A systematic review of nerve grafting, end-to-end repair, and nerve transfer for obturator nerve injuries.

OBJECTIVE: Obturator nerve injury can occur as a complication of gynecologic surgeries, occurring most frequently in patients with endometriosis and genitourinary malignancies. The resulting injury causes paresthesia and major weakness in adduction and atrophy of the adductor group of lower extremity muscles. The objective of this study was to conduct a systematic review and meta-analysis of the effectiveness of end-to-end repair, nerve grafting, and nerve transfer in improving motor function in patients with obturator nerve injury. METHODS: PubMed, Cochrane, Medline, and Embase libraries were searched from May 1994 to August 2020 according to the PRISMA guidelines for articles that present functional outcomes after obturator nerve injury in patients treated with nerve grafting, end-to-end repair, or nerve transfer. RESULTS: A total of 25 patients from 22 studies were included in the study, 15 of whom were treated with end-to-end repair (60%), nine with nerve grafting (36%), and one with nerve transfer (4%). Of the 15 patients with transection data, two had incomplete (13%) and 13 had complete (87%) nerve transections. The patients underwent pelvic lymphadenectomy (n=24) and radical cystectomy (n=1) operations. The mean Medical Research Council (MRC) score was 2.95±1.7 immediately after treatment and 4.77±0.6 at the final follow-up. All patients achieved good outcomes (MRC ≥3) at the final follow-up. The mean MRC score for end-to-end repair (n=15), nerve grafting (n=9), and nerve transfer (n=1) was 4.8±0.6, 4.7±0.8, and 5, respectively. Patients with end-to-end repair had higher immediate post-operative strength than those treated with nerve grafting (p=0.03) and tended to achieve full functional recovery after shorter periods of time (rho=-0.65, p=0.049). Other parameters did not correlate with MRC. CONCLUSION: End-to-end repair, nerve grafting, and nerve transfer are equally effective in restoring function in patients with obturator nerve injury. However, patients treated with end-to-end repair had higher immediate post-operative strength than those treated with nerve grafting.

Evaluation of Altrazeal transforming powder dressing on stage 2-4 pressure ulcers: a clinical case series.

OBJECTIVE: Pressure ulcers (PUs) are hard-to-heal, open wounds that affect millions of adults worldwide. Patients experience physical, mental, social and financial impairment. On average, <50% of stage 3 and 4 PUs heal by the sixth month. Treatment of PUs is highly variable due to a patient's comorbidities, demographics and wound characteristics. Because of this, there exists no standard dressing for PUs. Altrazeal transforming powder dressing (TPD, Uluru Inc., US) offers a promising new form of wound treatment; however, little evidence exists for TPD in the treatment of hard-to-heal PUs. This case series sought to examine the effect of TPD in hard-to-heal PUs that have previously undergone unsuccessful standard of care (SoC) wound therapy. METHODS: This case series used retrospective data from patients with stage 2-4 PUs that failed to heal after SoC therapies. Factors examined were: number of dressing changes; time between dressing changes; time to wound closure; and pain level. While data were assessed for all patients, we focused on the six particular cases that most clearly illustrated the effect of TPD on wound healing. RESULTS: Each of the 21 patients treated with TPD experienced successful and expedited wound closure. Stage 4 PUs took an average of 87 days with approximately six dressing changes to closure. Stage 3 PUs took an average of 41 days with approximately four dressing changes, and stage 2 PUs an average of 13 days to closure with approximately one dressing change. In the cases presented herein for which pain scores were reported, each showed a reduction in pain from an 8 or 9/10 to a 1 or 2/10 with the first dressing change. CONCLUSION: In this case series, TPD effectively reduced pain and healed PUs that had previously failed SoC interventions. We suggest future prospective studies in order to more effectively measure the wound healing capability and healthcare utilisation of TPD for treatment of PUs.

Treatment Strategies of Complications of Breast Implants Associated With Ventriculoperitoneal Shunts: A Case Report and Review of the Literature.

ABSTRACT: Breast augmentation is among the most commonly performed cosmetic procedures in the United States. As these patients age or develop comorbidities, surgeons across many other disciplines will inevitably encounter these patients in their own practices. Consequently, surgeons must be aware of the potential interactions between breast implants and devices commonly used in their fields. This case, the second of its kind encountered by our own department, describes a woman who suffered one such interaction: migration and coiling of a ventriculoperitoneal shunt around her breast implant. A systematic review was conducted to characterize breast-related ventriculoperitoneal shunt complications reported in the literature and generate an algorithm for management of the most commonly reported scenarios. Recognition of potential complications will aid surgeons in appropriate operative planning and prevention of these adverse events.

The Use of Botulinum Toxin to Prevent Anastomotic Thrombosis and Promote Flap Survival: A Bridge to Developing Clinical Studies.

BACKGROUND: Despite the possibility of using botulinum toxin to improve perfusion and prevent vasospasm, only a few studies have examined the use of botulinum toxin in the setting of flap surgery and thrombosis, and the mechanisms have not been fully explained. OBJECTIVE: The primary objective of this study was to provide a comprehensive review of the effectiveness of botulinum toxin in anastomotic thrombosis prevention and surgical flap survival to determine the value of conducting large-scale human trials. METHODS: Using the SYRCLE and CAMRADES criteria, a systematic review was performed. PubMed, Medline, EmBase, and the Cochrane Library were searched for studies that met our eligibility criteria. RESULTS: Twenty studies were included in the final selection. A total of 397 subjects were included. Eighteen studies used botulinum toxin type A alone, one used botulinum toxin type B alone, and only one used both botulinum toxin type A and botulinum toxin type B. The most commonly used injection technique was a preoperative intradermal injection. The most common procedure performed was a pedicled flap with random pattern skin flaps (65%). The mean injection dose was 28.17 ± 49.21 IU, whereas the mean reported injection time for studies using animal models was 7.4 ± 6.84 days. CONCLUSIONS: Similar mechanisms demonstrated in animal models may be replicable in humans, allowing botulinum toxin to be used to prolong flap survival. However, many factors, such as optimal injection techniques, dosages, and long-term outcomes of botulinum use in flap surgery, need to be further assessed before applying this to clinical practice.

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis.

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.

Structural basis for telomerase RNA recognition and RNP assembly by the holoenzyme La family protein p65.

Telomerase is a ribonucleoprotein complex essential for maintenance of telomere DNA at linear chromosome ends. The catalytic core of Tetrahymena telomerase comprises a ternary complex of telomerase RNA (TER), telomerase reverse transcriptase (TERT), and the essential La family protein p65. NMR and crystal structures of p65 C-terminal domain and its complex with stem IV of TER reveal that RNA recognition is achieved by a combination of single- and double-stranded RNA binding, which induces a 105° bend in TER. The domain is a cryptic, atypical RNA recognition motif with a disordered C-terminal extension that forms an α helix in the complex necessary for hierarchical assembly of TERT with p65-TER. This work provides the first structural insight into biogenesis and assembly of TER with a telomerase-specific protein. Additionally, our studies define a structurally homologous domain (xRRM) in genuine La and LARP7 proteins and suggest a general mode of RNA binding for biogenesis of their diverse RNA targets.

A Comparative Analysis of Online Reporting of Possible Complications for Minimally Invasive Cosmetic Procedures.

Background: The rise in Botox, fillers, and chemical peel procedures demands transparent online information that discloses all relevant risks and complications. This study assesses the quality of complication disclosure on the most popular cosmetic sites. Methods: The top 50 Google search results for "Botox," "fillers," and "chemical peel" were analyzed for their reporting on relevant complications. Websites were categorized based on their origin. An overall complication, prevention, management, prevalence, and disclaimer score were assigned to each site. Results: A total of 136 websites were analyzed. Of these websites, 31 (22.7%) did not mention any complications or risks associated with the treatment. The most commonly reported complications were bruising (67.0%) for Botox, swelling (79.0%) for fillers, and redness (58%) for chemical peels. The least-reported serious complications were toxin spread effects (31.0%) for Botox, vision loss (23.0%) for fillers, and allergic reaction for chemical peel (18.0%). Reports of serious and rare side effects were significantly lower than those of common side effects (Botox, P = .001; fillers, P = .004; chemical peels, P < .001). The overall mean (standard deviation) complication score across all websites was 2.81/5 (1.31). Online health reference and academic/hospital sites disclosed complications better than sources in most other categories (P < .001). Conclusions: The reporting of online complications for the top 3 cosmetic procedures performed in the US is highly variable, biased, and at times, completely absent. Patients pursuing cosmetic surgery are heavily influenced by the internet and vulnerable to misinformation. Cosmetic procedure websites are in need of drastic improvement to ensure the health and safety of all patients.

Websites or Videos: Which Offer Better Information for Patients? A Comparative Analysis of the Quality of YouTube Videos and Websites for Cosmetic Injectables.

BACKGROUND: YouTube is used by more than 70 percent of adults and 81 percent of 15- to 25-year-olds. The information quality of videos related to the two most performed aesthetic procedures-botulinum toxin type A (Botox) and soft-tissue filler injections-has not been assessed or compared to that of websites. METHODS: A YouTube search for "Botox" and "fillers" was performed in July of 2020, identifying the most popular health information videos. Quality was assessed using the validated Journal of American Medical Association, Health on the Net principles, and the DISCERN criteria in addition to a procedure-specific content score. Quality scores were compared between different groups of video contributors and against websites. RESULTS: A total of 720 measurements of quality were performed across 95 YouTube videos and 85 websites. The mean quality scores were as follows: Journal of the American Medical Association, 1.74/4 ± 0.718; Health on the Net, 6.66/16 ± 2.07; DISCERN, 40.0/80 ± 9.25; and content, 39.1/100 ± 11.9. Physician, nonphysician health professionals, and other (news, magazine channels, and influencers) were all of higher quality than patient-based videos (p < 0.001). The mean DISCERN percentage score for videos was 50.04 ± 11.57 and significantly less than that of websites, 55.46 ± 15.74 (p = 0.010). The mean content scores showed a similar result, 39.06 ± 11.92 versus 60.76 ± 17.65 (p < 0.001), respectively. CONCLUSIONS: Improvement is needed in the quality of YouTube videos related to aesthetic injectables. Plastic surgeons, who are the most frequent video contributors, are most qualified to provide this change. Plastic surgeons should include videos as part of their online presence, as they may help facilitate a greater viewership.

Do Websites Serve Our Patients Well? A Comparative Analysis of Online Information on Cosmetic Injectables.

BACKGROUND: Patients access online cosmetic health information to help with decision making. This information is unregulated, variable in quality, and may be biased. This study compared the most popular cosmetic injectables websites to assess their readability, quality, and technical performance. METHODS: A Google search for "Botox" (botulinum toxin type A) and "fillers" was performed in July of 2020, identifying the most popular health information websites. Sites were analyzed for their readability and quality of health information using the validated DISCERN criteria and the Health on the Net Foundation Code of Conduct principles. Technical qualities were evaluated using two website performance algorithms, WooRank and WebsiteGrader. RESULTS: Eighty-five websites were analyzed (13 academic/hospital websites, seven commercial websites, 25 private practice board-certified websites, seven private practice not-board-certified websites, 16 online health reference websites, and 17 other websites). The mean readability consensus score was 11 (eleventh grade reading level). The mean DISCERN quality scores were higher for online health reference websites compared to academic/hospital websites (p = 0.045), commercial websites (p = 0.045), private practice board-certified websites (p < 0.001), and private practice not-board-certified websites (p = .002). No correlation between a website's rank and its DISCERN score was found (ρ = -0.07; p = 0.49). CONCLUSIONS: Cosmetic injectable websites are too difficult to read by the sixth grade standard recommended by the National Institutes of Health and the American Medical Association. Online health reference sites are higher in quality than physician sites. This has implications for the ability of many patients to be fully informed consumers. The readability, quality, and technical aspects of websites may affect the overall accessibility of patient health information.

The Asian Eye: Anthropometric Eye Measurements of Attractiveness in Young East Asian Women.

BACKGROUND: Because of the high volume of Asian eyelid operations performed and the complexity of the Asian eye, there is a need to define exactly what anthropometric measurements determine attractiveness. METHODS: Eye photographs of young East Asian women were collected from publicly available sources online. Photographs were evaluated on a Likert scale ranging from 1 to 5 for attractiveness. Thirty-seven anthropometric measurements were collected using ImageJ from the most attractive and least attractive eyes to discover which features play the most important role in attractiveness. RESULTS: A total of 322 right eye photographs were evaluated for attractiveness. Sixty-six eyes received a median score of greater than or equal to 4.0 and were included in the attractive cohort. Forty-three eyes received a score of less than or equal to 2.0 and were included in the unattractive cohort. The superior brow peak was more lateralized compared to the upper lid crease and upper lash line peaks in attractive eyes. A greater palpebral aperture height-to-upper lid show ratio was found to be more associated with attractive eyes than with unattractive eyes. At the midpupillary line, the ratio was on average 1.58 ± 0.32 in attractive eyes and 1.22 ± 0.43 in unattractive eyes ( p < 0.001). Eyes with convergence of the upper lid crease with the upper lash line were more likely to be deemed unattractive ( p < 0.001). CONCLUSIONS: East Asian eyes have specific anthropometric measurements that are more associated with attractiveness. These ideal measurements are different from those in Caucasians, suggesting ethnic variability in features defining attractiveness and a need to tailor surgical care appropriately.

Scar Perception: A Comparison of African American and White Self-identified Patients.

Scars can have significant morbidity and negatively impact psychological, functional, and cosmetic outcomes as well as the overall quality-of-life, especially among ethnic minorities. The objective of this study was to evaluate African American and White patients' perception of their scars' impact on symptoms, appearance, psychosocial health, career, and sexual well-being, using validated assessment tools. Method: A total of 675 abdominoplasty and breast surgery patients from four providers completed the SCAR-Q, and Career/Sexual Well-Being scales via phone or email. A higher score on both assessments indicates a more positive patient perception. Results: Of the 675 respondents, 77.0% were White, and 23.0% were African American. White patients scored significantly higher on the SCAR-Q (232 ± 79 versus 203 ± 116), appearance (66 ± 26 versus 55 ± 29), and Career/Sexual Well-Being (16 ± 2 versus 15 ± 5) scales than African American patients (P < 0.001, P < 0.001, P < 0.001, respectively). There was no significant correlation between duration after surgery and symptoms or appearance scores for African American patients (P = 0.11, P = 0.37). There was no significant correlation between patient age and SCAR-Q score or time after surgery and psychosocial scores. Conclusions: African American patients are more likely to have lower perceptions of their scarring appearance, symptoms, psychosocial impact, career impact, and sexual well-being impact than White patients. Scar appearance and symptoms are less likely to improve over time for African American patients. This study highlights the need to address patient ethnicity when considering further follow-up, counseling, or other measures to enhance scar perception.

Analysis of Reapplications to Integrated and Independent Plastic Surgery Residency.

BACKGROUND: Plastic surgery is one of the most competitive specialties to match, with integrated plastic surgery having the highest rate of unmatched applicants in all categorical specialties. Unmatched applicants face difficult challenges, especially because there is a lack of data to help inform and guide both reapplicants and their advisors. METHOD: A national survey targeting plastic surgery applicants to both integrated and independent tracks from 2014 to 2020 was conducted in August 2020 to identify reapplicants, their application characteristics, and their outcomes. RESULTS: Eighteen of the 54 (33.3%) integrated reapplicants responded to the survey, as well as 7 of the 42 (16.7%) independent reapplicants. Fifty percent of integrated reapplicants and 43% of independent reapplicants successfully eventually matched. For integrated reapplicants, the mean (SD) number of first cycle invites was the greatest predictor of eventual match success, 9.00 (5.93) invites for reapplicants that eventually successfully matched compared with 2.89 (2.89) for those that remained unmatched, P = 0.025. Integrated reapplicants obtained on average 2.47 less invites during the reapplicant cycle compared with the initial cycle, P = 0.046. A Fisher exact test revealed no differences in match outcomes of those integrated reapplicants who spent time in between cycles pursuing research compared with a preliminary surgical year, P = 0.99. CONCLUSIONS: Reapplication to both integrated and independent plastic surgery may result in worse matching outcomes compared with the initial match. Applicants should attempt to preemptively address potential initial application weaknesses as reapplication after a failed initial attempt may carry disadvantages.

Which Resources Are Better: Sales or Scholarly? An Assessment on the Readability, Quality, and Technical Features of Online Chemical Peel Websites.

BACKGROUND: Chemical peels are an exceedingly popular cosmetic treatment with a wide variety of suppliers, each with its own online health resource describing the procedure. With increasing reliance on the internet for medical information, it is crucial that these resources provide reliable information for patients to make informed decisions. OBJECTIVES: The aim of this study was to examine popular chemical peel resources and determine if those that offered chemical peel treatments (Sales) had lower readability, quality of information, and technical features compared with those that did not (Scholarly). METHODS: The term "chemical peel" was searched in July 2020 and the top 50 websites were retrieved for analysis. Each resource's readability, quality, and technical features were measured through 8 readability formulas, the DISCERN and Health on the Net Code (HONcode), and 2 website performance monitors. RESULTS: The 50 websites were analyzed with an average Fry readability score of 13th grade. Scholarly websites displayed higher readability than Sales (Flesch Reading Ease 54.4 > 47.4, P = 0.047 and Coleman-Liau Index 10.6 < 11.7, P = 0.04). Scholarly resources surpassed Sales both in quality (DISCERN 56.4 > 39.7, P < 0.001 and HONcode 11.8 > 9.5, P = 0.032) and technical features (WooRank 76.9 > 68.6, P = 0.0082). CONCLUSIONS: The average readability of chemical peel resources is too difficult, and their quality must be improved. Scholarly resources exhibited higher readability, quality, and technical features than Sales websites.

A Case Report of Severe Hyponatremia Secondary to Coronavirus Disease 2019 Viral Pneumonia.

As of December 2020, the coronavirus disease 2019 (COVID-19) pandemic has resulted in 82.2 million cases worldwide. We report the case of a 69-year-old South Asian female with a history of hypertension, hypothyroidism, meningiomatosis, and urinary incontinence who contracted COVID-19 and developed severe hyponatremia. She was initially medically managed with antibiotics, anti-parasitics, anti-coagulants, and steroids. After experiencing breathlessness, chest discomfort, high systolic blood pressure, and tachycardia, she was admitted and diagnosed with post-COVID pneumonia, and was conservatively treated with steroids. She showed improvement, and was discharged upon being declared hemodynamically stable. While the patient was at home, she experienced periods of breathlessness and acral edema. This case raises the question of the correlation between hyponatremia and COVID-19, especially in regards to symptomatic presentations, including altered mental status, headache, and nausea. As there are limited studies that show severe electrolyte disorders leading to mortality, more research is needed to understand hyponatremia in cases with COVID-19.

Surgical Simulation Course for Facial Fracture Education.

A hands-on facial fracture simulation course can be an important adjunct teaching modality in resident education and training, enhancing both resident confidence and competence in treatment of facial fractures. In this study, 11 plastic surgery residents participated in a surgical wet laboratory and lecture focusing on operative management of facial fractures. Pre- and post-course questionnaires were administered as clinical knowledge assessments. Pre-course, 40% of participating residents reported feeling comfortable with facial fracture management (>5 of 10) and 50% of residents achieved competence on clinical assessment (scoring >50%). Following the simulation course, these same assessments were re-administered. Post-course, comfortability with fracture management increased to 100% among participating residents, and 90% of residents scored >50%, demonstrating improvement in clinical competency.

Novel Use of a Closed Liposuction System: Treatment of an Acute Morel-Lavallée Lesion of the Upper Extremity.

Morel-Lavallée lesions (MLL) are closed post-traumatic soft tissue shear injuries that occur between fascial planes and may result in tissue loss. Current treatment options for MLL include percutaneous drainage and open irrigation and debridement. A few cases of suction-assisted lipectomy (SAL) have been described for subacute and chronic MLL of the lower extremity. We present the first case report of using a closed SAL system to treat an acute MLL of the upper extremity. A 78-year-old female with right forearm MLL presented after blunt force trauma while on apixaban. After inpatient monitoring and anticoagulant drug clearance, a closed system SAL was performed to evacuate the hematoma and prevent ischemia of overlying soft tissues. Treatment outcomes were measured by clinical exam and CT imaging. Pre-operative diagnostic CT scan demonstrated a 4.8 x 6.6 x 13 cm fluid collection between fascial layers of the right forearm. SAL resulted in the evacuation of 300 cc of coagulated blood. Post-operative CT imaging of the right upper extremity did not show any measurable fluid collection. Clinical exam demonstrated resolution of swelling and soft tissue compromise. The patient reported significant pain reduction, resumed her anticoagulation, and was discharged home. There were no notable complications at her three month post-operative visit. Consideration of a constant low-pressure SAL system can successfully treat MLL in the acute period. This system is relatively minimally invasive, results in faster healing times compared to open debridement, and still results in effective hematoma evacuation.

Pyogenic Flexor Tenosynovitis Caused by Shewanella putrefaciens.

Flexor tenosynovitis is a surgical emergency due to the risk of tendon necrosis which can lead to subsequent amputation. We report a case of flexor tenosynovitis with Shewanella putrefaciens as the implicated organism, though the patient's mechanism of penetrating trauma did not involve a marine exposure. Shewanella are Gram negative bacilli associated with marine environments and have rarely been implicated in human disease. This patient presented with all four of Kanavel's signs and required open surgical irrigation and debridement; he was found to have purulence but no flexor tendon necrosis. This case emphasizes the importance of considering marine organisms as putative for flexor tenosynovitis, even if marine exposure does not occur at the time of the penetrating trauma. It also emphasizes the need to obtain a thorough patient history, especially in cases of infection, to assess for all possible environmental exposures.

A Case Report of Rapidly Lethal Acute Respiratory Distress Syndrome Secondary to Coronavirus Disease 2019 Viral Pneumonia.

As of April 2020, the coronavirus 2019 (COVID-19) pandemic has resulted in more than 210,000 deaths globally. The most common cause of death from COVID-19 is acute respiratory failure. We report the case of a 78-year-old female with a history of hypertension, cerebrovascular accident (CVA), type 2 diabetes mellitus, and sarcoidosis, who presented to the emergency department with one day of dyspnea. The patient experienced a rapid decline in respiratory function and was intubated in the intensive care unit (ICU), meeting the Berlin criteria for severe acute respiratory distress syndrome (ARDS). Chest radiography revealed diffuse bilateral coalescent opacities, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA swab test was positive for COVID-19. The patient experienced acute kidney injury with uptrending creatinine levels and remained lethargic and unresponsive throughout her ICU stay, suggestive of potential hypoxic brain injury. In light of the patient's poor clinical status, age, and significant comorbidities, prognosis was conveyed about medical futility and patient's family agreed to terminal extubation and the patient expired peacefully, exactly one week from hospital admission. This case report highlights the speed at which severe ARDS can present and contribute to end-organ dysfunction in COVID-19 patients.

U.S. Healthcare Insurance Market Concentration from 2001 to 2016: Increased Growth in Direct Written Premiums and Overall Decreased Market Consolidation.

With the establishment of state-based health insurance marketplaces, how U.S. health insurers are responding to market pressures and influencing premiums have represented important questions. We made novel use of the Standard and Poor's (S&P) Financial, a Wall Street financial dataset platform, to analyze trends in market capitalization and total direct written premiums (DWPs) from 2001 to 2016 of the top 5, 10, and 25 health insurance companies. Our results indicate that the market concentration of publicly traded companies has remained relatively stable over the past decade. The top 5, 10, and 25 health insurance companies were 43.5%, 57.5%, and 78.6% of the total market share in 2001 and 39.4%, 52.9%, and 72.8% in 2016, respectively. DWPs have grown nearly four-fold from $177 billion to $631 billion at a compounded annual rate of 8.8%, consistent with overall healthcare sector growth. Aggregating state-specific data, the overall U.S. health insurance market has become slightly less consolidated over recent years, as measured using the population-weighted Herfindahl-Hirschman index, a measure for market concentration, falling from 3,817 to 2,174 during this time period. As health insurance costs place a growing burden on American families, additional efforts are needed to study the impact on choice, quality, access, cost, and value to patients and providers from evolving health insurance markets.