Trends In Medical And Pharmacy Spending In The Affordable Care Act Markets, 2015-19.

To control rising costs, it is critical for payers, providers, and policy makers to understand trends in health care spending. Using data from both on- and off-exchange Affordable Care Act (ACA)-compliant small-group and individual insurance markets in the United States for the period 2015-19, we analyzed the contributions of trends in utilization, unit price, and service mix to growth in overall health care spending. Overall annual growth trends in health care spending per member per month during that period were 4.0 percent in the small-group market and 1.1 percent in the individual market. In the small-group market, professional and outpatient facility services contributed the most to spending growth, driven by unit price increases. In the individual market, pharmacy and outpatient facility services accounted for the greatest growth in spending, driven by a combination of unit price increases and changes in the mix of services. Addressing these contributors to growth can help contain costs and premiums and provide more stability to ACA-compliant insurance markets.

A 4-Year Retrospective Claims Analysis of Oral Corticosteroid Use and Health Conditions in Newly Diagnosed Medicare FFS Patients with COPD.

Purpose: We analyzed population-level administrative claims data for Medicare fee-for-service (FFS) beneficiaries to provide insights on systemic oral corticosteroid (OCS) use patterns and associated health conditions and acute events among patients newly diagnosed with chronic obstructive pulmonary disease (COPD). Background: COPD is a progressive inflammatory disease of the lungs, characterized by acute exacerbations that may lead to increased mortality. Short courses of systemic corticosteroids (SCS) are recommended to reduce recovery time from exacerbations, although SCS use has been associated with increased risk of adverse events. Methods: This study used 2013-2019 Medicare 100% FFS research identifiable files, which contain all Medicare Parts A, B, and D paid claims incurred by 100% of Medicare FFS beneficiaries. Descriptive statistics for patients newly diagnosed with COPD were analyzed, including OCS use, select health conditions and acute events, and COPD exacerbations. Statistical models were used to analyze the relationship between the incidence of select health conditions and events and cumulative OCS dosage. Results: Of Medicare FFS patients newly diagnosed with COPD, 36% received OCS in the 48 months following diagnosis, and 38% of OCS episodes lasted longer than the recommended 5-7 days. Patients had a variety of health conditions or acute events in the 24-month period prior to new COPD diagnosis, such as hypertension, depression/anxiety, type 2 diabetes, or osteoporosis, that could heighten the risks of OCS use. Patients treated with >1000 mg of prednisolone equivalent OCS in the 48 months following COPD diagnosis had a higher incidence of new conditions or events, including cardiovascular disease, heart failure, hypertension, obesity, dyspepsia, infections, and depression/anxiety, than patients with no OCS use. Conclusion: These results highlight the potential risks of OCS in COPD treatment, including prolonged use among complex Medicare patients, and reinforce the importance of preventive treatment strategies and therapy optimization early in the disease course.

Single-dose lidocaine spinal anesthesia in hip and knee arthroplasty.

BACKGROUND: With the increasing interest in fast recovery and outpatient joint arthroplasty, short-acting local anesthetic agents and minimal narcotic use are preferred. Lidocaine is a fast-onset, short-duration local anesthetic that has been used for many years in spinal anesthesia. However, lidocaine spinal anesthesia has been reported to have a risk of transient neurologic symptoms (TNSs). The purpose of this study is to determine the safety and efficacy of single-dose lidocaine spinal anesthesia in the setting of outpatient joint arthroplasty. METHODS: We performed a prospective study on 50 patients who received lidocaine spinal anesthesia in the setting of outpatient hip and knee arthroplasty. All patients received a single-shot spinal injection, with 2% isobaric lidocaine along with titrated propofol sedation. We evaluated demographic data, length of motor blockage, time to ambulation, time to discharge readiness, patient-reported symptoms of TNS. RESULTS: Of the 50 patients studied, 11 had total hip arthroplasty, 33 total knee arthroplasty, 5 unicompartmental knee arthroplasty, and 1 underwent isolated polyethylene liner exchange in a total knee arthroplasty. The average total duration of motor blockade was 2.89 hours (range 1.73-5.17, standard deviation 0.65). Average time from postanesthesia care unit to return of motor function was 0.58 hours (range 0-1.5, standard deviation 0.48). None of the patients reported TNS. CONCLUSIONS: Isobaric lidocaine spinal anesthesia appears to be a safe and effective regimen for outpatient hip and knee arthroplasty. All patients were discharged on the day of surgery with isobaric lidocaine spinal injection. There were no reports of TNSs.

Primary Retrograde Tibiotalocalcaneal Nailing For Fragility Ankle Fractures.

BACKGROUND: Ankle fragility fractures are difficult to treat due to poor bone quality and soft tissues as well as the near ubiquitous presence of comorbidities including diabetes mellitus and peripheral neuropathy. Conventional open reduction and internal fixation in this population has been shown to lead to a significant rate of complications. Given the high rate of complications with contemporary fixation methods, the present study aims to critically evaluate the use of acute hindfoot nailing as a percutaneous fixation technique for high-risk ankle fragility fractures. METHODS: In this study, we retrospectively evaluated 31 patients treated with primary retrograde tibiotalocalcaneal nail without joint preparation for a mean of 13.6 months postoperatively from an urban Level I trauma center during the years 2006-2012. RESULTS: Overall, there were two superficial infections (6.5%) and three deep infections (9.7%) in the series. There were 28 (90.3%) patients that went on to radiographic union at a mean of 22.2 weeks with maintenance of foot and ankle alignment. There were three cases of asymptomatic screw breakage observed at a mean of 18.3 months postoperatively, which were all treated conservatively.. CONCLUSIONS: This study shows that retrograde hindfoot nailing is an acceptable treatment option for treatment of ankle fragility fractures. Hindfoot nailing allows early weightbearing, limited soft tissue injury, and a relatively low rate of complications, all of which are advantages to conventional open reduction internal fixation techniques. Given these findings, larger prospective randomized trials comparing this treatment with conventional open reduction internal fixation techniques are warranted.

High-Fat Diet Alters the Orosensory Sensitivity to Fatty Acids in Obesity-Resistant but not Obesity-Prone Rats.

Gene-environment interactions play a role in the development of obesity but specific effects of diet on the orosensory detection of fatty acids have yet to be clarified. The objective of this study is to characterize the effect of prolonged (5-week) exposure to a high-fat (60%) diet on the behavioral sensitivity to the fatty acid linoleate following a conditioned taste aversion in obesity-prone and obesity-resistant rats. Exposure to the high-fat diet significantly enhanced the sensitivity of obesity-resistant (S5B/Pl) rats to linoleate while producing no effect on the fatty acid sensitivity for obesity-prone rats. Specifically, high-fat diet fed S5B/Pl rats showed stronger initial avoidance of linoleate and slower extinction rates than their normal diet cohorts. Our study suggests that prolonged dietary fat consumption may alter the behavioral sensitivity to fatty acids particularly in obesity-resistant animals.

Robotic guidance does not improve component position or short-term outcome in medial unicompartmental knee arthroplasty.

We performed a retrospective review in a matched group of patients on the use of robotic-assisted UKA implantation versus UKA performed using standard operative techniques to assess differences between procedures. While both techniques resulted in reproducible and excellent outcomes with low complication rates, the results demonstrate little to no clinical or radiographic difference in outcomes between cohorts. Average operative time differed significantly with, and average of 20 minutes greater in, the robotic-assisted UKA group (P=0.010). Our minimal clinical and radiographic differences lend to the argument that it is difficult to justify the routine use of expensive robotic techniques for standard medial UKA surgery, especially in a well-trained, high-volume surgeon. Further surgical, clinical and economical study of this technology is necessary.

Safety of bilateral total knee arthroplasty in morbidly obese patients.

There has been an increase in the prevalence of morbid obesity and the demand for total knee arthroplasty (TKA). Physicians must help patients with bilateral knee arthritis to make informed decisions regarding whether to undergo staged, sequential, or simultaneous TKA. The purpose of this study was to evaluate the perioperative complications of 2-team simultaneous bilateral TKA in the morbidly obese. The authors performed a retrospective review of the records at a single tertiary hospital from 1997 to 2007 and identified 35 morbidly obese (body mass index [BMI] greater than 40 kg/m(2)) patients who had undergone unilateral TKA, as well as 42 morbidly obese and 79 nonobese (BMI less than 30 kg/m(2)) patients who underwent simultaneous bilateral TKA. Clinical, operative, and postoperative variables and complication rates were recorded. Clinical variables were similar between the morbidly obese TKA patients. The bilateral group had significantly increased operative times (132.4 vs 115.5 minutes; P<.01), intravenous fluids (2556.1 vs 2114.7 mL; P=.03), percentage transfused (64.2% vs 11.4%; P<.01), days in the hospital (3.6 vs 3.2 days; P=.03), and discharge rates to rehabilitation facility (72.7% vs 48.6%; P=.01). Major and minor complications were few and comparable, with the need for manipulation under anesthesia in unilateral TKA (11.4%; P=.04) as the only significant difference between groups, including when comparing bilateral nonobese TKAs with bilateral morbidly obese TKAs. The authors feel that morbidly obese patients may undergo 2-team simultaneous bilateral TKA after careful discussion regarding some of the differences in short-term outcomes.

Investigation of free fatty acid associated recombinant membrane receptor protein expression in HEK293 cells using Raman spectroscopy, calcium imaging, and atomic force microscopy.

G-protein-coupled receptor 120 (GPR120) is a previously orphaned G-protein-coupled receptor that apparently functions as a sensor for dietary fat in the gustatory and digestive systems. In this study, a cDNA sequence encoding a doxycycline (Dox)-inducible mature peptide of GPR120 was inserted into an expression vector and transfected in HEK293 cells. We measured Raman spectra of single HEK293 cells as well as GPR120-expressing HEK293-GPR120 cells at a 48 h period following the additions of Dox at several concentrations. We found that the spectral intensity of HEK293-GPR120 cells is dependent upon the dose of Dox, which correlates with the accumulation of GPR120 protein in the cells. However, the amount of the fatty acid activated changes in intracellular calcium (Ca(2+)) as measured by ratiometric calcium imaging was not correlated with Dox concentration. Principal components analysis (PCA) of Raman spectra reveals that the spectra from different treatments of HEK293-GPR120 cells form distinct, completely separated clusters with the receiver operating characteristic (ROC) area of 1, while those spectra for the HEK293 cells form small overlap clusters with the ROC area of 0.836. It was also found that expression of GPR120 altered the physiochemical and biomechanical properties of the parental cell membrane surface, which was quantitated by atomic force microscopy (AFM). These findings demonstrate that the combination of Raman spectroscopy, calcium imaging, and AFM may provide new tools in noninvasive and quantitative monitoring of membrane receptor expression induced alterations in the biophysical and signaling properties of single living cells.

Intramedullary rod fixation of fibrous dysplasia without use of bisphosphonates.

PURPOSE: Controversy exists regarding approach to treatment of pediatric patients with fibrous dysplasia. METHODS: We retrospectively reviewed medical records of seven patients who were treated at our institution for fibrous dysplasia by intramedullary rod fixation without bisphosphonate supplementation. RESULTS: Seven patients with a total of ten fibrous dysplasia lesion sites surgically treated by intramedullary rod fixation were included. Of these ten lesion sites, eight demonstrated pathologic fracture at the time of fixation. Complete fracture healing was observed in all eight sites, with no incidence of recurrent pathologic fractures examined radiographically. There were no major infections or neurologic deficits, and lesions appeared to stabilize. CONCLUSIONS: In this series, intramedullary rod fixation proved to be successful in treatment of acute pathologic fracture and incompletely healed fibrous dysplasia lesions. We observed partial resolution of fibrous dysplasia lesions at all ten sites without significant long-term complications. Following treatment, there were no refractures. LEVEL OF EVIDENCE: Level IV, case series.

Activation of oral trigeminal neurons by fatty acids is dependent upon intracellular calcium.

The chemoreception of dietary fat in the oral cavity has largely been attributed to activation of the somatosensory system that conveys the textural properties of fat. However, the ability of fatty acids, which are believed to represent the proximate stimulus for fat taste, to stimulate rat trigeminal neurons has remained unexplored. Here, we found that several free fatty acids are capable of activating trigeminal neurons with different kinetics. Further, a polyunsaturated fatty acid, linoleic acid (LA), activates trigeminal neurons by increasing intracellular calcium concentration and generating depolarizing receptor potentials. Ion substitution and pharmacological approaches reveal that intracellular calcium store depletion is crucial for LA-induced signaling in a subset of trigeminal neurons. Using pseudorabies virus (PrV) as a live cell tracer, we identified a subset of lingual nerve-innervated trigeminal neurons that respond to different subsets of fatty acids. Quantitative real-time PCR of several transient receptor potential channel markers in individual neurons validated that PrV labeled a subset but not the entire population of lingual-innervated trigeminal neurons. We further confirmed that the LA-induced intracellular calcium rise is exclusively coming from the release of calcium stores from the endoplasmic reticulum in this subset of lingual nerve-innervated trigeminal neurons.

TRPM5 is critical for linoleic acid-induced CCK secretion from the enteroendocrine cell line, STC-1.

Fatty acid-induced stimulation of enteroendocrine cells leads to release of the hormones such as cholecystokinin (CCK) that contribute to satiety. Recently, the fatty acid activated G protein-coupled receptor GPR120 has been shown to mediate long-chain unsaturated free fatty acid-induced CCK release from the enteroendocrine cell line, STC-1, yet the downstream signaling pathway remains unclear. Here we show that linoleic acid (LA) elicits membrane depolarization and an intracellular calcium rise in STC-1 cells and that these responses are significantly reduced when activity of G proteins or phospholipase C is blocked. LA leads to activation of monovalent cation-specific transient receptor potential channel type M5 (TRPM5) in STC-1 cells. LA-induced TRPM5 currents are significantly reduced when expression of TRPM5 or GPR120 is reduced using RNA interference. Furthermore, the LA-induced rise in intracellular calcium and CCK secretion is greatly diminished when expression of TRPM5 channels is reduced using RNA interference, consistent with a role of TRPM5 in LA-induced CCK secretion in STC-1 cells.

Exposure to bushfire smoke during prescribed burns and wildfires: firefighters' exposure risks and options.

Firefighters are exposed to known health-damaging air pollutants present in bushfire smoke and poorly managed exposure can result in serious health issues. A better understanding of exposure levels and the major factors influencing exposures is crucial for the development of mitigation strategies to minimise exposure risks and adverse health impacts. This study monitored air toxics within the breathing zone of firefighters at prescribed burns and at wildfires in Australia. The results showed that exposure levels were highly variable, with higher exposures (sometimes exceeding occupational exposure standards) associated with particular work tasks (such as patrol and suppression) and with certain burn conditions. The majority of firefighter's exposures were at low and moderate levels (~60%), however considerable attention should be given to the high (~30%) and very high (6%) exposure risk situations for which acute and chronic health risks are very likely and for which control strategies should be developed and implemented to minimise health risks.

Orosensory detection of fatty acids by obesity-prone and obesity-resistant rats: strain and sex differences.

A series of brief-access (15s) behavioral assays following the formation of a conditioned taste aversion (CTA) to linoleic acid were performed in order to follow up on observations showing differences in the chemosensory responses to dietary fat in obesity-prone (Osborne-Mendel [O-M]) and obesity-resistant (S5B/Pl) rat strains. Strong aversions to linoleic acid (conditioned stimulus 100 microM) were generated in both O-M and S5B/Pl rats to concentrations as low as 2.5 microM. Observed strain differences were in contrast to expectations based upon electrophysiological studies previously showing greater fatty acid-induced inhibition of delayed rectifying K+ channels in S5B/Pl rats. In the CTA assays, the O-M rats showed aversions at lower fatty acid concentrations with more resistance to extinction in brief-access orosensory tests, suggesting that the obesity-prone strain may be more sensitive in the detection and subsequent avoidance of linoleic acid than the obesity-resistant strain. The independent variable of sex produced even greater differences in the avoidance of linoleic acid following conditioning than the effects of strain. Female rats of both strains were significantly more sensitive to fatty acids, showed greater cross-generalization from linoleic to oleic acid, and showed greater avoidance of linoleic acid than male counterparts. These findings suggest genetic influences on yet to be identified mechanisms potentially within the gustatory system that affect the sensitivity to detect the fatty acid chemicals found in dietary fat during brief-access orosensory testing.

Fatty acid responses in taste cells from obesity-prone and -resistant rats.

One of the transduction mechanisms for the chemoreception of fat has been proposed to involve the inhibition of delayed rectifying potassium (DRK) channels by polyunsaturated free fatty acids (PUFAs). In the present study we have compared the responsiveness of fungiform taste receptor cells (TRCs) to fatty acids in obesity-prone (Osborne-Mendel; O-M) and obesity-resistant (S5B/Pl) rat strains using patch clamp recording. TRCs from S5B/Pl rats were markedly more responsive to PUFAs than those from O-M, yet with identical inhibition constants. Moreover, addition of PUFAs to subthreshold concentrations of saccharin enhanced preference for the mixture in two-bottle preference tests compared to the saccharin alone in S5B/Pl but not O-M rats. The correlation between electrophysiological and behavioral effects of PUFAs suggested that differences in fatty acid-sensitive DRK expression may underlie the phenotypic differences between S5B/Pl and O-M rats. Consistent with this hypothesis, O-M rats exhibit a greater DRK current density and express quantitatively more DRK channels as assayed using quantitative real-time PCR. No differences were found when comparing expression of fatty acid activated two pore domain potassium channels. We propose that the ratio of fatty acid-sensitive DRK channels to fatty acid-insensitive DRK channels may be important to contributing to overall peripheral fatty acid sensitivity and in that way influence the strength of the resulting chemosensory response to fat.

Expression and characterization of delayed rectifying K+ channels in anterior rat taste buds.

Delayed rectifying K+ (DRK) channels in taste cells have been implicated in the regulation of cell excitability and as potential targets for direct and indirect modulation by taste stimuli. In the present study, we have used patch-clamp recording to determine the biophysical properties and pharmacological sensitivity of DRK channels in isolated rat fungiform taste buds. Molecular biological assays at the taste bud and single-cell levels are consistent with the interpretation that taste cells express a variety of DRK channels, including members from each of the three major subfamilies: KCNA, KCNB, and KCNC. Real-time PCR assays were used to quantify expression of the nine DRK channel subtypes. While taste cells express a number of DRK channels, the electrophysiological and molecular biological assays indicate that the Shaker Kv1.5 channel (KCNA5) is the major functional DRK channel expressed in the anterior rat tongue.

Establishment and Dispersal of Puccinia thlaspeos in Field Populations of Dyer's Woad.

Dyer's woad rust is being intensively studied as a biocontrol agent for the noxious weed dyer's woad. These studies report on methods to establish this fungus in woad populations and to obtain information about disease incidence and dispersal of the rust subsequent to establishment. Inoculum dosages as low as 1 mg/plant established disease in dyer's woad rosettes. Dosages higher than 1 mg/plant resulted in better levels of infection, and inoculation was equally effective when the inoculum was placed directly on the plants or on the soil adjacent to the plants. The highest incidence of infection occurred when plants were inoculated in the spring, whereas summer or fall inoculations did not result in infections. Large-scale inoculation of woad was effective and resulted in significant levels of disease. However, it was not clear if artificial inoculation was effective in changing disease incidence in populations of woad where the rust was present prior to treatment because there were no significant differences between inoculated and check plots. Woad rust is systemic but apparently it is not seed dispersed, even though some infected plants occasionally produce seed. Two years after inoculation, dyer's woad rust had dispersed an average of 14.6 m from the focus of inoculation. After 3 years, the dispersal distance had not increased and infected plants averaged only 10 m from the point of inoculation. Disease was maintained naturally in woad populations after treatment, but the overall percent infection in the treated plots decreased by 3 years after inoculation.