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The Hospital Outpatient Prospective Payment System has matured into a complex diagnosis-related group-like payment system over the past 18 years and has continued to become more prospective in paying for services that are bundled, packaged, and grouped into episodes of care. This payment system has become the basis by which payments for services in other payment systems, such as the ambulatory surgery centers and the Medicare Physician Fee Schedule, are made. The quality of hospital data has a greater effect on reimbursement of services than ever anticipated when this payment system was developed. Also, CMS methodological changes further distort reported hospital data, which often results in lowered payment levels for diagnostic imaging., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection., Objectives: The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival., Methods: This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome., Results: There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001)., Conclusions: ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Coccidioidal meningitis is a lethal disease, and current therapy is not curative or is burdened with serious toxicities and logistic difficulties. In a patient with refractory disease, continuous infusion amphotericin B therapy was given via a programmable implanted pump into the cisternal subarachnoid space. The patient progressively responded, evidenced clinically and by laboratory studies. Drug delivery issues were addressed during this course that could guide future use of this modality, which is a promising novel avenue of therapy for chronic meningitis.

Hypoglycaemia, defined as a plasma glucose concentration below 2.2 mmol/l, developed in 15 of 47 prospectively studied Gambian children with severe chloroquine-sensitive falciparum malaria. 5 of these hypoglycaemic children died compared with 1 in the normoglycaemic group (p = 0.02). In contrast to previous observations in quinine-treated adults, in whom hypoglycaemia was associated with hyperinsulinaemia, plasma concentrations of insulin were appropriately low and plasma ketones were high. Raised plasma concentrations of lactate and alanine suggested impairment of hepatic gluconeogenesis. In African children, hypoglycaemia is an important and treatable manifestation of severe malaria and is unrelated to antimalarial treatment.