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| New ASC Payment System Kind to Ophthalmology
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It's no surprise that a study appearing in the August issue of the Journal of Bone and Joint Surgery reports that specialty orthopedic hospitals are targeting healthier and wealthier patients as compared to general hospitals. However, the fact that researchers discovered specialty hospitals showed better patient outcomes following hip and knee replacement surgeries is worth noting.
"We suspected that specialty orthopedic hospitals were selecting low-risk patients for admission and that is what our analysis found," says Peter Cram, MD, assistant professor of internal medicine at the University of Iowa's Roy J. and Lucille A. Carver College of Medicine and the study's lead author. "But we also found that complications were less common in specialty hospitals even after accounting for the types of patients each hospital admitted - this was quite surprising."
The researchers examined Medicare beneficiaries who had hip-replacement surgery (51,788 patients) and total knee surgery (99,765 patients) in 38 specialty hospitals and 517 general hospitals between 1999 and 2003. After adjusting for patient characteristics and procedural volume, patients having surgery at specialty hospitals showed a 40 percent lower risk of post-op complications.
Dr. Cram says the results suggest a potential edge in the quality of care provided by specialty hospitals. He cautions that the findings need to be replicated in younger patient populations with different approaches toward measuring surgical complications as well as additional focuses on patient satisfaction, costs and symptom relief.
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| AGA Review Promotes Endoscopist-directed Sedation
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There's nothing to prevent endoscopists from safely and effectively directing sedation, according to a review appearing in the August issue of Gastroenterology, the journal of the American Gastroenterological Association, so long as the endoscopists are properly trained and experienced.
The AGA Institute-sanctioned review highlighted 16 specific points an endoscopist would have to know in order to ensure the safety and effectiveness of the sedation administered, including the following:
how to perform pre-procedure patient evaluations to spot potential problems;
knowing when to consult an anesthesia professional, as with patients showing severe systemic diseases or at a substantial risk of death;
the pharmacological properties of all agents used for sedation and reversal during the procedure;
how to recognize patients who fall into a deeper level of sedation than originally intended;
how to use non-invasive devices to monitor pulse oximetry and blood pressure; and
the specialized techniques for administering propofol, if its use is intended.
"Due to the widespread use of sedation during endoscopy procedures," says Lawrence Cohen, MD, associate clinical professor at Mount Sinai Hospital in New York City and co-author of the review, "it is of great importance that gastroenterologists implement sedation protocols in their practices to improve the quality of practice and minimize the risk of sedation-related adverse events."
The review also recommends comparing the new drug and drug-delivery systems for endoscopic sedation against conventional methods. "While there are several promising prospects on the horizon," says co-author Mark DeLegge, MD, a professor at the Medical University of South Carolina in Charleston, "we must make every effort to ensure that our procedures are safe and well tolerated with the agents that are currently available to us."
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| Study: Local Anesthesia May Reduce Post-Lap Pain
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The pre-operative administration of intraperitoneal local anesthesia can reduce analgesic needs in patients who undergo laparoscopic procedures that require a long-lasting pneumoperitoneum, according to a study published in the August issue of the British Journal of Surgery.
Researchers examined 66 patients who underwent laparoscopic fundoplication and 67 patients who had hernias repaired laparoscopically between July 2004 and Jan. 2005. For pain control, patients randomly received one of the following treatments: 50ml of a placebo saline solution, 50ml 0.5% lidocaine local anesthesia immediately following insufflation of the abdomen or 50ml 0.5% lidocaine at the conclusion of the operation. In each group, the solution was sprayed on the upper surface of the right and left liver lobe.
Patients' pain levels were assessed at six, 12, 24 and 48 hours post-op. Those who received pre-op placebos prior to fundoplication procedures reported the most severe shoulder and abdomen discomfort at six hours following surgery. The pre-op application of local anesthesia reduced overall reported pain scores in the shoulder by 19.5 percent and by 46.3 percent in the abdomen. Patients who received local anesthesia following fundoplication surgery reported pain scores similar to the placebo group.
Patients undergoing hernia repair reported the most severe shoulder and abdominal pain at six hours post-op. They claimed a gradual reduction in intensity to 40 percent of the initial shoulder pain score and 25 percent of the initial abdominal pain score at 48 hours post-op. Local anesthesia, administered before or after hernia surgery, appeared to have no effect on shoulder or abdominal pain intensity, according to the report.
"This study demonstrated that patients having laparoscopic fundoplication experienced significantly more abdominal and shoulder pain after operation than those undergoing hernia repair, and that this might be related to the longer duration of pneumoperitoneum needed for fundoplication," write the study's authors. "Pre-emptive administration of local anesthesia resulted in reduced postoperative analgesic consumption and lower pain intensity after fundoplication, but such effects were not seen with local anaesthetic administered at the end of operation or in patients who underwent laparoscopic hernia repair."
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| News and Notes
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The pre-operative administration of intraperitoneal local anesthesia can reduce analgesic needs in patients who undergo laparoscopic procedures that require a long-lasting pneumoperitoneum, according to a study published in the August issue of the British Journal of Surgery.
Researchers examined 66 patients who underwent laparoscopic fundoplication and 67 patients who had hernias repaired laparoscopically between July 2004 and Jan. 2005. For pain control, patients randomly received one of the following treatments: 50ml of a placebo saline solution, 50ml 0.5% lidocaine local anesthesia immediately following insufflation of the abdomen or 50ml 0.5% lidocaine at the conclusion of the operation. In each group, the solution was sprayed on the upper surface of the right and left liver lobe.
Patients' pain levels were assessed at six, 12, 24 and 48 hours post-op. Those who received pre-op placebos prior to fundoplication procedures reported the most severe shoulder and abdomen discomfort at six hours following surgery. The pre-op application of local anesthesia reduced overall reported pain scores in the shoulder by 19.5 percent and by 46.3 percent in the abdomen. Patients who received local anesthesia following fundoplication surgery reported pain scores similar to the placebo group.
Patients undergoing hernia repair reported the most severe shoulder and abdominal pain at six hours post-op. They claimed a gradual reduction in intensity to 40 percent of the initial shoulder pain score and 25 percent of the initial abdominal pain score at 48 hours post-op. Local anesthesia, administered before or after hernia surgery, appeared to have no effect on shoulder or abdominal pain intensity, according to the report.
"This study demonstrated that patients having laparoscopic fundoplication experienced significantly more abdominal and shoulder pain after operation than those undergoing hernia repair, and that this might be related to the longer duration of pneumoperitoneum needed for fundoplication," write the study's authors. "Pre-emptive administration of local anesthesia resulted in reduced postoperative analgesic consumption and lower pain intensity after fundoplication, but such effects were not seen with local anaesthetic administered at the end of operation or in patients who underwent laparoscopic hernia repair."
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