Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department.

Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.

Emergy-based indicators for evaluating ecosystem health: A case study of three benthic ecosystem networks influenced by coastal upwelling in northern Chile (SE Pacific coast).

It has been hypothesized that ecosystem health describes the state in which all processes operating within an ecosystem are functioning at a level of optimum efficiency to maximize system empower. In this study, systems analysis of networks and information flows is used within this definition of ecosystem health to assess the condition of the benthic ecosystems in three coastal bays in northern Chile. These highly productive ecosystems are characterized by the inflow of cold, nutrient-rich waters of low oxygen concentration derived from coastal upwelling of deep waters and the interruption of upwelling flow during El Niño events when warmer waters with higher oxygen and lower nutrient concentrations enter these coastal systems. Also, these ecosystems support important artisanal benthic fisheries and are affected by industrial activities in the coastal zone. Energy Systems Theory (EST) and Emergy Analysis (EA) were applied to quantify the health of these benthic ecosystems and evaluate differences in their structure, organization and functional capacities, which are related to their emergy signatures. The marked dominance of these benthic ecosystems by nitrate from upwelling resulted in unbalanced emergy signatures, suggesting less development and system diversity compared to other coastal ecosystems with more balanced emergy signatures. Macro-descriptors and network properties, such as emergy-based ascendency and the quality-adjusted Shannon diversity index were highest for Mejillones Bay, followed by Antofagasta and then Tongoy Bay. The Average Mutual Information (AMI) index adjusted for energy quality and the emergy-based A/C (ascendency to capacity) ratio, were higher for Tongoy Bay, suggesting functional differences in health among the three ecosystems. Thus, the emergy-based macro descriptors and other indicators used in our analysis indicate that the benthic networks examined have different structural and functional characteristics that lead to different characterizations of their states of health. As a result of this complexity, management policies should be implemented within a systemic context for analysis that considers all the factors determining the relative health of each ecosystem.

Role of surgery in the management of pulmonary sporotrichosis

Management of four patients with sporotrichosis is summarized; one was treated medically and three were treated surgically. Thirty-seven cases from the literature are reviewed. The role of surgery in the management of pulmonary sporotrichosis is outlined as follows: (1) diagnosis of pulmonary infiltrates and / or pulmonary cavities of undetermined origin, (2) surgical intervention in patients with persistent infiltrates with cavitary lesions resulting from sporotrichosis, following failed medical treatment, and (3) resection of associated pulmonary cavitary lesions in patients in spite of adequte medical control of sporothichosis. Surgical principles that must be observed in the management of pulmonary sporotrichosis follows: (1) Resection is the procedure of choice. The magnitude ranges from segmental resection to pneumonectomy. Clen resection is necessary. (2) Antifungal drug therapy - preferably with amphotericin B - is advisable preoperatively and postoperatively, since the major cause of late death is progression of the disease when clean resection has not been feasible. (3) Resection combined with drug therapy can be curative without increased risk in physiologically operable and anatomically resectable disease. (4) Thoracoplasty can be a lifesaving procedure for bilateral cavitary lesions with severe hemoptysis in patients with impaired pulmonary functions.