Transmetatarsal amputation of the toe: an analytic study of ischemic complications

Transmetatarsal amputations of the toes are very common procedures, particularly involving patients with diabetes mellitus and peripheral vascular disease. A complication of these operations is the onset of gangrene of an adjoining toe, which is usually ascribed to the underlying disease. It is suggested that another explanation may be responsible for this occurrence, namely, a combination of the variability of the bifurcation of the dorsal metatarsal arteries and the operative technique. The former is either not described or has different levels in different texts. The operation in nearly all texts is a classic racquet incision, without mention of the width of the racket. The combination of an incision widely diverging from the handle of the racket is in danger of severing the dorsal metatarsal artery, its bifurcation, or the digital branch to the adjacent toe. A patient with a good blood supply may be able to salvage the situation by way of the plantar vessels, but when the vascular status is parlous, which is the case in many amputations, the adjacent digit is at considerable risk. Clinical, radiological, and anatomic evidence is presented to support this contention. Based on the above, a safer operative technique is suggested to avoid possible complications.

Memory in pregnancy. II: Implicit, incidental, explicit, semantic, short-term, working and prospective memory in primigravid, multigravid and postpartum women

This study, using an information processing model of memory, made a detailed examination of the possible locus (loci) of any memory change in gravid and postpartum women using a battery of seven objective memory tests: implicit, incidental, explicit, semantic, short-term, working, and prospective memory. In addition, links were sought both between (a) self-reported data on sleep, health, and memory performance, and (b) these variables and objective memory performance. Five groups of women were tested (n = 22/23 per group), (1) primigravid, (2) multigravid, (3) postpartum, (4) non-pregnant parents with children, and (5) never been pregnant, on self-report and objective memory tests. The gravid and postpartum groups reported significantly more everyday forgetting than the non-pregnant groups but on the objective tests performed no differently from the non-pregnant groups on all tests. Sleep loss was a significant predictor of reported memory change, but not of any memory test performance, and may contribute to a perceived memory change. Pregnant women and new mothers generally should be confident of performing to their normal cognitive capabilities, but may be more affected than usual by a high cognitive load.

Memory in pregnancy. I: Subjective experiences and objective assessment of implicit, explicit and working memory in primigravid and primiparous women

This study investigated the belief held by over 50% of parous women that they are more forgetful during pregnancy and postpartum relative to other times. Comparisons were made between both the reported and objective memory performances of three groups of women (n = 20 per group), (1) primigravid, (2) primiparous (baby younger than 12 months), and (3) never been pregnant, matched on age and education levels. Participants completed a questionnaire on demographic, health, and sleep details, the Inventory of Memory Experiences, and tests of implicit, explicit, and working memory. The groups did not differ on self-rated levels of physical or emotional health, or anxiety level. The primigravid and primiparous groups reported overall poorer memory performance since pregnancy relative to controls. The primigravid group also reported significantly more sleep disruption, with this being a significant predictor of reported memory change. On the objective tests, there were no differences between groups on the implicit and explicit memory tests, but the primigravid and primiparous groups scored significantly lower on a test of working memory. Self-reports of memory change during pregnancy and postpartum may be related to life changes, such as sleep change, and may reflect changed perceptions rather than objective changes.

Phenotypic characterization of normal and CML CD34-positive cells: only the most primitive CML progenitors include Ph-neg cells

We studied the sequence of acquisition of CD33, CD38 and HLA-DR antigens on CD34+ cells from marrow and blood of Ph-chromosome positive CML patients and normal marrow. We examined the Ph status of the various CML cell populations. The mean proportions of normal and CML CD34+ cells expressing CD33 and CD38 were not significantly different. However, a significantly greater proportion of CML CD34+ cells expressed HLA-DR antigens compared with normal CD34+ cells and the level of HLA-DR expression per CML cell was abnormally high. When the sequence of acquisition of these antigens on normal and CML CD34+ cells was evaluated using 3-colour fluorescence analysis, the results suggested that HLA-DR was expressed earlier than CD38 or CD33 and these findings were confirmed by following the acquisition of CD38 and CD34+/DR+/CD38-subpopulation during liquid culture. We performed cytogenetic studies on CD34+ subpopulations in 6 cases. In 4 cases there were some Ph-negative metaphases detectable in the CD34+/DR-subpopulation (range 12.5 to 60%). In the CD34+/DR+ fractions, however, all 6 patients had only Ph-positive metaphases and only 1/5 patients had detectable Ph-negative metaphases in the CD34+/CD38-subpopulation. We conclude that expression of HLA-DR antigens may precede the expression of CD38 on CD34+ cells during normal stem cell differentiation. In CML DR may be expressed aberrantly and Ph-negative cells are found predominantly in the DR negative subpopulation.

DRGs, costs, and outcome for plastic surgical patients

The purpose of this study was to analyze hospital cost, resource utilization, and outcome by age for a large group of hospitalized plastic surgical patients using the DRG format. Hospital cost per patient for all plastic surgical admissions (both inpatient and potentially ambulatory patients) treated (N = 1632) at an academic medical center increased with age and peaked for plastic surgical patients 75 to 80 years of age ($11,585 per patient). Although DRG payment would have produced an aggregate profit of $2,404,854, older plastic surgical patients (65 years of age and above) generally produced losses. Older plastic surgical patients demonstrated a longer hospital length of stay, a greater severity of illness, a higher percent of outliers, and a greater mortality than younger plastic surgical patients. In addition, older plastic surgical patients had higher clinical resource utilization based on a number of clinical parameters such as emergency admission, SICU utilization, need for blood transfusions, and need for plasma product infusions. This study suggests that the current DRG reimbursement methodology may be inequitable vis-à-vis the older plastic surgical patient. As additional pressures encourage the performance of more ambulatory procedures (previously performed as inpatients), our profit margins may decline and possibly affect our ability to provide quality plastic surgical care.

Diagnosis related groups, resource utilization, age, and outcome for hospitalized nephrology patients

Economic incentives are rapidly changing for hospitals under the prospective Diagnosis Related Group (DRG) hospital reimbursement scheme. The purpose of this project was to study resource use, age, and outcome for nephrology admissions to a large academic medical center. Total hospital costs for the 784 nephrology admissions (January 1, 1985 to December 31, 1986) were $5,037,460. Mean hospital cost per patient and mortality generally increased with age. DRG payment for patients in the 13 nephrology DRGs analyzed would have produced an aggregate loss of $483,584; however, all age categories of patients 55 years of age and over generated significant losses (the highest was for patients 85 years and above, $5,343 loss per patient). Diabetic nephrology patients generated greater resource consumption compared with nondiabetic nephrology patients, as well as patients in medical and surgical DRGs with chronic renal failure compared with patients in these same DRGs without chronic renal failure. Older nephrology patients also demonstrated higher emergency and ICU admission and blood requirements than younger patients. This study suggests that the current DRG reimbursement scheme may be inequitable vis a vis older nephrology patients, as well as those with diabetes mellitus and chronic renal failure. Financial disincentives by DRGs may affect both the access and quality of care for groups of nephrology patients in the future.

Results of a technique of mitral valve repair

A particular technique for mitral repair of the posterior leaflet prolapse of the mitral valve has been used at Royal North Shore Hospital over a 15-year period. The anatomical details, complications and results of repair, as well as mortality, are reviewed in a group of 49 patients. Surgery in this group was performed with three peri-operative deaths. Three patients required re-operation due to the failure of repair; one patient within one month of surgery and the others at 6.5 and 9 years. All patients improved symptomatically following mitral repair. This series demonstrates that the repair of posterior leaflet prolapse can be performed in all patient age groups with low mortality and morbidity rates. A low incidence of reoperation for failure of repair and other complications related to valve surgery can be anticipated.