Health Care Markets, the Safety Net, and Utilization of Care among the Uninsured

Objective. To quantify the relationship between utilization of care among the uninsured and the structure of the local health care market and safety net.
Data Sources/Study Setting. Nationally representative data from the 1996 to 2000 waves of the Medical Expenditure Panel Survey (MEPS) linked to data from multiple secondary sources.
Study Design. We separately analyze outpatient care utilization and whether an individual incurred any medical expenditure among uninsured adults living in urban and rural areas. Safety net measures include distances between each individual and the nearest safety net providers as well as a measure of capacity based on local government and hospital health expenditures. Other covariates include the managed care presence in the local health care market, the percentage of individuals who are uninsured in the area, and local primary care physician supply. We simulate utilization using standardized predictions.
Principal Findings. Distances between the rural uninsured and safety net providers are significantly associated with utilization. In urban areas, we find that the percentage of individuals in the area who are uninsured, the pervasiveness and competitiveness of managed care, the primary care physician supply, and safety net capacity have a significant relationship with health care utilization.
Conclusions. Facilitating transport to safety net providers and increasing the number of such providers are likely to increase utilization of care among the rural uninsured. Our findings for urban areas suggest that the uninsured living in areas where managed care presence is substantial, and especially where managed care competition is limited, could be a target for policies to improve the ability of the uninsured to obtain care. Policies oriented toward enhancing funding for the safety net and increasing the capacity of safety net providers are likely to be important to ensuring the urban uninsured are able to obtain health care.     

BCL—2蛋白在癫痫过程中海马细胞内的变化

癫痫全面性强直阵挛发作（ＧＴＣＳ）可诱导脑细胞的损伤与修复过程。ＢＣＬ—２蛋白是具有介导多种细胞外信号保护细胞存活的重要的细胞浆蛋白之一。应用流式细胞免疫荧光技术对马桑内酯（ＣＬ）致痫大鼠海马细胞中ＢＣＬ—２蛋白进行检测。结果显示：ＣＬ诱导癫痫发作海马细胞中ＢＣＬ—２蛋白表达增高，发作６小时以内荧光指数（ＦＩ）（１．１２９±０．０４７，ｎ＝７）明显高于对照组（０．９９９±０．０９６，ｎ＝９），Ｐ＜０．００５，６～２４小时组（１．０２６±０．０６５，ｎ＝３）及２４小时以后组（０．９８２±０．０４３，ｎ＝６）ＦＩ回落，Ｐ＞０．０５。提示这种ＢＣＬ—２变化可能对损伤和凋亡细胞具有保护作用。     

Early bioprosthesis failure in mitral valve replacement

The causes of early bioprosthesis failure include infective endocarditis, pannus formation, and structural valve deterioration. We reported a patient who suffered from early mitral bioprosthesis failure due to leaflets restricted by the subvalvular apparatus and early pannus formation. In patients with symptoms relapse and mitral regurgitation recurrence early after mitral valve replacement, early pannus formation needs to be anticipated, and surgical intervention should be performed if symptoms persist after medical treatment.     

Reproductive tract immune cells from pregnant women or those using depot medroxyprogesterone acetate show no excess susceptibility to HIV-1: Results of an ex vivo fusion assay

IntroductionEx vivo fusion assays offer an efficient method for studying HIV-1 entry associated with contraceptive use and pregnancy outside of cohort studies of HIV-1 incidence.MethodsWe measured ex vivo HIV-1 fusion to cervical or endometrial immune cells from three groups of women: pregnant, non-pregnant not using hormonal or intrauterine contraception, and using depot medroxyprogesterone acetate (DMPA).Results and conclusionsThere was no excess susceptibility to HIV-1 fusion of cells from pregnant women or DMPA users compared to controls. Although the number of target cells in endometrium was higher in DMPA users compared to controls, HIV-1 fusion was lower.ImplicationsIn ex vivo assays, HIV-1 showed no enhanced fusion to cervical immune cells from pregnant women or DMPA users compared to controls, and lower fusion to endometrial immune cells from DMPA users. This assay is useful for studying hormonal and contraceptive effects on HIV-1 entry into reproductive tract immune cells.     

Repeat thymectomy in chronic refractory myasthenia gravis

Encouraged by recent results with "extended" thymectomy in the treatment of myasthenia gravis, we carried out repeat thymectomy in six patients with chronic, refractory disease who did not initially have extended thymectomy. All were completely disabled with longstanding myasthenia. Initial thymectomy (four transsternal, one transcervical, and one substernal) was carried out at a mean of 8.9 years previously (range, 5 to 18). There was no residual thymus observed with CT, but at repeat thymectomy, residual thymic tissue was present in five of six patients. Five patients significantly improved and four returned to full-time work. Mean prednisone dose declined from 51 mg to 18 mg/d, and mean pyridostigmine dose fell from 1,290 mg to 415 mg/d. No patient to date has had a complete remission. These results suggest that repeat thymectomy may benefit some patients with chronic disabling myasthenia gravis, especially when it is uncertain from a review of the operative report whether all thymic tissue was removed at the initial thymectomy.     

Relief of compromised translocated right coronary artery blood flow by clockwise rotation of the heart in a Jatene procedure

Saphenous vein graft pseudoaneurysms are an unusual but potentially fatal complication of coronary artery bypass grafting because of their high risk of rupture or thromboembolism. We experienced the case of a 58-year-old man with a saphenous vein graft pseudoaneurysm with a floating thrombus that had developed 17 years after the initial coronary artery bypass grafting. The prevention of thromboembolism during a surgical procedure has been crucial for this type of operation. We developed the idea of in situ revascularization using the right gastroepiploic artery under the beating heart on cardiopulmonary bypass followed by an aneurysmectomy under an arrested heart.