1329 Lusitana Street Suite 607
Honolulu HI 96813
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Neuraxial blockade for external cephalic version: Cost analysis. - The journal of obstetrics and gynaecology research
Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates.A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness.Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted.Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.Â© 2015 The Authors. Journal of Obstetrics and Gynaecology Research Â© 2015 Japan Society of Obstetrics and Gynecology.
Induction rates and delivery outcomes after a policy limiting elective inductions. - Maternal and child health journal
The purpose of this study was to assess induction rates, maternal, and neonatal outcomes following adoption of a policy prohibiting elective inductions at less than 39 weeks gestation and inductions between 39 and 41 weeks with an unfavorable cervix. A retrospective cohort study of all deliveries greater than or equal to 37 weeks gestation was conducted 1 year prior to through 1 year after implementation of the induction policy. Induction rates before and after the policy were calculated as the primary outcome while maternal and neonatal conditions were assessed as secondary outcomes. Elective inductions (p = 0.016), elective inductions less than 39 weeks gestation (p = 0.020), and elective inductions 39-40 weeks and 6 days gestation with an unfavorable cervix (p = 0.031) decreased significantly following adoption of the policy. Maternal and neonatal outcomes, including rates of cesarean deliveries, postpartum hemorrhage, chorioamnionitis, and neonatal intensive care unit admissions remained unchanged, though this study was not adequately powered to detect differences in these outcomes. An institutional induction policy was associated with a reduction in elective inductions prior to 39 weeks and up to 40 weeks and 6 days with an unfavorable cervix. These reductions were not accompanied by change in maternal or neonatal outcomes at our institution.
Hemodynamic effects of nifedipine tocolysis. - The journal of obstetrics and gynaecology research
To describe the effects of nifedipine tocolysis on blood pressure and heart rate in non-hypertensive women.This was a retrospective study from 2001 to 2011 to compare blood pressures and heart rates among non-hypertensive women on nifedipine tocolysis up to 8â€‰h after nifedipine initiation. Measurements at 20-60 and 61-120â€‰min were compared to assess the differential effects of dosing on hemodynamics and reflected the effects of the initial and complete loading doses, respectively. Charts were reviewed for hypotension-related emergent delivery.One hundred and thirty-eight patients were included. Over the 8-h study interval, mean systolic blood pressure (Pâ€‰<â€‰0.001) and mean diastolic blood pressure (Pâ€‰<â€‰0.001) decreased by 5â€‰mmHg and heart rate increased by 4â€‰b.p.m. (Pâ€‰<â€‰0.001). Systolic and diastolic blood pressures were unchanged from baseline up to 120â€‰min at all doses. Heart rate increased at both 20-60 and 61-120â€‰min when all doses were considered (Pâ€‰<â€‰0.001), but differential dosing effects were not observed. Rates of tachycardia increased (Pâ€‰<â€‰0.001), but rates of hypotension were unchanged. No hypotension-related emergent deliveries occurred.Nifedipine tocolysis was associated with hemodynamic changes in non-hypertensive women. Tachycardia was increased but hypotension was unaffected, supporting the general safety of nifedipine in this setting.Â© 2014 The Authors. Journal of Obstetrics and Gynaecology Research Â© 2014 Japan Society of Obstetrics and Gynecology.
Intraabdominal pressure with pelvic floor dysfunction: do postoperative restrictions make sense? - The Journal of reproductive medicine
To quantify and compare intraabdominal pressures (IAPs) in women with pelvic floor dysfunction during standard activities.Eligible subjects were women with pelvic organ prolapse and/or urinary incontinence presenting for urodynamic evaluation. IAPs were recorded for the following tasks: (1) standing up from a chair, (2) coughing, (3) lifting 10 lb (4.54 kg), (4) lifting 20 ;b (9.07 kg), and (5) pushing 20 lb (9.07 kg). Net pressures were compared by activity, age, and body mass index (BMI).We enrolled 147 subjects. The mean net IAPs generated were as follows: pushing 20 lb (11.6 cm H2O), lifting 10 lb (11.9 cm H2O), lifting 20 lb (19.6 cm H2O), standing up (36.8 cm H2O), and coughing (80.4 cm H2O). Coughing and standing up generated significantly more pressure than lifting either 10 or 20 lb (p < 0.001). IAPs were significantly lower for standing up in patients > or = 70 years old (p = 0.01) but otherwise did not vary by age. Obese subjects (BMI > or = 30.0) generated significantly more pressure than did normal-weight subjects (BMI 18.5-24.9) during all activities.Common activities such as standing up and coughing generate significantly more IAP than lifting up to 20 lb. This may have implications for postoperative restrictions in patients with pelvic floor dysfunction.
A simulation comparing the cost-effectiveness of adult incontinence products. - Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society / WOCN
To compare leak point volumes and cost-effectiveness of a variety of adult incontinence products.Adult incontinence products were purchased from local retail stores and categorized into moderate absorbency pads, moderate absorbency briefs, maximum absorbency pads, and maximum absorbent briefs. The leak point for each product was determined by applying fluid to the pad until the first drop of leakage from the pad or brief occurred. Cost-effectiveness was calculated by dividing the cost per product by the amount of fluid absorbed prior to the leak point. The leak points and cost-effectiveness of incontinence products were compared within and between categories.Significant differences in leak point volumes were present within all product categories except moderate absorbency pads. When comparing product categories, moderate absorbency pads were the least cost-effective, followed by maximum absorbency pads and absorbent briefs (P < .01).As a group, absorbent briefs are more cost-effective than incontinence pads, although products of similar absorbency category and design demonstrated varying leak points and cost-effectiveness. These findings may influence physician assessment of urinary incontinence as well as patient selection of incontinence products.
Effect of robotic surgery on hysterectomy trends: implications for resident education. - Journal of minimally invasive gynecology
To compare the surgical approach used for hysterectomy at 2 teaching hospitals before and after introduction of the robotic surgical system.Retrospective cohort study (Canadian Task Force classification II-3).Two gynecologic training sites at the University of Hawaii.Women who underwent hysterectomy between January 1, 2005, and December 31,Â 2011.ICD-9 procedural codes were used to identify hysterectomies performed between January 1, 2005, and December 31, 2011. Hysterectomies were categorized according to surgical approach: abdominal, vaginal, laparoscopic-assisted vaginal/total laparoscopic, and robotic. Each hysterectomy was also categorized according to primary preoperative diagnosis as general gynecology, gynecologic oncology, and urogynecology. The rates and numbers of hysterectomies performed during 2005-2006 (2 years before acquisition of the robot), 2007-2008 (first 2 years with the robot), and 2009-2011 (3-5 years after acquiring the robot) were compared using Ï‡(2) tests and analysis of variance. The numbers of hysterectomies reported in resident case logs were also collected and compared. A total of 5894 hysterectomies were performed between 2005 and 2011. The total number of hysterectomies performed at Hospital A, which acquired the robotic surgical system, increased over time (p = .04) but remained stable at Hospital B, which did not acquire the robotic surgical system. At Hospital A, the number of robotic hysterectomies increased as the number of abdominal hysterectomies decreased (p < .001), a trend consistent across all diagnostic categories. The number of vaginal and laparoscopic hysterectomies remained stable. Resident case logs also reflected a decrease in the number of abdominal hysterectomies (p = .002) and an increase in the number of combined laparoscopic/robotic hysterectomies (p < .001) performed. The total number of hysterectomies performed by residents was unchanged.Introduction of the robotic surgical system was associated with significant changes in the numbers and types of hysterectomies performed in both general and subspecialty gynecology. Although abdominal hysterectomies decreased as robotic hysterectomies increased, other hysterectomies did not. These trends mirror reported resident surgical experience and have implications for resident education.Copyright Â© 2014 AAGL. Published by Elsevier Inc. All rights reserved.
Normal oxygen saturation values in pediatric patients. - Hawaii medical journal
To determine normal oxygen saturation (OSAT) values in infants and children measured by pulse oximetryInfants and children admitted to a children's hospital for elective surgery from 11/20/2000 to 3/30/2002 underwent surgical clearance screens consisting of illness symptoms, vital signs and OSAT in room air Based on the presence of respiratory infection (RI) symptoms, a "normal" patient was defined as one without respiratory symptoms and who was not scheduled for surgery involving the airway pulmonary or cardiovascular systems (APC).Of the 3600 forms collected, 2069 were completely filled out and for elective surgery. For all age groups combined, the percent of patients undergoing APC surgery or with RI symptoms for each OSAT were as follows (OSAT: %patients APC/RI): 100%: 13%, 99%-99.5%: 15%, 98%-98.5%: 14%, 97%-97.5%: 18%, 96%-96.5%: 38%, 95%-95.5%: 29%, and <95%: 0%.Although OSAT of 95% and 96% are adequate (i.e., not requiring acute oxygen therapy), these values are associated with higher rates of APC/RI involvement and thus should be considered potentially abnormal. OSAT of 97% is on the border of normal. Normal OSATs can occur with APC/RI conditions, but an OSAT less than 97% is associated with a higher risk of an APC/RI condition.
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1329 Lusitana Street Suite 607 Honolulu, HI 96813
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