Impact of Patient Assistance Programs on Hospital Visits in Patients With Chronic Obstructive Pulmonary Disease or Asthma.

Background: The inability to afford medications can lead to nonadherence and uncontrolled disease states. As a result, patients may require an increase in acute healthcare utilization to control potential complications. Qualifying patients can apply for patient assistance programs (PAPs) through various manufacturers to receive medications at little to no cost. Having consistent access to necessary medications can increase adherence and decrease acute care utilization. The purpose of this study was to evaluate the impact of PAP enrollment on healthcare utilization in patients with asthma or chronic obstructive pulmonary disease (COPD). Objectives: The primary objective was to compare the number of ED visits and hospitalizations before and after PAP enrollment. Secondary objectives were the estimated ED and hospitalization costs before and after PAP enrollment. Methods: The retrospective, observational cohort study included patients of Piedmont Athens Regional Community Care Clinic who received medications for asthma or COPD through PAPs from January 2018 to March 2019. Results: A total of 269 patients were screened, and 56 patients met inclusion criteria. Of these, 28 patients had at least one hospital encounter. Primary objective resulted in cumulative number of ED visits decreased from 54 to 7 (P < 0.001) and cumulative hospitalizations decreased from 13 to 0 (P < 0.001). Secondary objective showed patients with at least one hospital encounter had a median cost decrease from $4683 to $0 (P < 0.001). The median hospital acquisition cost per person decreased from $351 to $0 (P = 0.002). Conclusion: A decrease in use of acute healthcare services was observed after PAP enrollment. This was associated with cost savings for patients and the healthcare system.

Metal-on-metal total hip arthroplasty is not associated with cardiac disease.

AIMS: Many case reports and small studies have suggested that cobalt ions are a potential cause of cardiac complications, specifically cardiomyopathy, after metal-on-metal (MoM) total hip arthroplasty (THA). The impact of metal ions on the incidence of cardiac disease after MoM THA has not been evaluated in large studies. The aim of this study was to compare the rate of onset of new cardiac symptoms in patients who have undergone MoM THA with those who have undergone metal-on-polyethylene (MoP) THA. PATIENTS AND METHODS: Data were extracted from the Standard Analytics Files database for patients who underwent MoM THA between 2005 and 2012. Bearing surface was selected using International Classification of Diseases ninth revision codes. Patients with a minimum five-year follow-up were selected. An age and gender-matched cohort of patients who underwent MoP THA served as a comparison group. New diagnoses of cardiac disease were collected during the follow-up period. Comorbidities and demographics were identified and routine descriptive statistics were used. RESULTS: We identified 29 483 patients who underwent MoM THA and 24 175 matched patients who underwent MoP THA. Both groups had a mean Charlson comorbidity index score of 4. There were no statistically significant differences in 30 of 31 pre-existing comorbidities. Patients undergoing MoM THA had a slightly lower incidence of cardiac failure compared with those undergoing MoP THA at three years (6.60% versus 7.06%, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.87 to 0.99) and four years (8.73% versus 9.49%, OR 0.91, 95% CI 0.86 to 0.97) postoperatively, with no difference in the incidence of new cardiac failure in between the groups at five years. There was no statistically significant difference in the incidence of arrhythmia, myocardial infarction and cardiomyopathy at any time between the two groups. CONCLUSION: MoM THA is not associated with cardiac complications. Initial reports may have represented individual instances of cardiac disease in patients with a failing MoM articulation rather than an emerging epidemiological trend. Cite this article: Bone Joint J 2018;100-B:28-32.

Radiographic scoring system for the evaluation of stability of cementless acetabular components in the presence of osteolysis.

AIMS: The stability of cementless acetabular components is an important factor for surgical planning in the treatment of patients with pelvic osteolysis after total hip arthroplasty (THA). However, the methods for determining the stability of the acetabular component from pre-operative radiographs remain controversial. Our aim was to develop a scoring system to help in the assessment of the stability of the acetabular component under these circumstances. PATIENTS AND METHODS: The new scoring system is based on the mechanism of failure of these components and the location of the osteolytic lesion, according to the DeLee and Charnley classification. Each zone is evaluated and scored separately. The sum of the individual scores from the three zones is reported as a total score with a maximum of 10 points. The study involved 96 revision procedures which were undertaken for wear or osteolysis in 91 patients between July 2002 and December 2012. Pre-operative anteroposterior pelvic radiographs and Judet views were reviewed. The stability of the acetabular component was confirmed intra-operatively. RESULTS: Intra-operatively, it was found that 64 components were well-fixed and 32 were loose. Mean total scores in the well-fixed and loose components were 2.9 (0 to 7) and 7.2 (1 to 10), respectively (p < 0.001). In hips with a low score (0 to 2), the component was only loose in one of 33 hips (3%). The incidence of loosening increased with increasing scores: in those with scores of 3 and 4, two of 19 components (10.5%) were loose; in hips with scores of 5 and 6, eight of 19 components (44.5%) were loose; in hips with scores of 7 or 8, 13 of 17 components (70.6%) were loose; and for hips with scores of 9 and 10, nine of nine components (100%) were loose. Receiver-operating-characteristic curve analysis demonstrated very good accuracy (area under the curve = 0.90, p < 0.001). The optimal cutoff point was a score of ≥ 5 with a sensitivity of 0.79, and a specificity of 0.87. CONCLUSION: There was a strong correlation between the scoring system and the probability of loosening of a cementless acetabular component. This scoring system provides a clinically useful tool for pre-operative planning, and the evaluation of the outcome of revision surgery for patients with loosening of a cementless acetabular component in the presence of osteolysis. Cite this article: Bone Joint J 2017;99-B:601-6.

Do pre-existing complications affect the failure to rescue quality measures?

BACKGROUND: A project sponsored by the University Health System Consortium has addressed the inaccuracy and high variability across institutions concerning the use of the failure to rescue (FTR) quality indicator defined by the Agency for Healthcare Research and Quality (AHRQ). Results indicated that of the complications identified by the quality indicator, 29.5% were pre-existing upon hospital admission. OBJECTIVE: The purpose of our study was to investigate the possible bias to FTR measures by including cases of complications that were pre-existing at admission. METHODS: Hospital discharges between 1 January 1996 and 30 September 2007 were retrospectively gathered from administrative databases. Using definitions outlined by the AHRQ and the National Quality Forum (NQF), FTR rates were calculated. Using present on admission coding, FTR rates were recalculated to differentiate between the rates of pre-existing and that of acquired cases. RESULTS: Using the AHRQ definition, the overall FTR rate was 11.60%. The FTR rate for patients with pre-existing complications was 8.85%, whereas patients with complications acquired during hospitalisation had an FTR rate of 18.46% (p<0.001). The NQF FTR rate was 9.93%. Pre-existing and acquired FTR rates using the NQF measure were 9.42% and 12.77%, respectively (p<0.001). CONCLUSIONS: Current definitions of FTR measures meant to identify inhospital complications appear biased by the inclusion of problems at admission. Furthermore, many patients with these complications are excluded from the algorithms. When taking into account the timing of the "complications", these measures can be useful for internal quality control. However, it should be stressed that the usefulness of the measures to compare institutions will be dependent on coding practices of institutions. Validation using chart review may be required.

Secular trends in hip fracture incidence and recurrence.

UNLABELLED: The decline in hip fracture incidence is now accompanied by a further reduction in the likelihood of a recurrent hip fracture among survivors of the first fracture. INTRODUCTION: Hip fracture incidence is declining in North America, but trends in hip fracture recurrence have not been described. METHODS: All hip fracture events among Olmsted County, Minnesota residents in 1980-2006 were identified. Secular trends were assessed using Poisson regression, and predictors of recurrence were evaluated with Andersen-Gill time-to-fracture regression models. RESULTS: Altogether, 2,752 hip fractures (median age, 83 years; 76% female) were observed, including 311 recurrences. Between 1980 and 2006, the incidence of a first-ever hip fracture declined by 1.37%/year for women (p < 0.001) and 0.06%/year for men (p = 0.917). Among 2,434 residents with a first-ever hip fracture, the cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men with death treated as a competing risk. Age and calendar year of fracture were independently associated with hip fracture recurrence. Accounting for the reduction in first-ever hip fracture rates over time, hip fracture recurrence appeared to decline after 1997. CONCLUSION: A recent reduction in hip fracture recurrence is somewhat greater than expected from the declining incidence of hip fractures generally. Additional research is needed to determine the extent to which this can be attributed to improved patient management.

Explosion of a vulvar hematoma during spontaneous vaginal delivery. A case report.

BACKGROUND: Vulvar hematoma formation during a spontaneous vaginal birth is rare. Although conservative management or observation is an option, complications, including delivery obstruction and excessive vaginal bleeding, may occur. CASE: A woman presented in active labor with an enlarging vulvar hematoma reaching the size of a softball. Spontaneous vaginal delivery occurred with an "explosion" of the hematoma and excessive blood loss. To obtain hemostasis, the hematoma cavity was explored and the bleeding points sutured. CONCLUSION: With a large intrapartum vulvar hematoma, the risk of rupture exists. If it occurs, delivery should be accomplished expediently, hemostasis achieved rapidly and blood loss monitored closely.

Patient satisfaction associated with correct identification of physician's photographs.

OBJECTIVE: To determine whether placement of photographs of physicians in hospital rooms improves patients' satisfaction with their medical care. PATIENTS AND METHODS: This is a prospective, controlled study of 224 patients admitted to general internal medicine services in a teaching hospital. The intervention consisted of photographs (8 x 10 in) of attending and resident physicians displayed in the patients' rooms. Before dismissal, patients completed a survey that required them to match names with photographs of physician caregivers and included patient satisfaction questions. The primary outcome was whether patients who had photographs in their hospital room would correctly identify more physicians than those with no photographs in their room. RESULTS: The presence of photographs on the hospital wall was associated with a significant improvement in the number of physicians identified correctly (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.47-2.27; P<.001). The percentage of physicians that patients identified by correctly matching their physicians' names to their photographs was significantly associated with satisfaction with physician responsiveness (OR, 1.19; 95% CI, 1.01-1.40; P=.03) and with the way in which physicians addressed questions regarding medical care (OR, 1.23; 95% CI, 1.05-1.44; P=.05). CONCLUSIONS: Patients who had photographs of their physicians on the wall of their hospital room were able to identify correctly a larger number of physicians on their team compared with patients who had no photographs. Patient satisfaction was related to the number of physicians' photographs that patients could identify correctly.

Medical care of elderly patients with hip fractures.

Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications.

Investigation of aqueous biphasic systems for the separation of lignins from cellulose in the paper pulping process.

In efforts to apply a polymer-based aqueous biphasic system (ABS) extraction to the paper pulping process, the study of the distribution of various lignin and cellulosic fractions in ABS and the effects of temperature on system composition and solute partitioning have been investigated. The partitioning of three lignin species (Indulin AT, Indulin C, and Reax 85A) have been studied in ABS prepared from stock solutions of 40% (w/w) poly(ethylene glycol) (PEG)-2000 and increasing concentrations of K2CO3, (NH4)2SO4, and NaOH. The partitioning of these lignins is affected by the free energy of hydration of the salt forming the ABS, the tie line length, and the dissociation of the sulfonic acid and hydroxyl groups of the distributed solutes. The partitioning of fibrous cellulose and diethylaminoethyl cellulose have been studied in 40% (w/w) PEG-2000-(NH4)2SO4 ABS. The hydrophilic nature of these species is important in terms of their phase preference when designing a polymer-based aqueous biphasic extraction process for use in a paper pulping process. Both cellulosic samples do not dissolve, but rather report to the salt-rich phase of an ABS. In both chemical pulping and Organosolv pulping, temperatures in excess of 120 degrees C are needed to solubilize the lignin from the cellulose fraction of wood. To study the effects of temperature on the phase diagram and solute partitioning, phthalic acid and NH499TcO4 (as system probes) have been partitioned in 40% (w/w) PEG-2000-(NH4)2SO4 ABS at known tie line lengths as a function of temperature. Temperature does not appear to affect the partitioning results beyond the expected increase in phase divergence as temperature is increased. The PEG-2000 polymer itself appears to be stable to chemical pulping conditions.

Solvatochromic studies in polyethylene glycol--salt aqueous biphasic systems.

The polarities of the co-existing phases of a polyethylene glycol (PEG)-2000-K3PO4 aqueous biphasic system (ABS) have been examined using Reichardt's carboxylated pyridinium-N-phenoxybetaine dye as a probe. Using this probe, the polarities of these phases have been compared to those of conventional solvent extraction systems and micellar systems using values obtained from the literature. In general, these extraction systems are comparable in polarity to rather polar solvents. Data on the free energy of transfer of solvents suggests that this may be due to the failure of the probe to account for the real polarity of the salt-rich phase compared to the polymer-rich phase. Examination of the monophasic region of these systems suggests that the reason for this is that the probe is partitioned to a discreet solvent domain dominated by PEG, even though phase separation of the solution is not observed. The use of linear free energy relationships for the characterization of ABS is briefly discussed.

Intrapartum fetal assessment. A review.

Some of the difficulty in assessing the clinical value of intrapartum fetal-heart-rate (FHR) monitoring stems from lack of uniformity in pattern interpretation and, therefore, in response to perceived FHR abnormalities. This article reviews the physiology and pathophysiology of FHR changes, stresses the new NICHD guidelines for unambiguously defining FHR patterns, emphasizes the avoidance of circumstances stressful to the fetus, and suggests appropriate treatment for the distressed fetus. The strong likelihood that such treatment will be successful in reversing abnormal FHR patterns, as well as the importance of preparing for expedient delivery should such treatment fail, are noted. Finally, some of the newer tools for judging the timing of perinatal brain injury are described.

Initial and repeat screening for Chlamydia trachomatis during pregnancy.

OBJECTIVES: The objective of this study is to determine the prevalence of Chlamydia trachomatis and risk factors for positive repeat tests in a high-risk population presenting for early prenatal care. METHODS: We completed a retrospective cohort study of 2,484 women who initiated prenatal care prior to 20 weeks gestation, delivered, and received testing for cervical C. trachomatis at Grady Memorial Hospital or a Grady-affiliated clinic between July 1, 1993 and December 31, 1994. We calculated adjusted odds ratios (OR) for selected risk factors for a positive initial test and for a positive subsequent test after an initial negative test. RESULTS: The prevalence of C. trachomatis was 14.8%. At initial testing, 10.4% of the women were positive. If the initial test was negative, 5.7% had a positive subsequent test; but if the initial test was positive, 32.0% had a positive subsequent test (P < 0.001). The variables significantly and independently associated with a positive initial test were black race/ethnicity, age less than 25, unmarried, and less than a high-school education (adjusted OR of 1.66, 3.53, 2.18, and 1.81, respectively). Variables significantly and independently associated with a positive subsequent test after a negative initial test were white race/ethnicity, black race/ethnicity, age less than 25, and less than a high-school education (adjusted OR 8.69, 7.77, 4.12, and 2.27, respectively). CONCLUSIONS: In our inner-city population, most pregnant women have risk factors suggesting the need to rescreen for C. trachomatis in the second half of pregnancy.

Influence of temperature upon protein partitioning in poly(ethylene glycol)-salt aqueous two-phase systems close to the critical point with some observations relevant to the partitioning of particles.

The partition of proteins in a poly(ethylene glycol) (PEG)-potassium phosphate aqueous two-phase system has been studied in systems which were produced by manipulation of the equilibrium temperature of a monophasic mixture composition close to the critical point. Precise control of the composition enabled the formation of biphasic systems lying very close to the critical point. A high-performance liquid chromatographic method for analysis of the phase compositions is presented. The generally applicability of the method to the partition of proteins and other particles is discussed.

Polymer-protein interactions in aqueous two phase systems: fluorescent studies of the partition behaviour of human serum albumin.

This study describes the partitioning of fluorescent macromolecules in aqueous two-phase systems (ATPS) comprising phosphate salt and poly(ethylene glycol) of three different molecular masses (i.e. 1000, 1450 and 2000 Da). The impact of system assembly was studied with fluorescent macromolecules introduced in contact with either (i) first salt, then polymer or (ii) first polymer, then salt, or (iii) with both salt and polymer simultaneously. Native human serum albumin (HSA) and derivatives labelled with N-(iodoacetylaminoethyl)-5-naphthylamine-1-sulphonic acid (1,5-IAEDANS) were partitioned using selected ATPS. Partitioning behaviour was characterised by molecular rotational studies of recovered proteins based upon changes of depolarisation. Measurements were undertaken by steady-state fluorescence or time-decay fluorescence using a single-photon counting system. In addition, circular dichroism was used as a tool for the study of macromolecular secondary structure. Two discrete categories of stable molecular structure have been identified that exist irrespective of the phase environment. The findings form the basis for a discussion of polymer protein interactions and the molecular micro-environment of proteins in ATPS.

Separation and recovery of food coloring dyes using aqueous biphasic extraction chromatographic resins.

Aqueous biphasic systems (ABS) and aqueous biphasic extraction chromatographic (ABEC) resins are currently under investigation for their utility in the removal of color from textile plant wastes. The structures of several widely used food colorings, suggest that these dyes would also be retained on the resins. In work currently in progress, we have begun to investigate the retention and resolution of several common food colorings including indigo carmine, amaranth, carminic acid. erythrosin B, tartrazine and quinoline yellow. The relationship between the uptake of these dyes on ABEC resins in terms of the binding strengths and capacities of the resins and their partitioning behavior in ABS is illustrated. Some possible theoretical and practical approaches to the prediction of the partitioning and retention behavior is discussed.

Partitioning of small organic molecules in aqueous biphasic systems.

Aqueous biphasic systems (ABS) are suitable for the separation of small organic molecules in industrial and environmental applications and thus, it is important to correlate partitioning behavior of model organic solutes with their structure in order to develop predictive models. The partitioning behavior of five, uncharged, substituted benzenes (benzene, toluene. chlorobenzene, 1,4-dichlorobenzene and 1,2,4-trichlorobenzene) were studied in ABS prepared from stock solutions of 40% (w/w) PEG-2000 and increasing concentrations of four water-structuring salts (K3PO4, K2CO3, (NH4)2SO4 and NaOH). For a given solute and a defined concentration of salt, the partition coefficients increase as the deltaGhyd value of the salt anion becomes more negative (e.g., Dbenzene increases in the order OH-

A comparison of subjective, psychomotor and physiological effects of a novel muscarinic analgesic, LY297802 tartrate, and oral morphine in occasional drug users.

This study compared the subjective, physiological and psychomotor effects of a novel muscarinic analgesic (LY297802) and oral morphine in healthy volunteers. Nine, non-dependent, occasional drug users participated in nine experimental sessions in which they received the following conditions: placebo, 0.1, 0.3, 0.56 and 1 mg of oral LY297802 and 10, 30, 56 and 100 mg of oral morphine. Subjective drug effects were assessed using the Visual Analog Scale (VAS), the Addiction Research Center Inventory (ARCI) and subjective and objective agonist and antagonist scales of the Adjective Rating Scale (ARS). These measures were collected 30 min before and every 30 min post drug administration for a 4-h period. Psychomotor performance was evaluated using the Digit Symbol Substitution Test (DSST) at these same time intervals. Physiological measures were collected continuously throughout the sessions. Oral morphine produced significant increases in some subjective effects scales, including elevations on the VAS, ARCI and ARS. In contrast, LY297802 did not engender changes different from placebo on any of these indices. Morphine produced significant dose-dependent effects in DSST performance, heart rate, blood oxygen saturation and pupil diameter. LY297802 significantly and dose dependently increased heart rate, mean arterial pressure and diastolic blood pressure. These results suggest that LY297802 does not induce subjective effects similar to morphine, but that it has some significant physiological effects.

Intrapartum maternal glucose infusion reduces umbilical cord acidemia.

OBJECTIVE: Our purpose was to compare the effects of intrapartum 5% glucose in the intravenous fluid on umbilical cord acid-base and glucose status after spontaneous vaginal delivery. STUDY DESIGN: This was a prospective randomized clinical trial in which gravid women with low-risk pregnancies at term were randomized by computer to receive lactated Ringer's solution, either with 5% glucose or without, as the maintenance intravenous fluid during active labor. Antepartum and intrapartum factors that might influence fetal-neonatal glucose levels were recorded. Umbilical arterial cord blood was assessed for glucose level and acid-base status. RESULTS: Of the 106 parturient patients who consented, 15 were excluded because of operative delivery (n = 8), preeclampsia (n = 2), shoulder dystocia (n = 1), intravenous fluid infusion duration of < 1 hour (n = 1), and cord blood data not available (n = 3). There were no statistical differences between the two groups regarding maternal age, parity, maternal weight at term, epidural placement, intravenous fluid duration, or gestational age. Infant birth weight, gender, Apgar scores, and incidence of meconium were not statistically different. Neonatal hypoglycemic episodes and intrapartum fetal heart rate tracing parameters were similar between groups. The difference between the umbilical artery pH values of those who were treated with lactated Ringer's solution with 5% glucose (n = 48) versus those treated with the solution without glucose (n = 43) approached significance, with a p value of 0.08 (mean +/- SD, 7.30 +/- 0.07 and 7.27 +/- 0.09, respectively). The PCO2 value of those treated with lactated Ringer's solution without glucose was higher (mean +/- SD, 50.6 +/- 12.9 mm Hg vs 44.8 +/- 9.9 mm Hg) (p = 0.02). Base excess (in milliequivalents per deciliter) and cord glucose (in milligrams per deciliter) levels, as well as the incidence of neonatal hypoglycemic episodes within the first 8 hours of life, were not statistically different. Despite failure of mean pH differences to achieve significance, the relative risk (0.22) for an umbilical arterial pH < or = 7.20 was significantly reduced (95% confidence interval 0.1 to 0.7) with lactated Ringer's solution containing 5% glucose. The relative risk (0.42) of having an umbilical artery cord blood PCO2 value > or = 55 mm Hg was also significantly lowered (95% confidence interval 0.19 to 0.93) when lactated Ringer's solution containing 5% glucose was used. CONCLUSIONS: Intrapartum intravenous fluid consisting of lactated Ringer's solution containing 5% glucose reduces umbilical cord acidemia and hypercarbia but does not change cord levels of glucose or base excess. Lactated Ringer's solution containing 5% glucose may be a preferable solution than without glucose as an intravenous fluid during labor.