Impact of health care payer type on HIV stage of illness at time of initiation of antiretroviral therapy in the USA

There is evidence that earlier initiation of HIV antiretroviral therapy (ART) is associated with better outcomes, including lower morbidity and mortality. Based on recent studies indicating that Medicaid enrollees are more likely to have suboptimal access to medical care, we hypothesized that HIV severity at time of ART initiation is worse for Medicaid patients than patients with other health care coverage. We conducted a US retrospective analysis of GE Centricity Outpatient Electronic Medical Records spanning 1 January 1997 through 30 September 2009. Subjects included all adult HIV patients initiating first-line ART who had CD4+ results within 90 days pre-initiation. HIV stage was defined using CD4 ranges: >500 (n=520), 351–500 (n=379), 201–350 (n=580), or ≤200 (n=406) cells/mm³, with lower CD4 count being indicative of increased disease severity. Payer type was defined as the patient's primary payer: Medicaid, Medicare, commercial insurance, self-pay or other/unknown. After controlling for demographic and clinical covariates, cumulative logit models assessed the effect of payer type on HIV stage at ART initiation. The study included 1885 subjects with the primary payer being Medicaid (n=218), Medicare (n=330), commercial insurance (n=538), self-pay (n=159) or other/unknown (n=640). Final logit models demonstrated that, compared to patients on Medicaid, the odds of initiating ART at a higher CD4 range were significantly greater for those commercially insured (odds ratio [OR]=1.53; P=0.005), self-paying (OR=1.56; P=0.023) and other/unknown (OR=1.79; P<0.001) and similar for patients enrolled in Medicare (OR=1.11; P=0.521). Medicaid patients initiated ART at a more advanced stage of HIV than patients who were commercially insured, self-paying, or had other/unknown coverage. With HIV treatment guidelines now supporting ART initiation in patients with higher CD4 counts, these findings underscore the need for mitigating barriers, particularly in the Medicaid population, that may delay treatment initiation.     

冠状动脉搭桥术早期并发症及死亡率(附196例报告)

1985年1月～1987年12月作者于荷兰格罗宁根医学科学院心胸外科主做了196例冠状动脉搭桥术。术后早期死亡2例(1.0％)、内出血3例(1.5％)、胸骨裂开2例(1.0％)、心律紊乱40例(20.4％)、围手术期心肌梗塞5例(2.6％),本文就术后早期并发症进行了讨论。     

Apports des explorations vasculaires ultrasonores à l''étude des néphropathies chez l''enfant

The proximity of child's kidneys from the cutaneous surface allows a particularly sensitive exploration by doppler sonography, which in addition has the major advantage of being a non-invasive, non-irradiating and painless technique. However there are two limitations to this technique: the lack of cooperation of some children and the still limited availability of high quality equipment in intensive care units. Indeed most of the applications described in this paper (ie. pyelonephritis, renovascular hypertension, tumors, acute renal insufficiency and renal vein thrombosis) require, besides an experienced operator, expensive power doppler equipment including high frequency and high resolution probes.     

Cardiac tamponade in a preterm neonate secondary to a chest tube

In a preterm infant, chest tubes were inserted for treatment of bilateral pneumothoraces. Hemorrhagic pericardial effusion with cardiac tamponade developed, probably resulting from traumatic injury by the left chest tube. The infant survived due to timely diagnostic and therapeutic intervention. No recurrence of pericardial effusion was seen and follow-up showed normal psychomotor development.