MR imaging of traumatic hepatic laceration: Evaluation and course of healing after surgery

Six patients with hepatic laceration underwent magnetic resonance imaging (MRI) at 0.5T. Acute hepatic laceration was slightly hypointense on T1-weighted spin-echo (SE) image, and hyperintense on T2- and proton-weighted SE images. Subacute laceration was heterogeneously intense on T1-weighted image and hyperintense on T2- and proton-weighted images. Consistent changes in signal intensity of postoperative hepatic laceration were observed. On Tl-weighted image, the signal intensity at first increased and then decreased from periphery to the center. On the T2- and proton-weighted images, the laceration was uniformly hyperintense relative to the liver prior to the appearance and growth of a hypointense ring at its periphery. The appearance of the above changes in signal intensity was also observed in postoperative recurrent hemorrhage. The postoperative biloma had none of the above changes in signal intensity. Our cases show that MRI is effective in the evaluation of hepatic laceration and in the assessment of the course of healing after operation.     

Contrast enhancement of the gastrointestinal tract on MR images using intravenous gadolinium-DTPA

Gadopentetate dimeglumine was administered intravenously to 16 patients undergoing abdominal magnetic resonance (MR) imaging. T1-weighted and fat-suppressed T1-weighted images were acquired before and after intravenous administration of 0.1 mmol/kg gadopentetate dimeglumine. The stomach, small bowel, and colon were analyzed regarding the presence and relative intensity of contrast enhancement. Diffuse enhancement of the gastrointestinal tract wall was observed in all patients following contrast material administration. Such enhancement was most conspicuous on fat-suppressed T1-weighted images. Quantitative measurements indicated that the wall of the gastrointestinal tract enhanced approximately 100% with gadopentetate dimeglumine. This study demonstrates that enhancement of the normal gastrointestinal tract occurs routinely when intravenous gadopentetate dimeglumine is administered, and such enhancement should not be considered indicative of gastrointestinal pathology. Furthermore, it suggests the potential utility for using intravenous rather than orally administered contrast agents to provide enhancement of the gastrointestinal tract on MR images.     

Hepatocellular carcinoma with tumor thrombus in the inferior vena cava and right atrium

Tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA) is rarely encountered. We have diagnosed before death and treated a case of hepatocellular carcinoma (HCC) with TT in the IVC and RA, accompanied by a brain metastasis. The image characteristics on computed tomography (CT), magnetic resonance imaging (MRI), and conventional angiography are discussed.     

Cost-effectiveness analysis of telotristat ethyl for treatment of carcinoid syndrome diarrhea inadequately controlled with somatostatin analogs

Aims: This study evaluated the cost-effectiveness of telotristat ethyl (TE) added to somatostatin analog octreotide (SSA?+?TE) compared to octreotide alone (SSA) in patients with carcinoid syndrome diarrhea (CSD) whose symptoms remain uncontrolled with SSA alone.

Materials and methods: A deterministic Markov model evaluated the costs and quality-adjusted life-years (QALY) gained with SSA?+?TE vs SSA per a third-party US payer perspective. The model reflected clinical practice and resource use estimates based on current standards of care, with utility estimates based on similar symptoms from ulcerative colitis. Treatment efficacy was based on the phase III clinical trial of SSA?+?TE vs SSA alone [TELESTAR, NCT01677910]. According to TELESTAR, 44% of SSA?+?TE and 20% of SSA patients responded to therapy after 12 weeks. At each 4-week assessment period, SSA patients not adequately controlled received increasing doses of SSA and SSA?+?TE patients discontinued TE and moved to SSA only. Drug costs for adequately and not adequately controlled patients were $4,291.75 and $5,890.57 for SSA, respectively, and $9,456.07 and $5,890.57 for SSA?+?TE, respectively.

Results: The base-case analysis demonstrated lifetime QALYs of 1.67 at a cost of $495,125 for the SSA cohort and 2.33 ($590,087) for SSA?+?TE with an incremental QALY for SSA?+?TE of 0.66 for an additional $94,962. The incremental cost per QALY gained was $142,545. Sensitivity analyses demonstrated high probability (>99%) of SSA?+?TE being cost-effective at thresholds for rare diseases and orphan drugs of $300,000–$450,000.

Limitations: The recent availability of TE precluded the incorporation of clinical and economic inputs based on real-world practice patterns. The scarcity of epidemiology and utility information for this rare condition required the use of some proxy estimates.

Conclusions: This analysis demonstrated TE is a cost-effective treatment option when used on top of standard of care in CSD patients.     

Real-world comparison of all-cause hospitalizations,hospitalizations due to stroke and major bleeding,and costs for non-valvular atrial fibrillation patients prescribed oral anticoagulants in a US health plan

Aims: To compare the risk of all-cause hospitalization and hospitalizations due to stroke/systemic embolism (SE) and major bleeding, as well as associated healthcare costs for non-valvular atrial fibrillation (NVAF) patients initiating apixaban, dabigatran, rivaroxaban, or warfarin.

Materials and methods: NVAF patients initiating apixaban, dabigatran, rivaroxaban, or warfarin were selected from the OptumInsight Research Database from January 1, 2013–September 30, 2015. Propensity score matching (PSM) was performed between apixaban and each oral anticoagulant. Cox models were used to estimate the risk of stroke/SE and major bleeding. Generalized linear and 2-part models were used to compare healthcare costs.

Results: Of the 47,634 eligible patients, 8,328 warfarin-apixaban pairs, 3,557 dabigatran-apixaban pairs, and 8,440 rivaroxaban-apixaban pairs were matched. Compared to apixaban, warfarin patients were associated with a significantly higher risk of all-cause (hazard ratio [HR]?=?1.30; 95% confidence interval [CI]?=?1.21–1.40) as well as stroke/SE-related (HR?=?1.60; 95% CI?=?1.23–2.07) and major bleeding-related (HR?=?1.95; 95% CI?=?1.60–2.39) hospitalization; rivaroxaban patients were associated with a higher risk of all-cause (HR?=?1.15; 95% CI?=?1.07–1.24) and major bleeding-related hospitalization (HR?=?1.71; 95% CI?=?1.39–2.10); and dabigatran patients were associated with a higher risk of major bleeding hospitalization (HR?=?1.46, 95% CI?=?1.02–2.10). Warfarin patients had significantly higher major bleeding-related and total all-cause healthcare costs compared to apixaban patients. Rivaroxaban patients had significantly higher major bleeding-related costs compared to apixaban patients. No significant results were found for the remaining comparisons.

Limitations: No causal relationships can be concluded, and unobserved confounders may exist in this retrospective database analysis.

Conclusions: This study demonstrated a significantly higher risk of hospitalization (all-cause, stroke/SE, and major bleeding) associated with warfarin, a significantly higher risk of major bleeding hospitalization associated with dabigatran or rivaroxaban, and a significantly higher risk of all-cause hospitalization associated with rivaroxaban compared to apixaban. Lower major bleeding-related costs were observed for apixaban patients compared to warfarin and rivaroxaban patients.     

Does integration and economic policy coordination promote business cycle synchronization in the EU?

Previous studies have discounted important factors and indirect channels that might contribute to business cycle synchronization (BCS) in the EU. We estimate the effects of market integration and economic policy coordination on bilateral business cycle correlations over the period 1995–2012 using a simultaneous equations model that takes into accounts both the endogenous relationships and unveils direct and indirect effects. The results suggest that (1) trade and FDI have a pronounced positive effect on BCS, particularly between incumbent and new EU members. (2) Rising specialization does not decouple business cycles. (3) The decline of income disparities in EU27 contributes to BCS, as converging countries develop stronger trade and FDI linkages. (4) There is strong evidence that poor fiscal discipline of EU members is a major impediment of business cycle synchronization. (5) The same argument holds true for exchange rate fluctuations that hinder BCS, particularly in EU15. Since BCS is a fundamental prerequisite and objective in an effective monetary union, the EU has to promote market integration and strengthen the common setting of economic policies.     

Macroeconomic imbalances and business cycle synchronization. Why common economic governance is imperative for the Eurozone

This paper investigates a new category of influential factors on business cycle synchronization (BCS), so far hardly regarded in the BCS literature. It provides an empirical assessment of the impact of macroeconomic imbalances, as monitored by the European Commission by the scoreboard indicators since 2011, on BCS in the Euozone. We use a quarterly data set covering the period 2002–2012 and estimate the direct and indirect effects of macroeconomic imbalances in the pre- and post-crisis period in a simultaneous equations model. Business cycle correlation between EA members is measured by the recently proposed dynamic conditional correlation of Engle (2002) which can better identify synchronous and asynchronous behaviour of BC than the commonly used measures. We find that appearing differences between EA members in current account, in government deficit and public debt, in private debt and unit labor cost developments have reduced BCS in the EA, even more in the post-crisis period than before. Moreover, these explanatory factors of BCS, generally reinforce each other and are also influenced by other critical macro imbalances. Since BCS is essential in a monetary union, this paper provides clear support that a stronger, common economic governance would be important for the functioning and survival of the Eurozone.     

正念思维对员工创造力的影响

在文献回顾的基础上,提出了正念思维的3大核心要素。基于认知理论,沿着“正念思维-工作自我效能感-员工创造力”研究思路,实证检验了正念思维与员工创造力之间的关系,探索了员工自我效能感在两者之间的中介作用。研究结果表明,正念思维对自我效能感产生正向影响,对员工创造力具有积极作用,自我效能感在正念思维对员工创造力的影响中具有部分中介作用。在正念思维的3个构成要素中,正念意识对员工创造力的影响和正念态度对自我效能感的影响分别大于其它要素。该研究扩展了员工创造力前因变量的研究成果,对管理者和员工提升创造力具有重要启示。     

Hospital cost and length of stay in idiopathic pulmonary fibrosis

Objective: To provide a detailed picture of the economic impact of hospitalization in idiopathic pulmonary fibrosis (IPF) and to identify factors associated with cost and length of stay (LOS).

Methods: In this retrospective cross-sectional study using the Nationwide Inpatient Sample (NIS), this study included hospitalizations for IPF (ICD-9-CM 516.3) with a principal diagnosis of respiratory disease (ICD-9-CM 460-519) from 2009–2011; lung transplant admissions were excluded. Total inpatient cost, LOS, in-hospital death, and discharge disposition were reported. Linear regression models were used to determine variables predictive of LOS and cost.

Results: From 2009–2011, 22,350 non-transplant IPF patients with a principal diagnosis of respiratory disease were admitted: mean (±SE) age was 70.0 (0.32), and 49.1% were female. While in hospital, 11.4% of patients received mechanical ventilation and 8.9% received non-invasive ventilation. Mean (±SE) LOS was 7.4 (0.15) days overall (p?Limitations: The positive predictive value of the algorithm used to identify IPF is not optimal. The NIS database does not follow patients longitudinally, and claims after admission are not available. Claims do not indicate whether listed diagnoses were present on admission or developed during hospitalization. The exclusion of transplant-related expenditures lead to under-estimation of cost.

Conclusion: Using a nationally-representative database, we found IPF respiratory-related hospitalizations represent a significant economic burden with ～7,000 non-transplant IPF admissions per year, at a mean cost of $16,000 per admission. Mechanical ventilation is associated with statistically significant increases in LOS and cost. Therapeutic advances that reduce rates and costs of IPF hospitalizations are needed.     

Information technology,efficiency and productivity: evidence from Korean local governments

This study evaluates the performance of Korean local government by measuring their technical efficiency (TE) and total factor productivity (TFP) growth and, more importantly, examining the impact of information technology (IT) on this performance. The study is different from received analysis in that a unique measure of the state of IT–the Informatization Index–is used to investigate the impact of IT on both TE and TFP growth. Empirical analyses are conducted on data from 222 Korean local governments for the period 1999 to 2001. In particular, data envelopment analysis techniques are applied to calculate TE scores and TFP growth rates for sampled local governments. The empirical findings confirm the positive impact IT has in improving technical efficiency and accelerating productivity growth. The estimated coefficients are correctly signed (with other regional characteristics controlled for) when TE scores and TFP growth rates are regressed on the Index. In addition, the findings indicate that economies of density are present in the production of local public services.     

Technical efficiency and ICT investment in Italian manufacturing firms

The importance of Information and Communication Technologies (ICTs) is a much debated question with extensive literature aimed at understanding the role of ICTs in increasing economic growth, firm productivity and firm efficiency. Different methods to estimate firm efficiency are used in this study. In particular, both the translog and the Cobb–Douglas production functions are used in order to estimate the impact of ICT on Technical Efficiency (TE) in Italian manufacturing firms over the period 1995 to 2003. Results show that ICT investments positively and significantly affected firms’ TE. Moreover, group, size and geographical position have a positive influence on TE. Finally, the results show that older firms are, on average, more efficient than newer ones.     

Association between provider specialty and healthcare costs and glycemic control for patients with diabetes

Aims: To analyze the association between provider, healthcare costs, and glycemic control for patients with diabetes mellitus (DM).

Materials and methods: This cross-sectional study identified adults with type 1 or 2?DM (T1D, T2D) in the Optum database. The main independent variable was provider (endocrinologist or primary care). Regression analysis compared total medical and pharmacy costs, adjusting for health status and other patient differences, by provider.

Results: For all patients, HbA1C improvement was greater, and medical costs significantly lower with an endocrinologist rather than a primary care provider. The largest HbA1C improvement (4%) occurred for insulin-dependent patients seen by endocrinologists. Significant medical savings with endocrinologist management occurred within the Medicare Advantage population in every sub-group of patients, with 14% lower costs ($4,767) for patients with T1D, 11% lower costs ($3,160) for patients with macro- and microvascular complications, and 10% lower costs ($2,237) for insulin-dependent patients. Within the commercial insurance population, medical costs were reduced by ≥9% in every sub-group of patients, with a 20% reduction ($8,450) for patients with micro- and macrovascular complications. Overall total costs (medical and pharmacy) were 8% ($1,541) higher for patients receiving endocrinologist rather than primary care, although endocrinologist care resulted in a 9% reduction (–$3,710) in costs for Medicare Advantage patients with T1D. Total medical costs (excluding pharmacy costs) may be a more accurate indicator of costs associated with patients in various stages of DM.

Limitations: There was insufficient data to develop risk-adjustment payments for pharmacy costs based on disease severity. The cross-sectional design identifies associations and not cause–effect relationships.

Conclusion: DM management by an endocrinologist was associated with greater HbA1C improvement and significantly lower medical costs. Total costs were higher with an endocrinologist, but for patients with T1D lower costs were seen, ranging from 2–9% regardless of insurance type.     

Hepatocellular carcinoma: Prospective assessments of the T-factor with CT,US, and MR imaging

The capabilities of computed tomography (CT), ultrasonography (US), and magnetic resonance (MR) imaging were studied in order to determine the role of each of these noninvasive examinations for estimating the T-factor of hepatocellular carcinomas (HCCs). Fifty-one patients with surgically proven HCCs received CT (50 patients), US (46 patients), and MR (44 patients). The images of CT, US, and MR were prospectively evaluated for main tumor size, intrahepatic metastases, and vascular invasion, which compose the T-factor of HCC, and compared to pathological results. The sizes of the main tumor were estimated correctly by all examinations. For estimating intrahepatic metastases, US (74%) and MR (73%) were superior to CT (65%). For estimating portal invasion, CT (79%) was superior to US (70%) and MR (66%), because CT could demonstrate the segmental staining caused by portal invasion. The estimates of hepatic venous invasion were difficult during any of the examinations. We conclude that presurgical evaluations of the T-factor require the use of US and CT or MR and CT.     

Healthcare costs of stroke and major bleeding in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants

Objective: To assess long-term healthcare costs related to ischemic stroke and systemic embolism (stroke/SE) and major bleeding (MB) events in patients with non-valvular atrial fibrillation (NVAF) treated with non-vitamin K antagonist oral anticoagulants (NOACs).

Materials and methods: Optum’s Clinformatics Data Mart database from 1/2009–12/2016 was analyzed. Adult patients with ≥1 stroke/SE hospitalization (index date) were matched 1:1 to patients without stroke/SE (random index date), based on propensity scores. Patients with an MB event were matched to patients without MB. All patients had an NOAC dispensing overlapping index date, ≥12?months of eligibility pre-index date, and ≥1 NVAF diagnosis. The observation period spanned from the index date until the earliest date of death, switch to warfarin, end of insurance coverage, or end of data availability. Mean costs were evaluated: (1) per-patient-per-year (PPPY) and (2) at 1, 2, 3, and 4?years using Lin's method.

Results: The cost differences were, respectively, $48,807 and $28,298 PPPY for NOAC users with stroke/SE (n?=?1,340) and those with MB (n?=?3,774) events compared to controls. Cost differences of patients with vs without stroke/SE were $49,876, $51,627, $57,822, and $60,691 at 1, 2, 3, and 4?years post-index, respectively (p?p?Limitations: Limitations include unobserved confounders, coding and/or billing inaccuracies, limited sample sizes over longer follow-up, and the under-reporting of mortality for deaths occurring after 2011.

Conclusions: The incremental healthcare costs incurred by patients with vs without stroke/SE was nearly twice as high as those of patients with vs without MB. Moreover, each additional year up to 4?years after the first event was associated with an incremental cost for patients with a stroke/SE or MB event compared to those without an event.     

Labour migration in the enlarged EU: a new economic geography approach

This paper studies the impact of migration policy liberalisation on international labour migration in the enlarged European Union (EU) in a structural economic geography approach. The liberalisation of migration policy would induce an additional 1.80–2.98% of the total EU workforce to change their country of location, with most of migrant workers relocating from the East to the West. The average net migration rate is decreasing in the level of integration, suggesting that from an economic point of view no regulatory policy responses are necessary to labour migration in the enlarged EU.     

国有上市企业运营效率测算和时空演进分析

以我国2015—2017年8个行业中的138家国有上市企业作为研究对象,运用数据包络法(DEA)及地理信息系统(GIS)可视化方法,从微观层面对国有上市企业样本的综合效率(TE)、纯技术效率(PTE),以及规模效率(SE)等运营效率进行指标构建、测算及时空演进评价。研究发现:首先,国有上市企业样本运营效率:①在时序演进(2015—2017年)方面呈现出先下降后上升的变化趋势;②在空间演进方面呈现出明显的区域分布非均衡性。其次,从行业层面而言,我国房地产及医药行业国有上市企业运营效率相对较高。鉴于此,如何促进不同区位不同行业的国有上市企业协调发展以进一步提高资源配置效率和企业运营效率显得尤为关键。     

Resource utilization and procedure-related costs associated with transfemoral transcatheter aortic valve replacement

Aims: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement for patients with aortic stenosis (AS). This study assessed the impact of changing from a self-expandable (SE) valve to a balloon-expandable (BE) valve on healthcare resource use and procedural costs in a population of inoperable AS patients.

Methods: In this retrospective single center study, data for 195 patients who received either an SE or a BE valve between 2010–2014 were collected. Procedural and post-procedural healthcare resource use and cost parameters were determined for the two groups.

Results: The study showed that overall procedural time, including time required by medical personnel, was significantly shorter for TAVI using a BE compared with an SE valve. Post-surgery, patients in the BE valve group had significantly shorter hospital stays than the SE valve group, including significantly fewer days spent in the intensive care unit (ICU). Additionally, trends towards reduced 30-day mortality, incidence of new permanent pacemaker implantation, and incidence of blood transfusion were observed in the BE valve group compared with the SE valve group. Finally, total procedural costs were 24% higher in the SE compared with the BE valve group.

Limitations: The BE valve data were acquired in a single year, whereas the SE valve data were from a 5-year period. However, a year-by-year analysis of patient characteristics and study outcomes for the SE valve group showed few significant differences over this 5-year period.

Conclusions: Overall, changing from an SE to a BE valve for TAVI in patients with severe AS reduced both healthcare resource use and procedure-related costs, while maintaining patient safety. For healthcare providers, this could increase efficiency and capacity within the healthcare system, with the added advantage of reducing costs.     

Burden of illness for super-refractory status epilepticus patients

Objective: To provide an estimate of the annual number of super-refractory status epilepticus (SRSE) cases in the US and to evaluate utilization of hospital resources by these patients.

Methods: The Premier Hospital Database was utilized to estimate the number of SRSE cases based on hospital discharges during 2012. Discharges were classified as SRSE cases based on an algorithm using seizure-related International Classification of Diseases-9 (ICD-9) codes, Intensive Care Unit (ICU) length of stay (LOS), and treatment protocols (e.g. benzodiazepines, anti-epileptic drugs (AEDs), and ventilator use). Secondary analyses were conducted using more restrictive algorithms for SRSE.

Results: A total of 6,325 hospital discharges were classified as SRSE cases from a total of 5,300,000 hospital discharges. Applying a weighting based on hospital characteristics and 2012?US demographics, this projected to an estimated 41,156 cases of SRSE in the US during 2012, an estimated incidence rate of ～13/100,000 annually for SRSE in the US. Secondary analyses using stricter SRSE algorithms resulted in estimated incidence rates of ～11/100,000 and 8/100,000 annually. The mean LOS for SRSE hospitalizations was 16.5 days (median =11; interquartile range [IQR]?=?6–20), and the mean ICU LOS was 9.3 days (median =6; IQR =3–12). The mean cost of an SRSE hospitalization was $51,247 (median = $33,294; 95% CI = $49,634–$52,861).

Limitations: The analysis uses ICD-9 diagnostic codes and claims information, and there are inherent limitations in any methodology based on treatment protocol, which created challenges in distinguishing with complete accuracy between SRSE, RSE, and SE on the basis of care patterns in the database.

Conclusion: SRSE is associated with high mortality and morbidity, which place a high burden on healthcare resources. Projections based upon the findings of this study suggest an estimated 25,821–41,959 cases of SRSE may occur in the US each year, but more in-depth studies are required.     

CT after enucleation of renal cell carcinoma

Computed tomography (CT) was performed in 28 patients 2 weeks to 120 months after enucleation of renal cell carcinoma. The postoperative defect could be exactly localized in all patients. A wedge-shaped (N = 11) or concave (N = 9) morphology was typical. No dependence between morphology of the defect and localization or size of the tumor or the operative technique was observed. The defects were smaller (1.9 cm) than the original prominent tumors (3.6 cm). Defect size was dependent on the operative technique: closure by suture of the renal capsule in smaller defects or by fat flap in larger ones. Postoperative hematomas or delayed perfusion in the adjacent parenchyma were seen in five patients. Tumor recurrence was correctly diagnosed in one patient.