Emergency Department and Inpatient Utilization Reductions and Cost Savings Associated With Trauma Center Mental Health Intervention: Results From a 5-year Longitudinal Randomized Clinical Trial Analysis.

OBJECTIVE: To identify and refer patients at high risk for the psychological sequelae of traumatic injury, the American College of Surgeons Committee on Trauma now requires that trauma centers have in-place protocols. No investigations have documented reductions in utilization and associated potential cost savings associated with trauma center mental health interventions. BACKGROUND: The investigation was a randomized clinical trial analysis that incorporated novel 5-year emergency department (ED)/inpatient health service utilization follow-up data. METHODS: Patients were randomized to a mental health intervention, targeting the psychological sequelae of traumatic injury (n = 85) versus enhanced usual care control (n = 86) conditions. The intervention included case management that coordinated trauma center-to-community care linkages, psychotropic medication consultation, and psychotherapy elements. Mixed model regression was used to assess intervention and control group utilization differences over time. An economic analysis was also conducted. RESULTS: Over the course of the 5-year intervention, patients demonstrated significant reductions in ED/inpatient utilization when compared with control patients [ F (19,3210) = 2.23, P = 0.009]. Intervention utilization reductions were greatest at 3 to 6 months (intervention 15.5% vs control 26.7%, relative risk = 0.58, 95% CI: 0.34, 1.00) and 12 to 15 months (intervention 16.5% vs control 30.6%, relative risk = 0.54, 95% CI: 0.32, 0.91) postinjury time points. The economic analysis suggested potential intervention cost savings. CONCLUSIONS: Mental health intervention is associated with significant reductions in ED and inpatient utilization, as well as potential cost savings. These findings could be productively integrated into future American College of Surgeons Committee on Trauma policy discussions.

Impact of the Affordable Care Act Medicaid expansion on oral surgery delivery at community health centers: an observational study.

BACKGROUND: Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. METHODS: Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012-2017. The analytic sample included 2054 CHC-year observations. RESULTS: Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). CONCLUSIONS: Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

Intraspinal TLR4 activation promotes iron storage but does not protect neurons or oligodendrocytes from progressive iron-mediated damage.

Iron is essential for basic cellular functions but in excess is highly toxic. For this reason, free iron and iron storage are controlled in the periphery by elaborate regulatory mechanisms. In contrast, iron regulation in the central nervous system (CNS) is not well defined. Given that excess iron is present after trauma, hemorrhagic stroke and neurodegeneration, understanding normal iron regulation and promoting iron uptake in CNS pathology is crucial. Peripherally, toll-like receptor 4 (TLR4) activation promotes iron sequestration by macrophages. Notably, iron-rich sites of CNS pathology typically contain TLR4 agonists, which may promote iron uptake. Indeed, our recent work showed impaired iron storage after acute spinal cord injury in mice with TLR4 deficiency. Here we used a reductionist model to ask if TLR4 activation in the CNS stimulates iron uptake and promotes neuroprotection from iron-induced toxicity. For this, we measured the ability of microglia/macrophages to sequester exogenous iron and prevent pathology with and without concomitant intraspinal TLR4 activation. Results show that, similar to the periphery, activating intraspinal TLR4 via focal LPS injection increased mRNA encoding iron uptake and storage proteins and promoted iron sequestration into ferritin-expressing macrophages. However, this did not prevent oligodendrocyte and neuron loss. Moreover, replacement of oligodendrocytes by progenitor cells - a normally robust response to in vivo macrophage TLR4 activation - was significantly reduced if iron was present concomitant with TLR4 activation. Thus, while TLR4 signaling promotes CNS iron uptake, future work needs to determine ways to enhance iron removal without blocking the reparative effects of innate immune receptor signaling.

Ferritin stimulates oligodendrocyte genesis in the adult spinal cord and can be transferred from macrophages to NG2 cells in vivo.

Injured CNS tissue often contains elevated iron and its storage protein ferritin, which may exacerbate tissue damage through pro-oxidative mechanisms. Therefore, therapeutic studies often target iron reduction as a neuroprotective strategy. However, iron may be crucial for oligodendrocyte replacement and remyelination. For instance, we previously showed that intraspinal toll-like receptor 4 macrophage activation induced the generation of new ferritin-positive oligodendrocytes, and that iron chelation significantly reduced this oligodendrogenic response. Since macrophages can secrete ferritin, we hypothesize that ferritin is a macrophage-derived signal that promotes oligodendrogenesis. To test this, we microinjected ferritin into intact adult rat spinal cords. Within 6 h, NG2+ progenitor cells proliferated and accumulated ferritin. By 3 d, many of these cells had differentiated into new oligodendrocytes. However, acute neuron and oligodendrocyte toxicity occurred in gray matter. Interestingly, ferritin-positive NG2 cells and macrophages accumulated in the area of cell loss, revealing that NG2 cells thrive in an environment that is toxic to other CNS cells. To test whether ferritin can be transferred from macrophages to NG2 cells in vivo, we loaded macrophages with fluorescent ferritin then transplanted them into intact spinal white matter. Within 3-6 d, proliferating NG2 cells migrated into the macrophage transplants and accumulated fluorescently labeled ferritin. These results show that activated macrophages can be an in vivo source of ferritin for NG2 cells, which induces their proliferation and differentiation into new oligodendrocytes. This work has relevance for conditions in which iron-mediated injury and/or repair likely occur, such as hemorrhage, stroke, spinal cord injury, aging, Parkinson's disease, and Alzheimer's disease.

Use of text messaging to enhance compliance with the accreditation council for graduate medical education resident duty hour requirements.

PURPOSE: Recently, the Accreditation Council for Graduate Medical Education (ACGME) has developed and enforced a complex set of regulations limiting resident duty hours (RDHs). One potential method to comply with these stringent regulations and better document resident work hours would be to use text message (TM)/short message service (SMS), allowing rapid, inexpensive, and interactive 2-way delivery of information. The purpose of this study was to document the successful implementation of TM to enhance compliance with the ACGME RDH regulations. METHODS: Our TM system uses TSHEETS (TS; Meridian, Ohio), which is an online time- and labor-management service. After our general surgical residents were registered with the system, the documentation of entry into (texting "t start" to a predetermined number) and exit out of (texting "t stop" to the same number) the hospital could easily be accomplished. The goals of this pilot study were to determine (1) the feasibility of implementing a program such as this and (2) if use of such a program was associated with high resident satisfaction and improved compliance. RESULTS: We registered 39 residents with TS. Within 3 days, compliance rose from 76.9% to 96.2%. After implementation of TM reminders, compliance increased to 100%. A time-tracking resident satisfaction survey was distributed after 8 weeks of data collection. Twenty six of 39 (67%) residents participated in the survey, with 25 (96%) being more satisfied with the current application as compared with either of the previous (manual or swipe card) systems, specifically regarding ease of use and overall ACGME RDH compliance. Self-reported resident scores of their ability to be compliant with ACGME RDH before versus after implementation increased from 47% to 75% (p < 0.05). CONCLUSIONS: We were able to implement successfully a novel technique for ACGME RDH documentation and compliance in a general surgery residency program through the use of TM; this approach employed a state-of-the-art time-tracking method that was associated with high levels of resident work-hour compliance and overall satisfaction.

The Evolution in the Management of Gastric Lymphoma.

The management of gastric lymphoma is a rapidly changing field. The classification and staging of lymphomas have been revised in the past two decades, reflecting diagnostic advances that include the use of immunohistochemical stains and cell-surface markers. Furthermore, the use of CT scanning and endoscopic ultrasound has revolutionized the non-operative diagnostic modalities available. Despite these advances, the future of gastric lymphoma research lies in the development of therapeutic regimens.

Calcifying fibrous pseudotumor of the neck: diagnostic challenges of a rare benign lesion.

Neck masses, frequently encountered by physicians, comprise a vast range of diagnoses, with malignancy being the greatest concern. Calcifying fibrous pseudotumor (CFP) is a rare lesion with unknown pathogenesis, characterized pathologically by a predominance of abundant hyalinized collagenous tissue with focal lymphoplasmacytic infiltrate and psammomatous or dystrophic calcifications. We present the case of a 29-year-old woman who presented with a 4-cm left neck mass, accompanied by constitutional symptoms of vague weakness and lethargy. After the lesion failed to respond to a course of antibiotic therapy, fine-needle aspiration was performed, the pathology of which was indeterminate. The concern was that the lesion was a lymphoproliferative disorder-further workup was performed. CT of the chest, abdomen, and pelvis revealed no evidence of adenopathy or neoplasms. Subsequently, an incisional biopsy was performed, suggesting a diagnosis of CFP. Magnetic resonance imaging with contrast, performed to delineate the anatomy, revealed the lesion in the left neck, deep to the left clavicle, that extended superiorly into the supraclavicular fossa. Complete surgical removal of the lesion was successfully performed, with immunophenotyping confirming the initial diagnosis of CFP. We present a case report of cervical CFP, discuss the approach to neck masses, and review the recent literature on this rare, benign entity.

Extensive stage small cell lung cancer presenting as an acute perforated appendix: case report and review of the literature.

Malignancies of the appendix are uncommon; a small subset of these lesions are actually metastatic cancers. In some rare cases, these lesions can cause obstruction, appendicitis, and perforation. M.K. is a 54-year-old man who presented to our institution with a 1-day history of right lower quadrant pain and a past medical history significant only for a 75-pack-year smoking history. CT scan revealed a perforated appendix, and the patient was taken to the operating room where a gangrenous appendix was removed uneventfully. Two days post-procedure, the patient was found to have acute mental status changes, requiring intubation and transfer to the surgical intensive care unit. As part of a workup, a CT scan of the head revealed multiple lesions compatible with metastatic disease. At that point, the pathology from the appendix came back as small cell lung cancer. Chest CT revealed hilar adenopathy and a hilar mass. The patient received emergent whole-brain irradiation therapy with improvement in his mental status, allowing him to be extubated and discharged from the hospital within 10 days of admission. Surgeons should remember that an underlying oncologic process may be the etiology of appendicitis in a small but important subgroup of patients.