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We use Benford's law to examine the non-random elements of health care costs. We find that as health care expenditures increase, the conformity to the expected distribution of naturally occurring numbers worsens, indicating a tendency towards inefficient treatment. Government insurers follow Benford's law better than private insurers indicating more efficient treatment. Surprisingly, self-insured patients suffer the most from non-clinical cost factors. We suggest that cost saving efforts to reduce non-clinical expenses should be focused on more severe, costly encounters. Doing so focuses cost reduction efforts on less than 10% of encounters that constitute over 70% of dollars spent on health care treatment.
Assessment of performance validity during neuropsychology evaluation is essential to reliably interpret cognitive test scores. Studies (Webber et al., 2018; Wisdom, et al., 2012) have validated the use of abbreviated measures, such as Trial 1 (T1) of the Test of Memory Malingering (TOMM), to detect invalid performance. Only one study (Bauer et al., 2007) known to these authors has examined the utility of Green’s Word Memory Test (WMT) immediate recall (IR) as a screening tool for invalid performance. This study explores WMT IR as an independent indicator of performance validity in a mild TBI (mTBI) veteran population.
Participants and Methods:
Participants included 211 (Mage = 32.1, SD = 7.4; Medu = 13.1, SD = 1.64; 94.8% male; 67.8% White) OEF/OIF/OND veterans with a history of mTBI who participated in a comprehensive neuropsychological evaluation at one of five participating VA Medical Centers. Performance validity was assessed using validated cut scores from the following measures: WMT IR and delayed recall (DR); TOMM T1; WAIS-IV reliable digit span; CVLT-II forced choice raw score; Wisconsin Card Sorting Test failure to maintain set; and the Rey Memory for Fifteen Items test, combo score. Sensitivity and specificity were calculated for each IR score compared with failure on DR. In addition, sensitivity and specificity were calculated for each WMT IR score compared to failure of at least one additional performance validity measure (excluding DR), two or more measures, and three or more measures, respectively.
Results:
Results indicated that 46.8% participants failed to meet cut offs for adequate performance validity based on the standard WMT IR cut score (i.e., 82.5%; M = 81.8%, SD = 17.7%); however, 50.2% participants failed to meet criteria based on the standard WMT DR cut score (M = 79.8% SD = 18.6%). A cut score of 82.5% or below on WMT IR correctly identified 82.4% (i.e., sensitivity) of subjects who performed below cut score on DR, with a specificity of 94.2%. Examination of IR cutoffs compared to failure of one or more other PVTs revealed that the standardized cut score of 82.5% or below had a sensitivity of 78.2% and a specificity of 72.4%; whereas, a cut score of 65% or below had a sensitivity of 41% and a specificity of 91.3%. Similarly, examination of IR cutoffs compared to failure of two or more additional PVTs revealed that the cut score of 60% or below had a sensitivity of 45.7% and specificity of 93.1% ; whereas, a cut score of 57.5% or below had a sensitivity of 57.9% and specificity of 90.9% when using failure of three or more PVTs as the criterion.
Conclusions:
Results indicated that a cut score of 82.5% or below on WMT IR may be sufficient to detect invalid performance when considering WMT DR as criterion. Furthermore, WMT IR alone, with adjustments to cut scores, appears to be a reasonable way to assess symptom validity compared to other PVTs. Sensitivity and specificity of WMT IR scores may have been adversely impacted by lower sensitivity of other PVTs to independently identify invalid performance.
Non-clinical aspects of life, such as social, environmental, behavioral, psychological, and economic factors, what we call the sociome, play significant roles in shaping patient health and health outcomes. This paper introduces the Sociome Data Commons (SDC), a new research platform that enables large-scale data analysis for investigating such factors.
Methods:
This platform focuses on “hyper-local” data, i.e., at the neighborhood or point level, a geospatial scale of data not adequately considered in existing tools and projects. We enumerate key insights gained regarding data quality standards, data governance, and organizational structure for long-term project sustainability. A pilot use case investigating sociome factors associated with asthma exacerbations in children residing on the South Side of Chicago used machine learning and six SDC datasets.
Results:
The pilot use case reveals one dominant spatial cluster for asthma exacerbations and important roles of housing conditions and cost, proximity to Superfund pollution sites, urban flooding, violent crime, lack of insurance, and a poverty index.
Conclusion:
The SDC has been purposefully designed to support and encourage extension of the platform into new data sets as well as the continued development, refinement, and adoption of standards for dataset quality, dataset inclusion, metadata annotation, and data access/governance. The asthma pilot has served as the first driver use case and demonstrates promise for future investigation into the sociome and clinical outcomes. Additional projects will be selected, in part for their ability to exercise and grow the capacity of the SDC to meet its ambitious goals.
Paediatricians play an integral role in the lifelong care of children with CHD, many of whom will undergo cardiac surgery. There is a paucity of literature for the paediatrician regarding the post-operative care of such patients.
Observations:
The aim of this manuscript is to summarise essential principles and pertinent lesion-specific context for the care of patients who have undergone surgery or intervention resulting in a biventricular circulation.
Conclusions and relevance:
Familiarity with common issues following cardiac surgery or intervention, as well as key details regarding specific lesions and surgeries, will aid the paediatrician in providing optimal care for these patients.
Single ventricle CHD affects about 5 out of 100,000 newborns, resulting in complex anatomy often requiring multiple, staged palliative surgeries. Paediatricians are an essential part of the team that cares for children with single ventricle CHD. These patients often encounter their paediatrician first when a complication arises, so it is critical to ensure the paediatrician is knowledgeable of these issues to provide optimal care.
Observations
We reviewed the subtypes of single ventricle heart disease and the various palliative surgeries these patients undergo. We then searched the literature to detail the general paediatrician’s approach to single ventricle patients at different stages of surgical palliation.
Conclusions and relevance
Single ventricle patients undergo staged palliation that drastically changes physiology after each intervention. Coordinated care between their paediatrician and cardiologist is requisite to provide excellent care. This review highlights what to expect when these patients are seen by their paediatrician for either well child visits or additional visits for parental or patient concern.
The UK asylum processat the time of writing is described in detail to illustrate more general practices and effects. Claim handling and the role of immigration detention are discussed.Legal representation is important but hard to find. Asylum claim interviews are described.The decision-making process is outlined. Tribunals, appeals, appeals rights exhaustion, and fresh claims are described.The National Referral Mechanism for people who have been trafficked is outlined.Claiming asylum has a human context.People are excluded from society.Shame can be induced, and ‘retraumatisation’ can occur. Detention without limit of time can distress and destabilise individuals who were mentally stable on arrival.Fear and uncertainty prevail.
Possible reactions of the host society are reviewed; suspicion and disbelief, and deprivation and demands as part of the ‘hostile environment’.
The key themes of medical care and the role of medical evidence are introduced.Forms of recognition as a refugee are described, and some of their practical and psychological consequences.
OBJECTIVES/GOALS: The primary goals of this study are 1) expand our understanding of the neural circuitry influenced by the neuropeptide Neuromedin U (NMU) via its receptor Neuromedin U Receptor 2 (NMUR2), and 2) provide alternative top-down mechanisms for how NMU regulates high fat food intake and cocaine taking. METHODS/STUDY POPULATION: Immunohistochemistry (IHC) for NMUR2 and cell markers was performed on rat brain tissue containing the medial prefrontal cortex (mPFC). To identify the source of the presynaptic NMUR2, anterograde tracing from the paraventricular nucleus or dorsal raphe nucleus to the mPFC utilizing an AAV2- dsRed-synaptobrevin fusion protein were performed (n=3) and will be followed by IHC. Using in vivo calcium imaging technology (InScopix nVista), neuronal activity (calcium transients) was recorded from the mPFC of two awake, freely behaving rats. Each animal underwent a single session of 30 minutes baseline activity, intraperitoneal NMU administration, and 30 minutes of post-treatment activity. Activity was then processed and recorded as distinct events using the InScopix data acquisition software. RESULTS/ANTICIPATED RESULTS: Medial prefrontal cortex staining for NMUR2 revealed a characteristic “beads on a string” motif, consistent with presynaptic receptor expression. Furthermore, we expect the anterograde tracing experiment will show colocalization of the dsRed-synaptobrevin fusion protein with NMUR2 on synaptic inputs into the medial prefrontal cortex. Following quantification of pre- and post- treatment events using the InScopix data acquisition software, total events during the pre- and post-treatment time periods were calculated. In these studies, both animals demonstrated a clear increase in calcium transient activity between pre- and post- treatment evaluations, suggesting that NMU administration increases the neuronal activity of neurons in the prefrontal cortex. DISCUSSION/SIGNIFICANCE: This research provides a new site of action for the known therapeutic effects of NMU. We demonstrate the presence of presynaptic NMUR2 in the mPFC and show that systemic administration of NMU increases mPFC neuronal activity. This illustrates NMU may act as a top-down mediator for substance use disorders and binge eating behaviors.
This paper presents a compilation of atmospheric radiocarbon for the period 1950–2019, derived from atmospheric CO2 sampling and tree rings from clean-air sites. Following the approach taken by Hua et al. (2013), our revised and extended compilation consists of zonal, hemispheric and global radiocarbon (14C) data sets, with monthly data sets for 5 zones (Northern Hemisphere zones 1, 2, and 3, and Southern Hemisphere zones 3 and 1–2). Our new compilation includes smooth curves for zonal data sets that are more suitable for dating applications than the previous approach based on simple averaging. Our new radiocarbon dataset is intended to help facilitate the use of atmospheric bomb 14C in carbon cycle studies and to accommodate increasing demand for accurate dating of recent (post-1950) terrestrial samples.
What is classical music? This book answers the question in a manner never before attempted, by presenting the history of fifteen parallel traditions, of which Western classical music is just one. Eachmusic is analysed in terms of its modes, scales, and theory; its instruments, forms, and aesthetic goals; its historical development, golden age, and condition today; and the conventions governing its performance. The writers are leading ethnomusicologists, and their approach is based on the belief that music is best understood in the context of the culture which gave rise to it . By including Mande and Uzbek-Tajik music - plus North American jazz - in addition to the better-known styles of the Middle East, the Indian sub-continent, the Far East, and South-East Asia, this book offers challenging new perspectives on the word 'classical'. It shows the extent to which most classical traditions are underpinned by improvisation, and reveals the cognate origins of seemingly unrelated musics; it reflects the multifarious ways in which colonialism, migration, and new technology have affected musical development, and continue to do today. With specialist language kept to a minimum, it's designed to help both students and general readers to appreciate musical traditions which may be unfamiliar to them, and to encounter the reality which lies behind that lazy adjective 'exotic'.
MICHAEL CHURCH has spent much of his career in newspapers as a literary and arts editor; since 2010 he has been the music and opera critic of The Independent. From 1992 to 2005 he reported on traditional musics all over the world for the BBC World Service; in 2004, Topic Records released a CD of his Kazakh field recordings and, in 2007, two further CDs of his recordings in Georgia and Chechnya.
Contributors: Michael Church, Scott DeVeaux, Ivan Hewett, David W. Hughes, Jonathan Katz, Roderic Knight, Frank Kouwenhoven, Robert Labaree, Scott Marcus, Terry E. Miller, Dwight F.Reynolds, Neil Sorrell, Will Sumits, Richard Widdess, Ameneh Youssefzadeh
High dietary phosphorus (P), particularly soluble salts, may contribute to chronic kidney disease development in cats. The aim of the present study was to assess the safety of P supplied at 1 g/1000 kcal (4184kJ) from a highly soluble P salt in P-rich dry format feline diets. Seventy-five healthy adult cats (n 25/group) were fed either a low P control (1·4 g/1000 kcal [4184kJ]; Ca:P ratio 0·97) or one of two test diets with 4 g/1000 kcal (4184 kJ); Ca:P 1·04 or 5 g/1000 kcal (4184kJ); Ca:P 1·27, both incorporating 1 g/1000 kcal (4184 kJ) sodium tripolyphosphate (STPP) – for a period of 30 weeks in a randomised parallel-group study. Health markers in blood and urine, glomerular filtration rate, renal ultrasound and bone density were assessed at baseline and at regular time points. At the end of the test period, responses following transition to a commercial diet (total P – 2·34 g/1000 kcal [4184kJ], Ca:P 1·3) for a 4-week washout period were also assessed. No adverse effects on general, kidney or bone (skeletal) function and health were observed. P and Ca balance, some serum biochemistry parameters and regulatory hormones were increased in cats fed test diets from week 2 onwards (P ≤ 0·05). Data from the washout period suggest that increased serum creatinine and urea values observed in the two test diet groups were influenced by dietary differences during the test period, and not indicative of changes in renal function. The present data suggest no observed adverse effect level for feline diets containing 1 g P/1000 kcal (4184 kJ) from STPP and total P level of up to 5 g/1000 kcal (4184 kJ) when fed for 30 weeks.
We say that
$\mathcal {I}$
is an ideal independent family if no element of
${\mathcal {I}}$
is a subset mod finite of a union of finitely many other elements of
${\mathcal {I}}.$
We will show that the minimum size of a maximal ideal independent family is consistently bigger than both
$\mathfrak {d}$
and
$\mathfrak {u},$
this answers a question of Donald Monk.
Firearm injury in the United States is a public health crisis in which physicians are uniquely situated to intervene. However, their ability to mitigate harm is limited by a complex array of laws and regulations that shape their role in firearm injury prevention. This piece uses four clinical scenarios to illustrate how these laws and regulations impact physician practice, including patient counseling, injury reporting, and the use of court orders and involuntary holds. Unintended consequences on clinical practice of laws intended to reduce firearm injury are also discussed. Lessons drawn from these cases suggest that physicians require more nuanced education on this topic, and that policymakers should consult front-line healthcare providers when designing firearm policies.
Coronavirus disease 2019 (COVID-19) has migrated to regions that were initially spared, and it is likely that different populations are currently at risk for illness. Herein, we present our observations of the change in characteristics and resource use of COVID-19 patients over time in a national system of community hospitals to help inform those managing surge planning, operational management, and future policy decisions.
To determine risk factors for mortality among COVID-19 patients admitted to a system of community hospitals in the United States.
Design:
Retrospective analysis of patient data collected from the routine care of COVID-19 patients.
Setting:
System of >180 acute-care facilities in the United States.
Participants:
All admitted patients with positive identification of COVID-19 and a documented discharge as of May 12, 2020.
Methods:
Determination of demographic characteristics, vital signs at admission, patient comorbidities and recorded discharge disposition in this population to construct a logistic regression estimating the odds of mortality, particular for those patients characterized as not being critically ill at admission.
Results:
In total, 6,180 COVID-19+ patients were identified as of May 12, 2020. Most COVID-19+ patients (4,808, 77.8%) were admitted directly to a medical-surgical unit with no documented critical care or mechanical ventilation within 8 hours of admission. After adjusting for demographic characteristics, comorbidities, and vital signs at admission in this subgroup, the largest driver of the odds of mortality was patient age (OR, 1.07; 95% CI, 1.06–1.08; P < .001). Decreased oxygen saturation at admission was associated with increased odds of mortality (OR, 1.09; 95% CI, 1.06–1.12; P < .001) as was diabetes (OR, 1.57; 95% CI, 1.21–2.03; P < .001).
Conclusions:
The identification of factors observable at admission that are associated with mortality in COVID-19 patients who are initially admitted to non-critical care units may help care providers, hospital epidemiologists, and hospital safety experts better plan for the care of these patients.
To date, nearly 10,000 World Trade Center (WTC) responders have been diagnosed with at least one type of WTC-related cancer, and over 70 types of cancer have been related to WTC occupational exposure. Due to the observed latency period for malignancies, the WTC Health Program anticipates increases in rates of new cancer diagnoses. Given the growing number of cancer diagnoses in this population, there is an urgent need to develop a novel intervention to address the psychosocial needs of WTC responders with cancer. Meaning-centered psychotherapy (MCP) is a structured psychotherapeutic intervention originally developed to help patients with advanced cancer find and sustain meaning in life despite illness-related limitations. Existential distress and loss of meaning are critical and understudied elements of psychological health that have been widely overlooked among WTC responders with cancer.
Method
We have adapted MCP for WTC responders (MCP-WTC) for the treatment of WTC responders who have been diagnosed with WTC-certified cancers. MCP-WTC aims to target the complex crisis in meaning faced by those responders who responded to the 9/11 attacks and subsequently were diagnosed with cancer as a result of their service.
Results
We describe the adaptation of MCP-WTC and the application of this intervention to meet the unique needs of those exposed to the terrorist attacks of September 11, 2001 (9/11), participated in the rescue, recovery, and clean-up effort at Ground Zero, and were diagnosed with WTC-related cancer. We highlight the novel aspects of this intervention which have been designed to facilitate meaning-making in the context of the patient's response to 9/11 and subsequent diagnosis of cancer.
Significance of results
This work provides a rationale for MCP-WTC and the potential for this intervention to improve the quality of life of WTC responders and help these patients navigate life after 9/11 and cancer.
Understanding the distribution, abundance and habitat preferences of species in the Southern Ocean provides a foundation for assessing the impacts of environmental change and anthropogenic disturbance on Antarctic ecosystems. In near-shore waters at Casey and Davis Stations, photoquadrat surveys were used to determine sea anemone distribution and abundance, habitat preferences, associations with other species and the impact of human disturbance on sea anemone distribution. Two distinct sea anemone morphotypes were found in this study: large sea anemones that require hard substrate for attachment and small, burrowing sea anemones found in muddy sediment. The large sea anemones were found in rocky habitats, with the exception of some sedimentary habitats where other biota were used as substrate. The large sea anemones were associated with a diverse community of epibenthic species found in rocky habitats. The burrowing sea anemones were associated with a less diverse assemblage of sediment-dwelling epibenthos. At Casey Station, sea anemones were more abundant in habitats adjacent to a former waste disposal site than at control sites. The reason for this is not yet known, but may be due to high organic matter inputs or, alternatively, a longer sea ice duration providing protection from ice scour.