Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration

Background

Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head.

Methods

The demonstration was conducted in 2005–2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework.

Results

Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa.

Conclusion

The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.     

Prevalence of fungal infections detected from biopsies and autopsies in the past 11 years at the University Hospital Joan XXIII in Tarragona, Spain

Infectious diseases caused by fungal pathogens have increased in the past 10 years. More than 300 pathogenic fungal species have been incriminated as the etiologic agents. We carried out a retrospective study (1994-2004) to evaluate the prevalence of mycoses at the University Hospital Joan XXIII (330 beds). This report found 0.24% of the studied cases (78,310 biopsies and 753 autopsies) were diagnosed as fungal infections (0.21% of the total studied biopsy and 4.25% of the whole autopsies). Skin and mucose were involved in 66% of cases, followed by other less affected anatomical areas. 61% of studied cases were caused by Candida spp (the most frequent in our environment), followed by Aspergillus spp (10%) and the Zygomycetes (5%). The most important underlying illness was obstructive chronic pulmonary disease followed by diabetes and AIDS. The incidence of mycoses increased with the patient's age, especially those patients in their 80s. Antifungal management improved the clinical outcome of the patient but predisposing factors are crucial for diagnosis. Systemic mycoses have poor prognosis with 91% of fatal outcome. Thus, it is important to perform a rapid diagnosis of the fungal infections a diagnostic area in which pathology could play a major role.     

An update on the occurrence of Paracoccidioides species in the Midwest region,Brazil: Molecular epidemiology,clinical aspects and serological profile of patients from Mato Grosso do Sul State

BackgroundParacoccidioidomycosis (PCM) is a systemic and endemic fungal infection in Latin American, mainly in Brazil. The majority of PCM cases occur in large areas in Brazil, comprising the South, Southeast and Midwest regions, with the latter demonstrating a higher incidence of the species Paracoccidioides lutzii.Methodology and main findingsThis study presents clinical, molecular and serological data of thirteen new PCM cases during 2016 to 2019 from the state of Mato Grosso do Sul, located in the Midwest region, Brazil. From these thirteen cases, sixteen clinical isolates were obtained and their genomic DNAs were subjected to genotyping by tub1 -PCR-RFLP. Results showed Paracoccidioides brasiliensis sensu stricto (S1) (11/16; 68.8%), Paracoccidioides restrepiensis (PS3) (4/16; 25.0%) and P. lutzii (1/16; 6.2%) as Paracoccidiodes species. Therefore, in order to understand whether the type of phylogenetic species that are circulating in the state influence the reactivity profile of serological tests, we performed double agar gel immunodiffusion (DID), using exoantigens from genotyped strains found in this series of PCM cases. Overall, our DID tests have been false negative in about 30% of confirmed PCM cases. All patients were male, most with current or previous rural activity, with ages ranging from 17 to 59 years, with 11 patients (84.6%) over 40 years of age. No clinical or epidemiological differences were found between Paracoccidioides species. However, it is important to note that the only case of P. lutzii died as an outcome.ConclusionsThis study suggests P. brasiliensis sensu stricto (S1) as the predominant species, showing its wide geographic distribution in Brazil. Furthermore, our findings revealed, for the first time, the occurrence of P. restrepiensis (PS3) in the state of Mato Grosso do Sul, Brazil. Despite our setbacks, it would be interesting to provide the complete sequencing of these clinical isolates to complement the molecular information presented.     

Fungal keratitis in the State of Paraná-Brazil: clinical, epidemiological and diagnostic findings

Fungal keratites is more prevalent in tropical and subtropical regions, such as Brazil, and causes high morbidity. Usually, it is preceded by underlying conditions like ocular trauma or immunosuppression. The diagnosis is confirmed by the demonstration of the etiologic agent in the clinical specimen. Data were analysed from 49 patients with fungal keratitis observed in Ophthalmologic Division of Hospital de Clinicas, Federal University of Parana, from 1983 to 1997. The diagnosis was confirmed by culture and/ or direct examination. Of the cases studied, 22% were diagnosed only by direct examination; 50% by isolation in culture and 26% by the association of the both methods. The most prevalent etiologic agents were: Fusarium sp. (32%), Aspergillus sp. (16,5%) and Penicillium sp. (10%).     

Use of fungal metabolites to protect wood-based panels against mould infection

Wood-based composites such as oriented strand board (OSB) are principle framing elements in building construction in North America. However, these materials are often affected by moulds in wet or humid environmental conditions. A common control method for prevention of mould growth on panels is preservative treatment of panels with various pesticides or chemicals. In recent years, environmentally friendly pest control methods are required because of environmental issue. This research aimed to develop a biological technology to protect OSB against mould infection by post-treatment of panels with natural extracts from fungal antagonists. In this study, the culture metabolites of a fungal antagonist, Phaeotheca dimorphospora DesRochers & Ouellette, were extracted, and the antibiotic activity of the extracts was tested in Petri plates against various moulds and decay fungi. The OSB panels were then dip-treated with the extracts and exposed to a humid environment for mould growth testing in a period of 8 weeks. The results showed that the mycelia growth of all fungi tested (moulds, white-rot and brown-rot fungi) was inhibited by the extracts of P. dimorphospora on agar plates. Panel samples dipped with the fungal extracts in acetone got little mould growth on them, whereas untreated control panels and those samples treated with acetone alone were seriously affected by various moulds.     

Human infections by black yeasts of genus Exophiala

Clinical and laboratory aspects of the infections caused by Exophiala species are reviewed with regard to its epidemiology, diagnosis and treatment. Exophiala is a genus of dematiaceous hyphomycetes whose taxonomy and nomenclature undergo constant revision. Exophiala species are widely distributed in nature, and they are uncommon human pathogens. In recent years it appears to have increased its frequency as a cause of human infections, mainly in immunocompromised patients. They have been associated with phaeohyphomycosis, chromoblastomycosis, eumycotic mycetoma and disseminated infection. The procedures recommended for diagnosis consist of detection of fungal elements in tissue and growth of the organism in culture. Identification is mostly based upon microscopic observation of morphological characteristics and conidiogenesis, combined with the evaluation of physiological tests and nitrate and carbohydrate assimilations. Antifungal agents such as amphotericin B, itraconazole and voriconazole showed in vitro activity to most of the Exophiala species of clinical interest. The therapeutic recommendations are mainly deduced from the observation of single cases.     

An outbreak of fungal dermatitis and stomatitis in a free-ranging population of pigmy rattlesnakes (Sistrurus miliarius barbouri) in Florida

Between September 1997 and March 1998, a severe skin, eye, and mouth disease was observed in a population of dusky pigmy rattlesnakes (Sistrurus miliarius barbouri), at the Lake Woodruff National Wildlife Refuge in Volusia County, Florida (USA). Three affected pigmy rattlesnakes were submitted for necropsy. All snakes had severe necrotizing and predominantly granulomatous dermatitis, stomatitis, and ophthalmitis, with involvement of the subadjacent musculature and other soft tissues. Numerous fungal hyphae were seen throughout tissue sections stained with periodic acid Schiff and Gomori's methenamine silver. Samples of lesions were cultured for bacteria and fungi. Based on hyphae and spore characteristics, four species of fungi were identified from culture: Sporothrix schenckii, Pestalotia pezizoides, Geotrichum candidum (Galactomyces geotrichum), and Paecilomyces sp. While no additional severely affected pigmy rattlesnakes were seen at the study site, a garter snake (Thamnophis sirtalis) and a ribbon snake (Thamnophis sauritis) with similar lesions were found. In 1998 and 1999, 42 pigmy rattlesnakes with multifocal minimal to moderate subcutaneous masses were seen at the study site. Masses from six of these snakes were biopsied in the field. Hyphae morphologically similar to those seen in the severe cases were observed with fungal stains. Analysis of a database representing 10,727 captures in previous years was performed after the 1998 outbreak was recognized. From this analysis we determined that 59 snakes with clinical signs similar to those seen during the 1998 outbreak were documented between 1992 and 1997. This study represents the first documented report of a mycotic disease of free-ranging snakes.     

病理确诊深部真菌病45例分析

目的 探讨深部真菌病病理诊断的价值。方法 回顾性分析我院1995年1月-2004年12月期间,经病理确诊为深部真菌病45例患者的临床及病理资料,其中副鼻窦真菌感染14例;肺部真菌病19例;胃肠道真菌病4例;口腔真菌病2例,脑部真菌病2例,其他真菌病4例。结果 我院近5年来真菌病的确诊病例明显增多,且内脏及器官真菌病患者多合并基础性疾病,如血液病、肿瘤等。部分病例的致病菌根据病理确定有曲霉、念珠菌及隐球菌等。临床上主要采用手术结合氟康唑静滴的治疗方法。结论 我院经病理确诊的真菌病例呈上升趋势,病理组织学特点结合特殊染色可将大部分致病菌鉴定至属,治疗前最好进行培养鉴定至种。     

Fungal infections in paediatric patients with chronic granulomatous disease

Chronic granulomatous disease (CGD) is a primary immunodeficiency resulting from a disfunction of microbial capacity of phagocytes. Patients with this disease show great susceptibility to fungal and bacterial infections. Between 1988 and 1998, five paediatric patients with CGD who acquired mycotic infections were studied at the Paediatric Hospital Prof. Dr. J. P. Garrahan and their clinical and microbiological characteristics were described. The fungal infection appeared at the mean-age of 8.3 years (range: 1.1-17 years). All the patients had fever and lung involvement, three of them had suppurative abscesses of soft tissues. The mycological diagnosis was determined by microscopy, culture of clinical samples and serologic tests. There were three cases of disseminated aspergillosis, two cases of mixed infection: one due to Candida albicans and Nocardia asteroides and the other due to Scedosporium apiospermum and Cladosporium spp. Four out of the 5 patients died because of an infections process beyond control. Our conclusion is that new therapeutic measures must be considered along with the study of emerging pathogens in this group of patients.     

Tinea unguium in the north-west of Iran (1996-2004)

Tinea unguium is a common mycosis in many part of the world including Iran. The prevalence of this mycosis varied depending on time, health level and geographical location. To stabilise the etiological, epidemiological and risk factors of tinea unguium in North-west Iran, a study of patients with suspected dermatophyte infections of their nails was carried out between 1996 and 2004. During this study 590 (354 females and 236 males) patients with clinical presentation of fungal infection in fingernails, toenails or in the both sites, were investigated using direct microscopy and culture of clinical samples. Tinea unguium was documented in 41 cases (7%) and among positive cases, 16 cases (39% total positive cases) were female and 25 cases (61% total positive cases) were male. Seventeen patients (41% total positive cases) had tinea unguium in their finger nails and 24 patients (59% total positive cases) had infection in their toe nails. According to the isolated etiologic agent, 66% (19 cases) of tinea unguium infections were caused by zoophilic drematophytes, 31% (9 cases) were caused by anthropophilic drematophytes and 3% (1 case) were caused by geophilic dermatophytes. With regard of sex, tinea unguium did not show a significant difference. The highest prevalence of tinea unguium was found in patients between 11 and 40 years of age. In conclusion the current results identified the etiological agents and epidemiological aspects of tinea unguium in North-west Iran. Tinea unguium in this region is associated with animal husbandry and direct or indirect contact with their products (wool, leather).     

Prevalence of low positive anti-HCV antibodies in blood donors: Schistosoma mansoni co-infection and possible role of autoantibodies

Patients infected with schistosoma frequently show a high seroprevalence of anti-hepatitis C virus (anti-HCV) antibodies. The aim of this study was to find the underlying reason for this phenomenon, and to examine a possible involvement of autoantibodies. Out of 2,400 Egyptian blood donors, 192 (8%) were anti-HCV positive by ELISA. They were 133 males and 59 females with age ranging from 27 to 48 years. According to optical density ratio (ODR) of anti-HCV antibodies, 96 cases were low positive (LP) with ODR (1-2) designated as group I, and 96 were high positive (HP) with ODR (> or =2) (group II). Both groups were examined for quantitative HCV core antigen (HCVcAg), liver function (Albumin, ALT, AST) and anti-Schistosoma mansoni(anti-Sm) IgG. Group I cases were HCVcAg negative with normal liver function tests, and 44 of them were anti-Sm positive. Ninety cases (93.75%) of group II were HCVcAg positive with markedly affected liver function tests and 72 cases were anti-Sm positive. All group I cases were examined for autoimmune markers (ANA, AMA, SMA and LKM). In group I, 33 (75%) of anti-Sm positive cases were positive for one or more of the autoimmune markers examined, while none of anti-Sm negative was positive for any marker with significant difference between the two groups (P < 0.0001). Our results primarily on blood donors indicate that LP anti-HCV frequently represents false-positive reactivity with a possible role of Sm-induced autoantibodies in this phenomenon.     

一例喉真菌病病例报道并文献复习

目的:探讨喉真菌病的临床特征、诊断要点和治疗方案。方法:回顾我院收治的一例喉真菌病患者的临床病例资料,并对1992年至今国内外报道的类似病例33例进行文献复习。本研究共纳入患者34例,男性16例,女性18例,年龄14-67岁,临床表现以声嘶为主,可伴有咽痛、咽干等咽喉不适感,其中有16例患者被误诊为急性喉炎,27例患者有不同程度的抗生素和(或)糖皮质激素使用史。结果:34例患者中,13例通过病理确诊为喉真菌病。所有患者均予抗真菌药物治疗,其中有1例同时行手术治疗,均治愈。结论:喉真菌病临床罕见,症状无特异性,易误诊,但病理学检查可靠,全身或局部使用抗真菌药物疗效佳,预后良好。     

12 例多系统萎缩患者的临床特点和诊断分析

目的:研究12例多系统萎缩(multiple system atrophy MSA)患者的临床特点,分析诊断要点。方法:回顾性分析12例多系统萎缩病例,探讨其临床特点和早期诊断的要点。结果:本组病例均为慢性、隐袭性起病,男性居多,男:女=1.4:1。平均发病年龄49.2岁(35.0岁～72.0岁)。平均病程33个月(6个月～60个月)。MSA-P亚型4例,MSA-C亚型8例,以MSA-C亚型占优势。MSA-P亚型中以行动迟缓为主要首发表现(75%),主要体征分别为肌张力增高(100%)、直立性低血压(75%)、锥体束征(75%);MSA-C亚型以行走不稳为主要首发表现(62.5%),主要体征为共济失调(100%),直立性低血压、小脑性语言、锥体束征(分别为62.5%)。结论:多系统萎缩是一种散发性的神经系统变性疾病,成年起病,临床表现多样。对于早期单纯以帕金森综合征、小脑功能障碍或自主神经功能紊乱为主要症状的患者,特别是无家族史者,要注意甄别有无其他系统受累的症状或体征,同时结合影像学检查、左旋多巴类药物治疗反应性等临床特点,对于早期正确诊断MSA有一定帮助。     

鼻内镜下手术结合术后鼻窦冲洗治疗变应性真菌性鼻窦炎的临床研究

目的:研究鼻内镜下手术结合术后鼻窦冲洗治疗变应性真菌性鼻窦炎的临床疗效。方法:选取2010年3月到2013年3月我院收治的变应性真菌性鼻窦炎患者67例为研究对象,对其临床资料进行回顾分析,所有患者均给予鼻内镜下手术结合术后鼻窦冲洗治疗,术后随访患者1年。另选取健康者50例为对照组,应用视觉模拟量表(VAS)评价患者术前术后主观感受,应用鼻内镜和鼻腔纤毛功能评价患者术前术后客观感受,并应用生活质量量表(SF-36)评价患者的生活质量。结果:患者术后VAS评分为(18.5±1.3)分显著优于术前的(29.3±0.2)分,与术前比较差异具有统计学意义(t=11.026,P=0.018);术后鼻内镜总分为(4.1±0.2)分显著优于手术前,与手术前比较差异具有统计学意义(t=9.037,P=0.027);术后1年鼻纤毛传输速度(6.9±0.3)mm/min,与对照组比较差异无统计学意义(t=3.984,P=0.092);术后1年SF-36评分为(649.6±23.2)分,与对照组比较差异无统计学意义(t=4.018,P=0.096)。结论:鼻内镜下手术结合术后鼻窦冲洗治疗变应性真菌性鼻窦炎具有较好的临床疗效,能显著改善患者的症状,提高患者的生活质量。     

Fungal neuroinfections: rare disease but unacceptably high mortality

Within last 25 years we have observed 20 cases of fungal meningitis and/or cerebral abscesses. Commonest etiologic agens was Candida spp. (C. albicans 9 of 20). Molds were responsible for 4 cases of brain abscess. Mortality was 50% what seems to be very high. Extremely high mortality is caused by delayed onset of therapy, severe underlying disease and multiresistant fungal organisms such as Mucorales, Fusarium solani and Aureobasidium.     

Chlamydospores of Rhizopus microsporus var. rhizopodiformis in Tissue of Pulmonary Mucormycosis

Hyphae are usually the only fungal elements found in tissue of mucormycosis, and other fungal elements are quite rarely encountered. We found chlamydospores in bronchial lumina in autopsied tissue of pulmonary mucormycosis of a diabetic patient. Chlamydospores are thick-walled, asexually produced spores arising from the modification of a hyphal segment. This is the first histologic demonstration of chlamydospores in mucormycosis in which the causative fungus is culturally identified to species level. Rhizopus microsporus var. rhizopodiformis was isolated from the present autopsied pulmonary tissue. A literature review of human infection by this fungus found 27 cases with histopathologic evidence.     

Pulmonary aspergillus intracavitary colonization (PAIC)

We have attempted to elucidate the natural history of pulmonary aspergillus intracavitary colonization (PAIC) based on more than 350 cases of the disease observed in the last 11 years and on data collected from the literature. The data indicate that PAIC is a dynamic process consequent to the continual growth and death of fungal elements and also with their relationships to the anatomic features of the cavity (valvular mechanisms, vascular alteration). The clinical presentations reflect immunological changes in the host. Metabolites produced by the species of Aspergillus involved affect the clinical presentation of the syndrome.     

Spread of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in hospitals in Taipei, Taiwan in 2005, and comparison of its drug resistance with previous hospital-acquired MRSA

Panton-Valentine leucocidin (PVL)-positive methicillin-resistant Staphylococcus aureus (PVL+ MRSA) is an emerging pathogen in the community worldwide. The incidence of PVL+ MRSA in Taipei, Taiwan was 23.3% for hospital MRSA. PVL+ MRSA was isolated from both outpatients and inpatients. Some PVL+ (mecA+) strains (36.8%) showed low MIC values (相似文献   

涉及临床各科的侵袭性真菌感染

真菌数量大、种类多、分布广。真菌感染因菌种的毒力、感染途径和宿主免疫状态等差异而出现不同的临床表现,临床各科医生都会遇到真菌病患者。真菌病的诊断取决于在病变组织内发现病原真菌成分如菌丝和(或)孢子。从病变组织中分离出真菌是菌种鉴定前提,也是抗真菌治疗的依据。“重视临床、强调菌学”是医学真菌研究的基本思路。真菌学家应该在联系临床与实验室中起关键作用。