The Affordable Care Act: Disparities in Emergency Department and Hospital Use for Mental Health Diagnoses In Young Adults

One of the first provisions of the Affordable Care Act to be implemented allowed young adults to remain on their parents' insurance plans until the age of 26. This study estimated the association between the dependent coverage provision and changes in young adults’ usage of Emergency Department (ED) and Hospital services for psychiatric diagnoses. We utilized a Quasi-Experimental Analysis of ED use and inpatient admissions in California from 2009-2011 for behavioral health diagnosis of individuals aged 19 to 31-years old. Analyses used a difference-in-differences approach comparing those targeted by the ACA dependent provision (19 to 25-year-olds) and those who were not (27 to 31-year-olds), evaluating changes in ED/Inpatient visit rates per 1,000 in California. Primary outcome measures included the quarterly ED/Inpatient visit rates with any psychiatric diagnosis, with subgroup analysis looking at the effects of race and gender on the primary outcome. It was found that while the young adult dependent provision was associated with 0.05 per 1,000 people (p<0.001) fewer psychiatric ED visits among the treatment group (19 to 25-year-olds) compared to the control group (27 to 31-year-olds), this significant reduction in psychiatric ED visits was not seen in males, hispanics, asians or pacific islanders. Furthermore, hispanics, asians, and pacific islanders were the only racial subgroups that did not see gains in the proportion of psychiatric ED visits covered by private insurance. Additionally, inpatient visit rates did not significantly change in the treatment group relative to the control group, however after stratification, rates significantly increased for males, whites, blacks, and mixed/other racial groups. While the source of admission from the ED did not significantly change in the treatment compared to the control group, admissions from sources other than the ED significantly increased overall, as well as for whites, blacks, mixed/other, and females. Ultimately, our research has shown that in one of the earliest aspects of the ACA, gender, and racial disparities exist

Scaphoid Fracture

History of present illness: A 25-year-old, right-handed male presented to the emergency department with left wrist pain after falling from a skateboard onto an outstretched hand two-weeks prior. He otherwise had no additional concerns, including no complaints of weakness or loss of sensation. On physical exam, there was tenderness to palpation within the anatomical snuff box. The neurovascular exam was intact. Plain films of the left wrist and hand were obtained. Significant findings: The anteroposterior (AP) plain film of this patient demonstrates a full thickness fracture through the middle third of the scaphoid (red arrow), with some apparent displacement (yellow lines) and subtle angulation of the fracture fragments (blue line). Discussion: The scaphoid bone is the most commonly fractured carpal bone accounting for 70%-80% of carpal fractures.1 Classically, it is sustained following a fall onto an outstretched hand (FOOSH). Patients should be evaluated for tenderness with palpation over the anatomical snuffbox, which has a sensitivity of 100% and specificity of 40%.2 Plain films are the initial diagnostic modality of choice and have a sensitivity of 70%, but are commonly falsely negative in the first two to six weeks of injury (false negative of 20%).3 The Mayo classification organizes scaphoid fractures as involving the proximal, mid, and distal portions of the scaphoid bone with mid-fractures being the most common.3 The proximal scaphoid is highly susceptible to vascular compromise because it depends on retrograde blood flow from the radial artery. Therefore, disruption can lead to serious sequelae including osteonecrosis, arthrosis, and functional impairment. Thus, a low threshold should be maintained for neurovascular evaluation and surgical referral. Patients with non-displaced scaphoid fractures should be placed in a thumb spica splint.3 Patients with even suspected scaphoid fractures should be placed in a thumb spica splint and re-evaluated in two weeks with repeat plain films.4 Further evaluation with MRI or bone scan should be considered if repeat plain films are negative and clinical suspicion remains high.3 In conclusion, scaphoid fractures can be difficult to identify; therefore, a high level of suspicion and low threshold for further imaging or intervention is warranted. Topics: Scaphoid, fracture, orthopedics, FOOSH injur

A Case of Erythema Nodosum with Coccidoidomycosis

Erythema nodosum (EN) is associated with many systemic diseases and infections. This case report provides an image of erythematous nodules, an overview of the various causes of EN, and the laboratory tests and imaging that can be done in the emergency department to narrow its broad differential diagnosis

A Case of Erythema Nodosum with Coccidoidomycosis

Erythema nodosum (EN) is associated with many systemic diseases and infections. This casereport provides an image of erythematous nodules, an overview of the various causes of EN, andthe laboratory tests and imaging that can be done in the emergency department to narrow its broaddifferential diagnosis