To make informed choices in the November elections, healthcare financial managers should understand the ramifications of the Republican and Democratic party platforms regarding the nation's healthcare system. Although the parties' positions may be only rhetorical, they can be seen as markers for future action. Between the GOP's support for Medicare privatization and the Democrats' proposal to create a Medicare set-aside fund, the Medicare program could look very different in the years to come.

Aged↗

PubMed2000

What now for Medicare reform?

Explore the source record for details and available documents.

Aged↗

PubMed1999

Laparoscopic Roux-en-Y gastric bypass: a totally intra-abdominal approach--technique and preliminary report.

BACKGROUND: Previous descriptions of a laparoscopic Roux-en-Y gastric bypass, using a circular stapler to perform the gastrojejunal anastomosis, have employed the esophagus as a conduit to introduce the anvil of the stapling device into the stomach. The authors believe that the risk of injury to the esophagus, as well as the difficulty in maneuvering the anvil from the pharynx to the proximal part of the stomach, make this technique less than optimal. In other descriptions (in a porcine model) the anvil has been guided into position through a distal gastrotomy by attaching it to a Prolene suture on a straight needle and directing the needle toward a chosen site. Although the authors prefer this method because it avoids potential esophageal injury, they sought a technique that would be even more precise in anvil placement and would avoid pushing a needle across gastric mucosa. METHODS: The authors have developed a method that is totally intra-abdominal and does not risk injury to the esophagus. The circular stapler is still used, thus giving a consistent, small opening through the gastrojejunal anastomosis. RESULTS: Over a 1-year period, 49 (of 50) patients underwent laparoscopic Roux-en-Y gastric bypass with the described method. The average body mass index dropped from 42.63 to 34.12 over the first postoperative 3 months, with an average loss in excess body weight of 38.5%. The length of hospitalization following the procedure averaged 3.8 days, and the time to return to work (where applicable) was 11.9 days. CONCLUSION: This totally intra-abdominal laparoscopic technique is feasible and advantageous.

Abdomen↗

PubMed1999

Cost-effective use of echocardiography in children with Kawasaki disease.

OBJECTIVE: To determine whether a third echocardiogram, performed 6 months to 1 year after the onset of Kawasaki disease (KD), as recommended by current American Heart Association guidelines, identified any case of coronary artery abnormalities when previous echocardiograms were normal. METHODS: Children diagnosed with KD were identified by searching our institution's database. Cases were included in the study if diagnosed between June 1988 and December 1996 and if at least two echocardiograms were documented, including at least one study between 2 weeks and 2 months from the onset of KD and another in follow-up. The patients' charts were reviewed and videotapes of the echocardiograms were reviewed if reports were unclear or contradictory. McNemar's test for discordant pairs was used for statistical analysis. Additionally, a complete review was performed in all other cases of KD in the database in which a coronary artery abnormality had been identified. RESULTS: There were 203 patients diagnosed during the study period who had 2 or more echocardiograms performed, and 67 had the requisite studies in the subacute period and later follow-up. The median age at onset of KD was 3.0 years (range: 0.2-16), the median duration of follow-up was 12.5 months (range: 1.7-100), and the median number of echocardiograms performed was 3 (range: 2-8). Intravenous immunoglobulin was given in 62 cases, and high-dose aspirin was given in 63. There were 35 children with no echocardiographic abnormalities at any point, and 15 other children had early abnormalities (including coronary ectasia, perivascular brightness, pericardial effusion, and ventricular dysfunction) but had a normal echocardiogram between 2 weeks and 2 months. Of these 50 children, none were noted to have abnormalities on later studies. Three children had effusion and/or perivascular brightness after 2 weeks; follow-up studies were normal in each. Six children had coronary ectasia after 2 weeks; it persisted on follow-up in 1 child and had resolved in 5 children. Eight children had coronary aneurysms on studies after 2 weeks; in 3 children, the aneurysm resolved on later follow-up. No coronary abnormalities were demonstrated on a late follow-up echocardiogram in any child with normal coronaries between 2 weeks and 2 months. CONCLUSIONS: All children with KD should have an echocardiogram at the time of diagnosis with a follow-up study 4 to 6 weeks after the onset of fever. In the current environment of cost-containment, additional echocardiographic studies are justified only if abnormalities are present at 4 to 6 weeks. Kawasaki disease, coronary artery aneurysm, echocardiography, coronary ectasia.

Adolescent↗

PubMed1999