Health care disparities in the acute management of venous thromboembolism based on insurance status in the U.S.

Acute venous thromboembolism (VTE) is common, costly, and potentially lethal. Therapeutic anticoagulation requires timely, closely monitored medical follow-up. If ineffective, clinical outcomes worsen and resource utilization increases. This risk may be magnified in uninsured patients. This study examined VTE care in hospital patients and investigated differences based on insurance status. We performed a retrospective chart review on medical VTE patients at an academic teaching hospital between December 1, 2007 and April 30, 2009. We reviewed medical records for demographics, insurance, admission status, length of stay (LOS), and 30-day Emergency Department (ED) recidivism and hospital readmission. Measured outcomes were analyzed based on payer source. We identified 234 medical VTE patients; 67 patients were uninsured (28.6%). 106 patients (45.3%) presented with deep vein thrombosis only. Most VTE patients were admitted to the hospital (171; 73.1%), including all 128 pulmonary embolism patients. Admitted uninsured patients averaged a LOS of 5.5 versus 3.7 days for insured (P = 0.03), with ED recidivism rates of 26.1 versus 11.3%, respectively (P = 0.02). Average cost for all VTE care in uninsured patients was $12,297 versus $7,758 for insured patients (P = 0.04). This study identified disparities in medical care and resource utilization for medical VTE patients based on insurance. Uninsured VTE patients were hospitalized nearly two additional days and were more than two times as likely to return to the ED within 30 days compared to insured patients. Additional research is needed to explain these disparities, and to explore system improvements for the uninsured VTE patient.

Mental retardation and sentences for murder: comparison of two recent court cases.

Several states and the United States have laws that exempt persons who have mental retardation from the death penalty and other severe sentences. Two recent murder cases in Indiana, which has such a law, illustrate some of the problems in applying it. The characteristics of the two defendants were quite similar, but one defendant was found to have mental retardation and was exempted from the death penalty and the other was not. The disparity was attributed to differences in the assessment of adaptive behavior and to general stereotypes of people who have mental retardation. Equal application of sentencing limitation laws requires greater involvement of professionals with specialized training and experience in mental retardation.

A PAF receptor antagonist, BN 52021, attenuates thromboxane release and improves survival in lethal canine endotoxemia.

Platelet-activating (PAF) is a putative mediator in endotoxemia and sepsis. Administration of a PAF receptor antagonist prior to endotoxin improves survival in rats and attenuates the hypotension of endotoxemia. Both PAF and endotoxin stimulate eicosanoid production. We hypothesized that a PAF receptor antagonist, BN 52021, would alter the hemodynamic events, improve the survival and attenuate the eicosanoid release associated with endotoxemia in a resuscitated, but lethal, canine model. Male dogs were randomzied to two groups (n = 10 each). Group I received only E. coli endotoxin, 1 mg/kg IV, at time 0, while group II received BN 52021, 5 mg/kg IV, 30 min before and again 240 min after endotoxin treatment. During the 4-h study period, hemodynamics were measured and blood samples were taken at 0, 2, 60, 120, and 240 min. Survival was determined at 24, 48, and 72 h. All group I animals died before 24 h; all group II lived longer than 72 h (P less than 0.05). In group I, plasma TXB2 values increased from a baseline value of 0.26 +/- .04 ng/ml to 4.38 +/- 1.56 ng/ml at 120 min and then decreased to 2.64 +/- .96 ng/ml by 240 min. For group II, respective plasma TXB2 values were 0.35 +/- 0.13 ng/ml at baseline, 0.58 +/- 0.14 ng/ml at 120 min, and 0.39 +/- .09 ng/ml at 240 min. At the 120-min and 240-min time points, the groups differed at P less than 0.05. Heart rate tended to be less in group II, but MAP was unaffected. In group I, pH values were more acidotic than those observed in group II.

Platelet activating factor receptor antagonist improves survival and attenuates eicosanoid release in severe endotoxemia.

Exogenous platelet activating factor (PAF) causes hypotension, plasma extravasation, metabolic acidosis, and death. These effects are similar to those of endotoxin as well as the eicosanoids. A specific PAF receptor antagonist, BN52021, was used to determine its effects on the hemodynamic events, the eicosanoid production, and on survival in severe rat endotoxemia. Endotoxin alone significantly produced hypotension, prostaglandins (TxB2, PGE2) release, and death. In contrast pretreatment with BN52021, a specific PAF receptor antagonist, significantly altered the hypotension, significantly attenuated the eicosanoid release, and improved the survival rate (p less than 0.01). These findings suggest that PAF receptor activation is an early event in endotoxemia. Eicosanoid release in endotoxemia could be related to PAF synthesis and PAF receptor activation. These findings support the hypothesis that there may be an intimate relationship between PAF and the eicosanoids and that in endotoxemia some of the effects of PAF may be mediated via the cyclo-oxygenase pathway.