine images acquired using the mobile CBCT scanner. The prone imaging position offered the best CNR and FOM values on the mobile CBCT scanner.

CONCLUSIONS

Head positioning has an impact on CBCT image quality. The best CBCT image quality can be achieved using the prone and supine imaging positions. The oblique imaging position offers inadequate image quality except in the sinus region.

FBXO10 deficiency and BTK activation upregulate BCL2 expression in mantle cell lymphoma

Targeting Bruton tyrosine kinase (BTK) by ibrutinib is an effective treatment for patients with relapsed/refractory mantle cell lymphoma (MCL). However, both primary and acquired resistance to ibrutinib have developed in a significant number of these patients. A combinatory strategy targeting multiple oncogenic pathways is critical to enhance the efficacy of ibrutinib. Here, we focus on the BCL2 anti-apoptotic pathway. In a tissue microarray of 62 MCL samples, BCL2 expression positively correlated with BTK expression. Increased levels of BCL2 were shown to be due to a defect in protein degradation because of no or little expression of the E3 ubiquitin ligase FBXO10, as well as transcriptional upregulation through BTK-mediated canonical nuclear factor-κB activation. RNA-seq analysis confirmed that a set of anti-apoptotic genes (for example, BCL2, BCL-XL and DAD1) was downregulated by BTK short hairpin RNA. The downregulated genes also included those that are critical for B-cell growth and proliferation, such as BCL6, MYC, PIK3CA and BAFF-R. Targeting BCL2 by the specific inhibitor ABT-199 synergized with ibrutinib in inhibiting growth of both ibrutinib-sensitive and -resistant cancer cells in vitro and in vivo. These results suggest co-targeting of BTK and BCL2 as a new therapeutic strategy in MCL, especially for patients with primary resistance to ibrutinib.

A Novel Method of Orbital Floor Reconstruction Using Virtual Planning, 3-Dimensional Printing, and Autologous Bone

Fractures of the orbital floor are often a result of traffic accidents or interpersonal violence. To date, numerous materials and methods have been used to reconstruct the orbital floor. However, simple and cost-effective 3-dimensional (3D) printing technologies for the treatment of orbital floor fractures are still sought. This study describes a simple, precise, cost-effective method of treating orbital fractures using 3D printing technologies in combination with autologous bone. Enophthalmos and diplopia developed in a 64-year-old female patient with an orbital floor fracture. A virtual 3D model of the fracture site was generated from computed tomography images of the patient. The fracture was virtually closed using spline interpolation. Furthermore, a virtual individualized mold of the defect site was created, which was manufactured using an inkjet printer. The tangible mold was subsequently used during surgery to sculpture an individualized autologous orbital floor implant. Virtual reconstruction of the orbital floor and the resulting mold enhanced the overall accuracy and efficiency of the surgical procedure. The sculptured autologous orbital floor implant showed an excellent fit in vivo. The combination of virtual planning and 3D printing offers an accurate and cost-effective treatment method for orbital floor fractures.

Determinants of per diem Hospital Costs in Mental Health

INTRODUCTION

An understanding of differences in hospital costs between patient groups is relevant for the efficient organisation of inpatient care. The main aim of this study was to confirm the hypothesis that eight a priori identified cost drivers influence per diem hospital costs. A second aim was to explore further variables that might influence hospital costs.

METHODS

The study included 667 inpatient episodes consecutively discharged in 2014 at the psychiatric hospital of the Medical Centre-University of Freiburg. Fifty-one patient characteristics were analysed. Per diem costs were calculated from the hospital perspective based on a detailed documentation of resource use. Mixed-effects maximum likelihood regression and an ensemble of conditional inference trees were used to analyse data.

RESULTS

The study confirmed the a priori hypothesis that not being of middle age (33-64 years), danger to self, involuntary admission, problems in the activities of daily living, the presence of delusional symptoms, the presence of affective symptoms, short length of stay and the discharging ward affect per diem hospital costs. A patient classification system for prospective per diem payment was suggested with the highest per diem hospital costs in episodes having both delusional symptoms and involuntary admissions and the lowest hospital costs in episodes having neither delusional symptoms nor somatic comorbidities.

CONCLUSION

Although reliable cost drivers were identified, idiosyncrasies of mental health care complicated the identification of clear and consistent differences in hospital costs between patient groups. Further research could greatly inform current discussions about inpatient mental health reimbursement, in particular with multicentre studies that might find algorithms to split patients in more resource-homogeneous groups.

Altered nasal airflow: an unusual complication following implant surgery in the anterior maxilla

Dental implants have been in routine clinical use for over three decades and are a predictable treatment modality. However, as with all other aspects of dentistry, complications occur. A 50-year-old female patient with complaints of a long ongoing unpleasant altered nasal airflow presented herself at the VU University Medical Center Amsterdam. Visual inspection of the right nasal cavity revealed that the apical part of a dental implant placed in the upper right first incisor region had perforated the nasal floor and was partially protruding into the nasal cavity. Subsequent treatment consisted of a transnasal resection of the apical part of the dental implant to the level of the nasal floor. After a 12-month follow-up period, the patient reported having no altered nasal airflow. In conclusion, dental implants protruding into the nasal cavity can cause an alteration to the airflow. Furthermore, a partial removal of the apical part of the dental implant is a viable method of treating dental implants that extend into the nasal cavity.

The accuracy of ultrashort echo time MRI sequences for medical additive manufacturing

OBJECTIVES

Additively manufactured bone models, implants and drill guides are becoming increasingly popular amongst maxillofacial surgeons and dentists. To date, such constructs are commonly manufactured using CT technology that induces ionizing radiation. Recently, ultrashort echo time (UTE) MRI sequences have been developed that allow radiation-free imaging of facial bones. The aim of the present study was to assess the feasibility of UTE MRI sequences for medical additive manufacturing (AM).

METHODS

Three morphologically different dry human mandibles were scanned using a CT and MRI scanner. Additionally, optical scans of all three mandibles were made to acquire a "gold standard". All CT and MRI scans were converted into Standard Tessellation Language (STL) models and geometrically compared with the gold standard. To quantify the accuracy of the AM process, the CT, MRI and gold-standard STL models of one of the mandibles were additively manufactured, optically scanned and compared with the original gold-standard STL model.

RESULTS

Geometric differences between all three CT-derived STL models and the gold standard were <1.0 mm. All three MRI-derived STL models generally presented deviations <1.5 mm in the symphyseal and mandibular area. The AM process introduced minor deviations of <0.5 mm.

CONCLUSIONS

This study demonstrates that MRI using UTE sequences is a feasible alternative to CT in generating STL models of the mandible and would therefore be suitable for surgical planning and AM. Further in vivo studies are necessary to assess the usability of UTE MRI sequences in clinical settings.