Few Insurance-Based Differences in Upper Extremity Elective Surgery Rates After Healthcare Reform

Background  

Before the US Patient Protection and Affordable Care Act of 2010, there were documented insurance-based disparities in access to orthopaedic surgeons and care of orthopaedic conditions. While Massachusetts passed healthcare reform in 2007 with many similar provisions, it is unknown whether the disparities were present during the period of the law’s enactment.     

Tomato leaf curl virus from Bangalore (ToLCV-Ban4): sequence comparison with Indian ToLCV isolates, detection in plants and insects, and vector relationships}

Summary.  Tomato leaf curl virus (ToLCV) is a whitefly (Bemisia tabaci) transmitted geminivirus (family Geminiviridae, genus Begomovirus) causing a destructive disease of tomato in many regions of India, East Asia and Australia. While ToLCV isolates from Australia and Taiwan have a single genomic component (designated DNA-A), those from Northern India have two components (DNA-A and DNA-B). The ToLCV isolates from Southern India (Bangalore) previously cloned seem to have a DNA-A-like monopartite genome. We have used degenerate DNA-A-specific PCR primers to clone the genome of a ToLCV isolate (named ToLCV-Ban4) from field-infected tomato plants growing in Bangalore, India, in 1997. Degenerate DNA-B-specific PCR primers have not allowed to amplify a putative DNA-B from infected tomato, at the time when DNA-B fragments were amplified from plants infected by known bipartite begomoviruses. The full-length 2759 nucleotide-long DNA-A-like viral genome was sequenced. Similarly to other monopartite ToLCV and TYLCV isolates, ToLCV-Ban4 contains six open reading frames, two on the virion strand and four on the complementary strand. Sequence comparisons indicated that ToLCV-Ban4 is similar to the other three isolates from Bangalore previously sequenced, and is closely related to ToLCV-Ban2 (approximately 91\% nucleotide sequence identity). Phylogenetic analysis showed that the ToLCV isolates from Bangalore constitute a group of viruses separated from those of Northern India. ToLCV-Ban4 was detected in tomato and in its whitefly vector Bemisia tabaci by one or by a combination of ELISA, Southern blot hybridization and PCR. Parameters of virus acquisition, retention and transmission by the whitefly vector were investigated in the laboratory. Single whiteflies were able to acquire ToLCV-Ban4 from infected tomato and to transmit the virus to tomato test plants, but five insects were necessary to achieve 100% transmission. Minimum acquisition access and inoculation access periods were 10 min and 20 min, respectively. A latent period of 6 h was required for B. tabaci to efficiently infect tomato test plants. Following a 24 h acquisition access period the insect retained its ability to infect tomato test plants for 12 days, but not for its entire life. In one insect/one plant inoculation tests, female whiteflies were more efficient (∼95%) than males (∼25%) in transmitting the virus. Received July 5, 1999 Accepted March 2, 2000     

Traumatic wound dehiscence after deep anterior lamellar keratoplasty

A 5-year-old boy who had undergone deep anterior lamellar keratoplasty (DALK) in the right eye 8 months earlier presented with a full-thickness graft-host junction dehiscence and iris prolapse following an injury with a rubber ball. The junction was resutured and the graft became clear within 5 weeks. To our knowledge, this is the first reported case of wound dehiscence after DALK in a child. Although Descemet's membrane might be considered a protective barrier following DALK, the graft-host junction remains vulnerable and can rupture with blunt trauma.     

Mandated health insurance increases rates of elective knee surgery

BACKGROUND The recent federal ruling to against Affordable Care Act(ACA), specifically the mandate requiring people to buy insurance, has once again brought the healthcare reform debate to the spotlight. The ACA increased the number of insured Americans through the development of subsidized healthcare plans and health insurance exchanges. Insurance-based differences in the rate of upper extremity elective orthopaedic surgery have been described before and after healthcare reform in Massachusetts, where a similar mandate was put into place years before the ACA was passed. However, no comprehensive study has evaluated insurance-based differences of knee elective surgery before and after reform.AIM To investigate how an individual mandate to purchase health insurance affects rates of knee surgery.METHODS A retrospective review was performed within an orthopaedic surgery department at a tertiary-care, academic medical center in Massachusetts. The rate of elective knee surgery performed before and after the healthcare reform(2005-2006 and 2007-2010, respectively) was calculated. The patients were categorized by insurance type(Commonwealth Care, Medicare, Medicaid, private insurance,Workers' Compensation, TriCare, and Uninsured). Using χ2 testing, differences in rates of surgery between the pre-reform and post-reform period and among insurance subgroups were calculated.RESULTS Rate of surgery increased in the post-reform period(pre-reform 8.07%(95%CI:7.03%-9.11%), post-reform 9.38%(95%CI: 8.74%-10.03%)(P = 0.04) and was statistically significant. When the insurance groups and insurance types were compared, the rates of surgery are not significantly different before or after reform.CONCLUSION The increase in the rate of elective knee surgery in the post-reform period suggests that health care reform in Massachusetts has been successful in decreasing the uninsured population and may increase health care expenditures.This is a hypothesis generating study that suggests further avenues of study on how mandated coverage may change healthcare utilization and cost.     

Coronary vascular dysfunction in premenopausal women with diabetes mellitus

Background Diabetes mellitus abolishes the sex differential in coronary artery disease morbidity and mortality in premenopausal women. This finding is independent of other diabetes-associated risk factors, suggesting that other mechanisms such as impaired coronary vascular function may contribute to the increased cardiovascular risk in women with diabetes. The objective of this study was to investigate the effect of diabetes on coronary vascular function in premenopausal women. Methods We studied 13 premenopausal women with diabetes (aged 41 ± 10 years) who were free of overt cardiovascular complications, and 21 control women (12 age-matched and 9 postmenopausal [aged 56 ± 8 years]). We used [¹³N]-ammonia as the flow tracer and positron emission testing to measure myocardial blood flow (MBF) at rest, during maximal hyperemia, and in response to cold pressor testing. Results Baseline MBF was lower in the postmenopausal controls, reflecting the differences in cardiac work and oxygen demand as assessed by the rate-pressure product. However, baseline MBFs were similar in the 3 groups after normalization for differences in the rate-pressure product. During hyperemia, MBF increased and coronary vascular resistance decreased significantly in the 3 groups. However, the increase (from baseline) in MBF in the women with diabetes (164% ± 58%) was less than in the premenopausal controls (258% ± 81%, P = .021), but not significantly different from the postmenopausal control women (204% ± 104%, P = .51). Likewise, the increase in MBF in response to cold pressor testing in the women with diabetes (24% ± 19%) was significantly lower than in the premenopausal controls (60% ± 39%, P = .013), but similar to that in postmenopausal control women (27% ± 15%, P = .97). These differences persisted after adjusting for age and diabetes-associated metabolic abnormalities. Conclusions These results demonstrate reduced coronary vasodilator function and impaired response of resistance vessels to increased sympathetic stimulation in premenopausal women with diabetes, similar to those observed in healthy postmenopausal women in whom the sex differential in coronary artery disease morbidity and mortality is no longer present. (Am Heart J 2002;144:711-8.)     

Outcomes of keratoplasty in a cohort of Indian patients with xeroderma pigmentosum

Purpose:To evaluate the outcomes of keratoplasty for xeroderma pigmentosum (XP) performed at a tertiary eye care center.Methods:A retrospective review of medical records of those patients who were clinically diagnosed to have XP (54 eyes of 36 patients) and underwent keratoplasty; either deep anterior lamellar keratoplasty (DALK, four eyes), endothelial keratoplasty (EK, eight eyes), or penetrating keratoplasty (PK, 42 eyes) from 1994 to 2018.Results:The median age at surgery was 20.6 years (interquartile range [IQR], 14.6–27.6 years) and 20 (55.6%) were males. Graft failure occurred in 15 eyes (35.7%) in the PK group and two eyes (50%) in the DALK group; none failed in the EK group. The probability of graft survival in the PK group was 97.2% ± 2.7% at 1 year, 74.0% ± 8.0% at 2 years, and 54.8% ± 11.7% at 5 years. In the PK group, 13 eyes needed antiglaucoma medications, 11 eyes developed graft infiltrate, and 13 eyes needed secondary interventions (cataract surgery, excision biopsy, and tarsorrhaphy). In the EK group, three eyes needed secondary interventions (excision biopsy). Median postoperative endothelial cell density at the last follow-up in the PK group was 1214 cells/mm² (IQR, 623–2277 cells/mm²).Conclusion:Despite the complexities of the ocular surface and adnexal issues in XP, keratoplasty had reasonably good outcomes. More than half of the PK grafts survived 5 years with no failures in the EK group. Regular follow-up and timely management of suture-related infections raised intraocular pressure, and suspicious ocular surface lesions, in addition to solar protection, are important for the success of keratoplasty in these eyes.     

Clavicle and acromioclavicular joint injuries: a review of imaging,treatment, and complications

Fractures of the clavicle account for 2.6–5% of all fractures. Clavicular fractures have traditionally been treated conservatively, however, there has recently been increased interest in surgical repair of displaced clavicular fractures, with resultant lower rates of nonunion and malunion. Treatment of acromioclavicular (AC) separation has traditionally been conservative, with surgery reserved for patients with chronic pain or significant dislocation and acute soft tissue injury. It is important for the radiologist to become familiar with the surgical techniques used to fixate these fractures as well as the post-operative appearance and potential complications.     

Cardiac Troponin-I: A Predictor of Prognosis in Subarachnoid Hemorrhage

Background  Release of cardiac biomarkers is reported in patients with subarachnoid hemorrhage (SAH). Data addressing the impact of cardiac injury on outcome in these patients is sparse. This study was conducted to ascertain the association of elevation of serum cardiac Troponin-I (cTnI) with mortality and neurological outcome in patients with SAH. Methods  Medical records of all patients admitted with a diagnosis of SAH and at least one measured cTnI were reviewed. Demographic and clinical variables including admission neurological status were collected. Conservative and non-parametric statistics were used to assess association between cTnI and death or neurological outcome at discharge. Results  The study group comprised of 83 patients with a mean age of 59 years. There was a female (60%) and African-American (60%) preponderance. At admission, the median Glasgow Coma Scale (GCS) was 9, and 47% had a severe Hunt–Hess grade (HHG) of ≥4. Elevation of cTnI was found in 31 (37%) patients and was associated with worse baseline Fisher grade (p=0.01) and neurological status: GCS score (p=0.006) and HHG (p=0.007). Patients with abnormal cTnI were more likely to die (55% vs.27%; odds ratio 1.3–8.4, p = 0.01) and had a worse GCS score (p = 0.008) and HHG (p = 0.004) on discharge. On multivariate analysis, peak cTnI (p = 0.04) and admission GCS score of <12 (p = 0.02) were independent predictors of death at discharge. Conclusion  Patients with subarachnoid hemorrhage and elevated cTnI are found to have worse neurological status at admission. These patients have a worse neurological outcome and in-hospital mortality.