Big Med's Spread.

Policy Points Hospital executives posit a number of rationales for system mergers which lack any basis in academic evidence. Decades of academic research question whether system combinations confer public benefits. Antitrust authorities need to continue to closely scrutinize these transactions. Recently, mergers of hospital systems that span different geographic markets are on the rise. Economists have alerted policymakers about the potential impacts such cross-market mergers may have on hospital prices. We suggest there are other reasons for concern that scholars have not often confonted. Cross-market mergers may be conducted for purely self-serving reasons of organizational growth that increases executive compensation. Combinations of sellers should have clear advantages to consumers. System executives and their boards should bear the burden of proof. Federal regulators and state attorney generals should be cognizant that rationales for cross-market systems advanced by merging parties are unlikely to be operative or dominant in merger decision making. Policymakers should be careful about passing legislation that encourages hospitals to consolidate. CONTEXT: There is a growing trend of combinations among hospital systems that operate in different geographic markets known as cross-market mergers. Economists have analyzed these broader systems in terms of their anticompetitive behavior and pricing power over insurers. This paper evaluates the benefits advanced by these new hospital systems that speak to a different set of issues not usually studied: increased efficiencies, new capabilities, operating synergies, and addressing health inequities. The paper thus "looks under the hood" of these emerging, cross-market systems to assess what value they might bestow and upon whom. METHODS: The paper examines recently announced cross-market mergers in terms of their supposed benefits, as expressed by the systems' executives as well as by industry consultants. These presumed benefits are then evaluated against existing evidence regarding hospital system outcomes. FINDINGS: Advocates of cross-market hospital mergers cite a host of benefits. Research suggests these benefits are nonexistent. Additional evidence suggests other motives may be at play in the formation of cross-market mergers that have nothing to do with efficiencies, synergies, or community benefits. Instead these mergers may be self-serving efforts by system chief executive officers (CEOs) to boost their compensation. CONCLUSIONS: Cross-market hospital mergers may yield no benefits to the hospitals involved or the communities in which they operate. The boards of hospital systems that engage in these cross-market mergers need to exercise greater diligence over the actions of their CEOs.

Cell-based therapy of the elbow: evidence for lateral tendinopathy-a review on current treatments.

PURPOSE: Cell-based therapies are on the rise in treating intra and extraarticular pathologies, trying to avoid surgical intervention and support local repair processes. Therefore, the aim was to summarize current evidence-based treatment options for a cell-based therapy around the elbow. METHODS: Through a literature review up-to date treatment algorithms and therapies have been identified and have been rated according to their evidence level for clinical recommendation. RESULTS: Regarding the four extraarticular anatomical regions of the elbow (anterior, medial, posterior and lateral) and the joint itself, the lateral elbow and its´ tendinopathies as well as the use of cell-based treatment options have been extensively studied and, therefore, allow for clear and evidence-based recommendations. The remaining three regions as wells as the intraarticular application do not show enough evidence for a clinical recommendation. CONCLUSION: In conclusion the cell-based approach for treating elbow pathologies can only be recommended for the lateral elbow, as there has been shown sufficient evidence for the extraarticular application. It has to be mentioned, that the results from the lateral elbow maybe transferred to other extra-articular tendinopathies, as the lack of evidence may be due to the rare appearance of posterior, medial and anterior tendon affection. No recommendation can be given for intra-articular use. LEVEL OF EVIDENCE: IV.

Comparison of Superior Capsular Reconstruction and Partial Infraspinatus Repair: A Matched-Pair Analysis of Irreparable Rotator Cuff Tears.

BACKGROUND: Superior capsular reconstruction (SCR) represents a new option for the treatment of irreparable rotator cuff tears. PURPOSE/HYPOTHESIS: This study aimed to evaluate the clinical and radiologic outcomes of SCR and compare them with the outcomes of partial repair (PR) of the infraspinatus tendon. The hypothesis was that there would be no significant differences between the clinical and radiologic outcome parameters of SCR and PR after a minimum follow-up of 2 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Of 21 patients who underwent SCR, 20 patients were matched in a 1:1 ratio according to sex, age, and tear configuration with 20 of 60 patients who had undergone PR; all patients were prospectively evaluated for a minimum follow-up of 2 years. The investigated outcome measures included the Constant score; Western Ontario Rotator Cuff (WORC) index; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiologic analysis of acromiohumeral distance (AHD) and humeral head centralization (HHC). RESULTS: There were no differences in the demographic data between the SCR and PR groups. The mean age of both groups was 62.3 years (range, 47-79 years), the mean tear configuration was Bateman 3.0 and Patte 2.8, and the mean follow-up period was 29.4 months (range, 24-53 months). At final follow-up, no significant differences were seen between the SCR and PR groups with regard to Constant score (77.1 vs 82.7), age- and sex-adapted Constant score (85.5% vs 91.4%), DASH score (15.6 vs 7.8), or WORC index (81.1 vs 90.4). No significant differences in the AHD or HHC were seen between the groups. The reoperation rate was 4.8% (1/21) in the SCR cohort and 15% (9/60) in the PR cohort. CONCLUSION: Both SCR and PR resulted in significant improvements in patient-reported outcomes at 2-year follow-up, with no significant differences in clinical outcomes between the 2 techniques. Further follow-up is needed to determine whether there are long-term differences in HHC and development of cuff tear arthropathy. Further investigations should also focus on the cost-effectiveness of the respective procedures.

Meniscal Repair Techniques.

The menisci play a vital role in knee joint stability, load distribution, and lubrication, protecting the joint surfaces from degenerative change. Meniscal repair protects the joint from increased loading and when successful reduces progression of osteoarthritis. Successful repair involves accurate surgical techniques, guarded postoperative rehabilitation, and potential use of additional biologics to promote healing. An integrated approach to meniscal surgery is required as part of an overall strategy to preserve and restore knee function, preserving meniscal tissue whenever possible. This article reviews the repair techniques: procedures, indications, and rehabilitation for meniscal repair.

Competitive ELISA method for novel estrogen-negative breast cancer biomarker quantitation.

Estrogen-negative (ER-) breast cancer, is recognized as an aggressive subtype, more difficult to treat, with poor survival and prognosis. They are hormonally unresponsive, with no readily effective and specific target therapy. We have previously identified Nw-hydroxy L-Arginine (NOHA) as a blood-based biomarker to distinguish between ER- and ER+ breast cancer tumors based upon disease burden, progression and molecular phenotype (U.S. Utility Patent 10,073,099). In this study we have demonstrated a competitive ELISA based assay for NOHA measurement using a proprietary monoclonal antibody (mAb) specific for NOHA (U.S. provisional patent 62/754,053). The ELISA assay was evaluated on sensitivity, selectivity, precision, dilution linearity and percent recovery parameters. The assay showed sensitivity at ≥60 pg/ml NOHA antigen with 1 ng/ml NOHA mAb, and maintained NOHA antigen specificity even in the presence of other closely related cationic amino acids (i.e. L-Arginine, D-Arginine, l-Lysine, d-Lysine, L-Ornithine, and L-Citrulline). The reliability of the ELISA protocol was confirmed with the low percent-covariance, for all tested parameters of sensitivity (≤8.2%), selectivity (≤8.6%), precision (≤12.6%), dilution linearity (≤11.2%) and recovery (≤6.7%). Additionally, we can demonstrate NOHA quantification by this ELISA assay to complement the sensitivity achievable with LC-MS (in both assay buffer and with patient plasma samples), thus suggesting it's utility as a simple yet sensitive methodology that might help in ER- breast cancer prognosis, and disease progression monitoring without the need for expensive analytical equipment (such as LC-MS), large lab space, or specialized technical training.

Minimally Invasive Quadriceps Tendon Single-Bundle, Arthroscopic, Anatomic Anterior Cruciate Ligament Reconstruction With Rectangular Bone Tunnels.

Many surgeons use quadriceps tendon (QT) graft for anterior cruciate ligament (ACL) revision surgery; however, despite excellent clinical results, the QT has not achieved universal acceptance for primary ACL reconstruction. One of the reasons for this may be that the QT is technically demanding to harvest and the scar from open harvesting techniques is less cosmetically favorable than that from hamstring tendon techniques. Recent evidence has suggested that broad flat QT grafts may more closely mimic native ACL "ribbon-like" morphology than hamstring tendon grafts. Furthermore, rectangular bone tunnels may more accurately re-create native ACL attachments, allowing grafts to simulate native ACL rotation during knee flexion and potentially improving biomechanics. Rectangular tunnels have further advantages in revision cases, in which-in comparison with round tunnels-they have reduced overlap with pre-existing transtibial tunnels, increasing the chance of bypassing primary tunnels during revision surgery. Finally, instrumentation for minimally invasive QT harvesting has reduced technical difficulty and improved cosmetic results. Hence, technical and cosmetic concerns are no longer barriers to QT use. These anatomic and biomechanical advantages and technical developments make the QT an increasingly attractive option for both primary and revision ACL reconstruction.

Quadriceps Tendon Autograft Medial Patellofemoral Ligament Reconstruction.

PURPOSE: Critically evaluate the published literature related to quadriceps tendon (QT) medial patellofemoral ligament (MPFL) reconstruction. RECENT FINDINGS: Hamstring tendon (HT) MPFL reconstruction techniques have been shown to successfully restore patella stability, but complications including patella fracture are reported. Quadriceps tendon (QT) reconstruction techniques with an intact graft pedicle on the patella side have the advantage that patella bone tunnel drilling and fixation are no longer needed, reducing risk of patella fracture. Several QT MPFL reconstruction techniques, including minimally invasive surgical (MIS) approaches, have been published with promising clinical results and fewer complications than with HT techniques. Parallel laboratory studies have shown macroscopic anatomy and biomechanical properties of QT are more similar to native MPFL than hamstring (HS) HT, suggesting QT may more accurately restore native joint kinematics. Quadriceps tendon MPFL reconstruction, via both open and MIS techniques, have promising clinical results and offer valuable alternatives to HS grafts for primary and revision MPFL reconstruction in both children and adults.

A comparison of surgical exposures for posterolateral osteochondral lesions of the talar dome.

BACKGROUND: Perpendicular access to the posterolateral talar dome for the management of osteochondral defects is difficult. We examined exposure available from each of four surgical approaches. MATERIALS AND METHODS: Four surgical approaches were performed on 9 Thiel-embalmed cadavers: anterolateral approach with arthrotomy; anterolateral approach with anterior talo-fibular ligament (ATFL) release; anterolateral approach with antero-lateral tibial osteotomy; and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly allowing perpendicular access with a 2mm k-wire was measured. RESULTS: An anterolateral approach with arthrotomy provided a mean exposure of the anterior third of the lateral talar dome. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy. CONCLUSIONS: Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome.

Stability of Lisfranc injury fixation in Thiel Cadavers: Is routine fixation of the 1st and 3rd tarsometatarsal joint necessary?

BACKGROUND: There is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis. The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate. METHODS: Using 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st-5th) and 1st-2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability. RESULTS: At baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st-2nd intermetatarsal gap was 0mm. After transection of the Lisfranc ligament only, there was 1st-2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement. CONCLUSIONS: The results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd-4th) are intact, the 3rd ray does not need to be routinely stabilised.

Is the system really the solution? Operating costs in hospital systems.

Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types of systems are.

Horizontal and vertical integration of physicians: a tale of two tails.

PURPOSE: Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway. DESIGN/METHODOLOGY APPROACH: We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models. FINDINGS: The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners. RESEARCH LIMITATIONS: While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization. RESEARCH IMPLICATIONS: Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices. PRACTICAL IMPLICATIONS: Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats. ORIGINALITY/VALUE: This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.

The changing configuration of hospital systems: centralization, federalization, or fragmentation?

PURPOSE: Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000-2010 to ascertain whether they have become more centralized or decentralized. DESIGN/METHODOLOGY/APPROACH: We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different "clusters" defined by the American Hospital Association. FINDINGS: There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital. RESEARCH LIMITATIONS: Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization. RESEARCH IMPLICATIONS: Systems that appear to be able to centrally coordinate their services are those that operate in local or regional markets. Larger systems that span several states are likely to decentralize or fragment. PRACTICAL IMPLICATIONS: System fragmentation may thwart policy aims pursued in health care reform. The potential of Accountable Care Organizations rests on their ability to coordinate multiple providers via centralized governance. Hospitals systems are likely to be central players in many ACOs, but may lack the necessary coherence to effectively play this governance role. ORIGINALITY/VALUE: Not all hospital systems act in a systemic manner. Those systems that are centralized (and presumably capable of acting in concerted fashion) are in the minority and have declined in prevalence over most of the past decade.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration.

CONTEXT: Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P). METHODS: This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration. FINDINGS: The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians. CONCLUSIONS: Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

Leaf essential oil composition of three species of Myrcianthes from Monteverde, Costa Rica.

To examine the chemical diversity of essential oils from Myrcianthes species (Myrtaceae) as well as potential chemotaxonomic relationships between them, the leaf essential oils of M. fragrans (Sw.) McVaugh, M. rhopaloides (Kunth) McVaugh, and an undescribed species, Myrcianthes 'black fruit', from Monteverde, Costa Rica, were isolated by hydrodistillation and analyzed by GC/MS. The most abundant components of the essential oil of M. fragrans were 1,3,5-trimethoxybenzene (15.7%), (Z)-hex-3-en-1-ol (10.0%), alpha-cadinol (10.4%), eudesma-4(15),7-dien-1beta-ol (9.0%), caryophyllene oxide (7.8%), and spathulenol (7.5%). The leaf oils of two different samples of Myrcianthes rhopaloides were quantitatively different with one sample composed mostly of linalool (17.7%), alpha-cadinol (14.4%), spathulenol (11.1%), tau-cadinol (9.6%), and 1-epicubenol (6.9%), and the other was made up largely of (E)-hex-2-enal (46.1%), 1,8-cineole (12.5%), linalool (9.1%), alpha-cadinol (6.7%), and alpha-terpineol (4.4%). The major components in the leaf essential oil of Myrcianthes 'black fruit' were 1,8-cineole (38.3%), alpha-terpineol (21.2%), heptan-2-ol (15.5%), terpinen-4-ol (4.2%), and beta-pinene (3.8%). The leaf oil compositions of Myrcianthes in this study are very different from leaf oils from other members of Myrcianthes reported in the literature. A cluster analysis reveals large chemical variation not only between members of the genus, but also between samples of the same species.

Leaf essential oil composition of five Zanthoxylum species from Monteverde, Costa Rica.

The leaf essential oils from five species of Zanthoxylum (Rutaceae) from Monteverde, Costa Rica, have been obtained by hydrodistillation and analyzed by gas chromatography-mass spectrometry. The species examined include Z. fagara, Z. acuminatum, Z. melanostictum, Z. monophyllum, and an undescribed species. The most abundant classes of compounds found in Zanthoxylum leaf oils are acyclic and menthane monoterpenoids as well as simple alcohols, aldehydes, and ketones. In terms of molecular diversity, menthane and acyclic monoterpenoids, cadinane and mesocyclic sesquiterpenoids, and simple alcohols, aldehydes, and ketones dominate the essential oils of Zanthoxylum species. Monoterpenoids make up the majority of the mass of the leaf oils of Z. monophyllum, Z. acuminatum, Z. fagara, and Zanthoxylum sp. nov. Linalool, 4-terpineol, alpha-terpineol, and trans-2-hexenol, are found in all of the Zanthoxylum species examined in this study.

Phytomedicinal potential of tropical cloudforest plants from Monteverde, Costa Rica

A pharmacological survey of plants from Monteverde, Costa Rica, including 165 species representing 61 families has been carried out. Crude plant extracts have been tested for in-vitro bactericidal and fungicidal activity as well as cytotoxic and anti-herpes activity. Of these, 123 extracts exhibited notable cytotoxicity, 62 showed antibacterial activity, 4 showed antifungal activity, and 8 showed promising antiviral activity. Thus, 101 of the plant species examined in this work, or 62, showed marked bioactivity in one or more bioassays. These results underscore the phytomedicinal potential of Neotropical cloud forests.

Phytomedicinal potential of tropical cloudforest plants from Monteverde, Costa Rica.

A pharmacological survey of plants from Monteverde, Costa Rica, including 165 species representing 61 families has been carried out. Crude plant extracts have been tested for in-vitro bactericidal and fungicidal activity as well as cytotoxic and anti-herpes activity. Of these, 123 extracts exhibited notable cytotoxicity, 62 showed antibacterial activity, 4 showed antifungal activity, and 8 showed promising antiviral activity. Thus, 101 of the plant species examined in this work, or 62%, showed marked bioactivity in one or more bioassays. These results underscore the phytomedicinal potential of Neotropical cloud forests.