标题: Bloomberg BusinessWeek, Apr 1, 2019 (III) [打印本页] 作者: choi 时间: 4-4-2019 15:28 标题: Bloomberg BusinessWeek, Apr 1, 2019 (III) Ari Altstedter, The World's Cheapest Hospital Has to Get Even Cheaper. (the second of the three feature stories). https://www.bloomberg.com/news/f ... to-get-even-cheaper
Quote:
(a) "A normal heart has the rough dimensions of an apple [a Chinese-language textbook in Taiwan is more precise, says one's heart is about the size of his clenched fist], but the beige and purple mass beating between the man's ribs had inflated to the size of a cantaloupe—the result of clots in his pulmonary artery that were blocking the flow of blood to his lungs. With his own circulatory system effectively strangling him from the inside, his heart had swollen from the effort of keeping him alive. In the West, the condition would almost never be allowed to progress this far. But the patient, an outwardly healthy 31-year-old, lives in a remote city in western India, where doctors had no idea how sick he was. At such a late stage, the only way to save his life was this difficult and dangerous operation at Narayana Health City in Bangalore.
"After the body was cooled to protect against brain damage while the patient's heart was stopped, a nurse dimmed the overhead lights and the junior surgeon stood back, clearing space for Dr Devi Shetty, wearing an LED headlamp and loose dark-blue scrubs, to get to work. Shetty, 65, is tall and lean, with large brown eyes and a high, prominent nose. After collecting himself for a moment, he began digging deep into the pulmonary artery with scissors and forceps to remove the clots one by one, keeping his arms pinned tightly to his sides to reduce unwanted motion. Soft and sticky, the masses kept breaking apart as Shetty tried to secure his hold on them. But slowly the clots emerged, some congealed into floppy circles the size of a quarter, others with tiny arms where they’d branched off into capillaries, like miniature squids. Shetty had almost no margin for error. Miss one, and the whole ordeal would be for nothing; move too aggressively, and a slip could puncture a lung. It took 90 minutes to get them all.
"A pulmonary thromboendarterectomy, the surgery Shetty performed, can tie up an operating room for most of a day. In the US, the procedure can cost more than $200,000. Shetty did it for about $10,000 and turned a profit. A cardiac surgeon by training, Shetty is the founder and chairman of Narayana Health, a chain of 23 hospitals across India that may be the cheapest full-service health-care provider in the world. To American eyes, Narayana’s prices look as if they must be missing at least one zero, even as outcomes for patients meet or exceed international benchmarks. Surgery for head and neck cancers starts at $700. Endoscopy is $14; a lung transplant, $7,000. Even a heart transplant will set a patient back only about $11,000. Narayana is dirt cheap even by Indian standards * * *
(b) "In 2000, Shetty secured a $20 million investment from his father-in-law, the owner of a successful construction business, to create the first Narayana hospital, which would put assembly line surgery into action. (Narayana was the benefactor’s middle name.) Initially focused solely on cardiac procedures, Shetty gradually expanded Narayana's remit to include most major operations and set up regional hospitals that could feed patients with complex conditions into its two largest facilities: the Bangalore flagship and another in Kolkata.
作者: choi 时间: 4-4-2019 15:30
Note:
(a)
(i) summary underneath the title in print: Cancer surgery for $700/ A heart bypass for $2,000. Pretty good, but under India's new health-care system, not good enough.
(ii) Print and the online version are identical.
(b)
(i) I am unsure endless price slashing is the answer, or means, to low cost in healthcare. While I was in Taiwan, in early 1980s a major hospital (which cared about the two Chiang presidents: Veterans General Hospital) had an intractable bacterial infection at surgical wound of many patients coming out of open-heart surgery. The dedicated operating room was shut down, scrubbed and disinfected (including with ultraviolet light). All to no avail. (Of course, cardiac surgeons gid the fact from patients. Unlike in states of America, there was no law or regulation in Taiwan for a hospital to report incidents to a health department.)
(ii) Cove MR et al, Infectious Complications of Cardiac Surgery: A Clinical Review. Journal of Cardiothoracic and Vascular Anesthesia, 26: 1094 (2012; review) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613597/
("INFECTIOUS COMPLICATIONS after cardiac surgery occur in 5% to 21% of cases. Major infectious complications increase postoperative mortality by more than 5 times and prolong recovery. Forty-seven percent of these patients require more than 14 days in the hospital compared with 5.9% (p [probability] < 0.0001) of patients without a major infection. As a result, infectious complications substantially increase the cost of care. * * * The most common sites of infection are the respiratory tract (45.7%-57.8%), the surgical site (27.7%) * * * Surgical site infections (SSIs) after cardiac surgery can present with a wide range of severity. Superficial sternal [the adjective corresponfing to noun sternum 胸骨] wound infections (SSWIs) complicate 0.5% to 8% of cardiac surgery cases and involve the skin, subcutaneous tissue, and pectoralis fascia. Deep sternal wound infections (DSWIs) involve the sternal bone, the substernal space, and the mediastinum7 but are less common than SSWIs, with an incidence ranging between 0.4% and 2%.3,7-10 However, they are the most important and potentially lethal SSI * * * Staphylococcus aureus [金黃色葡萄球菌; found in skin of a healthy human] * * * is the most common cause of DSWIs") (citations omitted).
作者: choi 时间: 4-4-2019 15:33
(c) About quotation (a).
(i) The article does not say what and when caused heart to be of "the size of a cantaloupe." It does specify the treatment: pulmonary thromboendarterectomy (PTE) -- solely for chronic thromboembolic pulmonary hypertension (CTEPH). If a patient survives acute pulmonary embolism, without treatment he had a slight chance to develop CTEPH, one average 18 months later, whose breathlessness worses with time. The rest of (c) is devoted to pulmonary thromboendarterectomy (PTE), the surgical procedure -- as well as CTEPH. Then (d) is about acute pulmonary embolism.
(ii) PTE videos:
(A) UC San Diego Health Performs 4,000th Heart and Lung Surgery. YouTube.com, published by "UC San Diego Health" on Feb 20, 2019 (length: minutes 3:02). https://www.youtube.com/watch?v=nmtmWZ7oUIY
("UC San Diego Health performed its 4,000th pulmonary thromboendarterectomy (PTE), a lifesaving surgery to clear the lung’s arteries of scar-like tissue that robs patients of their ability to breathe. Sheila Holt was the milestone patient and needed the life-saving surgery to treat CTEPH. UC San Diego Health pioneered the surgery and has performed more than any other institute in the world")
There is no need to view it (most of which is talk), except seeing the patient with oxygen tubing (medical term: nasal cannula).
(B) UC San Diego Health's Dr Michael Madani Performs PTE Surgery. YouTube.com, published by "UC San Diego Health" on Feb 21, 2013. https://www.youtube.com/watch?v=opH7efa5Syw
(iii)
(A) The procedure pulmonary thromboendarterectomy (PTE) refers to thromboendarterectomy in pulmonary artery 肺动脉.
endarterectomy (n; from [Latin noun] endarterium [the lining of an artery; from combination of endo- and arterium] + -ectomy [from Ancient Greek -ektomía, "a cutting out of"): "the surgical procedure to remove plaque from an artery" https://en.wiktionary.org/wiki/endarterectomy
Usually it is a plaque (from atherosclerosis 动脉硬化) that is being removed. But the Latin term in fact means removal of things lining the artery.
(B) In a nutshell, the embolus that caused acute pulmonary embolism, when left untreated, had a small chance to -- far from being spontaneously absorbed -- attach itself to the lining of pulmonary artery and becomes scarred itself (now the embolus is called thrombus) and the lining also, damaging the latter in the process. Not to mention that the thing (embolus-turned thrombus) obstructs blood flow, causing right(-sided) heart failure.
(iv) This report is short, about CTEPH and PTE.
Panduranga P and Mukhaini M, An Elderly Man with Pulmonary Hypertension. Annals of Thoracic Medicine, 6: 43 (2011) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3023872/
("A 70-year-old male, non-smoker with no past medical or surgical problems presented with two months history of worsening exertional A 70-year-old male, non-smoker with no past medical or surgical problems presented with two months history of worsening exertional dyspnea [breathless when exercising or even walking]. He denied any history of chest pain, cough or hemoptysis 咳血. * * * right ventricular hypertrophy * * * calculated PA [pulmonary arteries: pulmonary artery and its branches; which is different from blood pressure in arteries of the body] systolic pressure of 80 mmHg [pulmonary hypertension (PH) is defined as higher than 25 mmHg] * * * Incidentally, there was an echogenic mass seen in the right PA suggestive of organized pulmonary thrombus * * * A computed tomography (CT) scan of chest confirmed proximal right PA thrombus [which looks grayish] causing partial obstruction * * * A diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) was made. He was treated with oral anticoagulation for three months, but there was persistence of PA thrombus and PH. He was advised to undergo pulmonary endarterectomy, but he declined. * * * Pulmonary endarterectomy is the first treatment option, followed by chronic oral anticoagulation in inoperable patients")
The authors are Indians from India based in Oman. 作者: choi 时间: 4-4-2019 15:34
(d)
(i) Pulmonary Embolism. Mayo Clinic, undated https://www.mayoclinic.org/disea ... causes/syc-20354647
("Symptoms[:]
• Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion.
• Chest pain. * * *
• Cough. The cough may produce bloody or blood-streaked sputum.
Other signs and symptoms that can occur with pulmonary embolism include: Leg pain or swelling, or both, usually in the calf * * *
Causes[:] Pulmonary embolism occurs when a clump of material, most often a blood clot, gets wedged into an artery in your lungs. These blood clots most commonly come from the deep veins of your legs. This condition is known as deep vein thrombosis (DVT)" )
Thrombosis in deep veins of the calf 小腿 is dislodged, flows up to the heart and wedge in the pulmonary artery (or its branch, whose symptoms are not as dramatic as that lodged in pulmonary artery). The preceding deep vein thrombosis (DVT) explains "leg pain or swelling, or both" in the Mayo quotation.
(ii) Fukuda I and Daitoku K, Surgical Embolectomy for Acute Pulmonary Thromboembolism. Annals of vascular diseases, 10: 107 (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579785/
("The pathophysiological effects of massive or sub-massive PE are hypoxemia due to ventilation-perfusion mismatch and right ventricular failure due to reduced net pulmonary arterial vascular beds")
, which includes a photo of pulmonary embolus, which is dark red, in pulmonary artery. Surgery is not the first choice (unless the patient is dying due to the massive size of embolus); treatment should be first with blood thinner (to dissolve embolus) or catheter (to mechanically remove embolus)