Development of a Microfluidic Chip Powered by EWOD for In Vitro Manipulation of Bovine Embryos

Digital microfluidics (DMF) holds great potential for the alleviation of laboratory procedures in assisted reproductive technologies (ARTs). The electrowetting on dielectric (EWOD) technology provides dynamic culture conditions in vitro that may better mimic the natural embryo microenvironment. Thus far, EWOD microdevices have been proposed for in vitro gamete and embryo handling in mice and for analyzing the human embryo secretome. This article presents the development of the first microfluidic chip utilizing EWOD technology designed for the manipulation of bovine embryos in vitro. The prototype sustains the cell cycles of embryos manipulated individually on the chips during in vitro culture (IVC). Challenges related to the chip fabrication as well as to its application during bovine embryo IVC in accordance with the adapted on-chip protocol are thoroughly discussed, and future directions for DMF in ARTs are indicated.

Electrically-driven handling of gametes and embryos: taking a step towards the future of ARTs

Electrical stimulation of gametes and embryos and on-chip manipulation of microdroplets of culture medium serve as promising tools for assisted reproductive technologies (ARTs). Thus far, dielectrophoresis (DEP), electrorotation (ER) and electrowetting on dielectric (EWOD) proved compatible with most laboratory procedures offered by ARTs. Positioning, entrapment and selection of reproductive cells can be achieved with DEP and ER, while EWOD provides the dynamic microenvironment of a developing embryo to better mimic the functions of the oviduct. Furthermore, these techniques are applicable for the assessment of the developmental competence of a mammalian embryo in vitro. Such research paves the way towards the amelioration and full automation of the assisted reproduction methods. This article aims to provide a summary on the recent developments regarding electrically stimulated lab-on-chip devices and their application for the manipulation of gametes and embryos in vitro.

The myths of emergency medical care access in the managed care era

In this paper, we examine the perception that emergency care is unusually expensive. We discuss the myths that have fueled the ineffective and sometimes deleterious efforts to limit access to emergency care. We demonstrate the reasons why these efforts are seriously flawed and propose alternate strategies that aim to improve outcomes, including cooperative ventures between hospitals and managed care organizations. We challenge managed care organizations and healthcare providers to collaborate and lead the drive to improve the cost and clinical effectiveness of emergency care.

The impact of physician economic incentives on admission rates of patients with ambulatory sensitive conditions: an analysis comparing two managed care structures and indemnity insurance

The utilization of financial incentives to limit the use of health resources by primary care physicians represents a common reimbursement strategy by managed care organizations. These arrangements are virtually nonexistent with indemnity insurance. This analysis compares the hospitalization rates of patients with low-acuity medical conditions--ambulatory sensitive conditions (ASCs)--among three groups receiving care from primary care physicians. The physicians were compensated under different reimbursement mechanisms, in which incentives for reduced resource utilization varied. The groups can be described as follows: (1) a capitated for-profit group practice in which the physician partners have a relatively high economic incentive for lower utilization (group I); (2) physicians providing care under the auspices of three separate independent practice associations, in which the associations are capitated but the physicians are paid on a discounted fee-for-service basis (the associations also were included in this group) (group II); and (3) physicians who service patients whose care continues to be paid for by traditional indemnity insurance (group III). Financial incentives in the third group cohort were believed to be low to intermediate, and the physicians were assumed to have had no economic incentives to restrain their use of healthcare resources. Additional data analysis examined the role of emergency department utilization among patients in the groups. Group I patients ages 25 to 44 were admitted for ambulatory sensitive conditions at a significantly lower rate than were patients in groups II or III--0.8/1,000, 2.7/1,000, and 2.9/1,000, respectively. No difference was apparent in admission rates between patients in groups II and III. Overall emergency department utilization rates were lowest in the group I capitated panel (70/1,000), much higher in the group II independent practice association panel (363/1,000) and highest in the group III indemnity panel (466/1,000). Each of these rates was significantly different from the other. Both the ED utilization rate and ambulatory sensitive condition admission rate may have been affected by differences in socioeconomic status among the patient panels in the three groups. The overall effect of this variable on the two admission rates could not be isolated.

Malpractice claims against emergency physicians in Massachusetts: 1975-1993

This study reviewed 549 malpractice claims filed against emergency physicians in Massachusetts from 1975 through 1993, with a total of $39,168,891 of indemnity and expense spent on the 549 closed claims. High-risk diagnostic categories (chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, epiglottitis, central nervous system bleeding, and abdominal aortic aneurysm) accounted for 63.75% of all closed claims and 64.23% of the total indemnity and expense spent on closed claims. Missed myocardial infarction (chest pain) claims accounted for 25.47% of the total cost of closed claims but only 10.38% of closed claims. The number of claims for missed myocardial infarction increased in the post-1988 closed claim group compared to the pre-1988 group; fractures and wounds were significantly less frequent in the post-1988 group. The frequency of high-risk claims decreased in the post-1988 group, largely because of the decline in fracture and wound claims. The category of missed myocardial infarction had a larger percentage of claims closed with indemnity payment than without indemnity payment. This parameter may serve as a marker for the overall seriousness of claims associated with a particular allegation, unlike the average cost per claim, which may be skewed by a few large awards.

Massachusetts emergency medicine closed malpractice claims: 1988-1990

STUDY PURPOSE

To describe the characteristics of malpractice claims against emergency physicians and to identify causes and potential preventability of such claims.

POPULATION

Malpractice claims closed in 1988, 1989, and 1990 against emergency physicians insured by the Massachusetts Joint Underwriters Association were compared with claims closed from 1980 to 1987 as investigated in our previous study.

METHODS

Retrospective review of malpractice claim files by board-certified emergency physicians.

RESULTS

The average indemnity and expense per claim were higher in the current study population than in our previous study population (P = .05). Claims in eight high-risk diagnostic areas (chest pain, abdominal pain, fractures, wounds, pediatric fever/meningitis, subarachnoid hemorrhage, aortic aneurysm, and epiglottitis) accounted for 50.8% of claims in this study and 55.5% of total monetary losses. Four claims in this study were related to two instances of failure of an emergency department radiograph follow-up system. The evaluation of patients who were intoxicated contributed to major monetary losses, especially in cases of fractures and head injury.

CONCLUSION

Emergency physicians must have a particular awareness of their great risk exposure for missed myocardial infarction. Addition of dictation or voice-activated record generation systems, departmental protocols for radiograph follow-ups, and holding and re-evaluation of the intoxicated patient will help provide systems supports for reducing the liability of individual emergency physicians.

The Massachusetts Emergency Medicine Risk Management Program. Massachusetts Chapter of the American College of Emergency Physicians

Reducing malpractice claims incidence and improving the quality of patient care are the goals of the Massachusetts Emergency Physician Risk Management Program. This innovative program entails computer audit of records in high-risk diagnostic categories. The program focuses on increasing physician awareness of high-risk diagnoses and on medical record documentation of a few critical actions pertinent to each diagnostic area.

Preventability of malpractice claims in emergency medicine: a closed claims study

We conducted a retrospective study of 262 malpractice claims against emergency physicians insured in Massachusetts by the state-mandated insurance carrier; these 262 claims were closed in the years 1980 through 1987. A total of $11,800,156 in indemnity and expenses was spent for these 262 claims. In 211 cases, the allegation was failure to diagnose a medical or surgical problem. One hundred eighty-four of these cases were included in the following eight diagnostic categories: chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, aortic aneurysm, central nervous system bleeding, and epiglottitis. These eight categories accounted for 66.44% of the total dollars spent for the 262 claims. Because of the high incidence and dollar losses attached to these eight diagnostic categories, the Massachusetts Chapter of the American College of Emergency Physicians (MACEP) has developed clinical guidelines for the evaluation of these high-risk areas. Of the 184 high-risk claims, 99 claim files were reviewed; 45 of these reviewed claims were judged by physician reviewers as preventable by the application of the MACEP high risk clinical guidelines. From 22.26% to 46.4% of the $11,800,156 spent on the 262 claims could have been saved by the application of the MACEP clinical guidelines.

Acute porphyria in the emergency department

Patients with acute hepatic porphyria present with abdominal pain and neurologic abnormalities. Although the disease is uncommon, the emergency physician will occasionally encounter a patient with porphyria. The relevant pathophysiology of acute hepatic porphyria and the treatment of the patient with acute hepatic porphyria are reviewed.