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Annals of Vascular Surgery Aug 2023Median arcuate ligament syndrome (MALS) is an uncommon diagnosis that is often associated with variable clinical presentation and inconsistent response to treatment. Due...
BACKGROUND
Median arcuate ligament syndrome (MALS) is an uncommon diagnosis that is often associated with variable clinical presentation and inconsistent response to treatment. Due to the nature of MALS, the optimal treatment modality and predictors of outcomes remain unclear.
METHODS
A retrospective review was performed of all median arcuate ligament release (MALR) procedures at a single academic institution between 2000 and 2020. Variables examined included patient demographics, symptom characteristics, operative technique (open, robotic, laparoscopic), patient symptoms before release, symptom relief within 1 year, and recurrence of symptoms between release and last clinical follow-up.
RESULTS
During the study period, 47 patients (75% female, mean age 42.1 years) underwent MALR with 19 (36%) robotic, 18 (34%) open, 14 (26%) laparoscopic, and 2 (4%) laparoscopic converted to open procedures. Abdominal pain, weight loss, and nausea and vomiting were the most common symptoms. Postoperatively, 19 (40%) had complete symptom relief within 1 year, 18 (38%) had partial relief, and 10 (21%) had no symptom improvement. 6 were excluded due to loss of follow-up. Laparoscopic and open procedures had the highest rate of complete symptom relief by year 1 with 7 (58%) and 8 (50%) respectively. Twenty-one (57%) patients had recurrence with the greatest rate of recurrence seen among laparoscopic (80%), compared to robotic (57%) and open (38%). Patients reporting a weight loss of 20 pounds or more before surgery were more likely to have partial or complete symptom relief after 1 year compared to those reporting less than 20-pound weight loss (92% vs. 64%). Furthermore, 84% of patients younger than 60 years old reported partial or complete symptom relief compared to only 56% of those older than 60.
CONCLUSIONS
MALS continues to be a rare disorder with widely variable surgical outcomes, requiring further study. While our patients presented with several gastrointestinal symptoms, the most common was postprandial pain. Our center employed laparoscopic, open, and robotic operative techniques with varying success rates, in terms of symptom relief and recurrence. Consistent with current literature, our study found greater surgical success among patients younger than 60 years regardless of operative technique. This suggests the need for better predictors to determine which patients are the most likely to have complete or prolonged remission of symptoms following MALR.
Topics: Humans; Female; Adult; Middle Aged; Male; Celiac Artery; Retrospective Studies; Treatment Outcome; Median Arcuate Ligament Syndrome; Ligaments; Laparoscopy; Weight Loss
PubMed: 36924990
DOI: 10.1016/j.avsg.2023.02.030 -
Journal of Epidemiology and Community... Dec 2000Half a century of research has provided consensual evidence of major personal requisites of adult health in nutrition, physical activity and psychosocial relations....
BACKGROUND
Half a century of research has provided consensual evidence of major personal requisites of adult health in nutrition, physical activity and psychosocial relations. Their minimal money costs, together with those of a home and other basic necessities, indicate disposable income that is now essential for health.
METHODS
In a first application we identified such representative minimal costs for healthy, single, working men aged 18-30, in the UK. Costs were derived from ad hoc survey, relevant figures in the national Family Expenditure Survey, and by pragmatic decision for the few minor items where survey data were not available.
RESULTS
Minimum costs were assessed at 131.86 pound sterling per week (UK April 1999 prices). Component costs, especially those of housing (which represents around 40% of this total), depend on region and on several assumptions. By varying these a range of totals from 106.47 pound sterling to 163.86 pound sterling per week was detailed. These figures compare, 1999, with the new UK national minimum wage, after statutory deductions, of pound 105.84 at 18-21 years and 121.12 pound sterling at 22+ years for a 38 hour working week. Corresponding basic social security rates are 40.70 pound sterling to 51.40 pound sterling per week.
INTERPRETATION
Accumulating science means that absolute standards of living, "poverty", minimal official incomes and the like, can now be assessed by objective measurement of the personal capacity to meet the costs of major requisites of healthy living. A realistic assessment of these costs is presented as an impetus to public discussion. It is a historical role of public health as social medicine to lead in public advocacy of such a national agenda.
Topics: Adolescent; Adult; Costs and Cost Analysis; Diet; Health Status; Housing; Humans; Income; Life Style; Male; Public Health; Recreation; Sensitivity and Specificity; Single Person; United Kingdom
PubMed: 11076983
DOI: 10.1136/jech.54.12.885 -
BMJ (Clinical Research Ed.) Jul 2003To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS,... (Clinical Trial)
Clinical Trial Randomized Controlled Trial
OBJECTIVES
To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.
DESIGN
Cost consequences study alongside randomised controlled trial.
SETTING
Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.
PARTICIPANTS
3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.
MAIN OUTCOME MEASURES
NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.
RESULTS
Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).
CONCLUSION
The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.
Topics: Cost of Illness; England; Family Practice; Health Care Costs; Health Services Research; Hospitals, Public; Humans; Patient Satisfaction; Program Evaluation; Referral and Consultation; Remote Consultation; State Medicine; Wales
PubMed: 12855528
DOI: 10.1136/bmj.327.7406.84 -
The Journal of Surgical Research Dec 2005Intraabdominal pressure (IAP) has been considered responsible for adverse effects in trauma and other abdominal catastrophes as well as in formation and recurrence of...
BACKGROUND
Intraabdominal pressure (IAP) has been considered responsible for adverse effects in trauma and other abdominal catastrophes as well as in formation and recurrence of hernias. To date, little information is available concerning IAP in normal persons. Our purpose in this study was to measure the normal range of IAP in healthy, nonobese adults and correlate these measurements with sex and body mass index (BMI).
METHODS
After Institutional Review Board approval, 20 healthy young adults (< or =30 years old) with no prior history of abdominal surgery were enrolled. Pressure readings were obtained through a transurethral bladder (Foley) catheter. Each subject performed 13 different tasks including standing, sitting, bending at the waist, bending at the knees, performing abdominal crunches, jumping, climbing stairs, bench-pressing 25 pounds, arm curling 10 pounds, and performing a Valsalva and coughing while sitting and also while standing. Data were analyzed by Student's t-test and Pearson's correlation coefficients.
RESULTS
Intraabdominal pressure was measured in 10 male and 10 female subjects. The mean age of the study group was 22.7 years (range, 18-30 years), and BMI averaged 24.6 kg/m(2) (range, 18.4-31.9 kg/m(2)). Mean IAP for sitting and standing were 16.7 and 20 mm Hg. Coughing and jumping generated the highest IAP (107.6 and 171 mm Hg, respectively). Lifting 10-pound weights and bending at the knees did not generate excessive levels of pressure with the maximum average of 25.5 mm Hg. The mean pressures were not different when comparing males and females during each maneuver. There was a significant correlation between higher BMI and increased IAP in 5 of 13 exercises.
CONCLUSION
Normal IAP correlates with BMI but does not vary based on sex. The highest intraabdominal pressures in healthy patients are generated during coughing and jumping. Based on our observations, patients with higher BMI and chronic cough appear to generate significant elevation in IAP. Thus, this group of patients may potentially be at increased risk for abdominal wall hernia formation following surgery.
Topics: Abdomen; Adolescent; Adult; Body Mass Index; Catheterization; Cough; Exercise; Female; Humans; Male; Manometry; Posture; Pressure; Reference Values; Sex Factors; Urinary Bladder; Valsalva Maneuver
PubMed: 16140336
DOI: 10.1016/j.jss.2005.06.015 -
Plastic and Reconstructive Surgery Jun 2006Massive weight loss, defined as loss of 50 percent of excess weight, often results in laxity and redundancy of the abdominal skin, causing disabling rashes, pain,...
BACKGROUND
Massive weight loss, defined as loss of 50 percent of excess weight, often results in laxity and redundancy of the abdominal skin, causing disabling rashes, pain, physical limitation, back strain, and cosmetic deformity. The heavier the panniculus, the more marked the symptoms. Panniculectomy can treat these symptoms, but the approach must be customized because of complex medical and surgical histories related to obesity and the size of the panniculus. The aim of this study was to analyze a series of massive panniculectomies greater than 10 pounds following massive weight loss and to investigate the outcomes achieved.
METHODS
All patients undergoing massive abdominal panniculectomy by a single plastic surgeon at an academic hospital from October of 2000 to December of 2003 were retrospectively studied. Seven men and 17 women qualified: one woman had a two-stage abdominal panniculectomy, each time with greater than 10-pound abdominal skin resections. All but one patient had gastric bypass. Average weight loss was 171 pounds, with an average maximum body mass index of 70.5 and a minimum body mass index of 43.7 (morbid obesity is defined as a body mass index greater than 40). Patient presentation was regularly complicated by abdominal scars. Abdominal panniculectomy was performed with conservative undermining. Hernias were repaired at the time of surgery. Routine prophylaxis against thromboembolism was performed.
RESULTS
Average abdominal skin resection was 16.1 pounds, ranging from 10.3 to 49 pounds. Hernia repair was necessary in 13 patients. Additional surgery performed at the time of panniculectomy included skin reduction surgery of the back (40 percent), chest (32 percent), inner thigh (28 percent), and arm (28 percent). Blood transfusion was necessary in five of the cases (20 percent). Length of stay averaged 3 days. Complications included wounds requiring debridement, dressings, vacuum-assisted closure therapy and/or delayed primary closure (20 percent), and seroma requiring drain replacement or dressings (28 percent). Uncomplicated healing occurred in 44 percent of cases.
CONCLUSION
Massive abdominal panniculectomy is challenging to plan, execute, and manage after surgery. The authors present their approach to these patients, with acceptable results.
Topics: Abdominal Wall; Adipose Tissue; Dermatologic Surgical Procedures; Female; Gastric Bypass; Humans; Lipectomy; Male; Obesity, Morbid; Plastic Surgery Procedures; Retrospective Studies; Treatment Outcome; Weight Loss
PubMed: 16772916
DOI: 10.1097/01.prs.0000218174.89832.78 -
Paediatrics & Child Health Apr 2018Despite a growing number of injuries, no studies exist to date that quantitatively assess the strangulation risk of amber teething necklaces. The objectives of this...
OBJECTIVE
Despite a growing number of injuries, no studies exist to date that quantitatively assess the strangulation risk of amber teething necklaces. The objectives of this study are to determine (a) if these necklaces release with the force required according to the American Society for Testing and Materials (ASTM) Standard Specification for Consumer Product Safety for Mechanical Requirements of Children's Jewelry, and (b) if they release with the mean force required to occlude a young child's airway, as determined in a study designed to inform manufacturing of products to reduce risk of accidental strangulation.
METHODS
Fifteen amber teething necklaces were purchased from retailers in Atlantic Canada. Necklaces were tested using the Breakaway Tension Test method reported in ASTM guidelines. Necklaces were tested with a 15 pound weight (industry standard) and with a 1.6 pound weight (mean force required to occlude a child's airway). It was recorded whether the necklace released or remained intact at the end of each trial.
RESULTS
Seven of fifteen necklaces did not open with 15 lbs of force. Eight of 10 necklaces tested did not open with 1.6 lbs of force.
CONCLUSION
Almost 50% of our sample failed to open with 15 pounds of force, which is the force used in the ASTM standard for children's jewelry. Eighty per cent of our sample failed to open with 1.6 pounds of force, which was the mean force to occlude a young child's airway in a published study. These necklaces pose a strangulation risk to young children if they were to become caught.
PubMed: 29686494
DOI: 10.1093/pch/pxx158 -
Urology Jan 1989Radiation exposure during extracorporeal shock-wave lithotripsy (ESWL) was calculated using a "worst-case method" in 135 randomly selected patients. The patients were... (Review)
Review
Radiation exposure during extracorporeal shock-wave lithotripsy (ESWL) was calculated using a "worst-case method" in 135 randomly selected patients. The patients were divided into four groups according to body weight: small (less than 140 pounds), medium (141-180 pounds), large (181-220 pounds), and very large (greater than 220 pounds). Average skin exposure was found to be 15.2 R (from 1.2 to 95.6 R). After implementation of a "radiation awareness program" radiation exposure was calculated in 128 cases (matched for body weight and stone burden) and average exposure was 9.5 R (from 0.9 to 33.4 R) with a reduction of 20, 37, 33, and 62 percent for each group, respectively. Radiation exposure reduction was primarily due to a reduction in the number of radiographic "snapshots" taken as a result of preferential use of special-mode fluoroscopic "stills."
Topics: Body Weight; Feedback; Fluoroscopy; Humans; Lithotripsy; Radiation Dosage; Radiation Monitoring; Radiography; Skin
PubMed: 2643243
DOI: 10.1016/0090-4295(89)90060-5 -
Archives of Disease in Childhood Mar 1988A six month evaluation of the costs of a regional neonatal medical and surgical unit was carried out. The total cost for six months was pounds 970,000 and this covered...
A six month evaluation of the costs of a regional neonatal medical and surgical unit was carried out. The total cost for six months was pounds 970,000 and this covered 4349 inpatient days and 282 admissions. For medical cases the cost ranged from pounds 132 to pounds 27,600 and the mean daily cost for different weight groups ranged from pounds 159 to pounds 274. The average daily cost for regional patients at pounds 258 was greater than for district patients who cost pounds 199. Altogether 23 medical patients weighing less than 1000 g at birth were admitted. The total cost for nine of these infants who died was pounds 30,991-about 3% of the unit's total budget.
Topics: Costs and Cost Analysis; Critical Care; Direct Service Costs; England; Humans; Infant Care; Infant, Newborn; Intensive Care Units, Neonatal; Referral and Consultation
PubMed: 3355211
DOI: 10.1136/adc.63.3.303 -
Intensive Care Medicine Oct 1998To determine whether the therapeutic intervention scoring system (TISS) reliably reflects the cost of the overall intensive care unit (ICU) population, subgroups of that...
OBJECTIVE
To determine whether the therapeutic intervention scoring system (TISS) reliably reflects the cost of the overall intensive care unit (ICU) population, subgroups of that population and individual ICU patients.
DESIGN
Prospective analysis of individual patient costs and comparison with TISS.
SETTING
Adult, 12 bedded general medical and surgical ICU in a university teaching hospital.
SUBJECTS
Two hundred fifty-seven consecutive patients including 52 coronary care (CCU), 99 cardiac surgery (CS) and 106 general ICU (GIC) cases admitted to the ICU during a 12-week period in 1994. A total of 916 TISS-scored patient days were analysed
MAIN OUTCOME MEASURES
A variable cost (VC) that included consumables and service usage (nursing, physiotherapy, radiology and pathology staff costs) for individual patients was measured daily. Nursing costs were calculated in proportion to a daily nursing dependency score. A fixed cost (FC) was calculated for each patient to include medical, technical and clerical salary costs, capital equipment depreciation, equipment and central hospital costs. The correlation between cost and TISS was analysed using regression analysis.
RESULTS
For the whole group (n = 257) the average daily FC was pound sterling 255 and daily VC was pound sterling 541 (SEM 10); range pound sterling 23-pound sterling 2,806. In the patient subgroups average daily cost (FC + VC) for CCU was pound sterling 476 (SEM 17.5), for CS pound sterling 766 (SEM 13.8) and for GIC pound sterling 873 (SEM 13.6). In the group as a whole, a strong correlation was demonstrated between VC and the TISS for each patient day (r = 0.87, p < 0.001) and this improved further when the total TISS score was compared with the total VC of the entire patient episode (r = 0.93, p < 0.001). This correlation was maintained in CCU, CS and GIC patient cohorts with only a small median difference between actual and predicted cost (2.2 % for GIC patients). However, in the individual patient, the range of error was up to +/- 65 % of the true variable cost. For the whole group the variable cost per TISS point was pound sterling 25.
CONCLUSION
These results demonstrate that TISS reliably measures overall ICU population costs as well as those of the subgroups CCU, CS and GIC. However, the relationship between TISS and cost is less reliable for the individual patient.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bias; Critical Care; Hospital Costs; Humans; Intensive Care Units; Length of Stay; Middle Aged; Nursing Staff, Hospital; Predictive Value of Tests; Prospective Studies; Regression Analysis; Reproducibility of Results; Severity of Illness Index; United Kingdom; Workforce; Workload
PubMed: 9840233
DOI: 10.1007/s001340050709 -
Advances in Therapy Mar 2010In patients receiving fibrinolytic therapy for ST-elevation myocardial infarction (STEMI), adjunct treatment with enoxaparin has been shown to provide superior net... (Comparative Study)
Comparative Study
INTRODUCTION
In patients receiving fibrinolytic therapy for ST-elevation myocardial infarction (STEMI), adjunct treatment with enoxaparin has been shown to provide superior net clinical benefit compared with unfractionated heparin (UFH) in the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment - Thrombolysis in Myocardial Infarction (ExTRACT-TIMI) 25 study. The objective of this study was to compare the cost effectiveness of enoxaparin and UFH strategies.
METHODS
A cost-utility analysis was conducted using a two-stage model: (1) A 30-day decision tree analytical model for the acute treatment phase, and (2) a lifetime Markov model (from 30 days post-STEMI until death) populated using patient survival data.
RESULTS
Assuming treatment continuation for 7 days, the mean day 1-30 incremental cost associated with enoxaparin was pound 49 per patient, and mean lifetime incremental cost was pound 592 per patient ( pound 91,091 vs. pound 90,499, respectively). Given an additional 0.048 life years gained per patient with enoxaparin, the cost per life year saved was pound 12,353, and given an additional 0.038 quality-adjusted life years (QALY) per patient with enoxaparin, the cost per QALY was pound 15,413. In an alternative scenario, reflecting contemporary practice assuming early treatment discontinuation at 48 hours, for example following urgent revascularization, the incremental cost per QALY was pound 13,556.
CONCLUSION
The use of an enoxaparin versus UFH strategy in patients receiving fibrinolytic therapy for STEMI, whether continued for 7 days or discontinued early, for example following urgent revascularization, is cost effective at a pound 20,000 willingness-to-pay threshold.
Topics: Cost-Benefit Analysis; Decision Trees; Electrocardiography; Enoxaparin; Fibrinolytic Agents; Heparin; Humans; Markov Chains; Myocardial Infarction; Quality-Adjusted Life Years
PubMed: 20422473
DOI: 10.1007/s12325-010-0013-x