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Fifty-one CT-guided percutaneous fine-needle aspiration biopsies (PFNAB) were performed on 46 consecutive patients over 15 months. Cytologies were obtained to identify primary or secondary malignancy in the abdomen, pelvis, retroperitoneum, bone, and paraspinal region. Adequate cytologic material was obtained in 50 of 51 biopsies. There were 29 true-positive, 0 false-positive, 12 true-negative, and two false-negative cases with an overall accuracy rate of 95 percent. There was one minor complication, mesenteric hemorrhage, which did not require transfusion. Fifteen of the 51 biopsies were performed on outpatients. The procedure is an accurate, safe, and cost-effective nonsurgical means of diagnosing primary or secondary malignancy.

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Objectives To examine the public health impact of mass vaccination with live attenuated human rotavirus vaccine (RIX4414) in a birth cohort in India, and to estimate the cost effectiveness and affordability of such a programme.

Design Decision analytical Markov model encompassing all direct medical costs. Infection risk and severity depended on age, number of previous infections, and vaccination history; probabilities of use of inpatient and outpatient health services depended on symptom severity.

Data sources Published clinical, epidemiological, and economic data. When possible, parameter estimates were based on data specific for India.

Population Simulated Indian birth cohort followed for five years.

Main outcome measures Decrease in rotavirus gastroenteritis episodes (non-severe and severe), deaths, outpatient visits, and admission to hospital; incremental cost effectiveness ratio of vaccination expressed as net cost in 2007 rupees per life year saved.

Results In the base case, vaccination prevented 28 943 (29.7%) symptomatic episodes, 6981 (38.2%) severe episodes, 164 deaths (41.0%), 7178 (33.3%) outpatient visits, and 812 (34.3%) admissions to hospital per 100 000 children. Vaccination cost 8023 rupees (about £100, €113, $165) per life year saved, less than India’s per capita gross domestic product, a common criterion for cost effectiveness. The net programme cost would be equivalent to 11.6% of the 2006-7 budget of the Indian Department of Health and Family Welfare. Model results were most sensitive to variations in access to outpatient care for those with severe symptoms. If this parameter was increased to its upper limit, the incremental cost effectiveness ratio for vaccination still fell between one and three times the per capita gross domestic product, meeting the World Health Organization’s criterion for “cost effective” interventions. Uncertainty analysis indicated a 94.7% probability that vaccination would be cost effective according to a criterion of one times per capita gross domestic product per life year saved, and a 97.8% probability that it would be cost effective according to a criterion of three times per capita gross domestic product.

Conclusions Across a wide range of assumptions, mass RIX4414 vaccination in India would probably prevent substantial morbidity and mortality at a cost per life year saved below typical thresholds of cost effectiveness. The opportunity costs of such a programme in this or similar settings, however, should be weighed up carefully.

Transbronchial biopsy is the technique of choice for obtaining tissue for histological diagnosis in many pulmonary disorders. The procedure has usually been carried out as an inpatient procedure with the use of fluoroscopy, though this policy has recently been questioned. This report concerns a five year experience of 174 transbronchial biopsies performed without fluoroscopy as an outpatient procedure in patients with interstitial lung disease or a suspicion of sarcoidosis. Chest radiography was carried out only if the patient developed symptoms. No major complications were encountered and the overall complication rate was low. Pneumothorax occurred in six patients (3.4%), only one of whom required intercostal intubation, and bleeding of more than 30 ml occurred in two patients. Histological diagnosis was obtained in 154 patients (88%). In the experience of this group transbronchial biopsy has been safe when carried out as an outpatient procedure without fluoroscopic guidance.

While ultrasonography is widely performed prior to biopsy, colour Doppler examination is often used only to discover post-biopsy complications. Aim of this paper was to evaluate the usefulness of colour Doppler examination in planning the optimal site of puncture for renal biopsy. Present analysis includes 561 consecutive percutaneous renal biopsies performed from the same operator. Until August 2000 332 biopsies were performed after a preliminary ultrasonography (Group A). From September 2000, 229 patients underwent even a preliminary colour Doppler study (Group B). Postbioptic bleeding were categorized as minor (gross hematuria or subcapsular perinephric hematoma < 4 cmq of greater diameter) or major (hematoma >4 cmq of greater diameter; requiring blood transfusion or invasive procedures; leading to acute renal failure, urine tract obstruction, septicaemia, or death). Major complications were seen in 2.1% in Group A while in Group B only one case was reported (0.43%). Minor clinically significant complications occur in 7.8% in Group A and in 3.4% of cases of Group B. Colour Doppler reduced drastically the incidence of complications observed before the introduction of routine colour Doppler examination prior to biopsy. In our opinion, these data support the use of preliminary colour Doppler study when a biopsy is planned.

Arteriographic examination of the coronary, cerebral, and peripheral circulatory systems is the ultimate diagnostic technique for the identification and quantification of atherosclerotic occlusive disease. In the past, hospitalization has been required for this invasive procedure. Recently, however, the concept of outpatient catheterization and arteriography has become a reality.

To investigate the integrity, safety, and cost-effectiveness of our outpatient invasive procedures laboratory, we analyzed our experience with 254 cardiac catheterizations and 174 peripheral arteriograms performed during a 20-month period. There were no deaths or major complications. Minor complications (11%) included bleeding from the cutdown site, nausea, numbness, and allergic reactions. Two patients with arrhythmias required cardioversion. Nine patients (2%) were transferred to the hospital for observation or immediate surgery due to the nature of their atherosclerotic lesions.

This study reveals (1) the technical quality, safety, indications, and contraindications for outpatient catheterization and arteriography; (2) the enthusiastic patient acceptance of outpatient invasive diagnostic studies; (3) the economic impact of these procedures on escalating health-care costs; and (4) the potential for outpatient catheterization and arteriography on a broad scale.

Objective

To compare the cost of two treatment regimens for moderate to severe ovarian hyperstimulation syndrome (OHSS); conservative inpatient versus outpatient management with paracentesis.

Study design

A decision tree mathematical model comparing conservative inpatient versus outpatient management of moderate to severe OHSS was created. The common final pathway of either management was resolution of OHSS. Sensitivity analyses were performed over the range of variables.

Main outcome measure

Total management cost of ovarian hyperstimulation syndrome.

Results

The cost of conservative therapy including first tier complications was $10,098 (range $9,655 to $15,044). The cost of outpatient management with paracentesis was $1954 (range $788 to $12,041). This resulted in an estimated cost savings of $8,144 with outpatient management with paracentesis. One-way sensitivity analyses were performed. Varying the probability of admission after outpatient treatment still indicated outpatient treatment was the most cost effective (probability=1.0, cost $6,110). Varying the duration of hospitalization with primary inpatient treatment was equal to outpatient treatment costs only at a stay of 0.71 days or shorter.

Conclusion

Our model suggests early outpatient paracentesis for moderate to severe OHSS is the most cost effective management plan when compared to traditional conservative inpatient therapy. The cost savings for outpatient management persisted throughout a variety of outcome probabilities.

Fifty patients have been treated for upper tract urinary calculi by extracorporeal shock wave lithotripsy (ESWL) at the Devonshire Hospital lithotripter centre since November 1984. The average stay for an inpatient was 3 X 7 days. All patients suffered minimal postoperative discomfort and nearly all resumed normal activity within one day after discharge. Complications requiring auxiliary procedures were few. The procedure was found to be safe, cost effective, extremely well received by patients, and superior to all other methods of removing renal stones. This study confirms that treatment by ESWL is a specialised urological procedure that requires operators who are also trained in open, percutaneous, and ureteroscopic surgery and with a back up of a radiological team skilled in percutaneous renal puncture.

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OBJECTIVES--To cost a clinical unit over one month in 1991, to cost treatment of individual patients from audit data, and to compare this costing method with the hospital charging system. DESIGN--A financial breakdown was obtained for one month's work. Ward stay, operating time, investigations, and outpatient visits were costed and a formula (episode = days on ward+hours of operating+investigations+outpatient visits) was used to cost patient episodes from audit data. SETTING--The adult urology unit in a teaching hospital. MAIN OUTCOME MEASURES--Costs for each part of patients' treatment. RESULTS--Total cost was 147,796 pounds for 159 admissions, 738 inpatient days, 131 operations in 29 operating lists, and 615 outpatient visits. An uncomplicated transurethral prostatectomy cost 1140 pounds but complications increased this to 1500 pounds in another patient. The costs of diagnostic cystoscopy were 130 pounds in outpatients, 240 pounds in day surgery, and 430 pounds in inpatients. Hospital charges do not reflect the individual costs of treatment, charges being greater than costs for some patients and lower than costs for others. CONCLUSIONS--Clinicians can produce a financial analysis of their work and cost their patients' treatment. Audit is strongly advocated as a resource planning tool.

Introduction

The use of an automated biopsy device and real-time ultrasound (current technology) for percutaneous renal biopsies (PRBs) has improved the likelihood of obtaining adequate tissue for diagnosis and has reduced the complications associated with renal biopsies. Our objective was to evaluate the efficacy and safety of the current PRB procedure and identify possible risk factors for the development of major complications.

Material and methods

We collected all native kidney PRBs performed with current technology in our institute from January 1998 to April 2008. Studied variables were collected from the patient's chart at the time of the biopsy.

Results

We analyzed 623 (96.4%) of 646 renal biopsies performed with the current automated procedure guided by real-time ultrasound. Although the effectiveness was 97.6%, there were 110 complications. Fourteen (2.24%) of these complications were major: 9 cases of renal hematoma, 2 cases with macroscopic hematuria (which needed blood transfusion), 1 case of intestinal perforation (which required exploratory laparotomy), 1 nephrectomy and 1 case of a dissecting hematoma. The logistic regression analysis demonstrated the following risk factors for developing major complications: diastolic blood pressure ≥ 90 mmHg, RR 7.6 (95% CI 1.35-43); platelet count ≤ 120×103/µl; RR 7.0 (95% CI 1.9-26.2); and blood urea nitrogen (BUN) ≥ 60 mg/dl, RR 9.27 (95% CI 2.8-30.7).

Conclusions

The observed efficacy and safety of the current technique in the present study were similar to observations in previous studies. Diastolic blood pressure ≥ 90 mmHg, platelets ≤ 120×103/µl and BUN ≥ 60 mg/dl were independent risk factors for the development of major complications following PRB.

OBJECTIVE: To calculate the direct and indirect costs of asthma in Canada. DESIGN: Cost-of-illness study. SETTING: Canada. PATIENTS: All Canadians receiving inpatient or outpatient care for asthma in 1990. OUTCOME MEASURES: Direct costs incurred by inpatient care, emergency services, physician and nursing services, ambulance use, drugs and devices, outpatient diagnostic tests, research and education. Indirect costs from productivity loss due to absence from work, inability to to perform housekeeping activities, need to care for children with asthma who were absent from school, time spent travelling and waiting for medical care, and premature death from asthma. All costs are in 1990 Canadian dollars. RESULTS: Depending on assumptions, the total cost of asthma was estimated to be between $504 million and $648 million. Direct costs were $306 million. The single largest component of direct costs was the cost of drugs ($124 million). The largest component of indirect costs was illness-related disability ($76 million). CONCLUSIONS: Annual costs of treating asthma are comparable to the individual cost of infectious diseases, hematological diseases, congenital defects, perinatal illnesses, home care and ambulance services. Asthma costs may increase in the future, given current morbidity and mortality trends. Further evaluation of the effectiveness and cost-effectiveness of available asthma interventions in addition to aggregate cost data are required to determine whether resource allocation for the treatment of asthma can be improved.

Background

Inadequate surgical hemostasis may lead to transfusion and/or other bleeding-related complications. This study examines the incidence and costs of bleeding-related complications and/or blood product transfusions occurring as a consequence of surgery in various inpatient surgical cohorts.

Methods

A retrospective analysis was conducted using Premier's Perspective™ hospital database. Patients who had an inpatient procedure within a specialty of interest (cardiac, vascular, non-cardiac thoracic, solid organ, general, reproductive organ, knee/hip replacement, or spinal surgery) during 2006-2007 were identified. For each specialty, the rate of bleeding-related complications (including bleeding event, intervention to control for bleeding, and blood product transfusions) was examined, and hospital costs and length of stay (LOS) were compared between surgeries with and without bleeding-related complications. Incremental costs and ratios of average total hospital costs for patients with bleeding-related complications vs. those without complications were estimated using ordinary least squares (OLS) regression, adjusting for demographics, hospital characteristics, and other baseline characteristics. Models using generalized estimating equations (GEE) were also used to measure the impact of bleeding-related complications on costs while accounting for the effects related to the clustering of patients receiving care from the same hospitals.

Results

A total of 103,829 cardiac, 216,199 vascular, 142,562 non-cardiac thoracic, 45,687 solid organ, 362,512 general, 384,132 reproductive organ, 246,815 knee/hip replacement, and 107,187 spinal surgeries were identified. Overall, the rate of bleeding-related complications was 29.9% and ranged from 7.5% to 47.4% for reproductive organ and cardiac, respectively. Overall, incremental LOS associated with bleeding-related complications or transfusions (unadjusted for covariates) was 6.0 days and ranged from 1.3 to 9.6 days for knee/hip replacement and non-cardiac thoracic, respectively. The incremental cost per hospitalization associated with bleeding-related complications and adjusted for covariates was highest for spinal surgery ($17,279) followed by vascular ($15,123), solid organ ($13,210), non-cardiac thoracic ($13,473), cardiac ($10,279), general ($4,354), knee/hip replacement ($3,005), and reproductive organ ($2,805).

Conclusions

This study characterizes the increased hospital LOS and cost associated with bleeding-related complications and/or transfusions occurring as a consequence of surgery, and supports implementation of blood-conservation strategies.

Background

Hematopoieticic stem cell transplantation is the only therapeutic option that can cure thalassemia disease. Reduced intensity hematopoietic stem cell transplantation (RI-HSCT) has demonstrated a high cure rate with minimal complications compared to other options. Because RI-HSCT is very costly, economic justification for its value is needed. This study aimed to estimate the cost-utility of RI-HSCT compared with blood transfusions combined with iron chelating therapy (BT-ICT) for adolescent and young adult with severe thalassemia in Thailand.

Methods

A Markov model was used to estimate the relevant costs and health outcomes over the patients’ lifetimes using a societal perspective. All future costs and outcomes were discounted at a rate of 3% per annum. The efficacy of RI-HSCT was based a clinical trial including a total of 18 thalassemia patients. Utility values were derived directly from all patients using EQ-5D and SF-6D. Primary outcomes of interest were lifetime costs, quality adjusted life-years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) in US ($) per QALY gained. One-way and probabilistic sensitivity analyses (PSA) were conducted to investigate the effect of parameter uncertainty.

Results

In base case analysis, the RI-HSCT group had a better clinical outcomes and higher lifetime costs. The incremental cost per QALY gained was US $ 3,236 per QALY. The acceptability curve showed that the probability of RI-HSCT being cost-effective was 71% at the willingness to pay of 1 time of Thai Gross domestic product per capita (GDP per capita), approximately US $ 4,210 per QALY gained. The most sensitive parameter was utility of severe thalassemia patients without cardiac complication patients.

Conclusion

At a societal willingness to pay of 1 GDP per capita, RI-HSCT was a cost-effective treatment for adolescent and young adult with severe thalassemia in Thailand compared to BT-ICT.

The Angioseal vascular closure device has been shown to be safe and effective in reducing the time to hemostasis following percutaneous coronary intervention (PCI). The health economic implications of routinely using Angioseal after PCI have not been explored. We performed a cost-minimization analysis comparing routine Angioseal use after PCI to mechanical compression using a decision analytic model. The relative probabilities of 7 vascular access complications were derived from pooled analysis of published randomized trials. The incremental hospital cost of each vascular complication was estimated by a matched case control analysis of 3,943 patients who underwent PCI at our center between 1/02 and 12/04. Appropriate sensitivity and uncertainty analyses were performed. After accounting for differences in expected rates of specific complications between the two strategies, as well as the incremental costs of each vascular event, the routine use of Angioseal was associated with a reduced cost per PCI procedure of $44. Probabilistic sensitivity analysis of all model assumptions using second order Monte Carlo simulation confirmed the economic advantage of Angioseal in 74% of model replications. In conclusion, following PCI, the routine use of Angioseal for femoral vascular access management was associated with net cost savings as compared with mechanical compression. This cost savings was in addition to the previously demonstrated advantages of Angioseal in terms of patient comfort and preference.

Percutaneous renal biopsy (PRB) is a safe and effective tool in the diagnosis and management of renal disease. It is the gold standard for evaluating renal parenchymal disease. It is both useful for diagnosis and monitoring progress of renal diseases. Where facilities and personnel are available to carry out the procedure in developing countries, it has become increasingly difficult for patients to pay for hospital admission fees, the procedure, and processing of the samples obtained. Information on the success rate and safety of the procedure is of interest to nephrologists for cost-benefit considerations and medicolegal purposes. This paper reports the outcome of outpatient PRB done among patients of the University College Hospital, Ibadan, Nigeria. With the use of ultrasound guidance, PRB remains a safe procedure and can be done on an outpatient basis.

ABSTRACT

Percutaneous lung biopsy is one of the most common procedures performed in radiology departments and the minimally invasive gold standard for the histopathologic investigation of lung masses. Compared with other percutaneous biopsy procedures, lung biopsy carries a higher risk of potential complications, including occasional reports of death. Radiologists should be able to quickly recognize complications, provide required acute care, manage the patient to complete resolution, and obtain a consultation from colleagues in surgery and medicine when indicated. To this end, standing protocols for the performance of lung biopsy and the management of complications such as pneumothorax should be in place prior to performing percutaneous lung biopsy.

Background

Determining the direct cost of providing medical care to patients with HIV/AIDS is important for both short-term and long-term decision-making and for appropriate resource allocation. We aimed to categorize and measure the direct costs of medical care provided to the entire HIV-positive population receiving care in southern Alberta between 1995 and 2001.

Methods

We collected all patient-specific direct costs including the cost of pharmaceutical drugs (HIV and non-HIV drugs), outpatient care (including physician costs and laboratory testing), inpatient (in-hospital) care and home care (acute, long-term, palliative) from primary sources for all patients between April 1995 and April 2001. We determined cost per patient per month (PPPM) adjusted to 2001 Canadian dollars.

Results

Since 1995, the direct cost of providing medical care to patients with HIV/AIDS has increased primarily as a result of increased antiretroviral drug costs both in absolute and in PPPM terms. Mean PPPM expenditures increased from $655 in 1995/96, that is, before the use of highly active antiretroviral therapy (HAART), to $1036 in 1997/98 when HAART was widely used. During the following 3 years, mean overall PPPM costs remained stable. Antiretroviral drugs accounted for 30% ($198 PPPM) of the total cost in 1995/96 increasing to 69% ($775 PPPM) in 2000/01. Inpatient, outpatient and home care costs decreased in both percentage and cost PPPM between 1995/96 and 2000/01 from 26% to 10%, 27% to 14% and 8% to 3% respectively.

Interpretation

The cost of providing medical care to HIV-positive patients continues to increase, although the burden of costs is distributed differently from before the introduction of HAART, with the costs of drug therapy offsetting the costs of inpatient care and home care. Careful consideration of all aspects of direct costing data is needed when any health economic policy issues are examined.

Purpose

To conduct an economic evaluation comparing Ferinject® (ferric carboxymaltose [FCM]) with Venofer® (iron sucrose [IS]) and CosmoFer® (low-molecular-weight iron dextran [LMWID]) in the management of iron deficiency anemia in Greece.

Patients and methods

A cost-minimization analysis was conducted since there are no clear data indicating that one of these regimens is superior to the others in terms of efficacy. Main data inputs were based on bibliography and validated by clinicians. The economic evaluation was conducted for inpatients (ie, surgical patients or patients hospitalized due to a disease related to chronic or acute blood loss) and outpatients (eg, nondialysis chronic kidney disease patients), separately. Analysis was carried out from a National Health Service (NHS) perspective and also from a patient perspective. Total cost treatment reflects the cost of drugs, the cost of all resources expended in patient management such as the cost of disposables for each infusion, the monitoring costs during infusion (salaries of personnel), other hospital expenses, the cost for management of adverse events, the productivity loss, and the traveling cost for patients.

Results

In the case of outpatients, the mean total cost per patient in the FCM arm was €198.6, in the IS arm €627.7, and in the LMWID arm, €510.5. For inpatients the mean total cost was estimated at €189.2 for FCM while it was €419.9 and €228.8 for IS and LMWID, respectively. Budget impact analysis for a typical Greek hospital with 100 patients revealed that the total cost of FCM (inpatients analysis) was 113% and 15.4% lower against their comparators. In an outpatient situation, the total cost of FCM was 201.1% and 151.8% lower compared with IS and LMWID, respectively.

Conclusion

Ferric carboxymaltose may represent a cost-saving option compared with the most likely alternative existing therapies used for the management of anemia in the National Health Service of Greece.

Background:

The most frequent wound complication following repair of large incisional hernias is seroma formation, especially when the use of a mesh onlay requires extensive subcutaneous undermining. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant.

Methods:

A novel technique for treating persistent postoperative seromas is presented herein. This technique involves a 3-puncture minimally invasive approach that can be performed in an outpatient setting. Evacuation of serous fluid and fibrinous debris is followed by argon beam scarification of the seroma cavity lining. Talc slurry is then introduced into the cavity. Three patients have been treated with this technique.

Results:

All 3 patients had successful ablation of seromas that had persisted despite standard treatment modalities.

Conclusion:

A minimally invasive approach is a reasonable and safe alternative for treating persistent postoperative seromas.

Background

Accurate classification of individuals with kidney disease is vital to research and public health efforts aimed at improving health outcomes. Our objective was to identify and synthesize published literature evaluating the accuracy of existing data sources related to kidney disease.

Study design

A systematic review of studies seeking to validate the accuracy of the underlying data relevant to kidney disease.

Setting & Population

U.S.-based and international studies covering a wide range of both outpatient and inpatient study populations.

Selection Criteria for Studies

Any English-language study investigating the prevalence or etiology of kidney disease, the existence of co-morbid conditions, or the cause of death in those with CKD. All definitions and stages of CKD, including end-stage renal disease (ESRD), were accepted.

Index Tests

Presence of a kidney disease-related variable in existing datasets, including administrative datasets and disease registries.

Reference Tests

Presence of a kidney disease-related variable defined by laboratory criteria or medical record review.

Results

Thirty studies were identified. Most studies investigated the accuracy of kidney disease reporting, comparing coded renal disease to that defined by estimated glomerular filtration rate (eGFR). Sensitivity of coded renal disease varied widely (0.08–0.83). Specificity was higher, with all studies reporting values of ≥0.90. The studies evaluating the etiology of CKD, comorbidities, and the cause of death in CKD all used ESRD or transplant populations exclusively, and accuracy was highly variable when compared to ESRD registry data.

Limitations

Only English-language studies were evaluated.

Conclusions

Given the heterogeneous results of validation studies, a variety of attributes of existing data sources, including the accuracy of individual data items within these sources, should be carefully considered prior to use in research, quality improvement and public health efforts.

Background/Aims

Inpatient initiation of chronic hemodialysis is considered undesirable because of cost and possible harms of hospitalization. We examined the patient characteristics and outcomes associated with inpatient initiation.

Methods

In a prospective cohort study of incident dialysis patients, the independent association of inpatient hemodialysis initiation with patient outcomes was assessed in multivariable analyses with adjustment for patient characteristics and propensity for inpatient initiation.

Results

A total of 410 of 652 (63%) hemodialysis patients began as inpatients; uremia and volume overload were the most commonly documented reasons. Compared to outpatients, inpatients were more likely to be unmarried, report less social support, have multiple comorbidities and be referred to a nephrologist 4 months or less prior to initiation. Inpatient initiation was protective for subsequent all-cause hospitalization (incidence rate ratio (IRR) = 0.92, confidence interval (CI) 0.89–0.94); this was most pronounced among those who had the highest propensity for inpatient initiation (IRR = 0.66, CI 0.56–0.78), including those referred late to nephrology. Similar results were found for infectious hospitalization. Mortality [hazard ratio = 1.03, CI 0.82–1.30] and cardiovascular events were not significantly different for inpatients versus outpatients.

Conclusion

Inpatient hemodialysis initiation has a protective association with hospitalization among those patients referred late to nephrology, with multiple comorbidities and/or little social support.

Background

Percutaneous nephrolithotomy is a minimally invasive intervention for renal stone disease. Complications, which are rare and usually presented as case reports, are diversified as the utilization of the procedure is expanded. The procedure causes less blood loss and less morbidity when compared to open surgical procedures. Yet, there are some reports involving severe bleeding and relevant morbidity during surgery. These are usually related with the surgical technique or experience of the surgeon.

Renal sheaths are designed to cause minimal trauma inside the kidney and, to our knowledge, there are no reports presenting the rupture of a sheath causing severe bleeding during the procedure.

Case report

We present an adult patient who had severe bleeding during percutaneous nephrolithotomy due to parenchymal injury caused by a ruptured renal sheath. During retrieval, due probably to rough handling of the equipment, a piece of stone with serrated edges ruptured the tip of the sheath, and this tip caused damage inside the kidney. The operation was terminated and measures were taken to control bleeding. The patient was transfused with a total of 1600 ml of blood, and the stones were cleared in a second look operation.

Conclusion

Although considered to be a minimally invasive procedure, some unexpected complications may arise during percutaneous nephrolithotomy. After being fragmanted, stone pieces may damage surgical equipment, causing acute and severe harm to the kidney. Surgeons must manipulate the equipment with fine and careful movements in order to prevent this situation.

Summary

Medical errors represent a serious public health problem and pose a threat to patient safety. All patients are potentially vulnerable, therefore medical errors are costly from a human, economic, and social viewpoint. The present report aims not only to provide an overview of the problem on the basis of the published literature, but also to stress the importance of adopting standard terminology and classifications, fundamental tools for researchers to obtain valid and reliable methods for error identification and reporting. In fact, agreement on standard definitions allows comparison of data in different contexts. Errors can be classified according to their outcome, the setting where they take place (inpatient, outpatient), the kind of procedure involved (medication, surgery, etc.) or the probability of occurring (high, low). Error categories are analysed taking into consideration their prevalence, avoidance and associated factors as well as the different strategies for detecting medical errors. Incident reporting and documentation of near-misses are described as useful sources of information, and Healthcare Failure Mode Effect Analysis (HFMEA) and Root Cause Analysis (RCA) are seen as powerful methods for process analysis. Furthermore, means to increase patient safety are considered in the broader context of clinical risk management. New approaches in the field of medical errors are aimed at minimizing the recurrence of avoidable patterns associated with higher error rate. A system approach and a blame-free environment, aimed at better organizational performances, lead to much better results than focusing on individuals. Furthermore, use of technology, information accessibility, communication, patient collaboration and multi-professional team-work are successful strategies to reach the goal of patient safety within healthcare organizations.

In attempts to minimize the cost of health care, physicians are reducing the duration of hospital stay. Traditionally, at the Hospital for Sick Children, Toronto, otherwise healthy children undergoing adenoidectomy, tonsillectomy or adenotonsillectomy have been admitted the morning of surgery and discharged from hospital at 7 am the next day. The nursing records of 9409 patients aged 17 years or less who were managed in this way between 1980 and 1984 were reviewed to determine the occurrence of complications during the observation period. A total of 202 patients (2.15%) bled during the observation period. Of the 202, 6 (0.06% of all the patients) required a second general anesthetic for hemostasis; 1 of these 6 patients and 5 others required blood transfusions. Discharge was delayed for 42 patients (0.45% of all the patients) because of postoperative bleeding and for 57 patients (0.6%) for a variety of other reasons. Delayed discharge for reasons other than hemorrhage was more frequent among children less than 2 years of age and those over 12 years of age. The authors concluded that children undergoing adenoidectomy could safely be discharged the same day after 6 hours of observation following surgery. However, as a substantial number of children bled from the tonsillar fossa more than 6 hours after surgery, the efficacy of periodic examination of the oral cavity during the observation period in reducing the rate of hemorrhage after 6 hours must be evaluated before a same-day discharge program is established for children undergoing adenotonsillectomy.

Bleeding gastric ulcers have a propensity to occur in the critically ill and elderly. Various treatments include endoscopic or surgical intervention. The endoscopic route may have as high as a 25 percent rebleeding rate and a 50 to 90 percent rebleeding rate if there is a visible vessel. Surgical intervention has a mortality rate of as high as 25 percent. Described is a procedure which combines endoscopic and surgical techniques for the treatment of bleeding gastric ulcers - the percutaneous endoscopic method.

To evaluate the technique and efficacy of this procedure, a bleeding ulcer was created in a porcine stomach with multiple applications of standard biopsy forceps. After brisk hemorrhage developed, the percutaneous endoscopic method was employed and cessation of bleeding obtained.

The entire procedure was completed within 20 minutes. There were no immediate complications. Overall costs were much less than those for routine general surgery and about the same as for placement of percutaneous gastrostomy tube.

Background

The identification of safe and effective alternatives to blood transfusion is a public health priority. In sub-Saharan Africa, blood shortage is a cause of mortality and morbidity. Blood transfusion can also transmit viral infections. Giving tranexamic acid (TXA) to bleeding surgical patients has been shown to reduce both the number of blood transfusions and the volume of blood transfused. The objective of this study is to investigate whether routinely administering TXA to bleeding elective surgical patients is cost effective by both averting deaths occurring from the shortage of blood, and by preventing infections from blood transfusions.

Methods

A decision tree was constructed to evaluate the cost-effectiveness of providing TXA compared with no TXA in patients with surgical bleeding in four African countries with different human immunodeficiency virus (HIV) prevalence and blood donation rates (Kenya, South Africa, Tanzania and Botswana). The principal outcome measures were cost per life saved and cost per infection averted (HIV, Hepatitis B, Hepatitis C) averted in 2007 International dollars ($). The probability of receiving a blood transfusion with and without TXA and the risk of blood borne viral infection were estimated. The impact of uncertainty in model parameters was explored using one-way deterministic sensitivity analyses. Probabilistic sensitivity analysis was performed using Monte Carlo simulation.

Results

The incremental cost per life saved is $87 for Kenya and $93 for Tanzania. In Botswana and South Africa, TXA administration is not life saving but is highly cost saving since fewer units of blood are transfused. Further, in Botswana the administration of TXA averts one case of HIV and four cases of Hepatitis B (HBV) per 1,000 surgical patients. In South Africa, one case of HBV is averted per 1,000 surgical patients. Probabilistic sensitivity analyses confirmed the robustness of the model.

Conclusion

An economic argument can be made for giving TXA to bleeding elective surgical patients. In countries where there is a blood shortage, TXA would be a cost effective way to reduce mortality. In countries where there is no blood shortage, TXA would reduce healthcare costs and avert blood borne infections.