The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

STUDY DESIGN: Survey study. OBJECTIVE: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. SUMMARY OF BACKGROUND DATA: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. METHODS: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. RESULTS: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. CONCLUSIONS: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

The Prevalence of Incidental Mastoid Opacification and the Need for Intervention: A Meta-Analysis.

OBJECTIVES/HYPOTHESIS: The increasing use of cross-sectional imaging has led to the predicament of incidental mastoid opacification (IMO). We investigated the prevalence of IMO and the clinical need for ENT assessment or intervention when identified. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The PRISMA statement standards were used to search electronic databases including Medline, Embase, PubMed, and Web of Science. The selection criteria were mastoid opacification found on computed tomography (CT) or magnetic resonance imaging (MRI) as incidental findings. RESULTS: A total of 16 studies were identified for qualitative analysis and 15 for quantitative analysis, mainly retrospective. The pooled prevalence of IMO in 246,288 patients was 8.4% (95% CI 5.5-12.0). The prevalence of IMO was significantly higher in studies with children (17.2%, 95% CI 10.9-24.6) than those with adults (6.1%, 95% CI 3.3-9.6); smaller sample size studies (12.4%, 95% CI 8.1-17.3) compared to larger sample size studies (4.1%, 95% CI 1.5-7.8); and when IMO was detected by viewing images (14.5%, 95% CI 9.9-19.8) compared to reading reports (3.5%, 95% CI 1.3-6.6). Imaging modality was not a significant moderator due to similar IMO rate on CT (8.6%, 95% CI 1.8-19.7) and MRI (10.4%, 95% CI 4.9-17.6). Nine studies reported on clinical outcomes of patients with IMO, and none reliably reported any cases of clinical mastoiditis. CONCLUSIONS: The term "mastoiditis" on radiology reports based on IMO does not indicate a clinical diagnosis of mastoiditis, although the current body of evidence is limited. Otolaryngology review is suggested if clinical correlation detects otological signs or symptoms. LEVEL OF EVIDENCE: NA Laryngoscope, 132:422-432, 2022.

Impact of Forward Osmosis Operating Pressure on Deformation, Efficiency and Concentration Polarisation with Novel Links to CFD.

Forward osmosis (FO) modules currently suffer from performance efficiency limitations due to concentration polarisation (CP), as well as pressure drops during operation. There are incentives to further reduce CP effects, as well as optimise spacer design for pressure drop improvements and mechanical support. In this study, the effects of applying transmembrane pressure (TMP) on FO membrane deformation and the subsequent impact on module performance was investigated by comparing experimental data to 3D computational fluid dynamics (CFD) simulations for three commercial FO modules. At a TMP of 1.5 bar the occlusion of the draw-channel induced by longitudinal pressure hydraulic drop was comparable for the Toray (16%) and HTI modules (12%); however, the hydraulic perimeter of the Profiera module was reduced by 46%. CFD simulation of the occluded channels indicated that a change in hydraulic perimeter due to a 62% increase in shear strain resulted in a 31% increase in the Reynolds number. This reduction in channel dimensions enhanced osmotic efficiency by reducing CP via improved draw-channel hydrodynamics, which significantly disrupted the external concentration polarization (ECP) layer. Furthermore, simulations indicated that the Reynolds number experienced only modest increases with applied TMP and that shear strain at the membrane surface was found to be the most important factor when predicting flux performance enhancement, which varied between the different modules. This work suggests that a numerical approach to assess the effects of draw-spacers on pressure drop and CP can optimize and reduce investment in the design and validation of FO module designs.

Impact of FO Operating Pressure and Membrane Tensile Strength on Draw-Channel Geometry and Resulting Hydrodynamics.

In an effort to improve performances of forward osmosis (FO) systems, several innovative draw spacers have been proposed. However, the small pressure generally applied on the feed side of the process is expected to result in the membrane bending towards the draw side, and in the gradual occlusion of the channel. This phenomenon potentially presents detrimental effects on process performance, including pressure drop and external concentration polarization (ECP) in the draw channel. A flat sheet FO system with a dot-spacer draw channel geometry was characterized to determine the degree of draw channel occlusion resulting from feed pressurization, and the resulting implications on flow performance. First, tensile testing was performed on the FO membrane to derive a Young's modulus, used to assess the membrane stretching, and the resulting draw channel characteristics under a range of moderate feed pressures. Membrane apex reached up to 67% of the membrane channel height when transmembrane pressure (TMP) of 1.4 bar was applied. The new FO channels considerations were then processed by computational fluid dynamics model (computational fluid dynamics (CFD) by ANSYS Fluent v19.1) and validated against previously obtained experimental data. Further simulations were conducted to better assess velocity profiles, Reynolds number and shear rate. Reynolds number on the membrane surface (draw side) increased by 20% and shear rate increased by 90% when occlusion changed from 0 to 70%, impacting concentration polarisation (CP) on the membrane surface and therefore FO performance. This paper shows that FO draw channel occlusion is expected to have a significant impact on fluid hydrodynamics when the membrane is not appropriately supported in the draw side.

Toward Portable Artificial Kidneys: The Role of Advanced Microfluidics and Membrane Technologies in Implantable Systems.

Globally, around 2.6 million people receive renal replacement therapy (RRT), and a further 4.9-9.7 million people need, but do not have access to, RRT [1]. The next generation RRT devices will certainly be in demand due to the increasing occurrence of diabetes, atherosclerosis and the growing population of older citizens. This review provides a comprehensive, yet concise overview of the cleared and remaining hurdles in the development of artificial kidneys to move beyond traditional dialysis technology-the current baseline of renal failure treatment. It compares and contrasts the state-of-the-art in 'cell-based' and 'non-cell-based' approaches. Based on this study, a new engineering perspective on the future of artificial kidneys is described. This review suggests that stem-cell-based artificial kidneys represent a long-term, complete solution but it can take years of development due to the limitations of current cell seeding technology, viability and complicated behaviour control. Alternatively, there is much potential for near- and medium- term solutions with the development of non-cell-based wearable and implantable devices to support current therapies. Based on recent fundamental advances in microfluidics, membranes and related research, it may be possible to integrate these technologies to enable implantable artificial kidneys (iAK) in the near future.

Impacted denture in the oesophagus: review of the literature and its management.

Foreign body impaction in the oesophagus is a common cause of acute dysphagia. Oesophageal impaction of sharp objects such as dentures can be life threatening due to the risk of oesophageal perforation. This condition requires urgent treatment, and therefore prompt diagnosis and management is vital to avoid complications. Diagnosing oesophageal foreign body can be challenging due to its poor localising symptoms. We describe a case of an impacted denture in which considerable delays to treatment were encountered, and discuss the pitfalls and lessons learnt. This case and review of the literature draw attention to clinical assessment, investigation and treatment options for oesophageal foreign body impaction.

Cotton bud in external ear canal causing necrotising otitis externa and subdural abscess.

Necrotising otitis externa (NOE) is an infection originating in the soft tissues of the external auditory canal (EAC) spreading to the surrounding bone and rarely causing intracranial complications. It is usually caused by Pseudomonas aeruginosa and has historically occurred in elderly patients with diabetes or immunodeficiency. EAC foreign body is a risk factor for otitis externa but has not been described in NOE. A healthy 31-year-old man presented with new-onset seizures and worsening left-sided otalgia and otorrhoea. Brain imaging revealed left temporal subdural abscesses superior to the petrous bone. A retained cotton bud was identified in the left EAC, along with osseocartilaginous junction and mastoid granulation tissue. The foreign body was removed; a cortical mastoidectomy performed and intravenous antibiotic administered. At 10 weeks, the patient remained well, with no neurological deficit and no residual ear symptoms, and CT demonstrated complete resolution of the intracranial abscesses.

Alteration of fibrin clot properties by ultrafine particulate matter.

Both long- and short-term (1-2 hours) exposure to particulate matter (PM) are associated with morbidity and mortality caused by cardiovascular diseases. One of the underlying mechanisms may be due to changes to blood coagulability upon exposure to PM. We investigated this possibility by measuring differences in blood clots formed in the presence of particulate matter in vitro. Total (T)PM increased the permeation of clots in a dose-dependant manner. Filtered (F)PM (17 microg/ml) also produced a significant increase in permeation. Turbidity measured as maximum optical density (ODmax) was increased in a dose-dependant manner with increasing concentration of TPM and FPM. Turbidity measurements also showed a significantly faster rate of polymerisation in the presence of 68 microg/ml FPM. Laser scanning confocal microscopy (LSCM) showed a decrease in fibre density without a significant increase in fibre diameter. However, LSCM showed increased clot heterogeneity due to fibre clustering, creating areas of denser fibrin network surrounded by looser network. The presence of reactive oxygen species (ROS) scavenger mannitol inhibited the effects on fibre clustering. Our data show that TPM and FPM cause alterations in fibrin clot structure, likely through the formation of ROS. These changes in fibrin clot structure may play a role in thromboembolic events upon PM exposure.

An ECVAG trial on assessment of oxidative damage to DNA measured by the comet assay.

The increasing use of single cell gel electrophoresis (the comet assay) highlights its popularity as a method for detecting DNA damage, including the use of enzymes for assessment of oxidatively damaged DNA. However, comparison of DNA damage levels between laboratories can be difficult due to differences in assay protocols (e.g. lysis conditions, enzyme treatment, the duration of the alkaline treatment and electrophoresis) and in the end points used for reporting results (e.g. %DNA in tail, arbitrary units, tail moment and tail length). One way to facilitate comparisons is to convert primary comet assay end points to number of lesions/10(6) bp by calibration with ionizing radiation. The aim of this study was to investigate the inter-laboratory variation in assessment of oxidatively damaged DNA by the comet assay in terms of oxidized purines converted to strand breaks with formamidopyrimidine DNA glycosylase (FPG). Coded samples with DNA oxidation damage induced by treatment with different concentrations of photosensitizer (Ro 19-8022) plus light and calibration samples irradiated with ionizing radiation were distributed to the 10 participating laboratories to measure DNA damage using their own comet assay protocols. Nine of 10 laboratories reported the same ranking of the level of damage in the coded samples. The variation in assessment of oxidatively damaged DNA was largely due to differences in protocols. After conversion of the data to lesions/10(6) bp using laboratory-specific calibration curves, the variation between the laboratories was reduced. The contribution of the concentration of photosensitizer to the variation in net FPG-sensitive sites increased from 49 to 73%, whereas the inter-laboratory variation decreased. The participating laboratories were successful in finding a dose-response of oxidatively damaged DNA in coded samples, but there remains a need to standardize the protocols to enable direct comparisons between laboratories.