Background:The goal of the Patient Protection and Affordable Care Act (PPACA) was to expand patient access to health care. Since the rollout of the PPACA, Medicaid patients have demonstrated difficulty obtaining appointments in some specialty care settings.Purpose:To assess the effect of insurance type (Medicaid and private) on patient access to orthopaedic surgery sports medicine specialists for a semiurgent evaluation of a likely operative bucket-handle meniscus tear. The study was designed to determine whether disparities in access exist since the PPACA rollout.Study Design:Cohort study; Level of evidence, 2.Methods:The design was to call 180 orthopaedic surgery sports medicine specialists in 6 representative states (California, Ohio, New York, Florida, Texas, and North Carolina) between June 2015 and December 2015. An appointment was requested for the caller’s fictitious 25-year-old-brother who had suffered a bucket-handle meniscus tear. Each office was called twice to assess the ease of obtaining an appointment: once for patients with Medicaid and once for patients with private insurance. For each call, data pertaining to whether an appointment was given, wait times, and barriers to receiving an appointment were recorded.Results:A total of 177 surgeons were called within the study period. Overall, 27.1% of offices scheduled an appointment for a patient with Medicaid, compared with 91.2% (P < .0001) for a patient with private insurance. Medicaid patients were significantly more likely to be denied an appointment due to lack of referral compared with private patients (40.2% vs 3.7%, P < .0001), and Medicaid patients were more likely to experience longer wait times for an appointment (15 vs 12 days, P < .029). No significant differences were found in patients’ access to orthopaedic surgery sports medicine specialists between Medicaid-expanded and -nonexpanded states. Medicaid reimbursement for knee arthroscopy with meniscus repair was not significantly correlated with appointment success rate or patient waiting periods.Conclusion:Despite the passage of the PPACA, patients with Medicaid have reduced access to care. In addition, patients with Medicaid confront more barriers to receiving appointments than patients with private insurance and wait longer for an appointment.

Highlights d Core epitopes of the APS autoantigen b 2 GPI are conserved in R. int d Human b 2 GPI-specific Th1 cell clones and autoantibodies cross-react with R. int mimotopes d Mimotope-dependent anti-R. int titers correlate with antib 2 GPI titers in APS patients d Gavage of (NZW 3 BXSB)F 1 mice with R. int induces antib 2 GPI IgG and APS-like pathology Authors

Level II, prognostic study.

Given the vast antigenic source of the gut microbiota, we hypothesized that human gut commensal bacteria induce and sustain autoreactivity via cross-reactivity. As a paradigm, we studied the antiphospholipid syndrome (APS), which is a serious autoimmune clotting disorder of unknown etiology but with a well-defined major autoantigen, b2-glycoprotein I (b2GPI). Infectious triggers are implicated in transient autoantibody production, but the persistent stimuli for anti-b2GPI antibodies remain unknown. To this end, we characterized b2GPI-specific monoclonal autoantibody reactivity to an in silico identified candidate commensal, Roseburia intestinalis (R.int), that is abundant in human stool from APS patients as detected by a species-specific PCR. Using an APS-derived monoclonal antibody, P1-117, that binds to the major B cell epitope in domain I of b2GPI (RGGMR), we tested for cross-reactivity to anaerobically cultured R.int and its candidate cross-reactive R.int protein (WP_006857340.1). P1-117 bound significantly to R.int lysates whereas a control antibody specific for another epitope within b2GPI did not. Further, P1-117 displayed significant binding to the recombinantly expressed R.int cross-reactive candidate protein. BALB/cJ mice immunized with whole heat-killed R.int displayed significant cross-reactive splenocytes and low titers of cross-reactive IgG autoantibodies. In conclusion, we present here in vitro and in vivo studies supporting cross-reactivity of pathogenic b2GPI-specific autoantibody with a common gut commensal. This study provides a concept for persistently colonizing gut commensals as chronic cross-reactive triggers in genetically susceptible autoimmune hosts such as APS patients.