Mobile PCR-based surveillance for SARS-CoV-2 to reduce visiting restrictions in nursing homes during the COVID-19 pandemic: a pilot study.

PURPOSE: Residents in nursing homes for the elderly (NH) are at high risk for death from COVID-19. We investigated whether repeated non-mandatory RT-PCR SARS-CoV-2 surveillance of NH staff and visitors reduces COVID-19 incidence rates in NH residents and allows to reduce visiting restrictions. METHODS: This pilot study at the beginning of the COVID-19 pandemic compared a surveillance approach of regular, twice-weekly voluntary PCR testing of health-care workers (HCW) and visitors in interventional NH (INH) with a setting without regular testing in control NH (CNH). Residents were not tested routinely within this study. Testing was performed in a mobile testing site with same-day result reporting. SARS-CoV-2 incidence among residents in both INH and CNH was the primary endpoint; secondary endpoints being SARS-CoV-2 infection among visitors and HCW in INH. RESULTS: Two INH and two CNH participated between October and December, 2020. At INH1, 787 tests of HCW and 350 tests of visitors were performed, accounting for 18.1% (n = 1930) of visits. At INH2, 78 tests of HCW and 372 tests of visitors were done, i.e., 30.5% (n = 1220) of visits. At the two INH 23 HCW and three visitors tested positive for SARS-CoV-2. COVID-19 outbreaks occurred among residents in INH1 (identified through study testing) and in CNH1. Utilization of voluntary testing was low. CONCLUSION: In a real-world setting without available rapid testing, voluntary RT-PCR SARS-CoV-2 testing of HCW and visitors does not prevent COVID-19 outbreaks in NH. Complete, non-selective testing for these groups should be instituted before visiting restrictions can be reduced. TRIAL REGISTRATION: The study has been registered at ClinicalTrials.gov with the identifier: NCT04933981.

Revenue-based cost assignment: a potent but hidden threat to the survival of the multispecialty medical practice.

PURPOSE: To demonstrate detrimental effects of revenue-based cost assignment (RBCA) in clinical practice and to compare that system with activity-based costing (ABC). METHOD: Four cost-allocation methods including RBCA were applied to a comprehensive ophthalmology practice using typical accounting methods. Data were obtained by a survey of practitioners or practices and/or extracted from decision support and practice management systems. Inaccuracies and distortions in reported costs were enumerated. Accounting scenario analysis was used to predict resultant provider and managerial decisions. A sampling survey was used to analyze other specialties. ABC was applied to the practice. RESULTS: RBCA causes procedures with higher profitability to appear less profitable and those with lower profitability to appear more profitable. The distortion in reported costs, in medical settings, is often sufficient to incentivize providers with higher profitability to exit a practice and those with lower profitability to remain in it. The departure of providers causes the residual practice profits to decline. These detrimental effects occur in many subspecialties, which suggests a national effect on health care. ABC allocation can reduce cost distortions and eliminate detrimental effects. CONCLUSIONS: RBCA leads to fragmentation of health care and a reduction in the profitability of multispecialty practices. Its use may slow the updating of reimbursement and help eliminate low-profitability specialties.

RBRVS costing: the inaccurate wolf in expensive sheep's clothing.

Resource-Based Relative Value Scale (RBRVS) costing has been promoted as an accurate cost allocation methodology and has gained popularity in recent years as a way to support many aspects of medical practice management. In this article, we demonstrate that RBRVS (also known as relative value unit (RVU) costing), is simply an overly complex form of revenue-based cost assignment and is identical to ratio of cost to charges (RCC) and percent revenue cost assignment approaches. However, this equivalence can be easily obfuscated by routine numerical manipulations used in financial analysis for many aspects of practice management. Further we show that since RBRVS cost systems assume all procedures and hence providers earn the same profit margin, the reported costs derived from this analysis in complex medical settings are highly inaccurate. Reported costs are highly inaccurate because the equal profit margin assumption is inappropriate in most, if not all, medical settings. Furthermore, the equal profit margin assumption is in direct contradiction to the conceptual design of the RVU system where value is increased according to complexity and skill of a procedure. Finally, we demonstrate, no fundamental improvement is achieved in the accuracy of reported costs through the adoption of the more complicated component RBRVS approach. With medical costs at the forefront of the national agenda it is important that costs reported to the Centers for Medicare & Medicaid Services (CMS) and subsequently used in setting RVUs are accurate.

Histologic, ultrastructural, and immunofluorescent evaluation of human laser-assisted in situ keratomileusis corneal wounds.

OBJECTIVE: To evaluate human corneas after laser-assisted in situ keratomileusis at different postoperative intervals. METHODS: Thirty-eight postmortem corneas from 20 patients with postoperative intervals from 2 months to 6.5 years after laser-assisted in situ keratomileusis surgery were collected from eye banks. The corneas were trisected and processed for conventional histologic analysis, transmission electron microscopy, and immunofluorescence. RESULTS: Light microscopy and transmission electron microscopy showed focal undulations in Bowman layer, focal epithelial hypertrophic modifications, and a variably thick (range, 0.4-16.4-mum) lamellar stromal interface scar in all specimens. The flap wound margin, which was adjacent to the epithelium, healed by producing an approximately 8-mum-thick hypercellular fibrotic stromal scar, whereas the central and paracentral wound regions healed differently because a thinner (approximately 5-mum) hypocellular primitive stromal scar was present in all the corneas examined. Immunofluorescence identified increased type 3 collagen and myofibroblasts in the hypercellular fibrotic scar regions and decreased or absent levels of all corneal stromal components other than type 1 collagen in the hypocellular primitive scar regions. CONCLUSIONS: After laser-assisted in situ keratomileusis surgery, the keratocyte-mediated production of a variably thick lamellar corneal stromal scar occurs, resulting in 2 regional types of scarring. The hypercellular fibrotic scar at the wound margin is usually visible clinically and functions to hold the flap in place, while the more central hypocellular primitive scar is not visible clinically and allows easy lifting of the flap postoperatively.

2,4-Dinitrophenol pharmacologically promotes retinal detachment in rabbits.

PURPOSE: The most difficult and unpredictable step of macular translocation surgery is creating the retinal detachment. The authors evaluated the efficacy of 2,4-dinitrophenol (2,4-DNP) to promote retinal detachment in the rabbit. METHODS: A vitrectomy was performed in each eye of a Dutch-belted rabbit. One eye was injected with 0.1 cc of a 5 mmol/L 2,4-DNP, the other eye with 0.1 cc of BSS+. After 30 minutes, the minimum aspiration pressure required to visibly elevate the retina was recorded. Four nonvitrectomized eyes received an intravitreal injection of either 0.1 cc of BSS+ or 5 mmol/L 2,4-DNP, and were enucleated and fixated for histopathologic examination. RESULTS: In the 12 masked eyes, the mean aspiration pressure decreased from 217 +/- 20 mmHg in the six BSS+ eyes to 117 +/- 20 mmHg in the six 2,4-DNP treated eyes (P = 0.0022). A retinal detachment was present in three of six masked and two of two unmasked 2,4-DNP treated eyes and none of eight BSS+ treated eyes. There was no short-term toxicity to the retina at the light microscope level. CONCLUSION: Intravitreal injection of 2,4-DNP reduced the retinal adhesive force by over 50% when compared to the BSS+ treated control eyes, without any short-term retinal toxicity.

Pathologic findings in postmortem corneas after successful laser in situ keratomileusis.

PURPOSE: To examine the histologic and ultrastructural features of human corneas after successful laser in situ keratomileusis (LASIK). METHODS: Corneas from 48 eyes of 25 postmortem patients were processed for histology and transmission electron microscopy (TEM). The 25 patients had LASIK between 3 months and 7 years prior to death. Evaluation of all 5 layers of the cornea and the LASIK flap interface region was done using routine histology, periodic acid-Schiff (PAS)-stained specimens, toluidine blue-stained thick sections, and TEM. RESULTS: In patients for whom visual acuity was known, the first postoperative day uncorrected visual acuity was 20/15 to 20/30. In patients for whom clinical records were available, the postoperative corneal topography was normal and clinical examination showed a semicircular ring of haze at the wound margin of the LASIK flap. Histologically, the LASIK flap measured, on average, 142.7 microm (range, 100-200). A spectrum of abnormal histopathologic and ultrastructural findings was present in all corneas. Findings at the flap surface included elongated basal epithelial cells, epithelial hyperplasia, thickening and undulations of the epithelial basement membrane (EBM), and undulations of Bowman's layer. Findings in or adjacent to the wound included collagen lamellar disarray; activated keratocytes; quiescent keratocytes with small vacuoles; epithelial ingrowth; eosinophilic deposits; PAS-positive, electron-dense granular material interspersed with randomly ordered collagen fibrils; increased spacing between collagen fibrils; and widely spaced banded collagen. There was no observable correlation between postoperative intervals and the severity or type of pathologic change except for the accumulation the electron-dense granular material. CONCLUSIONS: Permanent pathologic changes were present in all post-LASIK corneas. These changes were most prevalent in the lamellar interface wound. These changes along with other pathologic alterations in post-LASIK corneas may change the functionality of the cornea after LASIK.

Histiocytoid variant of eccrine sweat gland carcinoma of the eyelid and orbit: report of five cases.

OBJECTIVE: To study the clinicopathologic features of the histiocytoid variant of adenocarcinoma of the eccrine sweat gland of the eye and orbit. DESIGN: Retrospective case series. PARTICIPANTS: Five patients undergoing orbital and eyelid biopsy as a diagnostic procedure. METHODS: The authors examined the clinical histories and pathologic findings of five patients with eccrine adenocarcinoma of the eyelid with orbital invasion. MAIN OUTCOME MEASURES: Clinical and histopathologic examinations, including routine histopathology, immunohistochemistry, and electron microscopy studies. RESULTS: The tumors presented as insidious, diffusely infiltrative, firm cutaneous masses in the periocular area that later infiltrated the orbit. Histopathologic examination revealed that the tumors infiltrated the dermis and were composed of cells with a histiocytic to signet ring appearance. Tumor cells exhibited intracellular mucin production. Immunohistochemical stains were positive in tumor cells for low and high molecular weight cytokeratins, carcinoembryonic antigen, and epithelial membrane antigen. Electron microscopic examination showed lumen formation and intracytoplasmic mucin in tumor cells. CONCLUSIONS: The histiocytoid variant of adenocarcinoma of the eccrine sweat gland of the eyelid may present as an insidious tumor and diffusely invade the orbit. These cases may be confused with metastatic adenocarcinoma.