Health care policy analysis of Medicaid's early and periodic screening, diagnosis, and treatment (EPSDT) benefit in Colorado

The purpose of this thesis is to identify "best practice" recommendations for successful implementation of the EPSDT outreach program at Memorial Health System's Hospital for Children in Colorado Springs through a policy analysis of Medicaid EPSDT services in Colorado. A successful program at Memorial will increase education and awareness of EPSDT services, enrollment, and access to and utilization of health care services for eligible children. Methodology utilized in this study included questionnaires designed for the EPSDT contract administrator and outreach coordinators/workers; analysis of current federal and state policies; and studies conducted at the federal and state level, and by various advocacy groups. The need for this analysis of EPSDT came about in part through an awareness of increasingly high numbers of children in poverty and who are uninsured. Though the percentage of children living in poverty in Colorado is slightly below the national average (see Table 2), according to data analyzed by The Annie E. Casey Foundation, the percentage of children (0-18) living in poverty in Colorado increased from 10% in 2000 to 16% in 2006, a dramatic increase of 60% surpassed by only one other state in the nation (The Annie E. Casey Foundation, 2008). By comparison, the U.S. percentage of children in poverty during the same time frame rose from 17% to 18% (The Annie E. Casey Foundation, 2008). What kind of health care services are available to this vulnerable and growing group of Coloradans, and what are the barriers that affect their enrollment in, access to and utilization of these health care services? Barriers identified included difficulty with the application process; system and process issues; a lack of providers; and a lack of awareness and knowledge of EPSDT. Fiscal restraints and legislation at the federal and state level are also barriers to increasing enrollment and access to services. Outreach services are a critical component of providing EPSDT services, and there were several recommendations regarding outreach and case management that will benefit the program in the future. Through this analysis and identification of a broad range of barriers, a clearer picture emerged of current challenges within the EPSDT program as well as a broad range of strategies and recommendations to address these challenges. Through increased education and advocacy for EPSDT and the services it encompasses; stronger collaboration and cooperation between all groups involved, including providing a Medical Home for all eligible children; and new legislation putting more money and focus on comprehensive health care for low-income uninsured children; enrollment, access to and utilization of developmentally appropriate and quality health care services can be achieved. ^

Molecular and genetic analysis of Myxococcus xanthus early *development

To identify more mutations that can affect the early development of Myxococcus xanthus, the synthetic transposon TnT41 was designed and constructed. By virtue of its special features, it can greatly facilitate the processes of mutation screening/selection, mapping, cloning and DNA sequencing. In addition, it allows for the systematic discovery of genes in regulatory hierarchies using their target promoters. In this study, the minimal regulatory region of the early developmentally regulated gene 4521 was used as a reporter in the TnT41 mutagenesis. Both positive (P) mutations and negative (N) mutations were isolated based on their effects on 4521 expression.^ Four of these mutations, i.e. N1, N2, P52 and P54 were analyzed in detail. Mutations N1 and N2 are insertion mutations in a gene designated sasB. The sasB gene is also identified in this study by genetic and molecular analysis of five UV-generated 4521 suppressor mutations. The sasB gene encodes a protein without meaningful homology in the databases. The sasB gene negatively regulates 4521 expression possibly through the SasS-SasR two component system. A wild-type sasB gene is required for normal M. xanthus fruiting body formation and sporulation.^ Cloning and sequencing analysis of the P52 mutation led to the identification of an operon that encodes the M. xanthus high-affinity branched-chain amino acid transporter system. This liv operon consists of five genes designated livK, livH, livM, livC, and livF, respectively. The Liv proteins are highly similar to their counterparts from other bacteria in both amino acid sequences, functional motifs and predicted secondary structures. This system is required for development since liv null mutations cause abnormality in fruiting body formation and a 100-fold decrease in sporulation efficiency.^ Mutation P54 is a TnT41 insertion in the sscM gene of the ssc chemotaxis system, which has been independently identified by Dr. Shi's lab. The sscM gene encodes a MCP (methyl-accepting chemotaxis protein) homologue. The SscM protein is predicted to contain two transmembrane domains, a signaling domain and at least one putative methylation site. Null mutations of this gene abolish the aggregation of starving cells at a very early stage, though the sporulation levels of the mutant can reach 10% that of wild-type cells. ^

Magnetic susceptibility dataset from the early Givetian to early Frasnian in the La Thure section

Recent advances in radiometric dating result in significant improvements in the geological timescale and provide better insight into the timing of various processes and evolutions within the Earth's system. However, no radiometric ages are contained within the Givetian. Consequently, the absolute ages of the Givetian Stage boundaries, as well as the stage's duration, remain poorly constrained. As an alternative, the analysis of sedimentary cycles allows for the estimation of the duration of this stage. We examined the high-resolution magnetic susceptibility signals of four Givetian outcrops in the Givet area for a possible astronomical imprint, to fully understand the rates of evolutionary and environmental change. All four sections are firmly correlated and wavelet analyses of the magnetic susceptibility signals reveal the imprint of astronomical eccentricity forcing. The highly stable 405 kyr cycles constrain the duration of the Givetian Stage at 4.35±0.45 Myr, which is in good agreement with the International Chronostratigraphic Chart (5.0 Myr). The studied sections also exhibit an imprint of obliquity, suggesting a climatic teleconnection between low and high latitudes. The corresponding microfacies curves demonstrate similar astronomical imprint, and thereby indicate that the observed 10**5 year-scale cyclicity is the result of climatic and environmental change.

Marine Isotope Stage (MIS) 11 results of model data with Community Climate System Model version 3 including the Dynamic Global Vegetation Model (CCSM3-DGVM) in NetCDF format at global and regional scale

The climate of Marine Isotope Stage (MIS) 11, the interglacial roughly 400,000 years ago, is investigated for four time slices, 416, 410, 400, and 394 ka. The overall picture is that MIS 11 was a relatively warm interglacial in comparison to preindustrial, with Northern Hemisphere (NH) summer temperatures early in MIS 11 (416-410 ka) warmer than preindustrial, though winters were cooler. Later in MIS 11, especially around 400 ka, conditions were cooler in the NH summer, mainly in the high latitudes. Climate changes simulated by the models were mainly driven by insolation changes, with the exception of two local feedbacks that amplify climate changes. Here, the NH high latitudes, where reductions in sea ice cover lead to a winter warming early in MIS 11, as well as the tropics, where monsoon changes lead to stronger climate variations than one would expect on the basis of latitudinal mean insolation change alone, are especially prominent. The results support a northward expansion of trees at the expense of grasses in the high northern latitudes early during MIS 11, especially in northern Asia and North America.

An early Eocene carbon cycle perturbation at in the Southern Alps

At least two transient events of extreme global warming occurred superimposed on the long-term latest Paleocene and early Eocene warming trend in the Paleocene-Eocene thermal maximum (PETM) (or ETM1 ~55.5 Ma) and the Elmo (or ETM2 ?53.6 Ma). Other than warmth, the best known PETM is characterized by (1) significant injection of 13C-depleted carbon into the ocean-atmosphere system, (2) deep-sea carbonate dissolution, (3) strong biotic responses, and (4) perturbations of the hydrological cycle. Documentation of the other documented and suspected "hyperthermals" is, as yet, insufficient to assess whether they are similar in nature to the PETM. Here we present and discuss biomagnetostratigraphic data and geochemical records across two lower Eocene successions deposited on a continental margin of the western Tethys: the Farra and Possagno sections in the Venetian pre-Alps. We recognize four negative carbon isotope excursions within chron C24. Three of these shifts correlate to known or suspected hyperthermals: the PETM, the Eocene thermal maximum 2 (~53.6 Ma), and the informally named "X event" (~52.5 Ma). The fourth excursion lies within a reverse subchron and occurred between the latter two. In the Farra section, the X event is marked by a ~0.6 per mil negative carbon isotope excursion and carbonate dissolution. Furthermore, the event exhibits responses among calcareous nannofossils, planktic foraminifera, and dinoflagellates that are similar to, though less intense than, those observed across the PETM. Sedimentological and quantitative micropaleontological data from the Farra section also suggest increased weathering and runoff as well as sea surface eutrophication during this event.

Early - Late Miocene palaeoclimate data and palaefloras of 48 samples from Southern China

Southern China, especially Yunnan, has undergone high tectonic activity caused by the uplift of Himalayan Mountains during the Neogene, which led to a fast changing palaeogeography. Previous study shows that Southern China has been influenced by the Asian Monsoon since at least the Early Miocene. However, it is yet not well understood how intense the Miocene monsoon system was. In the present study, 63 fossil floras of 16 localities from Southern China are compiled and evaluated for obtaining available information concerning floristic composition, stratigraphic age, sedimentology, etc. Based on such reliable information, selected mega- and micro-floras have been analysed with the coexistence approach to obtain quantitative palaeoclimate data. Visualization of climate results in maps shows a distinct spatial differentiation in Southern China during the Miocene. Higher seasonalities of temperature and precipitation occur in the north and south parts of Southern China, respectively. During the Miocene, most regions of Southern China and Europe were both warm and humid. Central Eurasia was likely to be an arid center, which gradually spread westward and eastward. Our data provide information about Miocene climate patterns in Southern China and about the evolution of these patterns throughout the Miocene, and is also crucial to unravel and understand the climatic signals of global cooling and tectonic uplift.

Cenozoic terrestrial palynomorphs from the late Oligocene to early Miocene section of sediment core CRP-2/2A (Table 1)

Sparse terrestrial palynomorphs (spores and pollen) were recovered from glacigene Lower Miocene and Oligocene core samples from the Cape Roberts Project (CRP) drillhole CRP-2/2A, Victoria Land Basin, Antarctica. Rarity of palynomorphs probably results from the spares periglacial vegetation in the surrounding landscape at the time of deposition, as well as dilution from rapid sediment accumulation. The Miocene and Late Oligocene vegetation is interpreted as including herb-moss tundra with low-growing woody plants (including Nothofagus and podocarp conifers) in more protected areas, similar to that encountered in the Miocene of CRP-1. Species richness and numbers of specimens increase downhole, a trend that begins very gradually below ~307 mbsf, and increases below ~443 mbsf through the Early Oligocene. These lower assemblages reflect low diversity woody vegetation dominated by several species of Nofhofagus and podocarps, growing in somewhat milder conditions, though still cold temperate to periglacial in the Early Oligocene. The CRP-2/2A core provides new biostratigraphical information, such as the First Appearance Datums (FADS) of Tricolpites sp. a near the Oligocene/Miocene boundary, and Marchantiaceae in the Early/Late Oligocene transition: these are taxa that along with N. lachlaniae, Coptospora spp. and Podocarpidites sp.b characterize assemblages recovered from outcrops of the Pliocene Sirius Group in the Transantarctic Mountains. Some elements of the extremely hardy periglacial tundra vegetation that survived in Antarctica into the Pliocene had their origin in the Oligocene during a time of deteriorating (colder, drier) climatic conditions. The CRP results highlight the long persistence of this tundra vegetation, through approximately 30 million years of dynamically changing climatic conditions. Rare Jurassic and more common Permian-Triassic spores and pollen occur sporadically throughout the core. These are derived from Jurassic Ferrar Group sediments, and from the Permian-Triassic Victoria Group, upper Beacon Supergroup. Higher frequencies of reworked Beacon palynomorphs and coaly organic matter below ~307 mbsf indicate greater erosion of the Beacon Supergroup for this lower part of the core. A color range from black, severely metamorphosed specimens, to light-colored, yellow (indicating low thermal alteration), reworked Permian palynomorphs, indicates local provenance in the dolerite-intruded Beacon strata of the Transantarctic Mountains, as well as areas (now sub-ice) of Beacon strata with little or no associated dolerite well inland (cratonwards) of the present Transantarctic Mountains.

Stable isotope record of Cibicidoides spp. from early and middle Miocene sediments

The middle Miocene delta18O increase represents a fundamental change in the ocean-atmosphere system which, like late Pleistocene climates, may be related to deepwater circulation patterns. There has been some debate concerning the early to early middle Miocene deepwater circulation patterns. Specifically, recent discussions have focused on the relative roles of Northern Component Water (NCW) production and warm, saline deep water originating in the eastern Tethys. Our time series and time slice reconstructions indicate that NCW and Tethyan outflow water, two relatively warm deepwater masses, were produced from ~20 to 16 Ma. NCW was produced again from 12.5 to 10.5 Ma. Another feature of the early and middle Miocene oceans was the presence of a high delta13C intermediate water mass in the southern hemisphere, which apparently originated in the Southern Ocean. Miocene climates appear to be related directly to deepwater circulation changes. Deep-waters warmed in the early Miocene by ~3°C (?20 to 16 Ma) and cooled by a similar amount during the middle Miocene delta18O increase (14.8 to 12.6 Ma), corresponding to the increase (?20 Ma) and subsequent decrease (~16 Ma) in the production of NCW and Tethyan outflow water. Large (>0.6 per mil), relatively rapid (~0.5 m.y.) delta18O increases in both benthic and planktonic foraminifera (i.e., the Mi zones of Miller et al. (1991a) and Wright and Miller (1992a)) were superimposed in the long-term deepwater temperature changes; they are interpreted as reflecting continental ice growth events. Seven of these m.y. glacial/interglacial cycles have been recognized in the early to middle Miocene. Two of these glacial/interglacial cycles (Mi3 and Mi4) combined with a 2° to 3°C decrease in deepwater temperatures to produce the middle Miocene delta18O shift.

Transient Holocene experiments under orbital forcing using the comprehensive global climate model CCSM3 (Community Climate System Model 3)

The Southern Hemisphere Westerly Winds (SWW) have been suggested to exert a critical influence on global climate through wind-driven upwelling of deep water in the Southern Ocean and the potentially resulting atmospheric CO2 variations. The investigation of the temporal and spatial evolution of the SWW along with forcings and feedbacks remains a significant challenge in climate research. In this study, the evolution of the SWW under orbital forcing from the early Holocene (9 kyr BP) to pre-industrial modern times is examined with transient experiments using the comprehensive coupled global climate model CCSM3. Analyses of the model results suggest that the annual and seasonal mean SWW were subject to an overall strengthening and poleward shifting trend during the course of the early-to-late Holocene under the influence of orbital forcing, except for the austral spring season, where the SWW exhibited an opposite trend of shifting towards the equator.

Effects of CO2-driven ocean acidification on early life stages of marine medaka (Oryzias melastigma)

The potential effects of elevated CO2 level and reduced carbonate saturation state in marine environment on fishes and other non-calcified organisms are still poorly known. In present study, we investigated the effects of ocean acidification on embryogenesis and organogenesis of newly hatched larvae of marine medaka (Oryzias melastigma) after 21 d exposure of eggs to different artificially acidified seawater (pH 7.6 and 7.2, respectively), and compared with those in control group (pH 8.2). Results showed that CO2-driven seawater acidification (pH 7.6 and 7.2) had no detectable effect on hatching time, hatching rate, and heart rate of embryos. However, the deformity rate of larvae in pH 7.2 treatment was significantly higher than that in control treatment. The left and right sagitta areas did not differ significantly from each other in each treatment. However, the mean sagitta area of larvae in pH 7.6 treatment was significantly smaller than that in the control (p = 0.024). These results suggest that although marine medaka might be more tolerant of elevated CO2 than some other fishes, the effect of elevated CO2 level on the calcification of otolith is likely to be the most susceptibly physiological process of pH regulation in early life stage of marine medaka.

Effects of ocean acidification caused by rising CO2 on the early development of three mollusks

Increasing atmospheric CO2 can decrease seawater pH and carbonate ions, which may adversely affect the larval survival of calcareous animals. In this study, we simulated future atmospheric CO2 concentrations (800, 1500, 2000 and 3000 ppm) and examined the effects of ocean acidification on the early development of 3 mollusks (the abalones Haliotis diversicolor and H. discus hannai and the oyster Crassostrea angulata). We showed that fertilization rate, hatching rate, larval shell length, trochophore development, veliger survival and metamorphosis all decreased significantly at different pCO2 levels (except oyster hatching). H. discus hannai were more tolerant of high CO2 compared to H. diversicolor. At 2000 ppm CO2, 79.2% of H. discus hannai veliger larvae developed normally, but only 13.3% of H. diversicolor veliger larvae. Tolerance of C. angulata to ocean acidification was greater than the 2 abalone species; 50.5% of its D-larvae developed normally at 3000 ppm CO2. This apparent resistance of C. angulata to ocean acidification may be attributed to their adaptability to estuarine environments. Mechanisms underlying the resistance to ocean acidification of both abalones requires further investigation. Our results suggest that ocean acidification may decrease the yield of these 3 economically important shellfish if increasing CO2 is a future trend.

Signals of resilience to ocean change: high thermal tolerance of early stage Antarctic sea urchins (Sterechinus neumayeri) reared under present-day and future pCO2 and temperature

We tested the hypothesis that development of the Antarctic urchin Sterechinus neumayeri under future ocean conditions of warming and acidification would incur physiological costs, reducing the tolerance of a secondary stressor. The aim of this study is twofold: (1) quantify current austral spring temperature and pH near sea urchin habitat at Cape Evans in McMurdo Sound, Antarctica and (2) spawn S. neumayeri in the laboratory and raise early developmental stages (EDSs) under ambient (-0.7 °C; 400 µatm pCO2) and future (+2.6 °C; 650 and 1,000 µatm pCO2) ocean conditions and expose four EDSs (blastula, gastrula, prism, and 4-arm echinopluteus) to a one hour acute heat stress and assess survivorship. Results of field data from 2011 to 2012 show extremely stable inter-annual pH conditions ranging from 7.99 to 8.08, suggesting that future ocean acidification will drastically alter the pH-seascape for S. neumayeri. In the laboratory, S. neumayeri EDSs appear to be tolerant of temperatures and pCO2 levels above their current habitat conditions. EDSs survived acute heat exposures >20 °C above habitat temperatures of -1.9 °C. No pCO2 effect was observed for EDSs reared at -0.7 °C. When reared at +2.6 °C, small but significant pCO2 effects were observed at the blastula and prism stage, suggesting that multiple stressors are more detrimental than single stressors. While surprisingly tolerant overall, blastulae were the most sensitive stage to ocean warming and acidification. We conclude that S. neumayeri may be unexpectedly physiologically tolerant of future ocean conditions.

Age determination of sediment cores of the California Current System

Alkenone sea surface temperature (SST) records were generated from the Ocean Drilling Program's (ODP) Sites 1014 and 1016 to examine the response of the California Current System to global climate change during the last 136 ka. The temperature differences between these sites (Delta SST(NEP)=SST(ODP1014)-SST(ODP1016)) reflected the intensity of the California Current and varied between 0.4 and 6.1 °C. A high Delta SST(NEP) (weaker California Current) was found for late marine isotope stage (MIS) 2 and early MIS 5e, while a low Delta SST(NEP) (stronger California Current) was detected for mid-MIS 5e and MIS 1. Spectral analysis indicated that this variation pattern dominated 23- (precession) and 30-ka periods. Comparison of the Delta SST(NEP) and SST based on data from core MD01-2421 at the Japan margin revealed anti-phase variation; the high Delta SST(NEP) (weakening of the California Current) corresponded to the low SST at the Japan margin (the southward displacement of the NW Pacific subarctic boundary), and vice versa. This variation was synchronous with a model prediction of the tropical El Niño-Southern Oscillation behavior. These findings suggest that the intensity of the North Pacific High varied in response to precessional forcing, and also that the response has been linked with the changes of tropical ocean-atmosphere interactions.

Seawater carbonate chemistry and early development of the sea urchin Lytechinus variegatus in a laboratory experiment using artificial seawater

Land-based aquaculture facilities often utilize additional bicarbonate sources such as commercial sea salts that are designed to boost alkalinity in order to buffer seawater against reductions in pH. Despite these preventative measures, many facilities are likely to face occasional reductions in pH and corresponding reductions in carbonate saturation states due to the accumulation of metabolic waste products. We investigated the impact of reduced carbonate saturation states (Omega Ca, Omega Ar) on embryonic developmental rates, larval developmental rates, and echinoplutei skeletal morphometrics in the common edible sea urchin Lytechinus variegatus under high alkalinity conditions. Commercial artificial seawater was bubbled with a mixture of air and CO2 gas to reduce the carbonate saturation state. Rates of embryonic and larval development were significantly delayed in both the low and extreme low carbonate saturation state groups relative to the control at a given time. Although symmetry of overall skeletal body lengths was not affected, allometric relationships were significantly different between treatment groups. Larvae reared under ambient conditions had significantly greater postoral arm and overall body lengths relative to body lengths than larvae grown under extreme low carbonate saturation state conditions, indicating that extreme changes in the carbonate system affected not only developmental rates but also larval skeletal shape. Reduced rates of embryonic development and delayed and altered larval skeletal growth are likely to negatively impact larval culturing of L. variegatus in land-based, intensive culture situations where calcite and aragonite saturation states are lowered by the accumulation of metabolic waste products.

Effects of seawater acidification on early development of the intertidal sea urchin Paracentrotus lividus, seawater carbonate chemistry and biological processes

The effect of pH ranging from 8.0 to 6.8 (total scale - pHT) on fertilization, cleavage and larval development until pluteus stage was assessed in an intertidal temperate sea urchin. Gametes were obtained from adults collected in two contrasting tide pools, one showing a significant nocturnal pH decrease (lowest pHT = 7.4) and another where pH was more stable (lowest pHT = 7.8). The highest pHT at which significant effects on fertilization and cleavage were recorded was 7.6. On the contrary, larval development was only affected below pHT 7.4, a value equal or lower than that reported for several subtidal species. This suggests that sea urchins inhabiting stressful intertidal environments produce offspring that may better resist future ocean acidification. Moreover, at pHT 7.4, the fertilization rate of gametes whose progenitors came from the tide pool with higher pH decrease was significantly higher, indicating a possible acclimatization or adaptation of gametes to pH stress.