Determinants and Policy Implications of Male Circumcision in the United States

Objective. We sought to determine whether lack of state Medicaid coverage for infant male circumcision correlates with lower circumcision rates.Methods. We used data from the Nationwide Inpatient Sample on 417 282 male newborns to calculate hospital-level circumcision rates. We used weighted multiple regression to correlate hospital circumcision rates with hospital-level predictors and state Medicaid coverage of circumcision.Results. The mean neonatal male circumcision rate was 55.9%. When we controlled for other factors, hospitals in states in which Medicaid covers routine male circumcision had circumcision rates that were 24 percentage points higher than did hospitals in states without such coverage (P < .001). Hospitals serving greater proportions of Hispanic patients had lower circumcision rates; this was not true of hospitals serving more African Americans. Medicaid coverage had a smaller effect on circumcision rates when a hospital had a greater percentage of Hispanic births.Conclusions. Lack of Medicaid coverage for neonatal male circumcision correlated with lower rates of circumcision. Because uncircumcised males face greater risk of HIV and other sexually transmitted infections, lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families covered by Medicaid.Three recent randomized clinical trials in South Africa, Kenya, and Uganda found that male circumcision reduces a man''s risk of becoming infected with HIV through contact with a female partner by 55% to 76%.^1–3 These results are consistent with meta-analyses based on observational studies in Africa^4,5 and the United States.^6,7The recent randomized clinical trial findings prompted the American Academy of Pediatrics (AAP) to form a committee in June 2007 to review its position on male circumcision.⁸ In 1999 the AAP had adopted a neutral stance, stating that the medical benefits were not compelling enough to recommend routine neonatal circumcision. In the wake of the AAP statement, several states withdrew Medicaid coverage for routine, nontherapeutic circumcision. Currently, 16 state Medicaid plans do not cover the procedure. In 2006, legislators in Hawaii and Vermont introduced resolutions challenging the need for state funding of routine male circumcision.⁹In view of the striking results from the African clinical trials, it is timely to examine the impact of US hospital- and state-level policies on domestic rates of male circumcision. In particular, we hypothesized that male circumcision rates would be higher in states in which the Medicaid program pays for routine circumcision.     

Ockham's razor or Hickam's dictum: a right atrial mass following excision of left atrial myxoma

We report a case of a 54-year-old man presenting with a rightatrial mass 7 months after undergoing a left atrial myxoma excisionsurgery. The differential diagnosis included recurrent myxomaor thrombus. The patient underwent repeat open sternotomy oncardiopulmonary bypass. Histopathological evaluation of themass revealed an organizing thrombus. This report is, to ourknowledge, the first that demonstrates right atrial thrombusshortly following excision of left atrial myxoma.     

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.     

Echocardiography and the Aging Heart

Improved understanding of changes in cardiac structure and function related to the aging process is critical to design strategies to reduce the high mortality and morbidity related to cardiovascular disease in the growing elderly population. Echocardiography, as a noninvasive, easily portable imaging technique not requiring radiation or contrast media is an ideal method of imaging the aging heart. Echocardiography has provided important insights into changes in cardiac structure and function occurring with aging. These changes include increased wall thickness and LV mass, increased myocardial fibrosis with resulting changes in diastolic and longitudinal systolic function and degenerative calcification of the left-sided valves. In addition, echocardiography has shown the prognostic importance of elevated LV mass, elevated LA volume and decreases in systolic function in the elderly as well as changes in cardiac structure associated with diseases in the elderly such as dementia and functional disability.     

Folate Levels in Patients Hospitalized with Coronavirus Disease 2019

We aimed to investigate the prevalence of decreased folate levels in patients hospitalized with Coronavirus Disease 2019 (COVID-19) and evaluate their outcome and the prognostic signifi-cance associated with its different levels. In this retrospective cohort study, data were obtained from the electronic medical records at the Sheba Medical Center. Folic acid levels were available in 333 out of 1020 consecutive patients diagnosed with COVID-19 infection hospitalized from January 2020 to November 2020. Thirty-eight (11.4%) of the 333 patients comprising the present study population had low folate levels. No significant difference was found in the incidence of acute kidney injury, hypoxemia, invasive ventilation, length of hospital stay, and mortality be-tween patients with decreased and normal-range folate levels. When sub-dividing the study population according to quartiles of folate levels, similar findings were observed. In conclusion, decreased serum folate levels are common among hospitalized patients with COVID-19, but there was no association between serum folate levels and clinical outcomes. Due to the important role of folate in cell metabolism and the potential pathologic impact when deficient, a follow-up of folate levels or possible supplementation should be encouraged in hospitalized COVID-19 patients. Fur-ther studies are required to assess the prevalence and consequences of folate deficiency in COVID-19 patients.     

Statin Therapy for Primary Prevention in the Elderly and Its Association with New-Onset Diabetes,Cardiovascular Events,and All-Cause Mortality

PurposeThis study assessed associations of the use of statins for primary prevention with cardiovascular outcomes among adults ages ≥70 years.MethodsIn a retrospective population-based cohort study, new users of statins without cardiovascular disease or diabetes mellitus were stratified by ages ≥70 years and <70 years. Using a time-dependent approach, adherence to statins was evaluated according to the proportion of days covered: <25%, 25%-50%, 50%-75%, and ≥75%. We assessed associations of statin therapy with increased risk of new-onset diabetes mellitus and with decreased risks of major adverse cardiovascular events and all-cause mortality.ResultsOf 42,767 new users of statins, 5970 (14%) were ages ≥70 years. The incident rates of major adverse cardiovascular events, all-cause mortality, and new-onset diabetes mellitus in the highest to lowest proportion of days covered categories were 16.9%, 16.7%, and 9.4% and 6.3%, 1.7%, and 9.4%, respectively. For the older group, the adjusted hazard ratios of major adverse cardiovascular events and mortality were significantly decreased for the highest adherence group (proportion of days covered ≥75%): 0.71 (0.57-0.88) and 0.68 (0.54-0.84), respectively. The respective hazard ratios were less favorable for the younger group: 0.80 (0.68-0.93) and 0.74 (0.58-1.03). The risk of new-onset diabetes mellitus was increased for the younger but not the older group.ConclusionsStatin use for primary prevention was associated with cardiovascular benefit in adults ages ≥70 years without a significant risk for the development of diabetes. These data may support the use of statin therapy for primary prevention in the elderly.     

Effect of food deprivation and refeeding on the concentration of vasopressin and oxytocin in discrete hypothalamic sites.

Recent evidence has implicated hypothalamic peptides, such as arginine vasopressin (AVP) and oxytocin (OT) in the control of feeding behavior. In this study, we investigated the impact of food deprivation (48 h) and subsequent refeeding (6 h) on the concentration of AVP and OT in discrete hypothalamic areas, as well as in the neurohypophysis. We also estimated in these rats certain peripheral measures, including hydroelectrolytic parameters, plasma and urine AVP, and plasma corticosterone. The results of this study revealed that food deprivation for 48 h produced little change in OT concentration in the various hypothalamic nuclei studied, including the paraventricular and supraoptic nuclei, with the exception of the median eminence (ME), where a significant decline (-36%; p < 0.05) was detected. This effect was not significantly reversed by 6 h of refeeding. With respect to AVP concentration, food deprivation caused a reliable decline exclusively in the parvocellular subdivision of the paraventricular nucleus (pPVN; -45%; p < 0.01) and in the supraoptic nucleus (SON; -45%; p < 0.01). No change in AVP was detected in the ME or in most other hypothalamic nuclei examined. Refeeding for 6 h actually potentiated the effect of food deprivation, decreasing further from baseline the content of AVP in the pPVN and SON. The only other hypothalamic area to exhibit a change in AVP content was the ventromedial nucleus, where AVP level increased (p < 0.001) after deprivation and declined to normal after 6 h of refeeding. The content of AVP and OT in the neurohypophysis was unaffected by food deprivation and subsequent refeeding.(ABSTRACT TRUNCATED AT 250 WORDS)