Daniel H. Wiznia

Stem Cells for Augmenting Tendon Repair

Tendon healing is fraught with complications such as reruptures and adhesion formation due to the formation of scar tissue at the injury site as opposed to the regeneration of native tissue. Stem cells are an attractive option in developing cell-based therapies to improve tendon healing. However, several questions remain to be answered before stem cells can be used clinically. Specifically, the type of stem cell, the amount of cells, and the proper combination of growth factors or mechanical stimuli to induce differentiation all remain to be seen. This paper outlines the current literature on the use of stem cells for tendon augmentation.

PBL 2.0: enhancing problem-based learning through increased student participation

Abstract Purpose : The purpose of this study was to test a new problem-based learning (PBL) method to see if it reinvigorated the learning experience. Method : A new PBL format called PBL 2.0, which met for 90 min two times per week, was introduced in 2009 into an 11-week integrated neuroscience course. One hundred second-year medical students, divided into 10 groups of 10, who had completed their first year of medical school using a traditional PBL format, participated in PBL 2.0. Students were prohibited from using computers during the first session. Learning objectives were distributed at the end of the first day to the small groups, and students were assigned to pairs/trios responsible for leading an interactive discussion on specific learning objectives the following day. Student-led ‘lectures’ were prohibited. All students were responsible for learning all of the learning objectives so that they could participate in their discussions. Results : One hundred and six students were surveyed and 98 submitted answers (92% response). The majority of groups adhered to the new PBL method. Students invested more time preparing the learning objectives. Students indicated that the level of interaction among students increased. The majority of students preferred the new PBL format. Conclusions : PBL 2.0 was effective in increasing student interaction and promoting increased learning.

The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act.

This study evaluated access to knee arthroplasty and revision in 8 geographically representative states. Patients with Medicaid were significantly less likely to receive an appointment compared to patients with Medicare or BlueCross. However, patients with Medicaid had increased success at making an appointment in states with expanded Medicaid eligibility (37.7% vs 22.8%, P=0.011 for replacement, 42.6% vs 26.9%, P=0.091 for revision), although they experienced longer waiting periods (31.5 days vs 21.1 days, P=0.054 for replacement, 45.5 days vs 22.5 days, P=0.06 for revision). Higher Medicaid reimbursement also had a direct correlation with appointment success rate for Medicaid patients (OR=1.232, P=0.001 for replacement, OR=1.314, P=0.014 for revision).

Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act

Background: The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty. Methods: We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral. Results: Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period. Conclusion: Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments. Level of Evidence: Level II, prognostic study.

Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient.

Background and Objectives The Affordable Care Act intended to “extend affordable coverage” and “ensure access” for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. Methods Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. Results Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. Conclusions Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.

The effect of helmets on motorcycle outcomes in a level I trauma center in Connecticut

ABSTRACT Objective: The State of Connecticut has a partial motorcycle helmet law, which has been linked to one of the lowest helmet compliance rates in the Northeast. We examine the clinical and financial impact of low motorcycle helmet use in the State of Connecticut. Methods: A retrospective cohort study comparing the outcomes between helmeted and nonhelmeted motorcycle crash victims over a 12.5-year period, from July 2, 2002, to December 31, 2013. All patients who were admitted to the hospital after a motorcycle crash were included in the study. Patients were stratified into helmeted and nonhelmeted cohorts. Group differences were compared using t-test or Wilcoxon rank test for continuous variables and chi-square test for dichotomous outcomes. Regression models were created to evaluate predictors of helmet use, alcohol and drugs as confounding variables, and factors that influenced hospital costs. Results: The registry included 986 eligible patients. Of this group, 335 (34%) were helmeted and 651 (66%) were nonhelmeted. Overall, nonhelmeted patients had a worse clinical presentation, with lower Glasgow Coma Scale (GCS; P <.01), higher Injury Severity Score (ISS; P <.01), higher incidence of loss of consciousness (LOC; P <.01), longer intensive care unit (ICU; P <.01) admissions, and higher incidence of head (P <.01) or face injuries (P <.01). Nonhelmeted patients were also twice as more likely to die from their injuries (P =.04, odds ratio [OR] = 1.89, 95% confidence interval [CI], 1.02–3.45). Financially, nonhelmeted patients incurred mean hospital costs of

PROMIS Computer Adaptive Tests Compared With Time to Brake in Patients With Complex Lower Extremity Trauma.

18,458, whereas helmeted patients incurred

The Economic Impact of Helmet Use on Motorcycle Accidents: A Systematic Review and Meta-analysis of the Literature from the Past 20 Years.

14,970 (P =.18). ISS, GCS, and ICU length of stay were significantly correlated with increased hospital costs (P <.01). Not using a helmet was a significant predictor of mortality (P =.04) after adjusting for alcohol/drug use and age. Conclusions: Helmet use is associated with lower injury severity and increased survival after a motorcycle crash. These outcomes remained consistent even after controlling for age and alcohol and drug use. The medical and financial impact of Connecticuts partial helmet law should be carefully evaluated to petition for increased education and enforcement of helmet use.

Access of Patients With Lumbar Disc Herniations to Spine Surgeons: The Effect of Insurance Type Under the Affordable Care Act

Objectives: To compare the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (PROMIS PF CAT and PROMIS PI CAT) with time to brake (TTB) in patients with complex lower extremity traumas for evaluating whether patients can safely return to driving. Design: Prospective. Setting: Level-1 trauma center. Patients: Sixty-three patients with lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia/fibula, ankle, and foot within 15 weeks of treatment. Intervention: The TTB of patients with complex lower extremity trauma were tested at various time points postoperatively on a computerized driving simulator. Patients concurrently completed PROMIS PF CAT and PROMIS PI CAT. Main Outcome Measure: Correlations between TTB, PROMIS PF CAT, and PROMIS PI CAT. Results: The mean TTB for the healthy control group was 0.61 seconds. There was a statistically significant correlation between time since treatment and TTB (B = −0.008 s/d; P = 0.041) for right-sided lower extremity injuries below the knee (tibia/fibula, ankle, foot). TTB for right-sided injuries below the knee also significantly correlated with PROMIS PI CAT (B = 0.022; P = 0.029). The PROMIS PI CAT value was 43 when the healthy control group TTB was equal to 0.61 seconds. Conclusions: This study suggests that the PROMIS PI CAT can be used as an adjunct to the TTB in assessing whether a patient can safely return to driving.

The Influence of Medical Insurance on Patient Access to Orthopaedic Surgery Sports Medicine Appointments Under the Affordable Care Act

Objective: The incidence and cost of motorcycle accidents are projected to increase. Motorcycle helmets are accepted as an effective strategy for reducing the morbidity and therefore the cost of motorcycle accidents. Despite this, states have continued to repeal helmet laws in the past 20 years. In addition, variations in the methodologies and outcomes of published reports have contributed to uncertainty regarding the health care dollars saved due to motorcycle helmet use. The purpose of this systematic review and meta-analysis is to clarify the economic impact of motorcycle helmet use. Methods: Our primary source was Medline. Search terms included “motorcycle,” “motorbike,” “motorcycle helmet,” “head protective devices,” and “cost and cost analysis.” The review only included articles that were primary studies, written in English, evaluations of periods after 1994, and published in a peer-reviewed journal. Two independent authors extracted data using predefined data fields. Meta-analysis was done using the R-metafor package. Results: Twelve papers met the criteria for inclusion. Meta-analysis demonstrated that nonhelmeted patients required