RESUMO
Surgeon providers and billing professionals use Current Procedural Terminology (CPT) codes to specify patient treatment and associated charges. In the present study, coding discrepancies between surgeons' first pass coding and employed coders' final codes were investigated. A total of 500 patients over 3 months were retrospectively analyzed for coding discrepancies. To quantify the impact of change, codes with the most accumulated discrepancies were studied and change to annual relative value unit (RVU) was determined. Final submission of codes to billing demonstrated a 161% increase in total codes by the professional coders, versus original surgeon-derived codes (1594 vs 987 CPT codes). The most common source of change between the surgeon and coder was the addition of distinct codes by the billing professional (270 patients, 54.51%). These results demonstrate the existence of coding discrepancies. Future investigation will evaluate the communication between surgeons and billing professionals.
Assuntos
Current Procedural Terminology , Cirurgiões , Humanos , Estudos RetrospectivosRESUMO
IMPORTANCE: United States government personnel experienced potential exposures to uncharacterized directional phenomena while serving in Havana, Cuba, from late 2016 through May 2018. The underlying neuroanatomical findings have not been described. OBJECTIVE: To examine potential differences in brain tissue volume, microstructure, and functional connectivity in government personnel compared with individuals not exposed to directional phenomena. DESIGN, SETTING, AND PARTICIPANTS: Forty government personnel (patients) who were potentially exposed and experienced neurological symptoms underwent evaluation at a US academic medical center from August 21, 2017, to June 8, 2018, including advanced structural and functional magnetic resonance imaging analytics. Findings were compared with imaging findings of 48 demographically similar healthy controls. EXPOSURES: Potential exposure to uncharacterized directional phenomena of unknown etiology, manifesting as pressure, vibration, or sound. MAIN OUTCOMES AND MEASURES: Potential imaging-based differences between patients and controls with regard to (1) white matter and gray matter total and regional brain volumes, (2) cerebellar tissue microstructure metrics (eg, mean diffusivity), and (3) functional connectivity in the visuospatial, auditory, and executive control subnetworks. RESULTS: Imaging studies were completed for 40 patients (mean age, 40.4 years; 23 [57.5%] men; imaging performed a median of 188 [range, 4-403] days after initial exposure) and 48 controls (mean age, 37.6 years; 33 [68.8%] men). Mean whole brain white matter volume was significantly smaller in patients compared with controls (patients: 542.22 cm3; controls: 569.61 cm3; difference, -27.39 [95% CI, -37.93 to -16.84] cm3; P < .001), with no significant difference in the whole brain gray matter volume (patients: 698.55 cm3; controls: 691.83 cm3; difference, 6.72 [95% CI, -4.83 to 18.27] cm3; P = .25). Among patients compared with controls, there were significantly greater ventral diencephalon and cerebellar gray matter volumes and significantly smaller frontal, occipital, and parietal lobe white matter volumes; significantly lower mean diffusivity in the inferior vermis of the cerebellum (patients: 7.71 × 10-4 mm2/s; controls: 8.98 × 10-4 mm2/s; difference, -1.27 × 10-4 [95% CI, -1.93 × 10-4 to -6.17 × 10-5] mm2/s; P < .001); and significantly lower mean functional connectivity in the auditory subnetwork (patients: 0.45; controls: 0.61; difference, -0.16 [95% CI, -0.26 to -0.05]; P = .003) and visuospatial subnetwork (patients: 0.30; controls: 0.40; difference, -0.10 [95% CI, -0.16 to -0.04]; P = .002) but not in the executive control subnetwork (patients: 0.24; controls: 0.25; difference: -0.016 [95% CI, -0.04 to 0.01]; P = .23). CONCLUSIONS AND RELEVANCE: Among US government personnel in Havana, Cuba, with potential exposure to directional phenomena, compared with healthy controls, advanced brain magnetic resonance imaging revealed significant differences in whole brain white matter volume, regional gray and white matter volumes, cerebellar tissue microstructural integrity, and functional connectivity in the auditory and visuospatial subnetworks but not in the executive control subnetwork. The clinical importance of these differences is uncertain and may require further study.
Assuntos
Encéfalo/patologia , Empregados do Governo , Doenças do Sistema Nervoso/diagnóstico por imagem , Adulto , Encéfalo/anatomia & histologia , Encéfalo/diagnóstico por imagem , Estudos de Casos e Controles , Cuba , Imagem de Difusão por Ressonância Magnética , Feminino , Substância Cinzenta/anatomia & histologia , Substância Cinzenta/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Doenças do Sistema Nervoso/etiologia , Ruído/efeitos adversos , Tamanho do Órgão , Valores de Referência , Estados Unidos , Substância Branca/anatomia & histologia , Substância Branca/diagnóstico por imagemRESUMO
Importance: From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. Objective: To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Design, Setting, and Participants: Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Exposures: Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Main Outcomes and Measures: Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Results: Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n = 16, 76%), vestibular (n = 17, 81%), and oculomotor (n = 15, 71%) abnormalities. Moderate to severe sensorineural hearing loss was identified in 3 individuals. Pharmacologic intervention was required for persistent sleep dysfunction (n = 15, 71%) and headache (n = 12, 57%). Fourteen individuals (67%) were held from work at the time of multidisciplinary evaluation. Of those, 7 began graduated return to work with restrictions in place, home exercise programs, and higher-level work-focused cognitive rehabilitation. Conclusions and Relevance: In this preliminary report of a retrospective case series, persistent cognitive, vestibular, and oculomotor dysfunction, as well as sleep impairment and headaches, were observed among US government personnel in Havana, Cuba, associated with reports of directional audible and/or sensory phenomena of unclear origin. These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma.
Assuntos
Empregados do Governo , Perda Auditiva Neurossensorial/etiologia , Doenças do Sistema Nervoso/etiologia , Ruído/efeitos adversos , Transtornos Somatoformes/etiologia , Adulto , Encéfalo/diagnóstico por imagem , Concussão Encefálica/diagnóstico , Concussão Encefálica/etiologia , Cuba , Diagnóstico Diferencial , Feminino , Cefaleia/etiologia , Perda Auditiva Neurossensorial/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/reabilitação , Neuroimagem , Testes Neuropsicológicos , Doenças do Nervo Oculomotor/etiologia , Equilíbrio Postural , Transtornos de Sensação/etiologia , Transtornos Somatoformes/diagnóstico , Transtornos Somatoformes/reabilitação , Estados UnidosRESUMO
Dentofacial deformities have a marked impact on a patient's quality of life. Fortunately, these deformities often can be corrected through orthodontic and surgical treatment. In adults, transverse maxillary discrepancies are often corrected by performing a surgically assisted rapid palatal expansion (SARPE) procedure. This procedure is accompanied by many of the same complications involved in performing a Le Fort I osteotomy. Although major complications from maxillary surgery are uncommon, severe hemorrhage and cerebrovascular accidents are real risks accompanied by serious sequelae. The purpose of this case report is to describe a case in which a patient developed a massive middle cerebral artery infarct after a SARPE procedure. The authors discuss the possible etiology and pathogenesis of the complication. They also aim to remind surgeons of this rare complication to ensure prompt recognition and management to prevent delays in care.