Utilization and Cost of Gender-affirming Surgery in the United States from 2012-2019

OBJECTIVE

To characterize the trends in and characteristics associated with the utilization and cost of gender-affirming surgery (GAS) in the United States from 2012-2019.

SUMMARY BACKGROUND DATA

GAS is one option among gender-diverse (GD) people to transition from their biologic anatomy to the anatomy congruent with their gender. Little is known about its utilization and cost trends and whether patient and hospital characteristics are associated with differences in utilization and cost.

METHODS

This serial cross-sectional study collected retrospective data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), a representative pool of inpatient visits in the United States. Records from 2012-2019 that indicated ages 18 or older, GD diagnoses, and GAS procedures were identified using the International Classification of Diseases, Ninth and Tenth Revisions. Within this cohort, demographics, utilization, and cost were collected and analyzed using descriptive statistics and multivariable regression models.

RESULTS

6,325 records with GD diagnoses and GAS procedures were identified. From 2012-2019, utilization increased by more than 5-fold (0.9 to 5.0 per 100,000 records among all records), and the mean, inflation-adjusted cost increased by 36% ($19,451 to $26,517). This cost trend was similar by type of surgery, and genital surgery had consistently higher costs than chest surgery from 2012 to 2019 (genital: $21,487 to $26,712, chest: $13,238 to $21,309). Lower odds of utilization were found in records with Medicaid (OR = 0.27, 95% CI [0.22-0.35], P<0.001) and Medicare (OR = 0.15, 95% CI [0.11-0.23], P<0.001) compared to private insurance, as well as those in the lowest income quartile (OR = 0.68, 95% CI [0.54-0.85], P<0.001) compared to the highest quartile. Lower costs were found in records that indicated hospital location in the Midwest (27% lower, 95% CI [0.61-0.87], P<0.001), Northeast (34% lower, 95% CI [0.55-0.80], P<0.001) and South (39% lower, 95% CI [0.53-0.71], P<0.001) compared to the West.

CONCLUSIONS

As demand for GAS increases with varying utilization and costs based on patient and hospital characteristics, there will likely be a need for more qualified surgeons, increased insurance coverage, and policies to ensure equitable access to GAS.

Conservative Management of Penile and Urethral Lichen Sclerosus: A Systematic Review

PURPOSE

We evaluate the efficacy and safety profiles of currently available conservative management options for penile and urethral lichen sclerosus.

MATERIALS AND METHODS

A systematic review of existing literature on lichen sclerosus was conducted utilizing the PubMed, Embase, and Web of Science databases. References were assessed for relevance to nonsurgical management of male genital lichen sclerosus by title and abstract by 3 independent reviewers, then reviewed in full and in duplicate by 5 independent reviewers.

RESULTS

Seventeen studies describing conservative management of histologically confirmed penile and urethral lichen sclerosus in male patients were included in the final review. We present available evidence supporting the use of 4 major treatment modalities represented in the existing literature: topical corticosteroids, tacrolimus, platelet-rich plasma, and CO2 laser. We also briefly discuss the limited studies on the use of oral acitretin and polydeoxyribonucleotide injections. Outcomes assessed include symptoms, clinical appearance, quality of life, sexual satisfaction, adverse effects, and long-term efficacy of treatment.

CONCLUSIONS

Topical corticosteroids remain the mainstay of conservative management of penile and urethral lichen sclerosus, with current literature supporting the use of other therapies such as tacrolimus and platelet-rich plasma as alternatives or adjuvant treatments when escalation of treatment is necessary. Future research should further explore the efficacy and safety of newer therapies through additional controlled clinical trials in the targeted population.

Topographic congruence of calcified parenchymal neurocysticercosis and other structural brain lesions with epileptiform activity

Introduction:

Calcified parenchymal neurocysticercosis (NCC) lesions are commonly detected in many individuals with refractory epilepsy. However, the relationship between these lesions and epilepsy is not fully determined. We sought to determine if calcified parenchymal NCC demonstrated topographic congruence with epileptiform activity in refractory epilepsy patients. Additional patients with other structural brain lesions were included for comparison.

Subjects and Methods:

Retrospective cross-sectional analysis of all patients treated at a community-based neurology clinic for refractory epilepsy during a 3-month period and with structural brain lesions detected by neuroimaging studies.

Results:

A total of 105 patients were included in the study, including 63 with calcified parenchymal NCC lesions and 42 with other structural brain lesions. No significant relationship was detected between hemispheric localization of calcified parenchymal NCC lesions and epileptiform activity. For those with other structural brain lesions, the hemispheric localization was significantly related to the side of epileptiform activity (Chi-square = 11.13, P = 0.025). In addition, logistic regression models showed that those with right-sided non-NCC lesions were more likely to have right-sided epileptiform activity (odds ratio = 4.36, 95% confidence interval [CI] =1.16–16.31, P = 0.029), and those with left-sided non-NCC lesions were more likely to have left-sided epileptiform activity (odds ratio = 7.60, 95% CI = 1.89–30.49, P = 0.004).

Conclusion:

The lack of correlation between the side of calcified parenchymal NCC lesions and the side of the epileptiform activity suggests that these lesions may be incidental findings in many patients.

Formulation development and evaluation of alginate microspheres of Ibuprofen

The present study was designed to investigate the effects of different variables on the release profile of ibuprofen microspheres formulated using modified emulsification method. Eight batches of microspheres (F1-F8) were prepared by applying 2³ factorial design. The amount of sodium alginate, amount of calcium chloride, and amount of magnesium stearate were selected as formulation variables. All the batches were evaluated in terms of percentage yield, percentage encapsulation efficiency and in vitro release characteristics. The batch F7 was found to be optimum batch and was further characterized via scanning electron microscopy (SEM) and particle size analysis. Multiple linear regression was applied to confirm significant effect of each variable on release characteristics. The model developed in the present study can be effectively utilized to achieve the formulation with desired release characteristics.

De novo collapsing glomerulopathy in a renal allograft recipient

Collapsing glomerulopathy (CG), characterized histologically by segmental/global glomerular capillary collapse, podocyte hypertrophy and hypercellularity and tubulo-interstitial injury; is characterized clinically by massive proteinuria and rapid progressive renal failure. CG is known to recur in renal allograft and rarely de novo. We report de novo CG 3 years post-transplant in a patient who received renal allograft from haplo-identical type donor.

The use of intravitreal bevacizumab in neovascular glaucoma: a case report

PURPOSE

To assess the short-term safety and efficacy of an intravitreal injection of bevacizumab in a patient with neovascular glaucoma.

CASE REPORT

Intravitreal bevacizumab injection was given in a patient with neovascular glaucoma and the changes in the visual acuity, intraocular pressure (lOP), iris neovascularisation were noted before injection and after one day, one week, three weeks and six weeks. Regression of the iris new vessels and normalization of the intraocular pressure was noted.

CONCLUSION

Intravitreal bevacizumab was effective and safe in the short-term in a patient with neovascular glaucoma. It may be a useful adjunctive treatment.

Endophthalmitis following cataract surgery

This article is an attempt to review the latest advances in recognition, treatment, and prevention of postcataract extraction endophthalmitis.

Postcataract cystoid macular edema

Ocular tissues, like those of other organs, exhibit well-defined morphologic reactions to local trauma and insult in the form of hyperemia, vasodilation, increased permeability of blood vessels, and edema. Cystoid macular edema (CME) following cataract surgery is one such manifestation, and it can result in either temporary, or rarely, a permanent reduction of visual acuity. Although its cause remains obscure, the relationship of CME to the details of the surgical procedures and their complications are becoming clearer. Likewise more insight into the phenomenon is being imparted by the agents being used in the preventative or curative line of management in CME.

Telemedicine in ophthalmology

Comprehensive telemedicine promises a world of medicine freed of geographic borders, time zones, and personnel shortages. It could open the door to more accessible medical delivery systems and economical widespread screening for disease. No region of the world would be too remote or too poor to receive high quality medical care. This article traces the development and current applications and initiatives in the field of telemedicine as applied to ophthalmology in the wider sense. Uses for clinical diagnosis and management, screening, research, education and peer interaction are discussed.

The impact of information technology on the practice of ophthalmology

Information technology has had a tremendous impact on the outlook of our professional lives. The Internet has revolutionised the speed of access to information with touch of a button. This article discusses the various aspects of information technology which are changing and enhancing our professional lives. It provides tips to enable the busy practising clinician to use the available resources effectively. Problems such as reliability of information on the web and how to assess the quality of such matter are also discussed.

Precise molecular weight determination of PCR products of the rRNA intergenic spacer region using electrospray quadrupole mass spectrometry for differentiation of B. subtilis and B. atrophaeus, closely related species of bacilli

Assessment of 16S-23S rRNA intergenic spacer region (ISR) sequence variability is an important supplement to 16S rRNA sequencing for differentiating closely related bacterial species. Species differentiation can also be achieved by determination of approximate size of PCR (polymerase chain reaction) products of ISRs, based on their relative electrophoretic mobility on agarose gels. Closely-related species can have ISR PCR products that are similar in size. More precise molecular weight (M.W.) determination of these products might allow improved discrimination of such species. Electrospray quadrupole mass spectrometry (ESI-Q-MS) has the potential to provide such precision. For ESI-Q-MS analysis, size limitation of PCR products is currently limited to around 130 base pairs (bp). Bacillus subtilis and Bacillus atrophaeus are two closely related species with few distinguishing phenotypic characteristics. B. subtilis has recently been sub-divided into two subgroups, W23 (type strain, W23) and 168 (type strain, 168). PCR products amplified from the ISR including the 5' terminal end of the 23S rRNA and a conserved portion of the ISR were analyzed by ESI-Q-MS. A 119 or 120 bp PCR product was produced for B. atrophaeus strains. However, strains of B. subtilis subgroups W23 and 168 each produced 114 bp products. In summary, a mass spectrometry method was developed for differentiation of B. subtilis and B. atrophaeus. Also, the genetic similarity of B. subtilis subgroups W23 and 168 was confirmed. Accurate determination of the molecular weight of PCR products from the 16S-23S rRNA intergenic spacer region using electrospray quadrupole mass spectrometry has great potential as a general technique for characterizing closely related bacterial species.

Electrospray quadrupole mass spectrometry analysis of model oligonucleotides and polymerase chain reaction products: determination of base substitutions, nucleotide additions/deletions, and chemical modifications

ESI FTICR mass spectrometry is the only technique currently used for accurate molecular weight analysis of PCR products above 100 bp in size. This is important in demonstrating the potential for MS in making major contributions in the molecular biology and genomics areas. In the near future, it is more likely that less expensive, more user friendly MS techniques will be used for high-throughput analyses (including MALDI TOF and ESI quadrupole). There have been numerous reports on the use of MALDI TOF. The current report is to the first to evaluate the use of ESI-quadrupole analysis of PCR products. Synthetic oligonucleotides (30 and 89 mers) and polymerase chain reaction products of varying molecular weight (62, 88, 89, and 114 bp) were analyzed by ESI using a quadrupole MS. The mass accuracy for nucleic acids in the 30-62 bp range was shown to allow determination of nucleotide substitutions and additions/deletions. For higher molecular weight PCR products (88-114 bp), the mass accuracy of ESI-MS distinguishes single or multiple nucleotide insertions/deletions. In addition, ESI quadrupole MS allows determination of molecular weight of both strands of higher molecular weight ds PCR products and can distinguish nucleotide modifications (e.g., with biotin). In conclusion, it is demonstrated that ESI-MS occupies an intermediate position (as compared to MALDI TOF and ESI FTICR) with regard to mass accuracy and resolution in analysis of nucleic acids.

Identification of Brucella by ribosomal-spacer-region PCR and differentiation of Brucella canis from other Brucella spp. pathogenic for humans by carbohydrate profiles

Molecular and chemical characteristics often provide complementary information in the differentiation of closely related organisms. The genus Brucella consists of a highly conserved group of organisms. Identification of the four species pathogenic in humans (Brucella melitensis, Brucella abortus, Brucella suis, and Brucella canis) is problematic for many clinical laboratories that depend primarily on serology and phenotypic characteristics to differentiate species. PCR amplification of the 16S-23S ribosomal DNA interspace region was evaluated for species-specific polymorphism. B. abortus, B. melitensis, B. suis, and B. canis produced identical PCR interspace profiles. However, these PCR products were unique to brucellae, allowing them to be readily distinguished from other gram-negative bacteria (including Bartonella spp. and Agrobacterium spp.). Carbohydrate profiles differentiated B. canis from the other three Brucella species due to the absence of the rare amino sugar quinovosamine in the three other species. PCR of the rRNA interspace region is useful in identification of the genus Brucella, while carbohydrate profiling is capable of differentiating B. canis from the other Brucella species.

Ophthalmology on the information superhighway: an introduction to the Internet

Internet, e-mail, world wide web and the information superhighway have fast become part of the modern human vocabulary. How are we as ophthalmologists affected by this revolution and how can we utilise the enormous potential of this revolution? This article provides an overview of the practicalities and possibilities of this new medium.

Polypeptides of the lens fibre cell intracellular matrix

The cytoskeletal proteins of the vertebrate lens fibre cell comprise polypeptides raging in mol.wt from 43,000 to 250,000 daltons. The main intermediate filament polypeptide of the pickerel, Northern frog, chick, bovine, and human lens has a mol.wt of 54,000 daltons. Peptide analysis revealed that the chick 54,000 dalton protein was more similar to the bovine protein than to the pickerel protein.

Impulsivity/sociability and reinforcement in verbal operant conditioning

The present investigation was designed to study the relationship between impulsivity/sociability and modes of reinforcement in verbal operant conditioning. Two 2x3 randomized block designs, one each for impulsivity and sociability, were replicated ten times. One hundred and twenty undergraduate female students (60 for impulsivity and 60 for sociability) were individually subjected to Taffel's verbal conditioning procedure. When the conditioning scores of high and low scorers on the impulsivity and sociability scales were compared, it was found that under rewarding conditions ('good' and 'buzzer' in respect of sociability and 'good' in respect of impulsivity) the high scorers' score and under punishing conditions ('electric shock') the low scorers' score was the higher of the two. The study also revealed that the high scorers (on the impulsivity scale) conditioned more under rewarding conditions while the low scorers (both on the impulsivity and sociability scales) conditioned more under punishing ones.