On the bright side of market concentration in a mixed-oligopoly healthcare industry.

We describe the healthcare industry as a mixed oligopoly, where a public and two private providers compete, and examine the effects of a merger between the two private healthcare providers on prices, quality, and welfare. When the price and (eventually) quality of the public provider are regulated, the cost synergies required for the merger to increase consumer welfare are less significant than in a setting with only profit-maximizing providers. When, instead, the public provider can adjust its policy to the rivals' behavior and maximizes a weighted sum of profits and consumer surplus (i.e., it has 'semi-altruistic' preferences), the merger is consumer surplus increasing if the public provider is sufficiently altruist, in some cases even absent efficiencies. These results suggest that ignoring the role and objectives of the public sector in the healthcare industry may lead agencies to reject mergers that, while would decrease consumer welfare in fully privatized industries, would increase it in mixed oligopolies.

Characterization of the Technofunctional Properties and Three-Dimensional Structure Prediction of 11S Globulins from Amaranth (Amaranthus hypochondriacus L.) Seeds.

Amaranth 11S globulins (Ah11Sn) are an excellent source of essential amino acids; however, there have been no investigations on the characterization of their techno-functional properties at different pH conditions and NaCl concentrations, which are necessary for food formulations. In this work, we report a new two-step purification method for native Ah11Sn with purity levels of ~95%. LC-MS/MS analysis revealed the presence of three different Ah11Sn paralogs named Ah11SB, A11SC, and Ah11SHMW, and their structures were predicted with Alphafold2. We carried out an experimental evaluation of Ah11Sn surface hydrophobicity, solubility, emulsifying properties, and assembly capacity to provide an alternative application of these proteins in food formulations. Ah11Sn showed good surface hydrophobicity, solubility, and emulsifying properties at pH values of 2 and 3. However, the emulsions became unstable at 60 min. The assembly capacity of Ah11Sn evaluated by DLS analysis showed mainly the trimeric assembly (~150-170 kDa). This information is beneficial to exploit and utilize Ah11Sn rationally in food systems.

Polyserositis as a Post-Covid-19 Complication.

INTRODUCTION: Polyserositis is described as inflammation with effusion of more than one serous membrane. There is very little published literature linking it to COVID-19 as a late complication. OBJECTIVE: Present and describe a case of post-COVID-19 polyserositis. METHODS: Data were collected from the medical record of a female patient admitted for fainting spells and marked weakness. The patient underwent a clinical evaluation, additional hematology, imaging and histopathology tests, and a surgical procedure. The new index, called the abdominal adipose deposit index, was obtained by multiplying the subcutaneous fat thickness by visceral fat thickness, both measured by ultrasound. A cutoff point was established that facilitated discernment of an unhealthy phenotype: normal weight but metabolically obese, a cardiometabolic risk factor. RESULTS: We present the case of a 57-year-old female patient admitted to hospital for fainting spells and marked weakness, four months after COVID-19 infection. She also had a history of obesity, asthma, type 2 diabetes mellitus and a cholecystectomy in December 1992 for gallstones. Clinical assessment revealed pericardial effusion and bilateral pleural effusion, in addition to a tumor-like lesion outside the pericardium, proximal to the right ventricular wall. A surgical procedure and findings from additional tests led to diagnoses of thymic remnants and polyserositis. CONCLUSIONS: This is a case of polyserositis in a post-COVID-19 patient. After other causes of polyserositis were ruled out, and since there is a likely physiological and pathogenic mechanism operating between the two diseases, the polyserositis was determined to be a late complication of COVID-19. To date, it is the second case reported in the world and the first reported in Cuba.

Patient Satisfaction and Risk of Falls with the Use of Intermittent Pneumatic Compression Devices Following Total Joint Arthroplasty.

INTRODUCTION: Patients who undergo total joint arthroplasty (TJA) are at a high risk for the development of thromboembolic complications. The rate at which venous thromboembolism occurs following TJA has been reported to be between 0.5% to 1.0%. As a result, the utilization of prophylactic therapies is considered the standard of care in this patient population. The primary purpose of the current study was to 1. evaluate patient satisfaction with the home use of intermittent pneumatic compression (IPC) devices following TJA and 2. evaluate the risk of self-reported falls secondary to the use of these devices following TJA. METHODS: This is a single institution, prospective study on patients who underwent TJA at an urban, academic orthopedic specialty hospital. Utilizing an electronic patient rehabilitation application (EPRA) that wirelessly pushes digital surveys at predefined time intervals, patients were surveyed regarding their use and satisfaction with their home IPC devices. They were also asked if they experienced any falls or near-falls. Surveys were administered on postoperative day 14, and patients were given 10 days to submit their responses. Using our institutions data warehouse, patient demographics including age, sex, surgery, laterality, insurance type, and length of stay were collected. RESULTS: Survey responses were collected from 424 patients who underwent TJA between August 2018 and January 2019. Of the respondents, 248 were female and 176 were male. Approximately 79% of patients in the cohort were satisfied with their use of their compression devices compared to 21% of patients who were unsatisfied. During this time, 19.3% (82 patients) also reported at least one tripping episode at home while using the device, while 80.7% (342 patients) never had a tripping incident at home. Finally, 1.4% (six patients) had at least one fall at home, while 98.6% (418 patients) did not have any falls at home. CONCLUSION: These results suggest that our patients were significantly dissatisfied with their home intermittent compression devices. There are a significant number of trips or falls following TJA and further study is needed examining the potential causality of these devices and their cords in these falls.

Development of a rapid, high-sensitivity, low-cost fluorescence method for protein surface hydrophobicity determination using a Nanodrop fluorospectrometer.

A microvolumetric method for surface hydrophobicity (H0) determination of proteins using a Nanodrop fluorospectrometer was developed. This method reduces the protein and fluorophore quantities that are necessary for sample preparations and readings by two and three orders of magnitude, respectively, compared to conventional methods. In addition, readings can be obtained in just 2-6 s. Bovine serum albumin (BSA) and 1-anilino 8-naphthalene sulfonic acid (ANS) were used for the first optimization of appropriate fluorophore-protein conditions for H0 determination (20 µM ANS, 0.5-4 µM BSA, pH 5). Based on validation guidelines, the novel method shows linear behavior, good intraday precision, accuracy, and sensitivity. This method was robust against several factors, as determined by a Youden-Steiner test. Additional surface hydrophobicity determinations using several proteins demonstrate suitable method applicability. The present microvolumetric method provides a reliable technique to determine the H0 of proteins for pharmaceutical, biotechnological, and food applications.

Comparison of Different Laboratory Tests to Identify "Aspirin Resistance" and Risk of Vascular Events among Ischaemic Stroke Patients: A Double-Blind Study.

"Aspirin resistance" (AR) is associated with increased risk of vascular events. We aimed to compare different platelet function tests used in identifying AR and assess their implications on clinical outcome. We performed platelet aggregation studies on non-cardioembolic ischaemic stroke patients taking aspirin 100 mg/day and 30 non-stroke controls. Data were collected on demographics, vascular risk factors, and concomitant medications. Cut-offs for AR were (1) light transmission aggregometry (LTA) of ≥20% using arachidonic acid (AA), ≥70% using ADP, or ≥60% using collagen; and (2) VerifyNow® assay ≥ 550 ARU. Telephone follow-ups were conducted by study staff blinded to AR status to ascertain the occurrence of vascular outcomes (stroke, myocardial infarction, amputation, death). A total of 113 patients were recruited, mean age 65 ± 8 years, 47% women, 45 ± 15 days from index stroke. 50 (44.3%, 95% CI 34.9-53.9) had AR on at least 1 test. Frequency of AR varied from 0% to 39% depending on method used and first vs. recurrent stroke. There were strong correlations between LTA AA, VerifyNow® and Multiplate® ASPItest (r = 0.7457-0.8893), but fair to poor correlation between LTA collagen and Multiplate® COLtest (r = 0.5887) and between LTA ADP and Multiplate® ADPtest (r = 0.0899). Of 103 patients with a mean follow up of 801 ± 249 days, 10 (9.7%) had vascular outcomes, of which six had AR by LTA-ADP. AR by LTA-ADP is associated with increased risk of vascular outcome (p = 0.034). Identification of AR is not consistent across different platelet function tests. LTA of ≥70% using 10 µM ADP in post-stroke patients taking aspirin is associated with increased risk of vascular outcome.

First Report of Sclerotium rolfsii Causing Collar Rot of Guar (Cyamopsis tetragonoloba) in Mexico.

Cyamopsis tetragonoloba (Fabaceae), also known as guar or cluster bean, is an annual legume grown mainly for industrial purposes and also as an ingredient for animal feed. In October 2021, collar rot symptoms were observed in five guar fields located in Guasave, Sinaloa, Mexico. Abundant white mycelium, and later brown and small sclerotia were observed at the base of the stems. Diseased plants showed reduced growth, wilting, and drying of the entire plant. Disease incidence ranged from 15 to 40%. Samples were collected from each field at two phenological stages (vegetative and reproductive). For fungal isolation, symptomatic stems pieces were surface sterilized with 2% sodium hypochlorite for 2 min, rinsed in sterilized distilled water two times, placed on PDA medium and incubated at 28°C in darkness for 3 days. Sclerotium-like colonies were consistently obtained and five isolates from five different fields were purified by the hyphal-tip method. Fungal colonies were white, cottony, and often forming fans. Sclerotia (1 to 2 mm diameter) were white at first and then gradually turned dark brown. Microscopic examination showed septate hyphae with some cells having clamp connections. A representative isolate was deposited in the Culture Collection of Phytopathogenic Fungi of the Faculty of Agriculture of Fuerte Valley at the Sinaloa Autonomous University under Accession no. FAVF647. For molecular identification, genomic DNA was extracted, and the internal transcribed spacer (ITS) region was amplified by PCR and sequenced using the primer pair ITS5/ITS4 (White et al. 1990). The sequence was deposited in GenBank (accession no. OM510466). BLASTn searches in GenBank showed 99.21 to 100% identity with the available sequences of Sclerotium rolfsii (accession nos. MK926446, MH854711, and KY175225). A phylogenetic analysis using the maximum Likelihood method placed isolate FAVF647 in the same clade as S. rolfsii. Pathogenicity tests were performed by inoculating 10 healthy guar seedlings (15-day-old) grown in pots. Four sclerotia were directly placed on the stem base of each plant. Five uninoculated guar seedlings were used as control. All plants were placed in a moist chamber at 25°C with a 12-h photoperiod for 2 days. Collar rot symptoms appeared on inoculated plants after 3 days, whereas control plants remained symptomless. Pathogenicity test was performed twice with similar results. The fungus was reisolated from the artificially inoculated plants, thus fulfilling Koch's postulates. Sclerotium rolfsii has been reported on guar plants in Australia, Brazil, Fiji, India, and the United States (Farr and Rossman 2022). To our knowledge, this is the first report of Sclerotium rolfsii causing collar rot of guar in Mexico. The disease is very common in guar fields in Sinaloa, Mexico, therefore additional studies are needed to develop effective disease-management strategies.

Amelioration of Pet Overpopulation and Abandonment Using Control of Breeding and Sale, and Compulsory Owner Liability Insurance.

Overpopulation and abandonment of pets are long-standing and burgeoning concerns that involve uncontrolled breeding and selling, illegal trafficking, overpopulation, and pet safety and well-being issues. Abandonment of pets creates numerous negative externalities and multimillion-dollar costs, in addition to severe consequences and problems concerning animal welfare (e.g., starvation, untreated disease, climatic extremes, uncertainty of rescue and adoption), ecological (e.g., invasive species and introduction of novel pathogens), public health and safety (e.g., risks to people from bites, zoonoses, or road hazards), and economic (e.g., financial burdens for governmental and nongovernmental organizations). These interwoven problems persist for several reasons, including the following: (1) lack of an efficient system for the prevention of abandonment and overpopulation, (2) lack of regulatory liability for pet owners, (3) lack of legal alternative to abandonment. This article proposes a novel comprehensive management system for amelioration of overpopulation and abandonment of pets aimed to tackle the current supply and demand dysfunction of the pet market and provide a legal alternative to abandonment.

Outcomes with Two Tapered Wedge Femoral Stems in Total Hip Arthroplasty Using an Anterior Approach.

BACKGROUND: The majority of hip arthroplasties in the United States utilize cementless acetabular and femoral components. Despite their similarities, stem geometry can still differ. The purpose of this study is to compare the clinical results of two wedge-type stem designs. METHODS: A retrospective study of patients who underwent primary THA utilizing a direct anterior approach between January 2016 and January 2017. Two cohorts were established based on femoral stem design implanted. Descriptive patient characteristics and surgical and clinical data was extracted which included surgical time, length of stay (LOS), presence of pain (categorized as groin, hip, or thigh pain) at the latest follow-up, and revisions. Immediate postoperative radiographs were compared with the latest follow-up radiographs to assess limb length discrepancies, stem alignment, and stem subsidence. RESULTS: A total of 544 patients were included. 297 patients received the Group A stem (morphometric) and 247 patients received the Group B stem (flat-tapered). A significantly higher proportion of Group B stems subsided ≥3 mm and were in varus alignment than the Group A design. Additionally, a significantly greater number of patients who received the Group B stem reported postoperative hip and thigh pain. The logistic regression found that the Group B stem was 2.32 times more likely to subside ≥3 mm than the Group A stem. CONCLUSION: Our study suggests modestly improved radiographic and clinical outcomes and fewer instances of thigh pain, subsidence, and varus alignment in the patients who received the Group Ahip stem. Further studies are warranted to assess long-term significance.

Clinical and Radiographic Outcomes after Direct Anterior Approach Total Hip Arthroplasty Using Two Specialized Surgical Tables.

BACKGROUND: Specialized tables for direct anterior (DA) approach total hip arthroplasty (THA) have required an unscrubbed assistant for manipulation of the operative limb. A novel surgical table attachment designed for the DA approach is fully surgeon controlled and partially automated. The purpose of this study is to compare the clinical outcomes in patients who underwent THA through a DA approach with an assistant-controlled vs the surgeon-controlled (SC) table. METHODS: This is a retrospective study of 343 patients who underwent primary THA between January 2017 and October 2017. Two cohorts were established based on the surgical table used. Surgical and clinical data included the surgical time, length of stay, presence of pain (groin, hip, or thigh pain) at latest follow-up, and revision for any reason. Immediate postoperative radiographs were compared with latest follow-up radiographs to assess for leg length discrepancy, stem alignment, and stem subsidence. RESULTS: One hundred sixty-seven (48.7%) cases were performed using the assistant-controlled table, and 176 (51.3%) cases were performed using the SC table. The surgical time was significantly greater for surgeries using the SC table (70.2 minutes vs 66.1 minutes, P < .001). Neither group experienced any intraoperative fractures or postoperative dislocations. There were no significant differences in any other clinical or radiographic outcomes. CONCLUSIONS: Although the surgical time with the self-controlled table was longer by approximately 4 minutes, this discrepancy disappeared with progression through the learning curve. In our experience, the SC table allows for greater autonomy for the operating surgeon and eliminates the need for a full-time employee in the operating room workflow.

Arthroplasty Surgeons Do Not Improve Acute Outcomes for Patients With Hip Fracture Relative to Other Subspecialists.

As bundled reimbursement models continue to evolve, there is a continued effort to increase the value of care for patients undergoing arthroplasty. The authors sought to evaluate the effect of surgeon specialization (arthroplasty vs non-arthroplasty) on acute outcomes for patients with hip fracture who underwent total hip arthroplasty (THA), in an effort to determine whether the value of care can be improved by surgeons specializing in these procedures. They performed a multicenter retrospective cohort study of patients who had hip fracture and were treated with THA between June 2013 and February 2018 at 2 academic institutions that were involved in bundled reimbursement initiatives. Patients were stratified based on the subspecialty training of the operative surgeon (fellowship-trained adult reconstruction vs other orthopedic sub-specialty), and 90-day readmissions, length of stay, and discharge disposition were compared between groups. A total of 291 patients were included in the final cohort, with 120 (41.2%) undergoing surgery performed by a fellowship-trained adult reconstruction surgeon. No significant difference was found in age, sex, race, or American Society of Anesthesiologists score between the 2 groups. In addition, no significant difference was found in length of stay, discharge to a facility, or 90-day readmissions on univariable or multivariable analysis when adjusted for age, sex, body mass index, and American Society of Anesthesiologists score. This study showed that the acute outcomes used to assess the value of care for patients undergoing THA were not significantly different when the surgery was performed by an adult reconstruction specialist compared with other orthopedic surgeons at 2 high-volume academic centers with perioperative care pathways. Alternative modalities to significantly improve acute postoperative outcomes in a bundled reimbursement model must be investigated. [Orthopedics. 2020;43(5):e442-e446.].

Barriers to Revision Total Hip Service Lines: A Surgeon's Perspective Through a Deterministic Financial Model.

BACKGROUND: Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs. QUESTIONS/PURPOSES: Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA? METHODS: Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts. RESULTS: Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day. CONCLUSIONS: In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training.

BACKGROUND: Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. METHODS: A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. RESULTS: A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02). CONCLUSION: In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.

Short-term outcomes with the REDAPT monolithic, tapered, fluted, grit-blasted, forged titanium revision femoral stem.

AIMS: Although good clinical outcomes have been reported for monolithic tapered, fluted, titanium stems (TFTS), early results showed high rates of subsidence. Advances in stem design may mitigate these concerns. This study reports on the use of a current monolithic TFTS for a variety of indications. METHODS: A multi-institutional retrospective study of all consecutive total hip arthroplasty (THA) and revision total hip arthroplasty (rTHA) patients who received the monolithic TFTS was conducted. Surgery was performed by eight fellowship-trained arthroplasty surgeons at four institutions. A total of 157 hips in 153 patients at a mean follow-up of 11.6 months (SD7.8) were included. Mean patient age at the time of surgery was 67.4 years (SD 13.3) and mean body mass index (BMI) was 28.9 kg/m2 (SD 6.5). Outcomes included intraoperative complications, one-year all-cause re-revisions, and subsidence at postoperative time intervals (two weeks, six weeks, six months, nine months, and one year). RESULTS: There were eight intraoperative complications (4.9%), six of which were intraoperative fractures; none occurred during stem insertion. Six hips (3.7%) underwent re-revision within one year; only one procedure involved removal of the prosthesis due to infection. Mean total subsidence at latest follow-up was 1.64 mm (SD 2.47). Overall, 17 of 144 stems (11.8%) on which measurements could be performed had >5 mm of subsidence, and 3/144 (2.1%) had >10 mm of subsidence within one year. A univariate regression analysis found that additional subsidence after three months was minimal. A multivariate regression analysis found that subsidence was not significantly associated with periprosthetic fracture as an indication for surgery, the presence of an extended trochanteric osteotomy (ETO), Paprosky classification of femoral bone loss, stem length, or type of procedure performed (i.e. full revision vs conversion/primary). CONCLUSION: Advances in implant design, improved trials, a range of stem lengths and diameters, and high offset options mitigate concerns of early subsidence and dislocation with monolithic TFTS, making them a valuable option for femoral revision. Cite this article: Bone Joint J 2020;102-B(2):191-197.

Fellows perspective of HPB training in Latin America.

BACKGROUND: Currently, no standards for HPB training exist in Latin America. The aim of this work is to evaluate fellows' experience of HPB training and the areas of opportunity to improve. METHODS: A 35 points survey was developed and distributed among fellows from dedicated HPB training programs in Latin America. The survey was applied by direct phone call (37%) or web based (63%), to fellows graduated between 2010 and 2014, from 7 different programs. RESULTS: Thirty-nine fellows from Argentina, Brazil, Chile and México were considered with a response rate of 82% (32/39). Most fellows (90%) shared cases with more than one co-fellow. Scrubbing with chief residents ocurred to 60% of fellows; only 14% of fellows noted having a primary surgeon role in more than 70% of cases. Median number of major hepatectomies during training was 15 (1-100), Whipple procedures 6 (1-40), and major bile duct repair 20 (1-80). Limited funding was the main reason to avoid HPB programs outside the country of origin. CONCLUSION: HPB training in Latin America requires more operative volume and autonomy. Financial burden is the main limitation to pursue training overseas. A multinational fellowship that takes advantage of each center may overcome differences in volume and type of cases.

Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program.

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS: The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS: The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS: These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Investigation of the confinement effect on the evaporation behavior of a droplet pinned on a micropillar structure.

Evaporation of sessile droplet suffers from reduced evaporation rate due to the confinement of vapor diffusion imposed by the bottom substrate. However, it is possible to change the evaporation behavior of a droplet by suspending it from the bottom substrate, in particular, supporting the droplet on a micropillar. This is expected to enable diffusion transport in the downward direction that will subsequently enhance evaporative transport. In this study, we investigate the diffusion confinement effect imposed by the bottom substrate and the side wall of the micropillar through numerical simulations and experimental investigation. The approximate solutions for total evaporation rate and local evaporative flux were subsequently derived from the total evaporation rate predicted by the simulation results. The simulation results, agreeing within 5% with the experimental measurements, show that increasing the micropillar height enhances the total evaporation rate from the suspended hemispherical droplet. This enhancement is due to a dramatic improvement of the local evaporation rate near the contact line region as micropillar heights increase. The micropillar heights examined for maximum evaporation rates were observed under substrate temperatures from 60-98 °C. The increasing pillar height leads to smaller vapor diffusion resistance but greater conduction resistance.

A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes.

BACKGROUND: Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA). METHODS: A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts. RESULTS: No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001). CONCLUSION: The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Cost-Effectiveness of Dual Mobility and a Value-Based Algorithm of Utilization.

Hip dislocation remains a major concern following total hip arthroplasty due to its high frequency and economic burden. This article evaluates the cost-effectiveness regarding dual mobility as an alternative to standard implant designs. A review of literature analyzing the PubMed Central database was undertaken using the following terms in the primary query: dual mobility, cost-effectiveness, cost-analysis, or economic analysis. Dual mobility systems may be a cost-effective alternative when the price of the implant does not exceed the traditional system by $1023. Dual mobility cups may be an essential component for the future success of value-based total hip arthroplasty.