Tercer molar heterotópico, etiología y manejo quirúrgico / Heterotopic third molar, etiology and surgical management

Los terceros molares heterotópicos son dientes que se encuentran incluidos en los maxilares y la mandíbula distantes a su sitio de erupción habitual. Su etiología no está bien definida y existen diversas teorías. Estos dientes pueden aparecer en diferentes zonas de las estructuras óseas, teniendo predilección por la mandíbula. Suelen aparecer entre la segunda y la séptima década de la vida, la mayoría de los casos son hallazgos imagenológicos en la consulta odontológica. El tercer molar mandibular es el diente que presenta heterotopía con mayor frecuencia, siendo su localización habitual en rama mandibular y en la región subcondílea. El quiste dentígero es la patología asociada más común. Presentamos un caso de tercer molar heterotópico en rama mandibular derecha de larga evolución, relacionado a un quiste dentígero, el cual se manejó bajo anestesia regional. Se describe la etiología, técnica quirúrgica y consideraciones especiales relacionados con los dientes heterotópicos (AU)

Heterotopic third molars are teeth that are embedded in the maxilla and mandible, remote from their usual eruption site. Its etiology is not well defined and there are various theories at the moment. These teeth can appear in different areas of the bone's structures, having a predilection for the jaw. They usually appear between the second and seventh decade of life, and in most cases are imaging findings. The mandibular third molar is the tooth with the most frequent heterotopia, being its usual location in the mandibular branch and in the subcondylar region. The dentigerous cyst is the most common associated pathology. We present a case of a long evolution heterotopic third molar in the right mandibular branch, related to a dentigerous cyst which was managed under local anesthesia. The etiology, surgical technique and special considerations related to heterotopic teeth are described (AU)

Use of long-term services and supports among dual-eligible beneficiaries with Alzheimer's disease and related dementias.

BACKGROUND: To respect people's preference for aging in place and control costs, many state Medicaid programs have enacted policies to expand home and community-based services as an alternative to nursing facility care. However, little is known about the use of Medicaid long-term services and supports (LTSS) at a national level, particularly among dual-eligible beneficiaries with Alzheimer's disease and related dementias (ADRD). METHODS: Using Medicare and Medicaid claims of 30 states from 2016, we focused on dual-eligible beneficiaries 65 years or older with ADRD and described their use of any form of LTSS and sub-types of LTSS (home-based, community-based, and nursing facility services) across states. RESULTS: We found that 80.5% of dual-eligible beneficiaries with ADRD received some form of Medicaid LTSS in 2016. The most common LTSS setting was nursing facility (46.7%), followed by home (31.5%) and community (12.2%). There was sizeable state variation in the percentage of dual-eligible beneficiaries with ADRD who used any form of LTSS (ranging from 61% in Maine to 96% in Montana). The type of LTSS used also varied widely across states. For example, home-based service use ranged from 9% in Maine, Arizona, and South Dakota to 62% in Oregon. Nursing facility services were the most common type of LTSS in most states. However, home-based service use exceeded nursing facility use in Oregon, Alaska, and California. CONCLUSIONS: Our findings suggest substantially different use of LTSS across states among dual-eligible beneficiaries with ADRD. Given the importance of LTSS for this population and their families, a deeper understanding of state LTSS policies and other factors that contribute to wide state variation in LTSS use will be necessary to improve access to LTSS across states.

Hospital Characteristics Associated With Heterogeneity in Institutional Postacute Care Spending Reductions Under the Comprehensive Care for Joint Replacement Model.

Importance: Prior research concluded that institutional postacute care spending decreased under the Comprehensive Care for Joint Replacement (CJR) model. Less is known about how changes in institutional postacute care spending varied across different types of hospitals. Objective: To measure hospital-level heterogeneity in the association of the CJR model with changes in institutional postacute care spending and to identify hospital characteristics associated with this variation. Design Setting and Participants: Using 100% Medicare claims data, this cross-sectional study assessed institutional postacute care spending from 2016 to 2017 among US hospitals randomly selected to participate in the CJR model and control group hospitals that were eligible but not selected for the participation in the CJR model. A causal forest was used to estimate the treatment effect of the CJR model conditional on hospital characteristics. Analysis was conducted between October 2019 and October 2021. Main Outcomes and Measures: The unit of analysis was each hospital; the outcome was the average per-episode Medicare spending for institutional postacute care within 90 days after hospital discharge for hip or knee joint replacement. Results: This study included 531 CJR participating hospitals and 658 control group hospitals from 2016 to 2017. The CJR model was associated with a $761 reduction in institutional postacute care spending (95% CI, -$1172 to -$351). The reduction in spending under the CJR model did not vary across conditional on hospital characteristics. Limited evidence was found for greater savings among hospitals with higher pre-CJR spending. However, this finding did not hold for hospitals in the highest quintile of pre-CJR spending. Conclusions and Relevance: In this cross-sectional study of 1189 hospitals, findings did not show strong evidence for significant heterogeneity in how the CJR model was associated with reductions in institutional postacute care spending across a range of hospital characteristics. Savings were not concentrated in hospitals with specific characteristics, such as hospitals with high-volume joint replacement or hospitals serving less medically or socially complex patients. Findings suggest that the CJR model created opportunities for savings across a spectrum of different hospitals.

Association of Medicare bundled payment model with joint replacement care for people with dementia.

BACKGROUND: We examined whether the Comprehensive Care for Joint Replacement (CJR) model was associated with changes in the receipt of joint replacement among people with Alzheimer's disease and related dementias (ADRD) as well as spending, health service use, and postsurgical outcomes among people with ADRD who underwent a joint replacement surgery. METHODS: Retrospective cohort study using 2013-2017 Medicare claims and Minimum Data Set. We used a difference-in-differences analysis to compare people with ADRD residing in CJR-participating treatment areas versus nonparticipating control areas on the receipt of joint replacement, episode spending during the index hospitalization and subsequent 90-day post-discharge period, discharges to an institutional post-acute care setting, and readmissions within 90 days of hospital discharge. RESULTS: Our sample included 3,361,950 Medicare enrollees with ADRD (2,156,995 women [64%]; mean [SD] age, 83 [8.0] years; 2,646,405 white [78%], 344,478 black [10%], 224,010 Hispanic [7%]). The receipt of replacement among people with ADRD changed similarly between CJR-participating treatment and control areas after CJR model was implemented, suggesting no association of CJR model with the receipt of replacement. Among people with ADRD who received joint replacement, the CJR model was associated with a $1029 decrease in spending per episode (95% confidence interval [CI] -$1577, -$481, p < 0.001), a 1.62 percentage point decrease in discharges to an institutional post-acute care setting (95% CI -3.17, -0.07, p = 0.04), but no changes in 90-day readmission (95% CI -2.68, 0.00, p = 0.051). CONCLUSIONS: Despite concerns that the CJR model could hinder people with ADRD from receiving joint replacement, the receipt of joint replacement did not change among people with ADRD under CJR. The CJR model was associated with decreased spending for people with ADRD who received joint replacements, driven by reduced discharges to an institutional post-acute care setting, without any changes in 90-day readmission.

Streptococcus pluranimalium, primeros casos pediátricos en México / Streptococcus pluranimalium first pediatric cases in Mexico

RESUMEN Introducción La taxonomía del género Streptococcus ha sido modificada con el uso de herramientas de biología molecular, que facilitan la identificación de especies que causan impacto en la patología humana tal como Streptococcus pluranimalium que, en México, hasta la fecha sólo ha sido reportado en adultos. Objetivo Reportar los primeros casos pediátricos de bacteriemia por Streptococcus pluranimalium. Casos clínicos Se presentan tres casos clínicos de pacientes femeninas en edad pediátrica, la primera de nueve meses con neumonía asociada a ventilador, recibió tratamiento con vancomicina. La segunda de 23 meses con absceso sub mandibular tratada con amoxicilina/sulbactam y la tercera de 11 años con endocarditis y bacteremia por Pseudomonas aeruginosa, recibió vancomicina, meropenem y gentamicina, falleció por insuficiencia cardiaca. Todas las pacientes cursaron con bacteriemia por Streptococcus pluranimalium. Discusión Streptococcus pluranimalium no ha sido reportado previamente en niños. Puede ser patógeno en diferentes y severos procesos infecciosos en seres humanos.

ABSTRACT Introduction Streptococcus gender taxonomy has changed, due to the use of molecular biology tools that allows the identification of new pathogenic species like Streptococcus pluranimalium, which in Mexico has only been reported in adults. Objetive To report the first three pediatric cases of Streptococcus pluranimalium bacteremia. Clinical Cases Three clinical cases of female patients of pediatric age, the first of nine months with ventilator-associated pneumonia, were treated with vancomycin. The second of 23 months with sub-mandibular abscess treated with amoxicillin / sulbactam and the third of 11 years with endocarditis and bacteremia by Pseudomonas aeruginosa, received vancomycin, meropenem and gentamicin, died of heart failure. All patients had bacteremia due to Streptococcus pluranimalium. Discussion Streptococcus pluranimalium has not been reported previously in children. It could be pathogen in different and severe animal and human infectious process.