Attributing inpatient care to diabetes: The case of Medicare for the elderly in Texas, 1995

Specific aims. This study estimated the accuracy of alternative numerator methods for attributing health care utilization and associated costs to diabetes by comparing findings from those methods with findings from a benchmark denominator method. ^ Methods. Using Medicare's 1995 inpatient and enrollment databases for the elderly in Texas, the researcher developed alternative estimates of costs attributable to diabetes. Among alternative numerator methods were selection of all records having diabetes as a principal or secondary diagnosis, and a complex ICD-9-CM sorting routine as previously developed for study of diabetes costs in Texas. Findings from numerator methods were compared with those from a benchmark denominator method based on attributable risk and adapted from a study of national diabetes costs by the American Diabetes Association. This study applied age, gender and ethnicity specific estimates of diabetes prevalence taken from the 1987–94 National Health Interview Surveys to person-months of Medicare Part A, non-HMO enrollment for Texas in 1995. Outcome measures were number of persons identified as having diabetes using alternative definitions of the disease; and number of hospital stays, patient days, and costs using alternative methods for attributing care and costs to diabetes. Cost estimates were based on Medicare payments plus deductibles, co-pays and third party payments. ^ Findings. Numerator methods for attributing costs to diabetes produced findings quite different than those from the benchmark denominator method. When attribution was based on diabetes as principal or secondary diagnosis, the resulting estimates were significantly higher than those obtained from the denominator method. The more complex sorting routine produced estimates near the lower boundary for the confidence interval associated with estimates from the benchmark method. ^ Conclusions. Numerator methods employed by previous researchers poorly estimate the costs of diabetes. While crude mathematical adjustment can be made to the respective numerator approaches, a more useful strategy would be to refine the complex sorting routine to include more hospitalizations. This report recommends approaches to improving methods previously employed in study of diabetes costs. ^

Positional candidate cloning of the RP10 form of retinitis pigmentosa

Retinitis pigmentosa (RP) is a genetically heterogeneous group of retinal degenerations that affects over one million people worldwide. To date, 11 autosomal dominant, 13 autosomal recessive, and 5 X-linked forms of retinitis pigmentosa have been identified through linkage analysis, but the disease-causing genes and mutations have been found for only half of these loci. My research uses a positional candidate cloning approach to identify the gene and mutations responsible for one type of autosomal dominant retinitis pigmentosa, RP10. The premise is that identifying the genes and mutations responsible for disease will provide insight into disease mechanisms and provide treatment options. Previous research mapped the RP10 locus to a 5cM region on chromosome 7q31 between markers D7S686 and D7S530. Linkage and fine-point haplotype analysis was used to reduce and refine the RP10 disease interval to a 4cM region located between D7S2471 and a new marker located 45,000bp telomeric of D7S461. In order to identify genes located in the RP10 interval, an extensive EST map was created of this region. Five EST clusters from this map were analyzed to determine if mutations in these genes cause the RP10 form of retinitis pigmentosa. The genomic structure of a known metabotrophic glutamate receptor, GRMS8, was determined first. DNA sequencing of GRM8 in RP10 family members did not identify any disease-causing mutations. Four other EST clusters (A170, A173, A189, and A258) were characterized and determined to be part of the same gene, UBNL1 (ubinuclein-like 1). The full-length mRNA sequence and genomic structure of UBNL1 was determined and then screened in patients. No disease-causing mutations were identified in any of the RP10 family members tested. Recent data made available with the release of the public and Celera genome assemblies indicates that UBNL1 is outside of the RP10 disease region. Despite this complication, characterization of UBNL1 is still important in the understanding of normal visual processes and it is possible that mutations in UBNL1 could cause other forms of retinopathy. The EST map and list of RP10 candidates will continue to aid others in the search for the RP10 gene and mutations. ^

Analysis of Synthetic Diamond Wafer Interferograms Using a Parallelized Simulated Annealing Algorithm

Diamonds are known for both their beauty and their durability. Jefferson National Lab in Newport News, VA has found a way to utilize the diamond's strength to view the beauty of the inside of the atomic nucleus with the hopes of finding exotic forms of matter. By firing very fast electrons at a diamond sheet no thicker than a human hair, high energy particles of light known as photons are produced with a high degree of polarization that can illuminate the constituents of the nucleus known as quarks. The University of Connecticut Nuclear Physics group has responsibility for crafting these extremely thin, high quality diamond wafers. These wafers must be cut from larger stones that are about the size of a human finger, and then carefully machined down to the final thickness. The thinning of these diamonds is extremely challenging, as the diamond's greatest strength also becomes its greatest weakness. The Connecticut Nuclear Physics group has developed a novel technique to assist industrial partners in assessing the quality of the final machining steps, using a technique based on laser interferometry. The images of the diamond surface produced by the interferometer encode the thickness and shape of the diamond surface in a complex way that requires detailed analysis to extract. We have developed a novel software application to analyze these images based on the method of simulated annealing. Being able to image the surface of these diamonds without requiring costly X-ray diffraction measurements allows rapid feedback to the industrial partners as they refine their thinning techniques. Thus, by utilizing a material found to be beautiful by many, the beauty of nature can be brought more clearly into view.

The meaning of informal BMT caregiving

Objectives. The aims of this qualitative descriptive exploratory study were to (1) describe informal caregiver commitment in informal caregiving; (2) describe caregiver expectations in informal caregiving; (3) describe caregiver role negotiation in informal caregiving, (4) identify other important caregiver energy sources; and (5) refine the conceptual model of Informal Caregiving Dynamics based on the study results. ^ Methods. Participants were 40 informal caregivers of blood and marrow transplant patients being treated at a comprehensive cancer center who told their caregiving stories in an audiotaped dialogue. Patients consented to have their caregivers contacted about the study and to have information collected from their medical records. To address the specific aims, the dialogues were analyzed for major elements and themes with an adaptation of the descriptive exploratory method. ^ Findings. Commitment was redefined as enduring caregiver responsibility that inspires life changes to make the patient a priority. Commitment calls caregivers to supportive presence and self-affirming loving connection with the patient. Expectation management was defined as envisioning the future and yearning to return to normal. Expectation management includes taking one day at a time, gauging behavior from past experiences with the patient, and reconciling anticipated to actual treatment twists and turns. Role negotiation was defined as appropriate pushing by the caregiver toward patient recovery and independence after getting a handle on complex care that demands shared responsibilities. Role negotiation happens as caregivers determine action with attention to patient voice and vigilantly bridge communication between patients and the health care system. Three additional energy sources of caring for self, gaining insight, and connecting with others, were identified and added to the model as underpinnings for commitment, expectation, and role negotiation respectively. ^ Discussion and implications. Methods of supporting informal caregivers that deserve investigation include consistent acknowledgment of caregiver contribution to patient care; provision of clear, present-focused information; opportunities to reconcile expectations with outcomes by developing a coherent caregiving story; and encouragement to maintain good health habits while caregiving. Patient contribution to the dynamics of caregiving warrants future research attention as does change in energy sources over time as a caregiver. ^

Organization of the inferotemporal cortex in the macaque monkey: Connections of areas PITv and CITvp

Visual cortex of macaque monkeys consists of a large number of cortical areas that span the occipital, parietal, temporal, and frontal lobes and occupy more than half of cortical surface. Although considerable progress has been made in understanding the contributions of many occipital areas to visual perceptual processing, much less is known concerning the specific functional contributions of higher areas in the temporal and frontal lobes. Previous behavioral and electrophysiological investigations have demonstrated that the inferotemporal cortex (IT) is essential to the animal's ability to recognize and remember visual objects. While it is generally recognized that IT consists of a number of anatomically and functionally distinct visual-processing areas, there remains considerable controversy concerning the precise number, size, and location of these areas. Therefore, the precise delineation of the cortical subdivisions of inferotemporal cortex is critical for any significant progress in the understanding of the specific contributions of inferotemporal areas to visual processing. In this study, anterograde and/or retrograde neuroanatomical tracers were injected into two visual areas in the ventral posterior and central portions of IT (areas PITv and CITvp) to elucidate the corticocortical connections of these areas with well known areas of occipital cortex and with less well understood regions of inferotemporal cortex. The locations of injection sites and the delineation of the borders of many occipital areas were aided by the pattern of interhemispheric connections, revealed following callosal transection and subsequent labeling with HRP. The resultant patterns of connections were represented on two-dimensional computational (CARET) and manual cortical maps and the laminar characteristics and density of the projection fields were quantified. The laminar and density features of these corticocortical connections demonstrate thirteen anatomically distinct subdivisions or areas distributed within the superior temporal sulcus and across the inferotemporal gyrus. These results serve to refine previous descriptions of inferotemporal areas, validate recently identified areas, and provide a new description of the hierarchical relationships among occipitotemporal cortical areas in macaques. ^

Characterization of the East Houston particulate matter <2.5 atmosphere; a novel method for desorbing organic constituents from airborne particulates

I have developed a novel approach to test for toxic organic substances adsorbed onto ultra fine particulate particles present in the ambient air in Northeast Houston, Texas. These particles are predominantly carbon soot with an aerodynamic diameter (AD) of <2.5 μm. If present in the ambient air, many of the organic substances will be absorbed to the surface of the particles (which act just like a charcoal air filter), and may be adducted into the respiratory system. Once imbedded into the lungs these particles may release the adsorbed toxic organic substances with serious health consequences. I used a Airmetrics portable Minivol air sampler time drawing the ambient air through collection filters samples from 6 separate sites in Northeast Houston, an area known for high ambient PM 2.5 released from chemical plants and other sources (e.g. vehicle emissions).(1) In practice, the mass of the collected particles were much less than the mass of the filters. My technique was designed to release the adsorbed organic substances on the fine carbon particles by heating the filter samples that included the PM 2.5 particles prior to identification by gas chromatography/mass spectrometry (GCMS). The results showed negligible amounts of target chemicals from the collection filters. However, the filters alone released organic substances and GCMS could not distinguish between the organic substances released from the soot particles from those released from the heated filter fabric. However, an efficacy tests of my method using two wax burning candles that released soot revealed high levels of benzene. This suggests that my method has the potential to reveal the organic substances adsorbed onto the PM 2.5 for analysis. In order to achieve this goal, I must refine the particle collection process which would be independent of the filters; the filters upon heating also release organic substances obscuring the contribution from the soot particles. To obtain pure soot particles I will have to filter more air so that the soot particles can be shaken off the filters and then analyzed by my new technique. ^

The effect of yoga on cardiovascular health as measured by heart rate variability in a sample of breast cancer patients

The study is a three-armed randomized controlled trial comparing values for heart rate variability (HRV), a measure of cardiovascular health, throughout a yoga intervention of breast cancer patients undergoing radiotherapy. Patients attended either a yoga (n=45), stretch, (n=46), or control (n=42) condition 3 times per week for 6 weeks of radiation. Electrocardiograms (ECGs) were conducted on each participant to provide the values necessary for HRV analysis. Analyses focused on examining scores for those participants with HRV baseline values considered to be below the cutoff point for healthy HRV levels, defined by the authors as below the cutpoint of 68 ms. From the entire sample of 133 with available baselines, 26 yogis, 26 stretchers, and 23 controls were determined to be “pathologic” in terms of HRV, and selected for follow-up analysis at 3 weeks and then again at 6 weeks. Though no statistically significant differences were found between either group means at each timepoint or group change score means, the yoga group had consistently higher mean score and mean change scores. These findings are suggestive and indicate the need to refine the use of ECGs and HRV analysis programs to more accurately and comprehensively assess the effects of yoga on cardiovascular health in cancer patients.^

Pediatric obesity: Managed care collaborating with providers to improve diagnosis and treatment

Child overweight and obesity reaches across ethnic, cultural, socioeconomic and regional barriers. It must be assessed, diagnosed and treated to help families make sustainable behavior changes. Treatment recommendations have been made to address pediatric overweight and obesity. They include screening for risk factors, monitoring BMI trends and educating patients and families to make small sustainable changes. Health insurance companies can play a meaningful role in supporting and facilitating provider education and behavior change to diagnose, treat and prevent pediatric overweight and obesity.^ The aims of this thesis were: (1) Describe a disease management program that uses evidence-based practices to create provider behavior change related to pediatric obesity screening, diagnosis and treatment. (2) Identify ways to improve the implementation of the program based on the perceptions of participating clinicians.^ A literature review was completed to evaluate current recommendations for screening and treating pediatric obesity using the Ovid data base. The evidenced-based recommendations were compared against the practices of the Healthy Lifestyles Program (HeLP). The literature confirmed that HeLP is following evidence-based recommendations for assessment, diagnosis and treatment of pediatric obesity.^ A Children’s Mercy Family Health Partners focus group was convened to create a provider survey. The goals of the survey were to assess providers’ perception of the Healthy Lifestyles Program (HeLP). The survey was sent out through email using Survey Monkey. All survey responses were anonymous. The survey was sent to a total of 80 providers who had completed HeLP. Twenty-five percent responded. The survey results were evaluated to make recommendations for HeLP.^ Results of the survey included motivating factors for participation in HeLP. Concern about the increasing prevalence of pediatric obesity was a frequent motivator for participation. Provider barriers to obesity diagnosis were evaluated. Lack of time during clinic visits a frequent barrier to obesity diagnosis. ^ In conclusion several recommendations for the HeLP were made based on survey results. It is recommended that the program evaluate methods and tools for facilitating effective weight management follow up visits. Promotional materials should highlight the increasing prevalence of pediatric obesity when advertising HeLP. These recommendations will be used to refine the current Healthy Lifestyles Program.^

Adherence to HIV /AIDS therapies among low -literacy populations: The ALP project

Adherence to HIV/AIDS therapies has been an important health problem since the early 1980s when AZT was first prescribed as a therapy for HIV/AIDS. It became particularly important between 1995 and 1997 with the advent of protease inhibitors (Chesney, Ickovics, Hecht, Sikipa, & Rabkin J., 1999) and became even more significant as persons with HIV/AIDS began to develop resistance to medications. Low-literacy populations have poorer health (Brez & Taylor, 1997) and higher AIDS rates (Simon, Hu, Diaz, & Kerndt, 1995), than their higher literacy counterparts due to delayed treatment (Baker, Parker, Williams, Clark, & Nurss, 1997), shame of literacy skills (Parikh, 1996), and poor access to care (Williams, et al., 1995). Poorer health and higher AIDS rates can also be attributed to poor patient-provider relationships (Crespo-Fierro, 1997; Eldred, Wu, Chaisson, & Moore, 1998) to a poorer understanding of medical protocols (Murphy, 1997), and inadequate patient education (Ungvarski, 1997; Davis, Michielutte, Askov, Williams, & Weiss, 1998, Doak, Doak, & Root, 1996). ^ The ALP intervention was developed for HIV positive low-literacy populations of African American women in Houston, Texas. The intervention was based on a needs assessment, using the PRECEDE model, an innovative process referred to as Intervention Mapping, and validated using formative evaluation methods with 54 individuals. The needs assessment resulted in a list of behavioral, environmental, predisposing, enabling, and reinforcing determinants of adherence. The Intervention Mapping framework was used to refine these determinants and develop a list of objectives describing what must be learned or changed to for the target population to adhere to HIV/AIDS therapies. Methods and strategies, were developed using theoretical constructs from the Health Belief Model (Rosenstock, 1974) and Social Cognitive Theory (Bandura, 1986). These theories, empirical evidence, and information from the target population indicated that perceived susceptibility, perceived severity, outcome expectations, and self-efficacy were important and changeable determinants of adherence to HIV/AIDS therapies for this population. ^ These components were brought together in the form of a theory-based color cartoon book and 10-minute cassette tape. The book was developed for people with 2.9 years of U.S. education as measured with the Flesch-Kincaid Grade Level method and the script was recorded onto a cassette tape to make it suitable for populations with even lower-literacy skills. A formative evaluation was conducted to ensure that the content and structure were accurate, clear, realistic, readable, appropriate, and likely to be used as intended. ^

Clay minerals in bottom sediments of the St. Anna Trough

This paper is devoted to studies of clay minerals from two cores collected in the northern and central regions of the St. Anna Trough, the largest trough of the Kara Sea. Upper Quaternary glacial, glaciomarine, and marine deposits are characterized by various contents of kaolinite, chlorite, illite, and smectite. It is established that, from older to younger deposits, amounts of kaolinite and chlorite generally decrease, while those of illite and smectite, on the contrary, increase. A joint analysis of distributions of clay and heavy minerals over the section allowed us to refine position of sources for terrigenous matter and their temporal variability. It is shown changes in sources of supply were directly related to climate changes that occurred when passing from glacial to marine sedimentation environments.

Upper Triassic nannofossils from Wombat Plateau, Northwest Australia

A taxonomic and biostratigraphic investigation has been carried out on Upper Triassic (Carnian-Rhaetian) nannofossils from Sites 759, 760, 761 and 764 drilled on the Wombat Plateau during ODP Leg 122. The recovery of continuous sequences containing well preserved nannofossils has enabled us to refine the previous taxonomy and biostratigraphy of this interval. Fossil assemblages are of two major types: (1) previously described calcareous taxa were recovered at Sites 761 and 764; and (2) sideritic forms, which may represent diagenetic replacement of calcareous nannofossils, were observed in material from Sites 759 and 760. The sideritic forms proved difficult to study taxonomically due to inadequate optical properties. Calcareous nannofossil assemblages in the Upper Triassic are dominated by Prinsiosphaera triassica. We show that the multitude of identities of this species in the light microscope are the result of selective etching on a layered structure. We propose an evolutionary lineage for the earliest known coccoliths, with Crucirhabdus primulus as the ancestor. This species gave rise to C. minutus and Archaeozygodiscus koessenensis. The Upper Triassic can be subdivided based on the sequential first occurrences of C. primulus and Eoconusphaera zlambachensis in the upper Norian. The late Norian and Rhaetian were times of slow evolution of calcareous nannofossils. However, we noted three morphometric changes in this time-interval which possess biostratigraphic utility: (1) P. triassica increases in diameter from an average of 6 µm to over 9 µm; (2) E. zlambachensis evolves from a stubby to an elongated shape; and (3) C. primulus increases in size. Upper Triassic assemblages from the Wombat Plateau are similar in composition and diversity to those which have been described in detail from the Alps. In both areas, nannofossiliferous sediments interfinger with massive limestones deposited in reef and peri-platform environments. Stable isotopic analyses of Wombat Plateau nannofossil assemblages indicate that they thrived in open ocean conditions. Biostratigraphy allows sequence chronostratigraphic interpretation of ODP Site 761 and supports the chronostratigraphic cycle charts of Haq et al. (1987).

Calcareous nannofossil bioevents of early-middle Pleistocene sediments from the Mediterranean Sea and the Noth Atlantic

Quantitative distributions of calcareous nannofossils are analysed in the early-middle Pleistocene at the small Gephyrocapsa and Pseudoemiliania lacunosa zone transition in deep-sea cores from the Mediterranean Sea and North Atlantic Ocean (Ocean Drilling Program [ODP] Sites 977, 964 and 967, Deep Sea Drilling Project [DSDP] Site 607). The temporal and spatial mode of occurrence of medium-sized gephyrocapsids and reticulofenestrids has been examined to refine biostratigraphic constraints and evaluate possible relationships of stratigraphic patterns to environmental changes during a period of global climatic deterioration. The timing of bioevents has been calibrated using high-resolution sampling and correlation to the delta18O record in chronologically well-constrained sections. Newly identified events and ecostratigraphical signals enhance the stratigraphic resolution at the early-middle Pleistocene. The first occurrence (FO) of intermediate morphotypes between Pseudoemiliania and Reticulofenestra (Reticulofenestra sp.) is proposed as a reliable event within marine isotope stage (MIS) 35 or at the MIS 35/34 transition. The distribution of Reticulofenestra asanoi is characterized by rare and scattered occurrences in its lowest range, but the first common occurrence (FCO) is consistently identified at MIS 32 or 32/31; the last common occurrence (LCO) of the species is a distinctive event at MIS 23. In the studied interval, Gephyrocapsa omega dominates among medium-sized Gephyrocapsa. The FO of G. omega and contemporaneous re-entry of medium-sized gephyrocapsids at the lower-middle Pleistocene transition are diachronous between the Atlantic Ocean and Mediterranean Sea and from the western to eastern Mediterranean. In the Mediterranean, the LO of G. omega falls at MIS 15, insolation cycle 54 and is isochronous among the sites. Abundance fluctuations of G. omega show notable relations to early-middle Pleistocene climate changes; they considerably increase in abundance at the interglacial stages, suggesting warm water preferences. Gephyrocapsa omega temporarily disappears during the glacial MIS 22 and MIS 20. Above MIS 20, an impoverishment in G. omega and in the total abundance of medium-sized gephyrocapsids occurs. A decrease in abundance of G. omega is observed between the western Site 977 and the easternmost Site 967 in the Mediterranean Sea, as a possible response to high salinity and/or low nutrient content. Possible environmental influences on the distribution of R. asanoi and of Reticulofenestra sp. are discussed.

Magnetostratigraphic age-depth tie points of ODP Leg 208 sites

We report the paleomagnetic and rock magnetic results from discrete sample analysis of sediments from Walvis Ridge, Leg 208 of the Ocean Drilling Program. In an effort to refine the shipboard magnetostratigraphy, alternating field and thermal demagnetization of discrete samples were carried out, predominantly on samples from Sites 1262 and 1267. Results are generally consistent with the shipboard pass-through cryomagnetometer data, though in some cases the discrete samples resolved ambiguities in the reversal record. Significantly, the C24r/C24n reversal boundary was identified at Sites 1262 and 1267, and most boundaries in the Paleocene and Upper Cretaceous sections are now identified to within 10-30 cm. Magnetic mineralogy results show that prior to the late Miocene, the predominant detrital magnetic component was coarse-grained magnetite and that after the late Miocene, titanomagnetite has also been present. This suggests a possible change in detrital source at that time.

Poéticas de la hipérbole : Las obras de Angélica Gorodischer y Tununa Mercado

La tesis se propone, mediante eI despliegue de una argumentación desde distintos enfoques teórico-metodológicos y núcleos de sentido dar cuenta del modo como las políticas de Angélica Gorodischer tanto como la de Tununa Mercado [ambas escritoras argentinas contemporáneas aun en ejercicio] plantean la similitud de la figura de la hipérbole, como figura retórica que refine sus gestos escriturarios, en una par aumento, en la otra par disminución. De este modo, se verifica que lo que en apariencia resalta como una forma de abigarramiento y profusión y otra, en cambio, escueta y lacónica, responden en definitiva a un mismo énfasis retórico de sus respectivas ficciones

Procesos de innovación agroalimentaria y demanda internacional de alimentos frescos. El sector empaque de cítricos en Entre Ríos

Las firmas agroindustriales exportadoras argentinas de productos en fresco están transitando por un proceso progresivo de modernización e implementación de normativas internacionales sobre calidad agroalimentaria. Desde esta perspectiva, el presente trabajo aporta algunos elementos de análisis que permiten profundizar en el conocimiento del eslabón de acondicionamiento/ empaque del complejo agroindustrial citrícola del noreste de la provincia de Entre Ríos, departamentos de Concordia y Federación, a partir de la segunda mitad de la década de los noventa, centrando la mirada en las empresas exportadoras y en las innovaciones que han implementado para ajustar los estándares de calidad.