Publications

OBJECTIVES

The purpose of this study is to report the rate of anatomic reduction, articular subsidence, and clinical outcomes for Schatzker II tibial plateau fractures treated with structural bone allografts.

DESIGN

This is a retrospective case series.

SETTING

Academic Level I Trauma Center.

PATIENTS/PARTICIPANTS

A trauma registry was used to identify 77 Schatzker II tibial plateau fractures.

INTERVENTION

Schatzker II tibial plateau fracture open reduction internal fixation and structural bone graft using either Plexur P (N = 29) or fibular allograft (N = 48).

MAIN OUTCOME MEASUREMENT

The primary outcome was articular subsidence. Secondary outcomes included fracture malreduction and clinical outcomes including the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, and the Short Form (SF)-36.

RESULTS

No patients experienced subsidence > 2mm. This rate is significantly lower than published rates for autogenous iliac crest (30.3%, P < 0.0001) and calcium phosphate cement (8.7%, P = 0.0099). The rate of fracture malreduction was 11.7% (9/77); only 4 had more than 3 mm of residual incongruity. Average outcome scores were the following: Knee Outcome Survey Activities of Daily Living Scale, 81.7; Lower Extremity Functional Scale, 78.5; SF-36 physical component, 48.3; and SF-36 mental component, 53.1. There was no difference between patients treated with Plexur P or fibula with regard to the primary or secondary outcomes.

CONCLUSIONS

The use of structural allograft resulted in a high rate of anatomic reduction and negligible rate of articular subsidence and good clinical outcomes in the treatment of this population of Schatzker II tibial plateau fractures. This compares favorably with historical results using nonstructural grafts.

LEVEL OF EVIDENCE

Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

IMPORTANCE

There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance.

OBJECTIVE

To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties.

DESIGN, SETTING, AND PARTICIPANTS

We used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not.

MAIN OUTCOMES AND MEASURES

Our main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings (2005-2006, 2007-2008, and 2009-2010).

RESULTS

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001) and had declined by 19.5% since 2005-2006. Psychiatrists' Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02).

CONCLUSIONS AND RELEVANCE

Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties. These low rates of acceptance may pose a barrier to access to mental health services.

FTY720, an analogue of sphingosine-1-phosphate, is cardioprotective during acute injury. Whether long-term FTY720 affords cardioprotection is unknown. Here, we report the effects of oral FTY720 on ischemia/reperfusion injury and in hypomorphic apoE mice deficient in SR-BI receptor expression (ApoeR61(h/h)/SRB1(-/- mice), a model of diet-induced coronary atherosclerosis and heart failure. We added FTY720 (0.3 mg·kg(-1)·d(-1)) to the drinking water of C57BL/6J mice. After ex vivo cardiac ischemia/reperfusion injury, these mice had significantly improved left ventricular (LV) developed pressure and reduced infarct size compared with controls. Subsequently, ApoeR61(h/h)/SRB1(-/-) mice fed a high-fat diet for 4 weeks were treated or not with oral FTY720 (0.05 mg·kg(-1)·d(-1)). This sharply reduced mortality (P < 0.02) and resulted in better LV function and less LV remodeling compared with controls without reducing hypercholesterolemia and atherosclerosis. Oral FTY720 reduced the number of blood lymphocytes and increased the percentage of CD4+Foxp3+ regulatory T cells (Tregs) in the circulation, spleen, and lymph nodes. FTY720-treated mice exhibited increased TGF-β and reduced IFN-γ expression in the heart. Also, CD4 expression was increased and strongly correlated with molecules involved in natural Treg activity, such as TGF-β and GITR. Our data suggest that long-term FTY720 treatment enhances LV function and increases longevity in mice with heart failure. These benefits resulted not from atheroprotection but from systemic immunosuppression and a moderate reduction of inflammation in the heart.

Many outpatient clinics where health professionals train will transition to a team-based medical home model over the next several years. Therefore, training programs need innovative approaches to prepare and incorporate trainees into team-based delivery systems. To address this need, educators at the San Francisco Veterans Affairs (VA) Medical Center included trainees in preclinic team "huddles," or briefing meetings to facilitate care coordination, and developed an interprofessional huddle-coaching program for nurse practitioner students and internal medicine residents who function as primary providers for patient panels in VA outpatient primary care clinics. The program aimed to support trainees' partnerships with staff and full participation in the VA's Patient Aligned Care Teams. The huddle-coaching program focuses on structuring the huddle process via scheduling, checklists, and designated huddle coaches; building relationships among team members through team-building activities; and teaching core skills to support collaborative practice. A multifaceted evaluation of the program showed positive results. Participants rated training sessions and team-building activities favorably. In interviews, trainees valued their team members and identified improvements in efficiency and quality of patient care as a result of the team-based approach. Huddle checklists and scores on the Team Development Measure indicated progress in team processes and relationships as the year progressed. These findings suggest that the huddle-coaching program was a worthwhile investment in trainee development that also supported the clinic's larger mission to deliver team-based, patient-aligned care. As more training sites shift to team-based care, the huddle-coaching program offers a strategy for successfully incorporating trainees.