Assessing Changes in Insurance Status and Access to Care Among Patients Attending Chicago Sexually Transmitted Infection Specialty Clinics From 2013 to 2019.

BACKGROUND: Public sexually transmitted infection (STI) clinics are safety net providers for uninsured and underinsured individuals but are at risk for closure due to declining budgets and shifting priorities. This study sought to assess changes in insurance status and access to preventive care among public STI clinic patients after immediate and long-term implementation of the Affordable Care Act (ACA). METHODS: Patients receiving care in STI clinics administered by Chicago Department of Public Health were asked to complete an anonymous survey in 2013, 2014, and 2019. We estimated the prevalence rate ratio (PRR) of (1) being insured and (2) having access to preventive care over time, adjusted for age, race, and gender/sexual orientation, and employment status. RESULTS: Among 1711 respondents, compared with 2013 patients, patients were 1.41 (adjusted PRR [aPRR]) times more likely to report being insured in 2014 (95% confidence interval, 1.11-1.77) and 1.24 (aPRR) times more likely to report being insured in 2019 (95% confidence interval, 0.99-1.55). After adjusting for other significant variables (age, sex and orientation, and insurance status), reported access to preventive care increased by 34% among respondents in 2019 as compared with 2013 (aPRR, 1.34). Unsurprisingly, being insured was associated with increased preventive care access (aPRR, 1.78). CONCLUSIONS: Even after the implementation of the Affordable Care Act, a survey of public STI clinic patients in Chicago found a sizeable proportion of individuals without insurance, and many lacked access to preventive care, highlighting the continued need for these safety net clinics to provide STI care.

Extending the reach of stapled anastomosis with a prepared OrVil™ device in laparoscopic oesophageal and gastric cancer surgery.

INTRODUCTION: The introduction of minimally invasive surgery and the use of laparoscopic techniques have significantly improved patient outcomes and have offered a new range of options for the restoration of intestinal continuity. Various reconstruction techniques have been described and various devices employed but none has been established as superior. This study evaluates our experience with, and modifications of, the orally inserted anvil (OrVil™). METHODS: We conducted a prospective observational study on 72 consecutive patients who underwent OrVil™-assisted oesophago-gastric or oesophago-jejunal anastomosis between September 2010 and September 2013. We collected data including patient demographics, disease site, type of procedure, location of the anastomosis, involvement of resection margins and peri-operative complications. RESULTS: Seventy-two patients were included in the study. Patient ages ranged from 45 to 92 years (median ± SD = 69 ± 10 years). Total gastrectomy with Roux-en-Y anastomosis was the most-commonly performed procedure (n = 41; 57 %). R 0 resection was achieved in 67 patients (93 %). There were no Orvil™-related clinical leaks during the study period, and just two patients (2.8 %) demonstrated radiological evidence of leak, both of whom were managed conservatively. There were three in-hospital mortalities during the study period; these were unrelated to the anastomotic technique. CONCLUSION: Despite a steep learning curve, the OrVil™ device is safe and reliable. It also permits the creation of higher trans-hiatal anastomoses without resorting to thoracotomy in high-risk patients with cardia tumours. Certain shortcomings of the device, that had implications for patient safety, were identified and addressed by intra-operative modification during the study period. We commend the use of a prepared OrVil™ device, as a game changer, for upper gastrointestinal reconstruction.

The effects of VTA NMDA receptor antagonism on reward-related learning and associated c-fos expression in forebrain.

The mechanisms whereby reward-associated stimuli come to function as conditioned stimuli and acquire the capacity to activate the same neural regions activated by primary rewards (i.e., dopamine terminal regions) is not fully understood. We hypothesized that NMDA receptor stimulation in the VTA is necessary for the acquisition by a CS to both produce conditioned approach and activate dopamine terminal regions. Rats were tested in a conditioned approach protocol that consisted of light stimulus-food conditioning sessions (30 randomly presented light stimulus-food pellet pairings), a session with no stimuli or food and 1 session with only light stimulus (CS-only) presentations. Food trough head entries during the CS and just prior to the CS were recorded and a CS/pre-CS ratio indicating the conditioned approach response was calculated. Brain tissue was harvested after the CS-only session and processed for c-fos expression in prefrontal cortex area 2, nucleus accumbens core and shell and medial and lateral caudate. When bilateral intra-VTA microinjections of AP-5 (0, 0.25 or 0.5 µg) were made prior to each of the conditioning sessions the 0.5 µg AP-5 dose prevented the acquisition of conditioned approach; when 0.5 µg AP-5 injections were made prior to the CS-only test they failed to affect expression of the response. Also, 0.5 µg AP-5 prior to conditioning significantly reduced c-fos expression in response to the CS in nucleus accumbens core. These results suggest that VTA NMDA receptor stimulation is necessary for both the acquisition of reward-related learning and acquisition by the CS to activate dopamine terminal regions.