How Not to Think About Managed Care

The claim of this Article is that the concept of managed care, like many concepts now prominent in commentary about medical care finance and delivery in the United States, is incoherent and thus a barrier to useful analysis. To demonstrate this conclusion, we first discuss the managerial context in which managed care claims have arisen and outline the diverse trends to which the category is regularly and confusingly applied. We then suggest an alternative approach to characterizing recent changes in medical care and show how this approach alters and deepens our understanding of recent economic and political developments. We conclude by arguing for more neutral categories to make sense of past and projected developments in methods of reimbursement, techniques of management, and organizational structures

Joint infection after knee arthroscopy: Medicolegal aspects

SummaryIntroductionSeptic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients’ functional prognosis and engage surgeon's liability. This study analyzes the context of such infection occurrences, their management as well as their medicolegal consequences.Patients and methodsTwenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medical liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrolysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy.ResultsClinical signs of septic arthritis appeared after a median interval of 8 days (0–37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1–9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0–20), a total temporary work incapacity of 120 days (40–790), a suffering burden averaging 3 out of 7 (0–4,5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation.DiscussionSome risk factors of articular infection are known and well-identified. They can be linked to the patient's condition (addiction to smoking, surgical history, professional activity) or to medical management (intra-articular corticoid injections, interventions under oral anticoagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid's inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic management of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner.Level of evidenceLevel IV; economic and decision analysis, retrospective study

ISCEV guidelines for clinical multifocal electroretinography (2007 edition)

The clinical multifocal electroretinogram (mfERG) is an electrophysiological test of local retinal function. With this technique, many local ERG responses, typically 61 or 103, are recorded from the cone-driven retina under light-adapted conditions. This document specifies guidelines for performance of the test. It also provides detailed guidance on technical and practical issues, as well as on reporting test results. The main objective of the guidelines is to promote consistent quality of mfERG testing and reporting within and among centers. These 2007 guidelines, from the International Society for Clinical Electrophysiology of Vision (ISCEV: http://www.iscev.org), replace the ISCEV guidelines for the mfERG published in 2003

Risk factors associated with reticular pseudodrusen versus large soft drusen

PURPOSE: To investigate genetic, environmental, and systemic risk factors in prospectively identified subjects with the age-related macular degeneration (AMD) phenotypes of (1) reticular pseudodrusen without large soft drusen and (2) large soft drusen without reticular pseudodrusen. DESIGN: Prospective case-case comparison. METHODS: In a clinical practice setting, patients with AMD were sequentially screened using clinical examination and scanning laser ophthalmoscopy imaging to prospectively identify subjects (n = 73) with the phenotypes of (1) reticular pseudodrusen without large soft drusen (n = 30) or (2) large soft drusen without reticular pseudodrusen (n = 43). Subjects were genotyped for 2 alleles associated with AMD, age-related maculopathy susceptibility 2 (ARMS2) and complement factor H (CFH). A questionnaire was administered to collect history of smoking, hypertension, diabetes, and hyperlipidemia, as well as personal and family history of AMD. RESULTS: The reticular pseudodrusen group was older (median age 87 vs 81 years, P = .04) and had more female subjects (83.3% vs 48.8%, P = .003), later ages of AMD onset (83 vs 70 years, P = .0005), and a greater frequency of hypertension (76.7% vs 55.8%, P = .08). No significant differences were found in the distribution of the ARMS2 risk allele (P = .4) between the reticular pseudodrusen (homozygous = 20.0%; heterozygous = 56.7%) and large soft drusen (homozygous = 19.0%; heterozygous = 42.9%) phenotypes, or in the distribution of the CHF risk allele (P = .7) between the reticular pseudodrusen (homozygous = 26.7%; heterozygous = 56.7%) and large soft drusen (homozygous = 21.4%; heterozygous = 66.7%) phenotypes. CONCLUSIONS: The reticular pseudodrusen phenotype was associated with increased age, later age of AMD onset, and female sex

Updates to the list of Estonian lichenized, lichenicolous and allied fungi

Sixteen species are reported as new for Estonia. Among these species, ten are lichenized and six are lichen-habiting fungi. One lichen-habiting species – Bryostigma molendoi (Heufl. ex Arnold) S.Y. Kondr. & Hur (= Arthonia molendoi (Heufl. ex Arnold) R. Sant.) and one lichenized species – Lecania nylanderiana A. Massal. should be excluded from the Estonian list of lichenized and allied fungi as misidentifications. New locality data are given for two critically endangered (CR) lichens last found more than 45 years ago – Hypogymnia vittata (Ach.) Parrique and Nephroma bellum (Spreng.) Tuck. (Lõhmus et al., 2019). Additional information on the distribution in Estonia is provided for recently described Toniniopsis separabilis (Nyl.) Gerasimova & A. Beck (Gerasimova et al., 2021)

Clinical disorders affecting mesopic vision

Vision in the mesopic range is affected by a number of inherited and acquired clinical disorders. We review these conditions and summarize the historical background, describing the clinical characteristics alongside the genetic basis and molecular biological mechanisms giving rise to rod and cone dysfunction relevant to twilight vision. The current diagnostic gold standards for each disease are discussed and curative and symptomatic treatment strategies are summarized