Value of Surgical and Nonsurgical Treatment for Sleep Apnea: A Closer Look at Health Care Utilization.

OBJECTIVE: To determine how surgery, continuous positive airway pressure (CPAP), and no treatment impact health care utilization in patients who have obstructive sleep apnea (OSA). STUDY DESIGN: This is a retrospective cohort study of patients between the ages of 18 and 65 that were diagnosed with OSA (9th International Classification of Diseases) from January 2007 to December 2015. Data were collected over 2 years, and prediction models were generated to evaluate trends over time. SETTING: A population-based study using real-world data and insurance databases. METHODS: A total of 4,978,649 participants were identified, all with at least 25 months of continuous enrollment. Patients with previous soft tissue procedures not approved for OSA (nasal surgery), or without continuous insurance coverage were excluded. A total of 18,050 patients underwent surgery, 1,054,578 were untreated, and 799,370 received CPAP. IBM Marketscan Research database was utilized to describe patient-specific clinical utilization, and expenditures, across outpatient, and inpatient services, and medication prescriptions. RESULTS: When the cost of the intervention was eliminated in the 2-year follow-up, the monthly payments of group 1 (surgery) were significantly less than group 3 (CPAP) in overall, inpatient, outpatient, and pharmaceutical payments (p < .001). The surgery group was associated with less cumulative payments compared to the other 2 groups when the cost of the intervention (CPAP or surgery) was eliminated in all comorbidities and age groups. CONCLUSION: Treating OSA with surgery can lessen overall health care utilization compared to no treatment and CPAP.

Brazilian Public Health System: history and profile of heart failure care and the impacts of COVID-19 / Sistema Público de Saúde Brasileiro: história e perfil dos cuidados com a insuficiência cardíaca e os impactos da COVID-19

Objective: The objective of this study is to describe the general and specific context of hospitalizations for Heart Failure (HF) in the Unified Health System and its main care indicators and economic aspects in the period before and during COVID-19. Methods: The economic indicators were evaluated between January 2011 and June 2022, comparing these indicators before and during the COVID-19 pandemic, using data from the DataSUS Health Information of the Ministry of Health of Brazil. The number of hospitalizations, length of stay, lethality and hospitalization costs were evaluated. The ARIMA method and the general regression model were used to analyze monthly results before and during COVID-19. Results: Hospitalization for HF has decreased in the last 11 years, with the most significant drop in the COVID-19 pandemic. After the pandemic, there was an increase in lethality in patients hospitalized for HF and also an increase in length of stay, despite the decrease in hospitalizations. When analyzing the economic aspects, more than US$ 725 million were spent. The average ticket showed a clear drop in per capita investment, with a real devaluation of 30.46% in the period from 2011 to 2022, which can be related to two main hypotheses: increased effectiveness and effectiveness of the analysis of service costs and/ or chronic underfunding of the Brazilian Public Health System. Conclusion: HF has its lethality worsened over time, especially in the COVID-19 period, also associated with a significant expense with the SUS and a tendency to decrease the allocation of resources.

Objetivo: O objetivo deste estudo é descrever o contexto geral e específico das internações por insuficiência cardíaca (IC) junto ao Sistema Único de Saúde e seus principais indicadores assistenciais e aspectos econômicos no período pré e durante a COVID-19. Métodos: Os indicadores econômicos foram avaliados no período entre janeiro de 2011 e junho de 2022, comparando esses indicadores antes e durante a pandemia por COVID-19, utilizando dados do DataSUS Informações de Saúde do Ministério da Saúde do Brasil. Foram avaliados o número de internações, tempo de internação, etalidade e custos de internação. O método ARIMA e o modelo de regressão geral foram usados para analisar os resultados mensais antes e durante a COVID-19. Resultados: A hospitalização por IC diminuiu nos últimos 11 anos, com queda mais significativa na pandemia da COVID-19. Após a pandemia, houve aumento da letalidade em pacientes internados por IC e também um aumento do tempo de permanência, mesmo diante da diminuição das internações. Ao analisar os aspectos econômicos, foram gastos mais de US$ 725 milhões. O ticket médio apresentou uma clara queda no investimento per capita, com desvalorização real de 30,46% no período de 2011 a 2022, o que pode estar relacionado a duas hipóteses principais: aumento da efetividade e efetividade da análise de custos do atendimento e/ou subfinanciamento crônico do Sistema Público de Saúde Brasileiro. Conclusão: A IC tem sua letalidade agravada ao longo do tempo, principalmente no período da COVID-19, associada também a um gasto relevante com o sistema público brasileiro e a uma tendência de diminuição da alocação de recursos.

Patient and family experience with telemedicine and in-person pediatric and obstetric ambulatory encounters throughout 2020, during the COVID-19 epidemic: the distance effect.

BACKGROUND: Telemedicine has grown significantly in recent years, mainly during the COVID-19 pandemic, and there has been a growing body of literature on the subject. Another topic that merits increased attention is differences in patient and family experience between telehealth and in-person visits. To our team's knowledge, this is the first study evaluating pediatric and obstetrics outpatients experience with telemedicine and in-person visit types in an academic maternal and children's hospital, and its correlation with geographic distance from the medical center throughout 2020, during the COVID-19 crisis. METHODS: We aim to evaluate and compare patients' telemedicine and in-person experience for ambulatory encounters based on survey data throughout 2020, during the COVID-19 pandemic, with particular focus on the influence of distance of the patient's home address from the medical facility. A total of 9,322 patient experience surveys from ambulatory encounters (6,362 in-person and 2,960 telemedicine), in a maternal and children's hospital during 2020 were included in this study. The percentage of patients who scored the question "Likelihood to recommend practice" with a maximum 5/5 (top box) score was used to evaluate patient experience. The k-means model was used to create distance clusters, and statistical t-tests were conducted to compare mean distances and Top Box values between telemedicine and in-person models. Logistic regression analysis was used to evaluate the correlation between Top Box scores and patients' distance to the hospital. RESULTS: Top Box likelihood to recommend percentages for in-person and telemedicine were comparable (in-person = 81.21%, telemedicine = 81.70%, p-value = 0.5624). Mean distance from the hospital was greater for telemedicine compared to in-person patients (in-person = 48.89 miles, telemedicine = 61.23 miles, p-value < 0.01). Patients who live farther displayed higher satisfaction scores regardless of the visit type (p-value < 0.01). CONCLUSIONS: There is a direct relationship between the family experience and the distance from the considered medical center, during year 2020, i.e., patients who live farther from the hospital record higher Top Box proportion for "Likelihood to Recommend" than patients who live closer to the medical center, regardless of the approach, in-person or telemedicine.

Incidence and risk factors of chronic opioid use after sleep apnea surgery.

STUDY OBJECTIVES: To assess the incidence and risk factors of chronic opioid use after obstructive sleep apnea surgery. METHODS: Using IBM MarketScan research database, adults (>18 years) who underwent a variety of sleep surgery procedures between 2007 and 2015 were identified. Individuals with 1 year of insurance coverage before and after the surgical procedure were included. Additional anesthesia event(s) in the year following the procedure of interest and those who filled an opioid prescription within the year prior to surgery (not naive) were excluded. Outcomes included rates of persistent opioid use (additional opioid prescriptions filled 90-180 days postoperatively), prolonged use (additional opioid prescriptions filled 181-365 days postoperatively), and inappropriate use (> 100 morphine milligram equivalents). Evaluated variables include demographics, surgical procedures, and comorbidities. RESULTS: A total of 10,766 surgical procedures met the inclusion criteria. There was a trend of increased rates of perioperative opioid prescription. After multivariable logistic regression analysis, perioperative opioid prescription and smoking were independent risk factors for inappropriate opioid use (odds ratio [OR] = 31.51, P < .001; OR = 1.41, P = .016, respectively). Opioid prescription and hypertension were independent risk factors for persistent opioid use (OR = 37.8, P < .001, OR = 1.38, P = .008). Perioperative opioid prescription, previous opioid dependence diagnosis, smoking, and male sex were associated with continuous prolonged opioid use (OR = 73.1, 8.13, 1.95, and 1.55, respectively; P < .001, P = .020, P = .024, and P = .032, respectively). CONCLUSIONS: While efforts by different societies are being implemented to control the opioid crisis, we found that perioperative opioid prescription for airway surgery targeting obstructive sleep apnea is an independent risk factor for persistent, prolonged, and inappropriate opioid use. CITATION: Abdelwahab M, Marques S, Howard J, et al. Incidence and risk factors of chronic opioid use after sleep apnea surgery. J Clin Sleep Med. 2022;18(7):1805-1813.

Brazilian private health system: history, scenarios, and trends.

BACKGROUND: Health care is a complex economic and social system, which combines market elements and public and social interest. This combination in Brazil, like systems in China and United States of America, is operationalized through the public and private system. The sector represents approximately 9% of the country's GDP, of which 56% is privately sourced and 44% is of public origin. In the private sector includes a structure with 711 private health institutions, 47 million beneficiaries and revenues of US$30 billion a year. METHODS: Therefore, this research describes and analyzes the complementarity of Private Health before the Brazilian Unified Health System, highlighting its main characteristics, scenarios, and trends in the face of the health system and the Brazilian market. This descriptive and exploratory research uses secondary data from various sources, submitted to quantitative data analysis methods. The object of the research is the history of private health in Brazil and its main actors. RESULTS: The data are organized into three groups, each with its approach of collection and analysis. Thus, it is perceived as the notorious growth of large operators, to the detriment of operators with a lower concentration of beneficiaries; the increasing concentration of the market through mergers and acquisitions promoted by large publicly traded corporations, especially in regions with a lower rate of private health coverage; and the growth of the sector through business plans, whose central characteristic is the dependence on the country's employability rate. CONCLUSIONS: It is possible to perceive an intense trend of concentration of Brazilian private health in large institutions that have capitalized and have a great appetite for growth through mergers and acquisitions, whether from smaller operators or health institutions that integrate their health networks, following complementary health models already consolidated in countries such as China, and the United States of America, among others. This concentration projects a market with fewer options and competitiveness, reduction in transaction costs and increase the operational effectiveness of health care.

Perioperative Antibiotic Use in Sleep Surgery: Clinical Relevance.

OBJECTIVE: Upper airway surgery is a common therapeutic approach recommended for patients with obstructive sleep apnea (OSA) to decrease disease burden. We aimed to evaluate the effect of perioperative antibiotic prescription on complication rates. STUDY DESIGN: Retrospective cohort (national database). SETTING: Tertiary referral center. METHODS: This is a retrospective study of a large national health care insurance database (Truven MarketScan) from 2007 to 2015. Subjects diagnosed with OSA who had uvulopalatopharyngoplasty (UPPP) were included and stratified in single versus multilevel surgery. Other variables included smoking, age, sex, antibiotic prescription, and comorbidities based on the Elixhauser index. Evaluated outcomes were postoperative bleeding, intubation, pneumonia, superficial surgical site infection, tracheostomy, and hospital readmission. A multivariate regression model was created to assess each complication. RESULTS: A total of 5,798,528 subjects received a diagnosis of OSA, of which 39,916 were >18 years old and underwent UPPP, either alone or with additional procedures. The mean age was 43 years, and 73.4% were male. Antibiotic prescription was associated with less bleeding in UPPP alone, UPPP with nasal surgery, and UPPP with nasal and tongue surgery (P < .001, P < .001, and P = .006, respectively). It was also associated with a lower prevalence of surgical site infection, pneumonia, tracheostomy, intubation, and hospital readmission (P < .001). On a multivariate model, antibiotic prescription was significantly associated with a decreased rate of complications. CONCLUSIONS: Although former studies recommended against the use of antibiotics after tonsillectomy, our results suggest that antibiotic prescription after UPPP for OSA was associated with less bleeding, surgical site infection, pneumonia, intubation, tracheostomy, and hospital readmission 30 days postoperatively.

Description of a new species of Ixodes (Acari: Ixodidae) and first report of Ixodes lasallei and Ixodes bocatorensis in Brazil.

In a recent study, we relegated the taxon Ixodes aragaoi Fonseca, 1935 to a junior synonym of Ixodes fuscipes Koch, 1844, and reinstated Ixodes spinosusNeumann, 1899 (a former synonym of I. fuscipes) to a valid species. We examined all lots of ticks formerly identified as I. fuscipes or I. aragaoi in three tick collections of Brazil. Through morphological analysis, some of the examined specimens could not be assigned to either I. fuscipes or I. spinosus based on the examination of the type specimens of these two species. Herein, we report these ticks to represent three different species: Ixodes catarinensis n. sp. Onofrio & Labruna, Ixodes lasalleiMéndez Arocha and Ortiz, 1958, and Ixodes bocatorensisApanaskevich and Bermúdez, 2017. The latter two species are reported for the first time in Brazil. Phylogenetic analysis inferred from the tick 16S rRNA gene partial sequences corroborated our morphological analysis, indicating that I. spinosus, I. lasallei, I. bocatorensis, and I. catarinensis n. sp. form a natural group of neotropical ticks. With the present study, the number of Ixodes species in Brazil increases from 9 to 12. We propose a new identification key for females and males of Ixodes species currently recognized in Brazil.

A new species of Amblyomma (Acari: Ixodidae) associated with monkeys and passerines of the Atlantic rainforest biome, Southeastern Brazil.

Recent studies have reported several larvae of an unidentified Amblyomma species on passerine birds in Atlantic rainforest fragments in southeastern Brazil. These larvae yielded a unique 16S rRNA haplotype designated as Amblyomma sp. haplotype Nazaré, which showed nucleotide identity levels of 91% to Amblyomma parkeri Fonseca & Aragão, 1952 and 88% to Amblyomma longirostre (Koch, 1844). Herein, we describe Amblyomma sp. haplotype Nazaré as a new species, Amblyomma romarioi n. sp. Martins, Luz & Labruna, through a formal description of the male and female adult stages. Amblyomma romarioi is morphologically and genetically most closely related to A. parkeri, A. longirostre and Amblyomma geayi Neumann, 1899. Among males, the rectangular basis capituli and rounded coxa I spurs separates A. romarioi from A. parkeri, A. longirostre, and A. geayi, which have basis capituli triangular or slightly hexagonal, and pointed coxa I spurs. Among females, the V-shaped genital aperture and coxa I rounded spurs of A. romarioi contrasts to the U-shaped genital aperture and coxa I pointed spurs in A. parkeri, A. longirostre, and A. geayi. Larvae of A. romarioi have been collected on 24 species of passerines. The few records of nymphs and adults were on the black-fronted titi monkey Callicebus nigrifrons (Spix, 1823). The current distribution of A. romarioi is restricted to the Brazilian Atlantic rainforest, southeastern Brazil, in areas with altitude between 363 and 1600 m, within the distribution of C. nigrifrons. We discuss ecological features of Amblyomma romarioi, comparatively to A. parkeri, A. longirostre and A. geayi. The present study increases the Brazilian tick fauna to 74 species.

Occurrences of triatomines (Hemiptera: Reduviidae) and first reports of Panstrongylus geniculatus in urban environments in the city of Sao Paulo, Brazil.

This note reports on occurrences of triatomine species in the city of Sao Paulo, Brazil, registered between 1988 and 2017. Records of triatomines captured in Sao Paulo are based on specimens received spontaneously from Health Surveillance Centers, Health Centers and Zoonosis Control Centers in the city as well as from citizens. Species were identified morphologically at the Public Health Entomology Laboratory, Faculty of Public Health, University of Sao Paulo, where the triatomines, which are vectors of Chagas disease, were tested for Trypanosoma cruzi infection. The first reported occurrence of triatomine bugs in urban Sao Paulo was in 1988. The specimen, which was captured in Jardim Sao Luiz district, was from the genus Panstrongylus and was registered as Panstrongylus sp. but was not sexed. Since this first recorded occurrence, the following species have been found in the city: Panstrongylus geniculatus (2 occurrences), P. megistus (15 occurrences), Triatoma infestans (1 occurrence) and T. sordida (3 occurrences). In this paper, the importance of reporting occurrences of triatomine bugs in the city of Sao Paulo, one of the largest metropolis in the world, is discussed with an emphasis on P. megistus. The occurrences discussed here indicate the importance of entomological surveillance for these vectors even in urban centers although the possibility of vector transmission of Chagas disease in these centers is very low.

Mosquito Faunal Survey In a Central Park of the City of São Paulo, Brazil.

A total of 2,582 specimens of mosquitoes of 16 taxonomic categories grouped into 5 genera (Aedes, Culex, Mansonia, Toxorhynchites, and Wyeomyia) were collected in a central park of São Paulo City, Brazil. It is crucial to include such an area in official entomological surveillance programs since this park has all the epidemiological characteristics needed to maintain an enzootic cycle of arboviruses.

Immature mosquitoes in bamboo internodes in municipal parks, city of são paulo, Brazil.

We conducted an inventory of the mosquito fauna of the internodes of bamboo plants grown in municipal parks in the city of São Paulo, Brazil. During October 2010 to July 2013, a total of 8,541 immature stages belonging to 21 mosquito species were collected from bamboos over 61 municipal parks. Of these, Aedes albopictus was the most abundant species followed by Ae. aegypti found in broken bamboos in most parks. The former species was 7.2 times more abundant than the latter when both species shared the same habitat. Other species collected from bamboos included Culex quinquefasciatus and Haemagogus leucocelaenus. In bamboos with perforated internodes, species of the genus Wyeomyia were the most prevalent. Differences were also observed in species composition and abundance of mosquitoes collected in transversely broken bamboos and those collected from perforated bamboo internodes. Constant surveillance of these breeding sites is crucial due to the epidemiological importance of the species found. Furthermore, these breeding sites may help maintain some native wild mosquito populations along with a variety of other invertebrates found in these urban green areas.

Redescription of Amblyomma varium Koch, 1844 (Acari: Ixodidae) based on light and scanning electron microscopy.

Amblyomma varium Koch, 1844 is a Neotropical tick, known as the 'sloth's giant tick', with records from southern Central America to Argentina. It is found almost exclusively on mammals of the families Bradypodidae and Magalonychidae (Xenarthra). Differences exist in discussions with regard to the dentition of the female hypostome being either 3/3 or 4/4. The male was also originally described as having a short spur on coxa IV, but some specimens recently collected from different Brazilian localities have this spur three times longer. These differences beg the question of whether there is more than one species included under this taxon. In order to answer this question and to clarify the taxonomic characters of this species, 258 adult specimens were examined, and a redescription of male and female based on light and scanning electron microscopy is provided. In addition, DNA was extracted from males with either a long or a short spur on coxa IV to help settle this question for future investigations on their taxonomy. The morphological study showed that the dental formula pattern for males and females is 3/3 and 4/4, respectively. When sequenced, the 12 S rDNA genes of both A. varium males with long and short spurs on coxa IV were found to be identical, indicating that the length of the spurs on coxa IV is likely to be an intraspecifically polymorphic character of this species.

Parasitismo de Amblyomma fuscum ( Acari: Ixodidae ) em humanos / Parasitism of Amblyomma fuscum ( Acari: Ixodidae ) on humans

Amblyomma fuscum é uma espécie rara de carrapato, recentemente revalidada, com poucos registros de ocorrência na literatura. Neste trabalho, são informados dois registros de parasitismo de A. fuscum em seres humanos: um no Estado de São Paulo (SP) e outro possivelmente oriundo do Estado de Santa Catarina (SC), Brasil. Tratam-se dos primeiros registros de parasitismo em humano por esta espécie de carrapato. Um espécime adulto fêmea de A. fuscum foi coletado quando encontrava-se fixado à palma da mão de um dos autores deste trabalho, no município de Guarujá, SP. O segundo espécime, também adulto fêmea, foi coletado quando se encontrava fixado ao tornozelo de uma cidadã da cidade de São Paulo, que havia retornado de Lagoa da Conceição, em Florianópolis, SC, três dias antes. O presente registro de A. fuscum no município de Guarujá, SP, e outro possivelmente oriundo de Florianópolis, SC, reforça os achados prévios deste carrapato nesses dois Estados, especialmente em região costeira. Embora o estágio adulto de A. fuscum tenha sido associado primariamente com répteis, os vários registros em mamíferos (Carnivora e Edentata) e o presente registro em seres humanos sugerem uma baixa especificidade parasitária.

Redescription of larva, nymph and adults of Ixodes (I .) loricatus Neumann, 1899 (Acari: Ixodidae) based on light and scanning electron microscopy.

Ticks of the genus Ixodes are poorly known in the Neotropical zoogeographical region, from where only 45 species have been recorded. In Brazil, the genus is currently represented by eight species, four of which are known only from this country. This paper presents a redescription of all active stages in the life-cycle of I. loricatus , based on optical and scanning electron microscopy. In addition, the relationship of I. loricatus to other Neotropical Ixodes is presented and discussed.

Estudos biológicos, moleculares e taxonômicos de Ixodes ( I. ) loricatus NEUMANN, 1899 (Acari: Ixodidae) / Biological, molecular and toxonomical studies of Ixodes ( I. ) loricatus NEUMANN, 1899 (Acari: Ixodidae)

Objetivo. Ixodes loricatus é considerada envolvida na epidemiologia de Lymesimile, além de ser espécie insuficientemente conhecida por seus estágios imaturos. O estudo teve a finalidade acrescentar informações sobre a biologia e taxonomia, comparando dois grupos fenotipicamente distintos e as seqüências gênicas do 12S DNA mitocondrial, e redescrever os estágios biológicos por microscopia óptica e eletrônica devarredura. Métodos. Fêmeas inugurgitadas em marsupiais de Itapeví, SP foram separadas pela morfologia das placas espiraculares em dois grupos. Imaturos foram alimentados em gerbil e adultos em coelhos. Dados das gerações de cada grupo foram calculados por Mann-Whitney; intervalos de idade dos indivíduos F1, e proporções entre os grupos F2, foram comparadas às de outras espécies, para construção das matrizes de similaridade e topologias. Resultados. Em ambos os grupos, ocorreram semelhanças nos períodos de oviposição, incubação, eclosão e alimentação, e diferenças significativas nos sucessos de ingurguitamento, ecdise laral e ninfal. O melhor sucesso pré-alimar para imaturos foi com idade de 30-40 dias, enquanto para as fêmeas foi 41-50 dias. O caráter de diferenciação dos dois grupos não se manteve constante nas gerações seguintes, sendo provavelmente uma variação intraespecífica. Seqüências gênicas de ambos os grupos mostraram alta similaridade confirmando se tratar de uma única espécie. Conclusão. A biologia tradicional aliada à análise molecular, invalidam o "status" taxonômico de I. didelphidis, reforçando sinonimização com I. loricatus. A morfologia de imaturos é semelhante às quatro espécies do grupo loricatus, mas difere das espécies do grupo ricinus

Brazilian distribution of Amblyomma varium Koch, 1844 (Acari: Ixodidae), a common parasite of sloths (Mammalia: Xenarthra)

Amblyomma varium, commonly known in Brazil as the "carrapato-gigante-da-preguiça" (sloth's giant tick) is found from southern Central America to Argentina. The present study adds information on the geographical distribution of A. varium, as well as on their hosts, based on material deposited in the main Brazilian collections and on the available literature. Eighty-two vials, containing 191 adult specimens, deposited in five Acari collections between 1930 and 2001, were examined. These vials included data on the host and collection localities. The biology of A. varium is unknown. However it is known that, during the adult stage, the tick presents a high host specificity and is found almost exclusively on the sloths Bradypus tridactylus, B. variegatus, B.torquatus (Bradypodidae), Choloepus hoffmanni and C. didactylus (Megalonychidae). Based on the material examined, the states of Rondônia, Amazonas, Bahia and Alagoas are newly assigned to geographic distribution of A. varium in Brazil