Effect of primary care availability and health insurance coverage on risk and cost of Preventable Hospitalizations in Harris County

Preventable Hospitalizations (PHs) are hospitalizations that can be avoided with appropriate and timely care in the ambulatory setting and hence are closely associated with primary care access in a community. Increased primary care availability and health insurance coverage may increase primary care access, and consequently may be significantly associated with risks and costs of PHs. Objective. To estimate the risk and cost of preventable hospitalizations (PHs); to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs, first alone and then simultaneously; and finally, to estimate the impact of expansions in primary care availability and health insurance coverage on the burden of PHs among non-elderly adult residents of Harris County. Methods. The study population was residents of Harris County, age 18 to 64, who had at least one hospital discharge in a Texas hospital in 2008. The primary independent variables were availability of primary care physicians, availability of primary care safety net clinics and health insurance coverage. The primary dependent variables were PHs and associated hospitalization costs. The Texas Health Care Information Collection (THCIC) Inpatient Discharge data was used to obtain information on the number and costs of PHs in the study population. Risk of PHs in the study population, as well as average and total costs of PHs were calculated. Multivariable logistic regression models and two-step Heckman regression models with log-transformed costs were used to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs respectively, while controlling for individual predisposing, enabling and need characteristics. Predicted PH risk and cost were used to calculate the predicted burden of PHs in the study population and the impact of expansions in primary care availability and health insurance coverage on the predicted burden. Results. In 2008, hospitalized non-elderly adults in Harris County had 11,313 PHs and a corresponding PH risk of 8.02%. Congestive heart failure was the most common PH. PHs imposed a total economic burden of $84 billion at an average of $7,449 per PH. Higher primary care safety net availability was significantly associated with the lower risk of PHs in the final risk model, but only in the uninsured. A unit increase in safety net availability led to a 23% decline in PH odds in the uninsured, compared to only a 4% decline in the insured. Higher primary care physician availability was associated with increased PH costs in the final cost model (β=0.0020; p<0.05). Lack of health insurance coverage increased the risk of PH, with the uninsured having 30% higher odds of PHs (OR=1.299; p<0.05), but reduced the cost of a PH by 7% (β=-0.0668; p<0.05). Expansions in primary care availability and health insurance coverage were associated with a reduction of about $1.6 million in PH burden at the highest level of expansion. Conclusions. Availability of primary care resources and health insurance coverage in hospitalized non-elderly adults in Harris County are significantly associated with the risk and costs of PHs. Expansions in these primary care access factors can be expected to produce significant reductions in the burden of PHs in Harris County.^

Assessing how middle school students' nutrient intake varies based on the availability of a la carte offerings at lunch

Purpose: School districts in the U.S. regularly offer foods that compete with the USDA reimbursable meal, known as `a la carte' foods. These foods must adhere to state nutritional regulations; however, the implementation of these regulations often differs across districts. The purpose of this study is to compare two methods of offering a la carte foods on student's lunch intake: 1) an extensive a la carte program in which schools have a separate area for a la carte food sales, that includes non-reimbursable entrees; and 2) a moderate a la carte program, which offers the sale of a la carte foods on the same serving line with reimbursable meals. ^ Methods: Direct observation was used to assess children's lunch consumption in six schools, across two districts in Central Texas (n=373 observations). Schools were matched on socioeconomic status. Data collectors were randomly assigned to students, and recorded foods obtained, foods consumed, source of food, gender, grade, and ethnicity. Observations were entered into a nutrient database program, FIAS Millennium Edition, to obtain nutritional information. Differences in energy and nutrient intake across lunch sources and districts were assessed using ANOVA and independent t-tests. A linear regression model was applied to control for potential confounders. ^ Results: Students at schools with extensive a la carte programs consumed significantly more calories, carbohydrates, total fat, saturated fat, calcium, and sodium compared to students in schools with moderate a la carte offerings (p<.05). Students in the extensive a la carte program consumed approximately 94 calories more than students in the moderate a la carte program. There was no significant difference in the energy consumption in students who consumed any amount of a la carte compared to students who consumed none. In both districts, students who consumed a la carte offerings were more likely to consume sugar-sweetened beverages, sweets, chips, and pizza compared to students who consumed no a la carte foods. ^ Conclusion: The amount, type and method of offering a la carte foods can significantly affect student dietary intake. This pilot study indicates that when a la carte foods are more available, students consume more calories. Findings underscore the need for further investigation on how availability of a la carte foods affects children's diets. Guidelines for school a la carte offerings should be maximized to encourage the consumption of healthful foods and appropriate energy intake.^

The impact of parent acculturation on parental fruit and vegetable intake, child fruit and vegetable intake, and child perceived access and availability to fruits and vegetables in the home environment

The purpose of this thesis was to investigate the association between parent acculturation and parental fruit and vegetable intake, child fruit and vegetable intake, and child access and availability to fruits and vegetables. Secondary data analysis was performed on a convenience sample of low-income Hispanic-identifying parents (n = 177) and children from a baseline survey from the Sprouting Healthy Kids intervention. T tests were used to examine the association between parent acculturation status (acculturated or non-acculturated) and fruit intake, vegetable intake and combined fruit and vegetable intake of both the parent and the child. T tests were also used to determine the relationship between parent acculturation and child access and availability to fruits, vegetables, and combined fruits and vegetables. Statistical significance was set at a p level of 0.05. The mean FVI for the parents and children were 3.41 servings and 2.96 servings, respectively. Statistical significance was found for the relationships between parent acculturation and parent fruit intake and parent acculturation and child fruit access. Lower acculturation of the parent was significantly related to higher fruit intake. Counter to the hypothesis, higher acculturation was found to be associated with greater access to fruits for the child. These findings suggest the necessity for not only culturally specific nutrition interventions, but the need for interventions to target behaviors for specific levels of acculturation within a culture. ^

Increased carbon dioxide availability alters phytoplankton stoichiometry and affects carbon cycling and growth of a marine planktonic herbivore

Rising levels of CO2 in the atmosphere have led to increased CO2 concentrations in the oceans. This enhanced carbon availability to the marine primary producers has the potential to change their nutrient stoichiometry, and higher carbon to nutrient ratios are expected. As a result, the quality of the primary producers as food for herbivores may change. Here, we present experimental work showing the effect of feeding Rhodomonas salina grown under different pCO2 (200, 400 and 800 µatm) on the copepod Acartia tonsa. The rate of development of copepodites decreased with increasing CO2 availability to the algae. The surplus carbon in the algae was excreted by the copepods, with younger stages (copepodites) excreting most of their surplus carbon through respiration, and adult copepods excreting surplus carbon mostly as DOC. We consider the possible consequences of different excretory pathways for the ecosystem. A continued increase in the CO2 availability for primary production, together with changes in the nutrient loading of coastal ecosystems, may cause changes in the trophic links between primary producers and herbivores.

Light availability determines susceptibility of reef building corals to ocean acidification

Elevated seawater pCO2, and in turn ocean acidification (OA), is now widely acknowledged to reduce calcification and growth of reef building corals. As with other environmental factors (e.g., temperature and nutrients), light availability fundamentally regulates calcification and is predicted to change for future reef environments alongside elevated pCO2 via altered physical processes (e.g., sea level rise and turbidity); however, any potential role of light in regulating the OA-induced reduction of calcification is still unknown. We employed a multifactorial growth experiment to determine how light intensity and pCO2 together modify calcification for model coral species from two key genera, Acropora horrida and Porites cylindrica, occupying similar ecological niches but with different physiologies. We show that elevated pCO2 (OA)-induced losses of calcification in the light (G L) but not darkness (G D) were greatest under low-light growth conditions, in particular for A. horrida. High-light growth conditions therefore dampened the impact of OA upon G L but not G D. Gross photosynthesis (P G) responded in a reciprocal manner to G L suggesting OA-relieved pCO2 limitation of P G under high-light growth conditions to effectively enhance G L. A multivariate analysis of past OA experiments was used to evaluate whether our test species responses were more widely applicable across their respective genera. Indeed, the light intensity for growth was identified as a significant factor influencing the OA-induced decline of calcification for species of Acropora but not Porites. Whereas low-light conditions can provide a refuge for hard corals from thermal and light stress, our study suggests that lower light availability will potentially increase the susceptibility of key coral species to OA.

Comparative responses of two dominant Antarctic phytoplankton taxa to interactions between ocean acidification, warming, irradiance, and iron availability

We investigated the responses of the ecologically dominant Antarctic phytoplankton species Phaeocystis antarctica (a prymnesiophyte) and Fragilariopsis cylindrus (a diatom) to a clustered matrix of three global change variables (CO2, mixed-layer depth, and temperature) under both iron (Fe)-replete and Fe-limited conditions based roughly on the Intergovernmental Panel on Climate Change (IPCC) A2 scenario: (1) Current conditions, 39 Pa (380 ppmv) CO2, 50 µmol photons/m**2/s light, and 2°C; (2) Year 2060, 61 Pa (600 ppmv) CO2, 100 µmol photons/m**2/s light, and 4°C; (3) Year 2100, 81 Pa (800 ppmv) CO2, 150 µmol photons/m**2/s light, and 6°C. The combined interactive effects of these global change variables and changing Fe availability on growth, primary production, and cell morphology are species specific. A competition experiment suggested that future conditions could lead to a shift away from P. antarctica and toward diatoms such as F. cylindrus. Along with decreases in diatom cell size and shifts from prymnesiophyte colonies to single cells under the future scenario, this could potentially lead to decreased carbon export to the deep ocean. Fe : C uptake ratios of both species increased under future conditions, suggesting phytoplankton of the Southern Ocean will increase their Fe requirements relative to carbon fixation. The interactive effects of Fe, light, CO2, and temperature on Antarctic phytoplankton need to be considered when predicting the future responses of biology and biogeochemistry in this region.

Brown trout redd superimposition in relation to spawning habitat availability

The relationship between redd superimposition and spawning habitat availability was investigated in the brown trout (Salmo trutta L.) population inhabiting the river Castril (Granada, Spain). Redd surveys were conducted in 24 river sections to estimate the rate of redd superimposition. Used and available microhabitat was evaluated to compute the suitable spawning habitat (SSH) for brown trout. After analysing the microhabitat characteristics positively selected by females, SSH was defined as an area that met all the following five requirements: water depth between 10 and 50 cm, mean water velocity between 30 and 60 cm s)1, bottom water velocity between 15 and 60 cm s)1, substrate size between 4 and 30 mm and no embeddedness. Simple regression analyses showed that redd superimposition was not correlated with redd numbers, SSH or redd density. A simulation-based analysis was performed to estimate the superimposition rate if redds were randomly placed inside the SSH. This analysis revealed that the observed superimposition rate was higher than expected in 23 of 24 instances, this difference being significant (P menor que 0.05) in eight instances and right at the limit of statistical significance (P = 0.05) in another eight instances. Redd superimposition was high in sections with high redd density. High superimposition however was not exclusive to sections with high redd density and was found in moderate- and low-redd-density sections. This suggests that factors other than habitat availability are also responsible for redd superimposition. We argue that female preference for spawning over previously excavated redds may be the most likely explanation for high superimposition at lower densities.

Food availability and predation risk, rather than intrinsic attributes are the main factors shaping the reproductive decisions of a long-lived predator

Funded by Natural Research Limited Natural Environment Research Council studentship. Grant Numbers: NE/J500148/1, NE/F021402/1

Carbohydrate-deficient glycoprotein syndrome type V: Deficiency of dolichyl-P-Glc:Man9GlcNAc2-PP-dolichyl glucosyltransferase

Deficiency of dolichyl-P-Glc:Man9GlcNAc2-PP-dolichyl glucosyltransferase is the cause of an additional type of carbohydrate-deficient glycoprotein syndrome (CDGS type V). Clinically this type resembles the classical type Ia of CDGS caused by the deficiency of phosphomannomutase. As a result of the glucosyltransferase deficiency in CDGS type V nonglucosylated lipid-linked oligosaccharides accumulate. The defect is leaky and glucosylated oligosaccharides are found on nascent glycoproteins. The limited availability of glucosylated lipid-linked oligosaccharides explains the incomplete usage of N-glycosylation sites in glycoproteins. This finding is reflected in the presence of transferrin forms in serum that lack one or both of the two N-linked oligosaccharides and the reduction of mannose incorporation to about one-third of control in glycoproteins of fibroblasts.

Transcriptional profiles of Haloferax mediterranei based on nitrogen availability

The haloarchaeon Haloferax mediterranei is able to grow in the presence of different inorganic and organic nitrogen sources by means of the assimilatory pathway under aerobic conditions. In order to identify genes of potential importance in nitrogen metabolism and its regulation in the halophilic microorganism, we have analysed its global gene expression in three culture media with different nitrogen sources: (a) cells were grown stationary and exponentially in ammonium, (b) cells were grown exponentially in nitrate, and (c) cells were shifted to nitrogen starvation conditions. The main differences in the transcriptional profiles have been identified between the cultures with ammonium as nitrogen source and the cultures with nitrate or nitrogen starvation, supporting previous results which indicate the absence of ammonium as the factor responsible for the expression of genes involved in nitrate assimilation pathway. The results have also permitted the identification of transcriptional regulators and changes in metabolic pathways related to the catabolism and anabolism of amino acids or nucleotides. The microarray data was validated by real-time quantitative PCR on 4 selected genes involved in nitrogen metabolism. This work represents the first transcriptional profiles study related to nitrogen assimilation metabolism in extreme halophilic microorganisms using microarray technology.

Strumenti e metodi per il miglioramento delle performance: il pilastro TPM del Focus Improvement. Il caso Philip Morris Manufacturing & Technology Bologna S.p.A.

Le peculiarità del contesto competitivo attuale richiedono alle aziende di muoversi con la massima velocità per rispondere il più rapidamente possibile al soddisfacimento delle richieste dei clienti. La ricerca di massima flessibilità non può prescindere dall’esigenza di mantenere alti livelli di efficienza produttiva e di tendere ad un continuo miglioramento dei flussi interni. L’elaborato ripercorre i passaggi fondamentali di un progetto di miglioramento delle performance di un impianto svolto nel primo semestre 2016 presso Philip Morris Manufacturing & Technology Bologna S.p.A. La metodologia utilizzata riprende strumenti, modelli e metodi dai principi alla base del Focus Improvement, primo pilastro del tempio della Total Productive Maintenance. Attraverso l’applicazione sistematica di tecniche tipiche del problem solving (ciclo di Deming) e di approcci analitici per la determinazione delle cause di guasto (curva di Pareto, Diagramma di Ishikawa), è stato possibile identificare i principali tipi di perdite (tempo, performance, difetti qualitativi) di una macchina industriale e mettere in atto gli interventi migliorativi necessari. L’analisi si conclude con la valutazione dei futuri sviluppi dello scenario, proponendo diverse alternative a seconda dell’abilità dell’organizzazione di sostenere i risultati raggiunti o addirittura di superarli.

Biological availability of pollutants to marine organisms /

Contract IAG-D-40541.