The Impact of Insurance Status on the Outcomes after Aneurysmal Subarachnoid Hemorrhage

Investigation into the association of insurance status with the outcomes of patients undergoing neurosurgical intervention has been limited: this is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping. The Nationwide Inpatient Sample (2001–2010) was utilized to identify patients; those with both an ICD-9 diagnosis codes for subarachnoid hemorrhage and a procedure code for aneurysm repair (either via an endovascular or surgical approach) were included. Hierarchical multivariate regression analyses were utilized to evaluate the impact of primary payer on in-hospital mortality, hospital discharge disposition, and length of hospital stay with hospital as the random effects variable. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region, location (urban versus rural), and teaching status, procedural volume, year of admission, and the proportion of patients who underwent ventriculostomy. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy; subgroup analyses evaluated for those who underwent endovascular and surgical procedures separately. 15,557 hospitalizations were included. In the initial model, the adjusted odds of in-hospital mortality were higher for Medicare (OR 1.23, p<0.001), Medicaid (OR 1.23, p<0.001), and uninsured patients (OR 1.49, p<0.001) compared to those with private insurance. After also adjusting for timing of intervention, Medicaid and uninsured patients had a reduced odds of non-routine discharge (OR 0.75, p<0.001 and OR 0.42, p<0.001) despite longer hospital stays (by 8.35 days, p<0.001 and 2.45 days, p = 0.005). Variations in outcomes by primary payer–including in-hospital post-procedural mortality–were more pronounced for patients of all insurance types who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and the complexities of the American healthcare delivery system.     

The zinc,copper, and manganese status of children with malabsorption syndromes and inborn errors of metabolism

The zinc, copper, and manganese status of seven children with malabsorption syndromes of varied etiology (MVE) and 12 with inborn errors of metabolism (IEM) receiving semi-synthetic diets was investigated using serum and hair trace element concentrations, dietary trace element intakes, and anthropometric measurements as the principal indices. The hair zinc levels of both test groups and hair manganese levels of the IEM group were significantly lower (p<0.05) than those of their respective healthy controls matched by age, sex, and geographic location, despite comparable dietary zinc and manganese intakes in test and control subjects. Four subjects from the malabsorption and five from the inborn errors group had hair zinc levels below 100 μg/g (range 30–88 μg/g). Of these nine subjects, serum zinc levels were determined for six, and five were less than normal (range 64–74 μg/dL). In contrast, the copper status of the MVE and IEM subjects, as indicated by hair and dietary copper levels, was not lower than the controls. Mean serum copper levels were 136±30 and 171±40 μg/dL for the IEM and MVE groups, respectively. Levels for the MVE subjects were higher than published normal values. The suboptimal zinc and manganese status observed in some of these test subjects probably arose from malabsorption and decreased availability of dietary zinc and manganese. However, the zinc depletion was not severe enough to result in linear growth retardation.     

The role of functional constraints in nonrandom mating patterns for a dance fly with female ornaments

Most hypotheses to explain nonrandom mating patterns invoke mate choice, particularly in species that display elaborate ornaments. However, conflicting selection pressures on traits can result in functional constraints that can also cause nonrandom mating patterns. We tested for functional load‐lifting constraints during aerial copulation in Rhamphomyia longicauda, a species of dance fly that displays multiple extravagant female‐specific ornaments that are unusual among sexual traits because they are under stabilizing selection. R. longicauda males provide females with a nuptial gift before engaging in aerial mating, and the male bears the entire weight of the female and nuptial gift for the duration of copulation. In theory, a male's ability to carry females and nuptial gifts could constrain pairing opportunities for the heaviest females, as reported for nonornamented dance flies. In concert with directional preferences for large females with mature eggs, such a load‐lifting constraint could produce the stabilizing selection on female size previously observed in this species. We therefore tested whether wild‐caught male R. longicauda collected during copulation were experiencing load‐lift limitations by comparing the mass carried by males during copulation with the male's wing loading traits. We also performed permutation tests to determine whether the loads carried by males during copulation were lighter than expected. We found that heavier males are more often found mating with heavier females suggesting that whereas R. longicauda males do not experience a load‐lift constraint, there is a strong relationship of assortative mating by mass. We suggest that active male mate choice for intermediately adorned females is more likely to be causing the nonrandom mating patterns observed in R. longicauda.     

Migratory patterns and connectivity of two North American grassland bird species

Effective management and conservation of migratory bird populations require knowledge and incorporation of their movement patterns and space use throughout the annual cycle. To investigate the little‐known migratory patterns of two grassland bird species, we deployed 180 light‐level geolocators on Grasshopper Sparrows (Ammodramus savannarum) and 29 Argos‐GPS tags on Eastern Meadowlarks (Sturnella magna) at Konza Prairie, Kansas, USA, and six US Department of Defense (DoD) installations distributed across the species' breeding ranges. We analyzed location data from 34 light‐level geolocators and five Argos‐GPS tags attached for 1 year to Grasshopper Sparrows and Eastern Meadowlarks, respectively. Grasshopper Sparrows were present on the breeding grounds from mid‐April through early October, substantially longer than previously estimated, and migrated on average ~2,500 km over ~30 days. Grasshopper Sparrows exhibited strong migratory connectivity only at a continental scale. The North American Great Lakes region likely serves as a migratory divide for Midwest and East Coast Grasshopper Sparrows; Midwest populations (Kansas, Wisconsin, and North Dakota; n = 13) largely wintered in Texas or Mexico, whereas East Coast populations (Maryland and Massachusetts, n = 20) wintered in the northern Caribbean or Florida. Our data from Eastern Meadowlarks provided evidence for a diversity of stationary and short‐ and long‐distance migration strategies. By providing the most extensive examination of the nonbreeding movement ecology for these two North American grassland bird species to date, we refine information gaps and provide key insight for their management and conservation.     

Factors that Influence the Way Communities Respond to Proposals for Major Changes to Local Emergency Services: A Qualitative Study

Objective

According to policy commentators, decisions about how best to organise care involve trade-offs between factors relating to care quality, workforce, cost, and patient access. In England, proposed changes such as Emergency Department closures often face public opposition. This study examined the way communities respond to plans aimed at reorganising emergency services, including the trade-offs inherent in such decisions.

Design

Cross-sectional study involving in-depth interviews. Participants selected their priorities for emergency care, including aspects they might be prepared to have ‘less’ of (e.g. rapid access) if it meant having ‘more’ of another (e.g. consultant-delivered care). A thematic analysis was carried out, combining inductive and deductive approaches, drawing on theories about risk perception.

Setting

Two urban areas of England; one where changes to emergency services were under consideration (‘Greenville’), and one where they were not (‘Hilltown’).

Participants

28 participants in total. Greenville interviewees included more common emergency service users - parents of young children (n=5) and older people (n=6) - plus patient representatives and individuals campaigning against service closures (n=9). Hilltown interviewees (n=8) received outpatient care for Chronic Obstructive Pulmonary Disease, an important cause of emergency admission.

Results

Most participants, in both areas, were not willing to accommodate the trade-offs involved in consolidating emergency services, principally because of the belief that timely access is associated with better outcomes. Participants did not consider the proposed improvements as gains worth having; interviewees believed care quality would be adversely impact, partly because increased patient numbers would place staff under greater pressure and result in longer waiting times.

Conclusions

Visible clinical leadership and detailed explanation of the case for change were insufficient to overcome opposition to the reconfiguration in Greenville, challenging the assumption that communities can be persuaded by evidence. Commissioners should make explicit credible plans to accommodate changes in patient flows, as well as clarifying the roles played by key staff groups.