Cardiac Surgery Utilization Across Vulnerable Persons After Medicaid Expansion
BACKGROUND:Medicaid expansion (ME) under the Affordable Care Act has reduced the number of uninsured patients, although its preferential effects on vulnerable populations have been mixed. This study examined whether ME preferentially improved cardiac surgery use by insurance strata, race, and income level. METHODS:Non-elderly adults (aged 18-64 years) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair were identified in the State Inpatient Databases for 3 expansion states (Kentucky, New Jersey, and Maryland) and 2 non-expansion states (North Carolina and Florida) from 2012 to the third quarter of 2015. We used adjusted Poisson interrupted time series to determine the impact of ME on cardiac surgery use for Medicaid or uninsured (MCD/UIS) patients, racial and ethnic minorities, and individuals from low-income areas. RESULTS:In expansion states, use among non-White MCD/UIS patients had a positive trend after ME (2.3%/quarter; PÂ = .156), whereas use for White MCD/UIS patients fell (-1.7%/quarter; PÂ = .117). In contrast, use among non-White MCD/UIS in non-expansion states decreased by 4.4% (P < .001) which was a greater decline than among White MCD/UIS patients (-1.8%/quarter; PÂ = .057). There was no substantial effect of ME on cardiac surgery use for MCD/UIS patients from low- versus high-income areas. CONCLUSIONS:These findings demonstrate that the use of cardiac surgical procedures was generally unchanged after ME; however, nonsignificant trend differences suggest a narrowing gap between vulnerable and non-vulnerable groups in ME states. These preliminary findings help describe the association of insurance coverage as a driver of cardiac surgery use among vulnerable patients.
Eclipse Stemless Shoulder Prosthesis versus Univers II Shoulder Prosthesis: A Multicenter, Prospective Randomized Controlled Trial
BACKGROUND:Total shoulder arthroplasty is an accepted treatment for glenohumeral osteoarthritis. The Arthrex Eclipse shoulder prosthesis is a stemless, canal-sparing, humeral prosthesis with bone ingrowth capacity on the trunnion as well as through the fenestrated hollow screw that provides both diaphyseal and metaphyseal load sharing and fixation. METHODS:16 sites in the United States enrolled 327 patients (237 Eclipse, 90 Univers II) between 2013-2019. All patients had glenohumeral arthritis refractory to non-surgical care. Exclusion criteria were strict to avoid confounding factors such as severe patient co-morbidities, arthritis not consistent with osteoarthritis, and medical or prior surgical treatments that may affect outcomes. Patients were randomized to Eclipse or Univers II using block randomization. RESULTS:149 Eclipse and 76 Univers II patients reached 2-year follow-up [139 (93.3%) Eclipse and 68 (89.5%) Univers II had complete data]. The success rate using the composite clinical success (CCS) score was 95% for Eclipse vs. 89.7% for Univers II group. No patient exhibited radiographic evidence of substantial humeral radiolucency, humeral migration, or subsidence at any point. There were 7 (3.2%) reoperations in the Eclipse and 3 (3.8%) in the Univers II group. CONCLUSION/CONCLUSIONS:The Arthrex Eclipse shoulder prosthesis is a safe and effective humeral implant for patients with glenohumeral arthritis at two-year follow-up with no differences in outcomes when compared to the Univers II. LEVEL OF EVIDENCE/METHODS:Level II; Randomized Controlled Trial; Treatment Study.
Robotic-assisted tracheobronchial surgery
Robotic technology is positioned to transform the approach to tracheobronchial surgery. With its magnified 3D view, intuitive controls, wristed-instruments, high-fidelity simulation platforms, and the steady implementation of new technical improvement, the robot is well-suited to manage the careful dissection and delicate handling of the airway in tracheobronchial surgery. This innovative technology has the potential to promote the widespread adoption of minimally invasive techniques for this complex thoracic surgery.
Contemporary Management of Mitral Valve Disease
Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience
BACKGROUND:Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30Â % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery. METHODS:This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8Â weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out. RESULTS:Seventy-three patients were treated with anti-TNF therapy within 8Â weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups. CONCLUSIONS:The use of anti-TNF medications in inflammatory bowel disease patients within 2Â months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications.
Browpexy through the upper lid (BUL): a new technique of lifting the brow with a standard blepharoplasty incision
BACKGROUND: Browpexy returns the brow to an anatomical, aesthetically-appealing location on the upper face. Recently, browlifting techniques have evolved from aggressive, open approaches toward less invasive, limited-incision techniques. Browpexy through the upper lid (BUL), an innovative technique based on earlier practices, anchors the underlying brow soft tissue to the bone, allowing for stabilization. Furthermore, this procedure can be performed concomitantly with an upper eyelid blepharoplasty through the same access incision. OBJECTIVE: The authors evaluate the efficacy of BUL in patients with ptotic eyebrows requiring stabilization and/or elevation and in patients with prominent brow fat pads. METHODS: The charts of 21 patients who were treated with BUL by the senior author (HMS) between February 2007 and October 2008 were retrospectively reviewed. RESULTS: The age range of the 21 patients in this study was 54 to 70 years. Twelve patients were men; nine were women. Each patient presented with complaints of tired-appearing or "weighed-down" upper eyelids. All patients were uniformly happy with their postoperative aesthetic results. There were no major immediate or long-term complications (including, but not limited to, uneven postoperative brow position, loss of suspension, frontal nerve injury, hematoma, infection, or wound dehiscence). No patients required reoperation for recurrent brow ptosis or upper lid deformity. CONCLUSIONS: BUL is ideal for patients with ptotic eyebrows who need brow stabilization and/or elevation, as well as for patients with prominent brow fat pads who require stabilization. BUL achieves excellent results through a standard upper eyelid blepharoplasty incision, and allows the surgeon to perform a concomitant upper eyelid blepharoplasty and browpexy without a traditional coronal, scalp, or forehead incision.
Internal mammary artery perforators for the salvage of a superficially dominant free flap breast reconstruction [Case Report]