Hyperhidrosis is a chronic condition characterised by excessive sweating [1], and can effect up to 3% of the population [2]. It can be classed as generalised; involving all the body’s sweat glands, or localized; affecting specific areas of the body only e.g., palms, soles of feet, groin [3]. The condition is seriously debilitating due to both emotional and social embarrassment. Some patients may also endure physical or occupational disability, hindering their activities of daily living and negatively impacting on their employability [4]. With this in mind it is important to treat patients with successful therapies and ensure adequate follow up is sought after the procedure.

Introduction Reimbursement for Carotid Duplex Ultrasound (CDU) is often tied to indications documented by International Classification of Diseases (ICD) codes. Methods We reviewed the clinical scenario of the initial ICD codes on 550 outpatient CDUs and re-classified them according to appropriateness guidelines and estimated cost savings if all Inappropriate (I) and some Uncertain (U) CDU were eliminated. Results The initial ICD codes were inaccurate in 17.4% and re-classified. In the United States, Medicare incurred charges of $568M and paid $82M for all out-patient CDU in 2011. Discussion Extrapolating from our data, elimination of all I and half of U CDU studies in Medicare patients would result in annual taxpayer savings of $17.5M. A sizeable number of ICD codes provided as indications for outpatient CDU testing are inaccurate based upon a clinician review. Vascular specialists using similar analytics will have to be at the forefront of limiting demand for I or U indications for non-invasive vascular testing. Uwe Reinhardt, a Princeton healthcare economist, has estimated that 20-30% of the 3 trillion dollars in healthcare spending may be without value and can be eliminated without compromising patient care [1]. The Institute of Medicine recently estimated that $210 billion annually is wasted on unnecessary diagnostic tests, procedures and treatment [2]. Until very recently the volume of imaging studies had been growing at a 6% annual rate for Medicare beneficiaries in the United States [3]. The possible reasons for physicians over utilizing imaging studies is evident in a Rand Corporation study, which showed that 85% of emergency department physicians perceived that unnecessary imaging studies were done mainly for fear of missing low probability diagnoses and fear of litigation [4]. In response to payer and media pressure, there is a national grass roots movement by all healthcare professionals which, seeks to protest healthcare overutilization and misuse [5]. Reimbursement by Medicare for Carotid Duplex Ultrasound (CDU) is tied to indications as documented by International Classification of Diseases (ICD) codes. Indications for CDU have been classified as Appropriate (A), Uncertain (U), or Inappropriate (I) by multi-specialty guidelines [6]. We hypothesized that a significant proportion of ICD codes offered as indications for CDU testing in the medical record were being performed for U or I indications. Therefore, we sought to validate the initial ICD codes for CDU by a clinician review of the medical record, re-classify the revised ICD codes according to appropriateness, and estimate the cost savings for Medicare if CDU for I and some U indications were eliminated.

Objective Great Saphenous Veins (SVs) are widely used in coronary and in non-coronary surgery, and the need for vascular transplants is increasing. In older pre¬servation solutions, hypothermia leads to damage induced by reactive oxygen species. Iron chelators in the newer Tissue Protection (TiProtec) solution shall par¬ticularly protect vessels by preventing from that damage. It was the aim to compare three preservation solutions to maintain function and viability of human SVs. Methods Vein segments were randomly assigned to Krebs-Henseleit Buffer (KHB), Viaspan (UW), or TiProtec. Contraction/relaxation in organ baths was assessed at 3, 24, 48 and 72h after removal. The protocol included three steps: receptor-independent contraction (KCl: 80µM), receptor-dependent contraction (PE: =30µM), endothelium-dependent relaxation (ACh: =20µM). Morphology: Vein segments were incubated with propidium iodide and 5-chloromethylfluorescein diacetate. Viability was assessed with fluorescence using laser scanning microscopy. Results KHB was inappropriate after only 3h. In TiProtec, SVs contraction/rela¬xa¬tion had increased further at 72h, but not in both other groups. More necrosis was found in KHB SVs than in UW or TiProtec at 3h. More viable cells were found in UW and in TiProtec SVs on day-1, while only few cells were viable in KHB on day-10. Summary and conclusion Even short storage of SVs in KHB is deleterious. UW preserved func¬tion better over time. The best functional and morphological results yielded TiProtec over time, and the amount of viable cells correlated with function. TiProtec seems a promising alternative for short- and mid-term hypothermic vein preservation.

Introduction and Objectives: There is constant pressure on Vascular Laboratories (VL) to produce accurate and timely testing. Others have studied cost savings related to reducing unnecessary venous duplex testing and after hour studies; however, little has been written regarding Upper Extremity Arterial Duplex (UEAD) and reduction of unnecessary testing. As transradial interventions increase in frequency, so too will UEAD. By evaluating the indications for the studies and the results, we hope to identify a subset of patients for whom UEAD testing is specifically indicated. Methods: We queried our prospectively maintained database for all UEAD performed between January, 2006 and December, 2013. We excluded tests for which the Testing Indications (TI) was not clearly noted or unrelated. UEAD were then separated broadly based on TI into objective or subjective findings, and then further subcategorized based on the specifics of the TI. The results of the UEAD were categorized as positive (abnormal) or negative (normal). Statistical analysis was performed with Chi Squared for nominal categorical data. Results: Overall 130 (35%) of 368 UEAD had positive (abnormal) findings. There was no difference in the number of abnormal UEAD when categorized broadly into objective or subjective indications (36% vs. 34%, p=0.4). When subdivided by their more specific indications, UEAD whose TI were findings such as a pulse deficit or bruit had the highest rate of abnormal tests. When the TI was for a presumed complication without objective findings, the UEAD displayed had the lowest rates of abnormal findings. Conclusion: Abnormal UEAD is found more often in patients who have objective findings on physical examination than, pre-existing diagnosis of vascular disease, or presumed complications without objective findings. However, not all objective findings were found to be highly correlated with abnormal UEAD. With further studies of patient characteristics we can develop guidelines for eliminating unnecessary UEAD.

Objective: To evaluate the compliance of our diagnosis and therapeutic procedures with international recommendations. Patients and methods: This is a retrospective study over a period of 5 years that included all patients admitted with suspected PE and those with Pulmonary Embolism (PE) confirmed prior to admission. Diagnostic and therapeutic procedures were based on those recommendations. We studied the compliance with the latest recommendations of management of the PE and search the factors of non-compliance at each stage. Results: 206 adult patients were selected. The Wells score compliance was 84.15% with a right evaluation method in 90%. The compliance for DD use was 69.11% with lack of dosage in 13% and wrong use in 26%. The realization of Pulmonary Computer Tomography (ASCP) was marked by a compliance rate of 73.13% with a missing utilization in 11.7% and 33.3% of wrong realization in patients who did not need ASCP. Among the 206 patients included, the PE was confirmed in 120 patients (58%), and reversed in 40 patients (20%) and unqualified in 46 patients (22%). In patients with PE overturned all showed clinical low and middle probability and the denial of the PE processes were non-compliant in 60 % of cases. Risk level stratification was made in 26.67% of patients with confirmed PE and its assessment was consistent with the recommendations in 87.5% of cases. Thrombolytic therapy was performed in 2 out of 4 patients with a high risk taking into account the existence of absolute contraindications and financial limitation. VKA were introduced in 92.50% of cases. In 55.85% of cases, their introduction was early and the treatment duration was specified in single patient. Conclusion: Diagnostic and therapeutic procedures of the PE at the cardiologic department of CNHU HKM by international recommendations are met but efforts are still needed regarding their optimal use.