Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery

BACKGROUND

Although clinical pathways have become popular strategies to improve the quality of medication in the field of laparoscopic surgeries, their economical effectiveness is not well defined. The aim of this study was to investigate the effect of clinical pathways for laparoscopic surgeries on cost and length of hospital stay.

METHODS

From January 2000 to June 2001, clinical pathways were introduced for laparoscopic surgeries, such as laparoscopic cholecystectomy (Lap. C, n = 210), laparoscopically assisted distal gastrectomy with Billroth-I reconstruction (Lap. B-I, n=33), and laparoscopically assisted colectomy (Lap. colon, n=34). We compared total lengths of hospital stay and the economical efficiency before and after pathway implementation at Wakayama Medical University Hospital.

RESULTS

The length of hospital stay in Lap. C was shortened from 7.8+/-2.6 (mean+/-SD) days to 6.9+/-2.0 days (p = 0.03) and the total costs during hospitalization decreased from yen 509,320+/-58,800 to yen 489,130+/-43,860 (p=0.009), resulting in less burden for patients. At the same time, the daily costs were increased from yen 66,230+/-8920 to yen 70,840+/-6820 (p=0.0001), indicating that more efficient medical care was being given to patients. Similar results were obtained in Lap. B-I and Lap. colon groups.

CONCLUSIONS

In our study, the implementation of clinical pathways in the field of laparoscopic surgeries produced significant decreases in length of total hospital stay and cost while maintaining the quality of patient outcomes.

Adenosquamous carcinoma of the pancreas: successful treatment with extended radical surgery, intraoperative radiation therapy, and locoregional chemotherapy

BACKGROUND

Adenosquamous carcinoma of the pancreas is a rare tumor with an extremely poor survival rate. No obvious evidence that multidisciplinary treatments improves the prognosis and survival has been reported.

PATIENT AND RESULTS

A 63-yr-old female with adenosquamous carcinoma of the pancreas underwent extended radical surgery, intraoperative radiation therapy, postoperative intraarterial chemotherapy, and external beam radiation therapy. The patient is alive at 40 mo after surgery with no recurrence.

CONCLUSIONS

Multidisciplinary treatments including aggressive surgery, intraoperative radiation therapy, and locoregional chemotherapy might improve the survival of patients with adenosquamous carcinoma of the pancreas to inhibit liver metastasis and local recurrence.

Association of emotional intelligence with alexithymic characteristics

We examined the association of emotional intelligence and alexithymic characteristics as the personality trait in cohorts of 267 college students and 398 psychiatric outpatients. Score on the Toronto Alexithymia Scale were significantly correlated with those on the Emotional Intelligence Scale, suggesting that alexithymic characteristics are related to lower emotional intelligence. In conclusion, these data suggest that emotional intelligence overlaps with alexithymia.

Validity and reliability of the Japanese version of the Emotional Intelligence Scale among college students and psychiatric outpatients

We examined the validity and reliability of the Japanese version of the Emotional Intelligence Scale in two samples of 267 college students and 398 psychiatric outpatients. Suitable validity and reliability of this scale were suggested by high correlations with scores on the NEO Personality Inventory, adequate internal consistency, and relatively high test-retest correlations. The Emotional Intelligence Scale seems suitable for both clinically distressed populations as well as comparative groups such as college students.

Positivity of extrapulmonary Ga-67 uptake in sarcoidosis: thyroid uptake due to chronic thyroiditis and bone uptake due to fibrous dysplasia

Ga-67 citrate scintigraphy was performed on a 29-year-old man who had been diagnosed as having pulmonary sarcoidosis by a transbronchial lung biopsy. A Ga-67 citrate scintigram showed increased uptake not only in the pulmonary hilum and mediastinum, but also in the thyroid gland and the right ilium. Chronic thyroiditis was confirmed by aspiration biopsy of the thyroid gland, and fibrous dysplasia was confirmed by CT guided biopsy of the right ilium. Extrapulmonary Ga-67 uptake in patients with sarcoidosis does not necessarily indicate the involvement of other tissues and organs.

On-chip integration of sequential ion-sensing system based on intermittent reagent pumping and formation of two-layer flow

A sequential ion-sensing system using a single microchip was successfully realized. The system developed here involves intermittent pumping of plural organic phases into a microchannel, followed by contact with a single aqueous phase to form a stable organic-aqueous two-layer flow inside the microchannel. Because the plural organic phases created by intermittent flow contain the same lipophilic pH indicator dye but different ion-selective neutral ionophores, different ions can be sequentially and selectively extracted into the different organic phases, where they can be determined by thermal lens microscopy (TLM). We used KD-A3 as the lipophilic pH indicator dye and valinomycin and DD16C5 as neutral ionophores to demonstrate sequential ion sensing of potassium and sodium ions by measuring the deprotonated dye caused by the ion extraction. The integrated microfluidic system proposed here allows multi-ion sensing, which is not easily demonstrated by conventional ion sensor technology using a solvent polymeric membrane. The minimum volume of single organic phase needed to obtain an equilibrium response without dilution by cross dispersion of two organic phases was ca. 500 nL in our system, indicating that the required amounts of expensive reagents in one measurement could be reduced to 1.7 ng and 2.8 ng for the dye and ionophore molecules, respectively.

Detectability of pulmonary perfusion defect and influence of breath holding on contrast-enhanced thick-slice 2D and on 3D MR pulmonary perfusion images

The present study assesses the detectability of perfusion defect and the influence of breathhold on pulmonary magnetic resonance (MR) perfusion imaging using contrast-enhanced thick-slice two-dimensional (2D) fast gradient-echo sequence compared with three-dimensional (3D) fast spoiled gradient-recalled sequence. Dynamic studies were performed in 16 patients. MR perfusion images were interpreted by two independent observers using perfusion scintigraphy as the reference standard. The patients were divided into two groups according to the duration of holding the breath measured during MR imaging. The sensitivity and specificity of 2D MR perfusion imaging in detecting perfusion defects were 93% and 94%, respectively, while those of 3D MR perfusion imaging were 89% and 85%, respectively. The diagnostic accuracy of 2D MR perfusion imaging was significantly higher than that of 3D MR perfusion imaging (P < 0.05) among those who could not hold their breath. Therefore, 2D MR perfusion imaging offers promise for evaluating pulmonary perfusion even among patients who cannot hold their breath.

Polyester microchannel chip for electrophoresis--incorporation of a blue LED as light source

A blue-light-emitting diode was incorporated as a fluorescence-excitation light source into a polyester microchannel chip fabricated by in situ polymerization. Placing the light-emitting facet of the diode close to the microchannel obviated any need for an additional optical arrangement. Fluorescence from the sample was transmitted by an optical fiber incorporated into the microchip perpendicular to the LED. FITC labeled amino acids were separated in the presence of 5 mM SDS by using the microchip and were detected by LED-induced fluorescence.

[Laparoscopic salvage of malfunctioning peritoneal dialysis catheters caused by ovarian fimbria: a case report]

We report a case of peritoneal dialysis catheter obstruction caused by ovarian fimbria, which was successfully treated with laparoscopic surgery. In June 2000, a 51-year-old woman, who started peritoneal dialysis in April 2000, complained of outflow obstruction of peritoneal dialysis fluid. Fluoroscopic imaging demonstrated the obstruction of peritoneal dialysis catheter by ovarian fimbria. Since the alpha technique under the fluoroscopic imaging did not improve the obstruction, the ovarian fimbria was removed laparoscopically in June 5, 2000. Peritoneal dialysis was successfully started the day after the surgery with no leakage of peritoneal dialysis fluid. The patient has remained without obstruction of peritoneal dialysis catheter for 8 months postoperatively.

Deep circumflex iliac perforator flap with iliac crest for mandibular reconstruction

The deep circumflex iliac myocutaneous perforator (DCIP) flap with iliac crest was used to reconstruct oromandibular defects in 10 patients. In seven of the patients a dominant perforator was found preoperatively using a Doppler flowmeter; in five of these seven patients a DCIP flap was successfully transferred. In two of the seven patients the dominant perforators were too narrow: one patient underwent a standard osteocutaneous flap transfer and one patient underwent a second flap transfer. In three patients no dominant perforator was found before or during surgery. The freedom of the DCIP flap from the harvested iliac crest facilitates correct positioning. However, to ensure that the DCIP flap can be safely elevated, the presence of perforators must be confirmed preoperatively. Even when a perforator has been identified, complicated dissection may be necessary. We stress the importance of a thorough knowledge of the anatomy of second flaps and of obtaining informed consent to use them.

18-Crown-6-Tetracarboxylic acid as a chiral additive for the simultaneous separation of o-, m- and p-enantiomers of phenylalanine family by capillary electrophoresis

Simultaneous separation of 12 o-, m- and p-positional enantiomers of tyrosine and fluorophenylalanine has been achieved by the use of optically active 18-crown-6-tetracarboxylic acid (18C6H4) as an additive in the background electrolyte. It has been investigated that the separation conditions such as pH, electroosmotic flow, the concentration of 18C6H4 and applied voltages have critical influence on the simultaneous separation. Based on the information of electropherograms obtained, the interaction between the chiral selector and positional enantiomers has been discussed. It was shown that alpha-methyl group in the amino acid enantiomers make the resolution be reduced, and that o-, m- and p-substituents have an influence on the resolution.

Interaction between 18-crown-6-tetracarboxylic acid and positional substituents of enantiomers and simultaneous separation of positional enantiomers of methyl-DL-tryptophans by capillary electrophoresis

18-Crown-6-tetracarboxylic acid (18C6H4) is a chiral selector with high selectivity for the enantioseparation of solutes bearing the primary amine function. This work presents the simultaneous separation of positional enantiomers of methyl-DL-tryptophans by using 18C6H4 as an additive to the background electrolyte. Separation conditions such as pH, the concentration of 18C6H4, and the applied voltages have critical inference on the simultaneous separation. The addition of cyclodextrins as anionic surfactants to the background electrolyte did not improve the separation. The selector-selectand interactions between 18C6H4 and the positional enantiomers have been investigated. It was observed that both the position and type of substituents contribute to the enantioselectivity. The migration order and resolution depended on the distance from the substituents to the asymmetric carbon of the enantiomers.

Temporary percutaneous aortic balloon occlusion to enhance fluid resuscitation prior to definitive embolization of posttraumatic liver hemorrhage

We successfully stabilized severe hemorrhagic shock following traumatic liver injury by percutaneous transcarotid supraceliac aortic occlusion with a 5 Fr balloon catheter. Then we were able to perform transfemoral embolization therapy of the hepatic arterial bleeding source. Transient aortic occlusion using a balloon catheter appears to be a useful adjunct in select cases where stabilization of the patient is necessary to allow successful selective embolization of the bleeding source.

Effect of sodium tauroursodeoxycholate on phalloidin-induced cholestasis in rats

We investigated the therapeutic effect of tauroursodeoxycholate on phalloidin-induced cholestasis in rats. Intrahepatic cholestasis was induced by administration of phalloidin (500 microg/kg, i.p.) for 7 days. From the day of the last phalloidin injection, tauroursodeoxycholate (60-360 micromol/kg) was given intravenously twice a day for 4 days. On the next day after the last tauroursodeoxycholate administration, bile flow, serum biochemical parameters and biliary lipid excretion rates were determined. Tauroursodeoxycholate significantly suppressed the decrease in bile flow and increases in serum alkaline phosphatase, leucine aminopeptidase and glutamic pyruvic transaminase activities, cholesterol, phospholipid and bile acid concentrations observed in phalloidin-induced cholestasis in rats. Furthermore, tauroursodeoxycholate significantly improved the biliary cholesterol and phospholipid excretion rates in phalloidin-induced cholestasis in rats. These results demonstrate the usefulness of tauroursodeoxycholate as a therapeutic agent in intrahepatic cholestasis.

A multidisciplinary approach to the treatment of malignant pelvic bone tumors: results with eight consecutive patients

The prognosis for malignant pelvic bone tumors is worse than that for malignant bone tumors of the extremities because definitive surgery in the pelvis is often difficult to accomplish. The results for eight patients who were treated consecutively with a multidisciplinary approach, from 1990, were analyzed. The histologic diagnosis was osteosarcoma in five patients, chondrosarcoma in two, and Ewing's sarcoma in one. Five lesions arose in the ilium and three in the pubis. The extraosseous tumors decreased in size and/or were encapsulated as a result of preoperative chemotherapy in six patients, four of these achieving a wide surgical margin. With respect to tumor location and surgical margin, all five lesions in the ilium involved the sacrum, four of these being resected with an inadequate margin. The three lesions in the pubis were resected with an adequate margin. Local recurrence was observed in two patients who had been treated with an inappropriate margin. During the period between 18 and 57 months after the first operation, five patients were continuously free of disease and one was still alive but had lung metastases. Our results indicate that a patient's chances of definitive surgery may be enhanced by a multidisciplinary approach, although the management of sacroiliac involvement remains challenging.

Expression of JNK cascade scaffold protein JSAP1 in the mouse nervous system

The mitogen-activated protein kinase (MAPK) cascades consist of MAPK, MAPK kinase (MAPKK), and MAPKK kinase (MAPKKK). The specificity of activation of MAPK cascades may be determined, in part, by scaffold proteins that organize multi-enzyme complexes. We have earlier reported a scaffold protein JSAP1 (also known as JIP3) in the JNK MAPK cascade. We also showed that, of the adult mouse tissues tested, JSAP1 mRNA was predominantly expressed in brain. Here we report the localization of JSAP1 protein in mouse embryos and adult brain by immunohistochemical analysis. In embryos (E11-16), JSAP1 immunoreactivity was mainly found in the central and peripheral nervous systems, where it was localized to the cell bodies and/or axons of developing neurons, but not neural precursor cells. In the adult brain, immunoreactive JSAP1 was localized mostly to cell bodies in almost all neurons. We also showed that the expression of JSAP1 transcripts and proteins gradually increased during the neural differentiation of mouse P19 embryonal carcinoma (EC) cells. Furthermore, we showed that overexpressed JSAP1 facilitated the efficient activation of JNK by MEKK1 in P19 cells. These results suggest that JSAP1 may function as a scaffold protein for the JNK signaling module in neuronal cells.

Continuous preconcentration system for nitrate ions using anionic reverse osmosis tubes coupled to an ion chromatograph

A continuous preconcentration system for nitrate ions was developed using cation exchange tubing made from Nafion perfluorosulfonic acid membrane. This method is based on ion exclusion effects and reverse osmosis phenomena. The system was evaluated by connecting it to an ion chromatograph. The concentration ratios could be increased by raising the pressures between the two sides of the cation exchange tubing. Twenty-fold concentration of nitrate ion was achieved when the pump pressure was 20 x 10(5) Pa. The relative standard deviations of the preconcentration ratio at four different pump pressures, 5, 10, 15 and 20 x 10(5) Pa were 1.2-2.8% (n = 5).