Impact of Medicaid expansion on young adult firearm and motor vehicle crash trauma patients.

BACKGROUND: The Affordable Care Act Medicaid expansion has increased insurance coverage and reduced some disparities in care and outcomes among trauma patients, but its impact on subsets of trauma patients with particular mechanisms of injury are unclear. This study evaluated the association of the Affordable Care Act Medicaid expansion with insurance coverage, trauma care, and outcomes among young adults hospitalized for firearm- or motor vehicle crash-related injuries. MATERIALS AND METHODS: We used statewide hospital discharge data from 5 Medicaid expansion and 5 nonexpansion states to compare changes in insurance coverage and outcomes among firearm and motor vehicle crash trauma patients aged 19-44 from before (2011-2013) to after (2014-2017) Medicaid expansion. We examined difference in differences overall, by race/ethnicity, and by zip-code-level median income quartile. RESULTS: Medicaid expansion was associated with a decrease in the proportion of young adult motor vehicle crash and firearm trauma patients who were uninsured (motor vehicle crash: difference in differences - 12.7 percentage points, P < .001; firearm: difference in differences - 30.7 percentage points, P < .001). Medicaid expansion was also associated with increases in the percentage of patients discharged to any rehabilitation (motor vehicle crash: difference in differences 1.78 percentage points, P = .001; firearm: difference in differences 2.07 percentage points, P = .02) and inpatient rehabilitation (motor vehicle crash: difference in differences 1.21 percentage points, P = .001; firearm: difference in differences 1.58 percentage points, P = .002). Among patients with firearm injuries, Medicaid expansion was associated with a reduction in in-hospital mortality (difference in differences - 1.55 percentage points, P = .002). CONCLUSION: In its first 4 years, the Affordable Care Act Medicaid expansion increased insurance coverage and access to rehabilitation among young adults hospitalized for firearm- or motor vehicle crash-related injuries while reducing inpatient mortality among firearm trauma patients.

Reprint of: Removal and formation of chlorinated triclosan derivatives in wastewater treatment plants using chlorine and UV disinfection.

Triclosan, a common antimicrobial agent, may react during the disinfection of wastewater with free chlorine to form three chlorinated triclosan derivatives (CTDs). This is of concern because the CTDs may be photochemically transformed to tri- and tetra-chlorinated dibenzo-p-dioxins when discharged into natural waters. In this study, wastewater influent, secondary (pre-disinfection) effluent, and final (post-disinfection) effluent samples were collected on two occasions each from two activated sludge wastewater treatment plants, one using chlorine disinfection and one using UV disinfection. Concentrations of triclosan and three CTDs were determined using ultra performance liquid chromatography-triple quadrupole mass spectrometry with isotope dilution methodology. Triclosan and the CTDs were detected in every influent sample at levels ranging from 453 to 4530 and 2 to 98 ng L(-1), respectively, though both were efficiently removed from the liquid phase during activated sludge treatment. Triclosan concentrations in the pre-disinfection effluent ranged from 36 to 212 ng L(-1), while CTD concentrations were below the limit of quantification (1 ng L(-1)) for most samples. In the treatment plant that used chlorine disinfection, triclosan concentrations decreased while CTDs were formed during chlorination, as evidenced by CTD levels as high as 22 ng L(-1) in the final effluent. No CTDs were detected in the final effluent of the treatment plant that used UV disinfection. The total CTD concentration in the final effluent of the chlorinating treatment plant reached nearly one third of the triclosan concentration, demonstrating that the chlorine disinfection step played a substantial role in the fate of triclosan in this system.

Removal and formation of chlorinated triclosan derivatives in wastewater treatment plants using chlorine and UV disinfection.

Triclosan, a common antimicrobial agent, may react during the disinfection of wastewater with free chlorine to form three chlorinated triclosan derivatives (CTDs). This is of concern because the CTDs may be photochemically transformed to tri- and tetra-chlorinated dibenzo-p-dioxins when discharged into natural waters. In this study, wastewater influent, secondary (pre-disinfection) effluent, and final (post-disinfection) effluent samples were collected on two occasions each from two activated sludge wastewater treatment plants, one using chlorine disinfection and one using UV disinfection. Concentrations of triclosan and three CTDs were determined using ultra performance liquid chromatography-triple quadrupole mass spectrometry with isotope dilution methodology. Triclosan and the CTDs were detected in every influent sample at levels ranging from 453 to 4530 and 2 to 98 ng L(-1), respectively, though both were efficiently removed from the liquid phase during activated sludge treatment. Triclosan concentrations in the pre-disinfection effluent ranged from 36 to 212 ng L(-1), while CTD concentrations were below the limit of quantification (1 ng L(-1)) for most samples. In the treatment plant that used chlorine disinfection, triclosan concentrations decreased while CTDs were formed during chlorination, as evidenced by CTD levels as high as 22 ng L(-1) in the final effluent. No CTDs were detected in the final effluent of the treatment plant that used UV disinfection. The total CTD concentration in the final effluent of the chlorinating treatment plant reached nearly one third of the triclosan concentration, demonstrating that the chlorine disinfection step played a substantial role in the fate of triclosan in this system.