Affordable Care Act Medicaid Expansion is Associated With Increased Utilization of Minimally Invasive Lung Resection for Early Stage Lung Cancer

OBJECTIVE

Minimally invasive lung resection (MILR) is underutilized in the United States. Under the Affordable Care Act (ACA), 39 states adopted Medicaid expansion, while 12 did not. Although Medicaid expansion has been associated with improved access to cancer care, its effect on utilization of MILR is unclear. We hypothesize that MILR would increase in Medicaid expansion states.

METHODS

The National Cancer Database was queried for adult patients from 2010 to 2018 with cT1/2N0M0 non-small cell lung cancer who received surgical resection by wedge, segmentectomy, or lobectomy. Patients were grouped by whether they received care in a state without Medicaid expansion vs expansion in January 2014. The outcome of interest was MILR (defined as video-assisted or robotic-assisted thoracoscopy) relative to open. Multivariable difference in differences (DID) cross-sectional analysis was used to estimate the average treatment effect (ATE) of Medicaid expansion.

RESULTS

There were 41,439 patients who met inclusion criteria: 20,446 (49.3%) in expansion states and 20,993 (50.7%) in non-expansion states. Multivariable DID analysis showed that Medicaid expansion was associated with an increase in Medicaid insurance type with an ATE of 7.4% (95% CI 7.1-7.7%, P = .002). Medicaid expansion was also associated with increased MILR utilization in unadjusted analysis (10,278/20,446 (50.3%) vs 9,953/20,993 (47.4%), p < .001) and in multivariable DID analysis (ATE 0.6%, 95% CI 0.3-0.8%, P = .008).

CONCLUSIONS

Although Medicaid expansion was associated with increased utilization of MILR for early stage lung cancer, the treatment effect was modest. This suggests that barriers in access to MILR are larger than simply access to care.

Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis

Background

Surgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated with SSRF procedural competency, little is known about the impact of provider specialization on SSRF performance frequency. We hypothesize that provider specialization would impact performance of SSRF.

Methods

The Premier Hospital Database was used to identify adult patients with rib fractures from 2015 and 2019. The outcome of interest was performance of SSRF, defined using International Classification of Diseases—10th Revision Procedure Coding System coding. Patients were categorized as receiving their procedures from a thoracic, general surgeon, or orthopedic surgeon. Patients with missing or other provider types were excluded. Multivariate modeling was performed to evaluate the effect of surgical specialization on outcomes of SSRF. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed excluding patients with ‘trauma center’ admissions.

Results

Among 39 733 patients admitted with rib fractures, 2865 (7.2%) received SSRF. Trauma center admission represented a minority (1034, 36%) of SSRF procedures relative to other admission types (1831, 64%, p=0.15). In a multivariable analysis, thoracic (OR 6.94, 95% CI 5.94–8.11) and orthopedic provider (OR 2.60, 95% CI 2.16–3.14) types were significantly more likely to perform SSRF. In further analyses of trauma center admissions versus non-trauma center admissions, this pattern of SSRF performance was found at non-trauma centers.

Conclusion

The majority of SSRF procedures in the USA are being performed by general surgeons and at non-trauma centers. ‘Subspecialty’ providers in orthopedics and thoracic surgery are performing fewer total SSRF interventions, but are more likely to perform SSRF, especially at non-trauma centers. Provider specialization as a barrier to SSRF may be related to competence in the SSRF procedures and requires further study.

Type

Therapeutic/care management.

Level of evidence

IV

Contemporary outcomes of surgical resection for chest wall chondrosarcoma

Objective

Chondrosarcoma is the most common primary malignant chest wall tumor and is historically associated with poor prognosis. Recommendations regarding surgical excision are on the basis of small, single-institution studies. We used a large national database to assess outcomes of surgery for chest wall chondrosarcoma (CWC) hypothesizing that surgical excision remains standard of care.

Methods

The National Cancer Databases for bone and soft tissue were merged to identify patients with chondrosarcoma from 2004 to 2018. Clinical and demographic characteristics of CWC were compared with chondrosarcoma from other sites. The primary outcome was overall survival described using Kaplan-Meier estimate. Univariable and multivariable Cox analysis was used to determine risk factors for poor survival among CWC patients who underwent surgery. Multivariable analysis of predictors of margin status was performed because of worse prognosis associated with positive margins.

Results

Among 11,925 patients with chondrosarcoma, 1934 (16.2%) had a CWC. Relative to other sites, CWC was associated with older age, male sex, White race, surgical resection, and care at a nonacademic institution. CWC was associated with 1-, 3-, 5-, and 10-year survival of 91.5%, 82.0%, 75.5%, and 62.7%, respectively. In univariable analysis, survival was associated with surgery (hazard ratio, 0.02; P < .001) and adversely affected by positive margins (hazard ratio, 2.66; P < .001). Multivariable analysis showed larger tumor size was independently associated with increased risk for positive margins (odds ratio, 1.04; 95% CI, 1.011-1.075).

Conclusions

CWC represents a different cohort of patients relative to chondrosarcoma from other sites. Surgical excision remains the optimal treatment, and positive margins are associated with poor prognosis.

Presence of any degree of coronary artery disease among liver transplant candidates is associated with increased rate of post-transplant major adverse cardiac events

The impact of coronary artery disease (CAD) among liver transplant candidates (LTC) on post-LT clinical outcomes remains unclear. The aim of this study is to determine association of presence and severity of CAD on post-LT major adverse cardiac events (MACE) including cardiac-associated mortality. We conducted a retrospective cohort analysis of 231 patients who underwent diagnostic coronary angiogram (DCA) during their LT evaluation at a tertiary medical center from 2012-2017. Patients were analyzed based on degree of CAD (no CAD, non-obstructive CAD [< 50% stenosis], obstructive CAD [≥50% stenosis]) per DCA results. MACE were noted at 30 days, 1 year, 3 years, and 5 years post-LT, and Kaplan-Meier curves were used to determine post-LT MACE-free probability. LTC with any CAD, including non-obstructive CAD, had lower MACE-free probability at all post-LT time points (0.94 vs 0.65 at 30 days, P = .001; 0.87 vs 0.59 at 1 year, P = .002; 0.87 vs 0.41 at 3 years, P < .001; 0.87 vs 0.37 at 5 years, P < .001). Identification of and medical intervention for non-obstructive CAD should be considered in all LTC, though further studies are necessary to determine optimal medical interventions to mitigate MACE risk in this cohort.

Optimal Surgical Timing After Neoadjuvant Therapy for Stage IIIa Non-Small Cell Lung Cancer

BACKGROUND

Patients with clinically/pathologically diagnosed stage IIIa non-small cell lung cancer (NSCLC) considered for surgery are recommended to undergo neoadjuvant chemotherapy with or without radiation. The timing of an operation after therapy is not standardized; therefore, we investigated the timing of intervention after neoadjuvant therapy and the impact on outcomes in this demographic.

METHODS

The National Cancer Database was queried between 2010 and 2015 for patients with clinical/pathologic stage IIIa NSCLC. Patients were then divided into short (<77 days), mid (77-114 days), and long delay (>114 days) groups based on interquartile values. These groups were then compared for age, race, gender, insurance type, Charlson-Deyo score, length of stay, readmission rate, and overall survival based on timing of operation.

RESULTS

There were 31,357 patients with clinical/pathologic stage IIIa NSCLC, and 5946 patients underwent surgical intervention. Preoperatively 3593 patients underwent chemoradiotherapy, 2185 underwent chemotherapy only, and 168 received radiation alone. The short, mid, and long delay groups were clinically and statistically similar in age, gender, insurance type, comorbidity index, treating facility type, and distance from home. Long delay groups had larger tumor size compared with other groups. Postoperative length of stay, rates of 30-day readmission, and 30- and 90-day mortality were similar across all groups. Cox modeling demonstrated a significant difference in survival when patients underwent earlier operative intervention compared with late operative intervention and when patients received chemoradiation compared with chemotherapy alone. Short, mid, and long delay group 1-year survivals were 82%, 83%, and 80% and 3-year survival 59%, 58%, and 52%, respectively (P = .0003).

CONCLUSIONS

The delay in surgical resection of stage IIIa NSCLC is not associated increased early mortality; however, it is associated with worse 3-year postresection survival.

Single Versus Double Lung Retransplantation Does Not Affect Survival Based on Previous Transplant Type

BACKGROUND

Survival following retransplantation with a single lung is worse than after double lung transplant. We sought to characterize survival of patients who underwent lung retransplantation based on the type of their initial transplant, single or double.

METHODS

The United Network for Organ Sharing database was queried for adult patients who underwent lung retransplantation from 2005 onward. Patients were excluded if they underwent more than one retransplantation. The patient population was divided into 4 groups based on first followed by second transplant type, respectively: single then single, double then single, double then double, and single then double. Descriptive analysis and Kaplan-Meier survival analysis were performed. A p value less than 0.05 was considered significant.

RESULTS

A total of 410 patients underwent retransplantation in the study time period. Overall mean survival for all patients who underwent retransplantation was 1,213 days. Kaplan-Meier survival analysis demonstrated no difference in graft survival between the 4 study groups (p = 0.146).

CONCLUSIONS

There was no significant difference in graft survival between recipients of retransplant with single or double lungs when stratified by previous transplant type. These results suggest that when retransplantation is performed, single lung retransplantation should be considered, regardless of previous transplant type, in an effort to maximize organ resources.

Temporal Formation and Immunolocalization of an Endospore Surface Epitope During Pasteuria penetrans Sporogenesis

The synthesis and localization of an endospore surface epitope associated with the development of Pasteuria penetrans was determined using a monoclonal antibody (MAb) as a probe. Nematodes, uninfected or infected with P. penetrans, were harvested at 12, 16, 24, and 38 days after inoculation (DAI) and then examined to determine the developmental stage of the bacterium. Vegetative growth of P. penetrans was observed only in infected nematodes harvested at 12 and 16 DAI, whereas cells at different stages of sporulation and mature endospores were observed at 24 and 38 DAI. ELISA and immunoblot analysis revealed that the adhesin-associated epitope was first detected at 24 DAI, and increased in the later stages of sporogenesis. These results indicate that the synthesis of adhesin-related proteins occurred at a certain developmental stage relative to the sporulation process, and was associated with endospore maturation. Immunofluorescence microscopy indicated that the distribution of the epitope is nearly uniform on the periphery of each spore, as defined by parasporal fibers. Immunocytochemistry at the ultrastructural level indicated a distribution of the epitope over the parasporal fibers. The epitope also was detected over other structures such as sporangium and exosporium during the sporogenesis process, but it was not observed over the cortex, inner-spore coat, outer-spore coat, or protoplasm. The appearance of the adhesin epitope first at stage III of sporogenesis and its presence on the parasporal fibers are consistent with an adhesin-related role in the attachment of the mature endospore to the cuticle of the nematode host.

Antibodies from Chicken Eggs as Probes for Antigens from Pasteuria penetrans Endospores

The bacteria Pasteuria spp. have been identified as among the most promising of several microbial organisms currently under investigation as biological control agents of plant-parasitic nematodes. As part of our goal to develop methods to discriminate isolates of Pasteuria penetrans with different host preferences, we investigated the potential of developing antibody probes to identify endospores of different isolates of P. penetrans. Polyclonal IgY antibodies were raised in chickens against endospores of P. penetrans isolates P20 and P100. Hens were injected with P20 or P100 endospore suspensions and boosted at 14 days. Anti-spore titers were determined with ELISA on yolk extracts of individual eggs as a function of time. The highest titers were found in eggs produced at 22 to 35 days after initial injections. Yolk extracts showing the highest titers were combined and processed to provide partially purified IgY preparations. SDS-PAGE and immunoblot analyses identified protein antigens with Mr values of 23-24, 46, and 57-59 KDa common to both P20 and P100 endospores. One protein antigen with an Mr value of 62 KDa was unique to the PI00 endospores. The IgY antibodies reduced the attachment of Pasteuria endospores to their nematode hosts, indicating antibody interaction with antigens on the endospore surface that are involved in the recognition and attachment processes.

Using laptop computers as a BMET field service tool

This system has been in operation for approximately two years at the time of this writing, and involves more than a dozen laptop computers. The true test of whether something is successful is the degree of acceptance that is generated by the people who must use it. Approximately two months after beginning this process, our biomedical equipment technicians (BMETs) asked us to expand utilization of this system to a greater segment of our client base because it was so much simpler than our prior paper method. Our ability to track events that occur in the field is much improved with any problems identified in procedures being communicated through the private comments. Not only are the printed PM forms far more legible than the prior hand-entered results, but the concept of test-to-standards now is far more practical because the testing protocols are a keypress away, and the question of whether the technician would take the time to look up in the cumbersome procedure manuals those things that he or she was only slightly unsure of is addressed. Additionally, we have seen more than a 25% reduction in data-handling associated with the processing of the PM inspections in this fashion. Even with the time necessary to create the data disks, upload them, and process them through the filter, we are still saving substantial time over the manual handling of paper.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential depolymerization mechanisms of pectate lyases secreted by Erwinia chrysanthemi EC16

The four pectate lyases (EC 4.2.2.2) secreted by Erwinia chrysanthemi EC16 have been individually produced as recombinant enzymes in Escherichia coli. Oligogalacturonates formed from polygalacturonic acid during reactions catalyzed by each enzyme have been determined by high-performance liquid chromatography analysis. PLa catalyzes the formation of a series of oligomers ranging from dimer to dodecamer through a random endolytic depolarization mechanism. PLb and PLc are trimer- and tetramer-generating enzymes with an identical combination of endolytic and exolytic mechanisms. PLe catalyzes a nonrandom endolytic depolymerization with the formation of dimer as the predominant product. The pectate lyases secreted by E. chrysanthemi EC16 represent a battery of enzymes with three distinct approaches to the depolymerization of plant cell walls.

Photosynthetic response of seagrasses to ultraviolet-a radiation and the influence of visible light intensity

Inhibition of photosynthesis by ultraviolet-A radiation (UV-A, 315-380 nanometers) was examined in three marine angiosperms: Halophila engelmannii Aschers, Halodule wrightii Aschers, and Syringodium filiforme Kütz. Sensitivity to UV-A and photosensitization to UV-A by photosynthetically active radiation (PAR, 380-700 nanometers) were characterized.Net photosynthesis by Halodule and Syringodium was unaffected by UV-A irradiation in the absence of PAR. Irradiation of Syringodium by a combined beam of UV-A and PAR resulted in photosynthetic inhibition. The depression of net photosynthesis was found to be a function of PAR intensity at a fixed level of UV-A irradiation. Inhibition of photosynthesis in Halodule by the combined beam was minimal and suggests adaptation to environmental irradiation levels.Halophila was the only species examined, subject to photosynthetic inhibition by UV-A in the absence of PAR. Irradiation with PAR intensities characteristic to Halophila in the natural system as the combined beam, appeared to negate the inhibition. Increasing the PAR component of the combined beam above environmental norms resulted in photosynthetic inhibition greater than that observed for UV-A alone.

Inhibition of seagrass photosynthesis by ultraviolet-B radiation

Effects of ultraviolet-B radiation on the photosynthesis of seagrasses (Halophila engelmanni Aschers, Halodule wrightii Aschers, and Syringodium filiforme Kütz) were examined. The intrinsic tolerance of each seagrass to ultraviolet-B, the presence and effectiveness of photorepair mechanisms to ultraviolet-B-induced photosynthetic inhibition, and the role of epiphytic growth as a shield from ultraviolet-B were investigated.Halodule was found to possess the greatest photosynthetic tolerance for ultraviolet-B. Photosynthesis in Syringodium was slightly more sensitive to ultraviolet-B while Halophila showed relatively little photosynthetic tolerance. Evidence for a photorepair mechanism was found only in Halodule. This mechanism effectively attenuated photosynthetic inhibition induced by ultraviolet-B dose rates and dosages in excess of natural conditions. Syringodium appeared to rely primarily on a thick epidermal cell layer to reduce photosynthetic damage. Halophila seemed to have no morphological or photorepair capabilities to deal with ultraviolet-B. This species appeared to rely on epiphytic and detrital shielding and the shade provided by other seagrasses to reduce ultraviolet-B irradiation to tolerable levels. The presence of epiphytes on leaf surfaces was found to reduce the extent of photosynthetic inhibition from ultraviolet-B exposure in all species.Observations obtained in this study seem to suggest the possibility of anthocyanin and/or other flavonoid synthesis as an adaptation to long term ultraviolet-B irradiation by these species. In addition, Halophila appears to obtain an increased photosynthetic tolerance to ultraviolet-B as an indirect benefit of chloroplast clumping to avoid photo-oxidation by intense levels of photosynthetically active radiation.