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AIMS Endothelial dysfunction (ED) and red blood cell distribution width (RDW) are both prognostic factors in heart failure (HF), but the relationship between them is not clear. In this study, we used a unique mouse model of chronic HF driven by cardiomyocyte-specific overexpression of activated Gαq protein (Tgαq*44 mice) to characterise the relationship between the development of peripheral ED and the occurrence of structural nanomechanical and biochemical changes in red blood cells (RBCs). METHODS AND RESULTS Systemic ED was detected in vivo in 8-month-old Tgαq*44 mice, as evidenced by impaired acetylcholine-induced vasodilation in the aorta and increased endothelial permeability in the brachiocephalic artery. ED in the aorta was associated with impaired nitric oxide (NO) production in the aorta and diminished systemic NO bioavailability. ED in the aorta was also characterised by increased superoxide and eicosanoid production. In 4- to 6-month-old Tgαq*44 mice, RBC size and membrane composition displayed alterations that did not result in significant changes in their nanomechanical and functional properties. However, 8-month-old Tgαq*44 mice presented greatly accentuated structural and size changes and increased RBC stiffness. In 12-month-old Tgαq*44 mice, the erythropathy was featured by severely altered RBC shape and elasticity, increased RDW, impaired RBC deformability, and increased oxidative stress (GSH/GSSH ratio). Moreover, RBCs taken from 12-month-old Tgαq*44 mice, but not from 12-month-old FVB mice, co-incubated with aortic rings from FVB mice, induced impaired endothelium-dependent vasodilation and this effect was partially reversed by an arginase inhibitor (ABH, 2(S)-amino-6-boronohexanoic acid). CONCLUSION In the Tgαq*44 murine model of HF, systemic endothelial dysfunction accelerates erythropathy and, conversely, erythropathy may contribute to endothelial dysfunction. These results suggest that erythropathy may be regarded as a marker and a mediator of systemic endothelial dysfunction in HF. In particular, targeting RBC arginase may represent a novel treatment strategy for systemic endothelial dysfunction in HF. RBC arginase and possibly other RBC-mediated mechanisms may represent novel therapeutic targets for systemic endothelial dysfunction in HF. TRANSLATIONAL PERSPECTIVE Endothelial dysfunction (ED) and red blood cell distribution width (RDW) both have prognostic value for heart failure (HF), but it is not known whether these pathologies are related. We comprehensively characterized endothelial and RBC functional status in a unique murine model of chronic heart failure with a prolonged time course of HF progression. Our results suggest that ED accelerates erythropathy and, conversely, erythropathy may contribute to ED. Accordingly, erythropathy in HF reflects ED and involves various changes (in functional, structural, nanomechanical, and biochemical levels) that could have diagnostic and therapeutic significance for HF.

Loss of function mutations in COQ4 lead to fatal neonatal mitochondrial disorders with CoQ10 deficiency. In two siblings with childhood-onset, slowly progressive ataxia from a consanguineous mating from Turkey, whole exome sequencing identified homozygous missense mutations in COQ4 (Gly55Val). Blood levels of CoQ10 were either below or at the low end of the normal range. The more severely affected of the siblings was given a high dose of CoQ10 (2000 mg/day) for one month, following which significant improvement in neurological signs and symptoms was noted. Our report indicates that COQ4 mutations are a rare cause of ataxia and that CoQ10 supplementation is a personalized treatment for this form of ataxia.

Background: The dialysis patient population in the United States continues to grow. Trends in rates of death and hospitalization among dialysis patients have important consequences for outpatient dialysis capacity and Medicare spending. Objectives: To estimate contemporary trends in rates of death and hospitalization among dialysis patients in the United States, overall and within subgroups. Methods: We used Medicare Limited Data Sets (100% sample) in 2014–2017 to estimate trends in rates of death and hospitalization among dialysis patients with Medicare Parts A and B enrollment. We used seasonal autoregressive integrated moving average models to identify secular trends in the incidence of outcomes. Results: There were 631,075 unique patients; 222,924 deaths; and 1,876,779 hospital admissions. Weekly risks of both death and hospitalization exhibited strong seasonality. However, overall weekly risks of death were 34.9, 35.4, 35.2, and 35.7 deaths per 10,000 patients in 2014–2017, respectively (p = 0.47, from a likelihood ratio test of secular trend). The overall weekly risk of hospitalization was 3.08, 3.05, 3.11, and 3.11% in 2014, 2015, 2016, and 2017, respectively (p = 0.30). There were significant secular trends in risk of death in subgroups defined by black race and residency in South Atlantic states (p < 0.05). There were also secular trends in risk of hospitalization in subgroups defined by age 20–44 years, concurrent enrollment in Medicaid, and residency in South Central states. Conclusion: For the first time since the beginning of this century, rates of both death and hospitalization among dialysis patients with Medicare fee-for-service coverage have stagnated. The reasons for this change are unknown and require detailed assessment. Persistent lack of change in clinical outcomes may alter the future expectations about dialysis patient population growth.

Introduction. The superficial mycoses remain a group of diseases of public health significance. The increased incidence of mycoses is related, among other factors, to deficiency of the immune system, coexisting systemic and dermatological diseases, long-term, non-target antibiotic therapy and the increase in the number of people at risk of immunosuppression. Objective. To analyze the etiology and epidemiology of mycosis in patients under 18 years of age in the years 2013–2016 diagnosed in the Unit of Medical Mycology at the Department of Dermatology, Poznan University of Medical Sciences. Material and methods . A retrospective, etiological and epidemiological analysis was performed on the incidence of superficial mycosis in 295 patients under 18 years of age diagnosed in the years 2013–2016 in the Unit of Medical Mycology at the Department of Dermatology, Poznan University of Medical Sciences. Results . The study group included mostly cases of dermatophytic superficial mycosis of the scalp with prevalent zoophilic species, including Microsporum canis as the most common. Conclusions. Superficial mycoses are common during childhood. Increased incidence of certain forms of superficial mycoses in children has been observed, for example infections transmitted from exotic animals or onychomycosis.

Background Spouses of Alzheimer's disease patients (AD spouses) may experience substantial health effects associated with their partner's chronic cognitive and behavioral dysfunction. Studies examining associations between the medical experiences of AD spouses in the period before and after their partner's AD diagnosis are limited, particularly those which measure health care resource use and cost. Methods AD patients were identified through multiple Medicare claims containing an AD diagnostic code. Their spouses were identified through special coding in the Medicare eligibility records. The AD spouses were matched demographically to the spouses of Medicare beneficiaries without a history of AD. Longitudinal and annual cross-sectional Medicare cost comparisons utilized log-transformed linear regression. The longitudinal period of observation began 12 months before the AD patient's initial claim listing AD and continued for up to 38 months afterwards. Results The study identified 16,322 AD spouses. Total per person costs were 24% higher in AD spouses than in the controls ($694/month vs $561/month). AD spouses' excess costs began 3 months before their partners' AD diagnoses and continued for ≥30 months. Being an AD spouse predicted 29% higher Medicare costs after adjustment for chronic health status (P < .001). Increasing AD patient care complexity had a substantial impact on AD spouse Medicare costs (P < .001). Conclusions This study documents a link between the health status of AD spouses and AD patients. Additional research is required to elicit the mechanism behind the association between AD spouse and AD patient diagnosis.

The validity of the standardized transfusion ratio, a quality measure for dialysis facilities, may have been affected by the transition from International Classification of Diseases, Ninth Revision (ICD-9) to International Classification of Diseases, Tenth Revision (ICD-10) procedure coding in October 2015. We analyzed Medicare Part A claims for inpatient care among dialysis patients in 2014-2017 and investigated billing patterns for blood transfusion during the last year of ICD-9 coding and the first and second years of ICD-10 coding. We identified 2205 hospitals with a steady volume of dialysis patient admissions. In nearly one-third (31.7%) of hospitals, the apparent incidence of blood transfusion during hospitalization fell >50% between the last year of ICD-9 coding and the first year of ICD-10 coding. Between the first and second years of ICD-10 coding, the apparent incidence of blood transfusion during hospitalization fell >20% in 24.5% of hospitals and rose >25% in 14.8% of hospitals. Furthermore, hospital-specific changes in the apparent incidence of blood transfusion among dialysis patients and all Medicare beneficiaries were highly correlated. These findings suggest that the standardized transfusion ratio reflects differential misclassification of transfusions among hospitals. Alternative measures to judge the quality of anemia management, such as attainment of hemoglobin within a target range, may be more appropriate.

The standardized transfusion ratio (STrR), a claims-based quality metric, was added to the ESKD Quality Incentive Program (QIP) in performance year 2016. The Centers for Medicare and Medicaid Services (CMS) recently proposed that the STrR constitute 22% of the total performance score for each

Aims Impaired awareness of hypoglycemia (IAH) is a limiting factor in the treatment of type 1 diabetes (T1D) and is a challenging condition to reverse. The objective of this study was to test the hypothesis that naltrexone therapy in subjects with T1D and IAH will improve counterregulatory hormone response and recognition of hypoglycemia symptoms during hypoglycemia. Methods We performed a pilot randomized double blind trial of 4weeks of naltrexone therapy (n=10) or placebo (n=12) given orally in subjects with T1D and IAH. Outcome measures included hypoglycemia symptom scores, counterregulatory hormone levels and thalamic activation as measured by cerebral blood flow using MRI during experimental hypoglycemia in all subjects before and after 4weeks of intervention. Results After 4weeks of therapy with naltrexone or placebo, no significant differences in response to hypoglycemia were seen in any outcomes of interest within each group. Conclusions In this small study, short-term treatment with naltrexone did not improve recognition of hypoglycemia symptoms or counterregulatory hormone response during experimental hypoglycemia in subjects with T1D and IAH. Whether this lack of effect is related to the small sample size or due to the dose, the advanced stage of study population or the drug itself should be the subject of future investigation.

Context Upregulated brain glucose transport in response to recurrent hypoglycemia may contribute to the development of hypoglycemia-associated autonomic failure (HAAF) and impaired awareness of hypoglycemia. Whether recurrent hypoglycemia alters glucose transport in the hypothalamus is unknown. Objective To test the hypothesis that hypothalamic glucose transport will increase in healthy volunteers preconditioned with recurrent hypoglycemia to induce HAAF. Setting University medical center. Design and Participants Thirteen healthy subjects underwent paired euglycemic and hypoglycemic preconditioning studies separated by at least 1 month. Following preconditioning, hypothalamic glucose transport was measured by magnetic resonance spectroscopy (MRS) in the afternoon on day 2 of each preconditioning protocol. Outcome Measure The ratio of maximal transport rate to cerebral metabolic rate of glucose (Tmax/CMRglc), obtained from MRS-measured glucose in the hypothalamus as a function of plasma glucose. Results HAAF was successfully induced based on lower epinephrine, glucagon, and cortisol during the third vs first hypoglycemic preconditioning clamp (P ≤ 0.01). Hypothalamic glucose transport was not different following recurrent euglycemia vs hypoglycemia (Tmax/CMRglc 1.62 ± 0.09 after euglycemia preconditioning and 1.75 ± 0.14 after hypoglycemia preconditioning; P was not significant). Hypothalamic glucose concentrations measured by MRS were not different following the two preconditioning protocols. Conclusions Glucose transport kinetics in the hypothalamus of healthy humans with experimentally induced HAAF were not different from those measured without HAAF. Future studies of patients with diabetes and impaired awareness of hypoglycemia will be necessary to determine if the existence of the diabetes state is required for this adaptation to hypoglycemia to occur.

Objectives To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders. Design Case–control concurrent study using Medicare administrative data. Setting HBPC practice in Washington, District of Columbia. Participants HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania. Intervention HBPC clinical service. Measurements Medicare costs, utilization events, mortality. Results Mean age was 83.7 for cases and 82.0 for controls (P

Aim: To assess the cost-effectiveness of first-line pemetrexed/platinum and other commonly administered regimens in a representative U.S. elderly population with advanced nonsquamous non-small cell lung cancer (NSCLC). Materials and Methods: This study utilized the Surveillance Epidemiology and End Results (SEER) cancer registry linked to Medicare claims records. The study population included all SEER-Medicare patients diagnosed in 2008-2009 with advanced nonsquamous NSCLC (stages IIIB-IV) as their only primary cancer and who started chemotherapy within 90 days of diagnosis. The study evaluated the four most commonly observed first-line regimens: paclitaxel/carboplatin, platinum monotherapy, pemetrexed/platinum and paclitaxel/carboplatin/bevacizumab. Overall survival and total healthcare cost comparisons as well as incremental cost-effectiveness ratios (ICERs) were calculated for pemetrexed/platinum versus each of the other three. Unstratified analyses and analyses stratified by initial disease stage were conducted. Results: The final study population consisted of 2,461 patients. Greater administrative censorship of pemetrexed recipients at the end of the study period disproportionately reduced the observed mean survival for pemetrexed/platinum recipients. The disease stage-stratified ICER analysis found that the pemetrexed/platinum incurred total Medicare costs of $536,424 and $283,560 per observed additional year of life relative to platinum monotherapy and paclitaxel/carboplatin, respectively. The pemetrexed/platinum versus triplet comparator analysis indicated that pemetrexed/platinum was associated with considerably lower total Medicare costs, with no appreciable survival difference. Limitations: Limitations included differential censorship of the study regimen recipients and differential administration of radiotherapy. Conclusions: Pemetrexed/platinum yielded either improved survival at increased cost or similar survival at reduced cost relative to comparator regimens in the treatment of advanced nonsquamous NSCLC. Limitations in the study methodology suggest that the observed pemetrexed survival benefit was likely conservative.

The 2017 AARP LTSS Scorecard reported that Connecticut ranked 51st nationally in the percent of home health patients that have a hospital admission and falls behind other states in utilization of palliative care. Home health providers suggest underutilization of hospice as a primary driver of high hospital admission rates. The study, funded by the Connecticut Department of Social Services, aimed to improve understanding of hospice utilization among Medicare/Medicaid dually eligible and Medicaid-only populations. Results of analysis of Medicaid-only (n=2,979) and Medicare/Medicaid dually eligible (n=12,090) decedents’ Medicare and Medicaid claims data from 2014 through 2016 showed that dually eligible decedents had a significantly higher rate of hospice use compared to Medicaid-only decedents (44% vs. 18%) and a significantly longer average length of stay in hospice (49.65 vs. 26.58 days). Dually eligible hospice users are more likely to have a diagnosis of Alzheimer’s disease and related disorders (47%) compared to Medicaid-only hospice users (19%). Other diagnoses show similar patterns. Geographic variation across regions was not substantial, indicating that the observation of low hospice use is a state-wide issue. Approximately 50% of hospice use was potentially concerning, including hospice dis-enrollment and very short/long hospice enrollment. Additionally, the analysis examined utilization within the two groups of decedents. Findings suggest where there are divergences in hospice utilization within Dual and Medicaid only populations. Recommendations include encouraging physician use of hospice/palliative screening tools and developing education interventions with physicians and patients to increase the understanding of the benefits of hospice and palliative care.

A spending cap is an insurance design feature that changes out-of-pocket prices faced by the insured after she exceeds a spending limit. Often the cap is a coverage limit, so that plan enrollees must pay full price after their spending has reached a specified level. Studies examining the effects of exceeding prescription drug spending caps on utilization and health have found that exceeding a cap results in greater out-of-pocket costs and self-reported financial burden (Tseng et al. 2003, 2004), reduction in drug utilization (Soumerai et al. 1991; Martin and McMillan 1996; Hsu et al. 2006, 2008; Joyce et al. 2007), and higher use of emergency room, hospital, and nursing home services (Soumerai et al. 1991; Hsu et al. 2006). Survey responses from enrollees provide most of what is known about the impact of exceeding a spending cap on enrollee prescription drug use. Prior studies have seldom been able to examine the prescription drug utilization of the same individuals before and after they reach an expenditure cap. When insurers pay nothing above an expenditure cap, enrollees are less likely to file claims for drugs purchased after the cap is exceeded.1 Thus, several previous cap studies have not observed actual levels of utilization and out-of-pocket costs after a cap was exceeded but instead have extrapolated past spending to estimate burden on beneficiaries (Tseng et al. 2003, 2004).2 An exception is a study of cost sharing of Medicare+Choice beneficiaries enrolled in a large prepaid integrated delivery system (Hsu et al. 2006). Hsu and colleagues found significantly lower drug utilization and greater nonadherence for beneficiaries subject to a spending cap in comparison with similar enrollees in a plan with no limit; to allay concern that postcap drug use might not be observed, they cite a concurrent survey of their study population reporting that beneficiaries did not buy drugs out of plan even after consumers faced the full drug price.3 For this study, we were able to observe the monthly prescription drug utilization of enrollees in a state pharmacy assistance plan with a soft cap that required enrollees to pay higher copayments (but less than full price) after they incurred total spending (both state coverage and out of pocket) greater than a threshold amount. This allowed us to address the following research questions: Do enrollees reduce prescription drug utilization and expenses when they face higher copayments after exceeding a soft cap? Do enrollees increase the proportion of drugs that are generic, as opposed to brand name, when they face higher copayments after exceeding a soft cap?

Objectives. The 1996 introduction of antiretroviral medications changed Medicare’s role in providing HIV care. We analyzed Medicare’s patient database in an effort to document the new HIV therapies’ effects on expenditures and outcomes. Methods. We examined the medical billing records of a 5% national Medicare sample from 1997 through 2003. The cohort was stratified by year and categorized by age, race/ethnicity, gender, and Medicare status. Population summaries were categorized according to presence of major chronic diseases and HIV-related conditions. Results. The number of Medicare beneficiaries with HIV increased from 42520 in 1997 to 76500 in 2003, whereas mortality among this group fell by 35%. HIV-associated infections declined by as much as 43% (mycoses). Heart and liver disease and diabetes increased by more than 50%. Adjusted annual per person Medicare expenditures fell 28%; expenditures were 49% higher for Blacks than for Whites. Conclusions. Improved HIV medical management has led to fewer deaths and has shifted treatment toward chronic care. However, successful management is complicated by conditions that have not been historically linked to HIV and whose effects vary according to race/ethnicity.

Zakazenia grzybami drozdzopodobnymi z rodzaju Candida stanowią coraz wiekszy problem kliniczny na oddzialach pediatrycznych. Drozdzyce skory i blon śluzowych są jednymi z najczestszych dermatoz. Ryzyko zakazenia grzybami drozdzopodobnymi z rodzaju Candida jest wyzsze u dzieci przewlekle chorych, leczonych dlugotrwale antybiotykami, glikokortykosteroidami czy lekami immunosupresyjnymi. Drobnoustroj ten nie jest skladnikiem tzw. fizjologicznej flory blon śluzowych, przewod pokarmowy jest naturalnym siedliskiem tego symbiotycznego mikroorganizmu. Dzieci z nieswoistymi zapaleniami jelit (IBD) nalezą do grupy wysokiego ryzyka rozwoju kandydozy. W zalezności od sprawności ukladu immunologicznego i stanu ogolnego dziecka Candida spp. moze powodowac niegroźne infekcje powierzchowne albo ciezkie zakazenia narządowe lub uogolnione. Zagrazające zyciu uogolnione infekcje grzybami drozdzopodobnymi zdecydowanie cześciej wystepują u osob, u ktorych stwierdzono nosicielstwo Candida spp. Czynnikiem ryzyka nosicielstwa Candida spp. jest czeste lub dlugotrwale stosowanie antybiotykow o szerokim zakresie dzialania. U dzieci z IBD kandydoza jamy ustnej wystepuje cześciej niz uwazane za charakterystyczne dla choroby Leśniowskiego-Crohna afty. Dysbioza w obrebie jelit uwazana jest za jeden z istotnych czynnikow, ktory przy odpowiednim podlozu genetycznym moze przyczyniac sie do rozwoju IBD. Candida albicans jest drobnoustrojem odpowiedzialnym za prawie 90% endogennych zakazen wywolywanych przez drozdzaki. W ostatnich latach stwierdzono zmniejszenie czestości zakazen wywolywanych przez Candida albicans na korzyśc innych szczepow z rodzaju Candida, w tym Candida parapsilosis. Nalezy pamietac o konieczności prowadzenia racjonalnej antybiotykoterapii u dzieci z IBD. Probiotyki wykazują korzystny wplyw na blone śluzową jelit poprzez zapobieganie dysbiozie, zmniejszenie ryzyka uogolnionej kandydemii oraz dzialanie przeciwzapalne.

Despite its implications on the personal and policy level, little is currently known about the specific diagnostic pathways that patients with cognitive impairment (CI) pass through before being diagnosed with Alzheimer disease (AD). Four major diagnostic pathways were identified in the Medicare claims records for 2001 to 2006: AD as initial diagnosis, cognitive disturbance followed by AD; dementia with suspected etiologies followed by AD; dementia without known cause followed by AD; and 1 triple pathway, cognitive disturbance followed by dementia without known cause followed by AD. For all of these pathways, previously low medical costs peaked during patients' month of initial diagnosis and then declined to a level substantially higher than before. The 3 CI pathways that transition to AD included another peak in costs when a secondary AD diagnosis occurred. Each time, inpatient and skilled nursing facility services were major cost contributors. The primary diagnoses on Medicare claims for the AD event were usually comorbidities rather than CI. A linear regression model adjusting for demographic factors, selected comorbidities, and overall frailty found that the transitional CI diagnoses were significant independent cost determinants. They increased Medicare expenditures by an estimated $4600 to $14,200 relative to patients whose initial CI diagnosis was AD.

Summary Aggressive chemotherapy and immunosuppressive treatment may prolong patients’ life, but influence the risk of severe, life-threatening infections. Here, we report the case of a 21-year-old caucasian female who developed a disseminated infection of Scedosporium prolificans after allogenic stem cell transplantation performed for treatment of relapsed acute lymphoblastic leukaemia. The pathogen was isolated from the blood and identified on the basis of its macroscopic and microscopic morphological features. The empirical treatment with amphotericin B provided no improvement. However, introduction of intravenous voriconazole resulted in amelioration of fever. Unfortunately, the patient died due to progression of underlying disease and multiorgan failure. However, this case report indicates a possible relevance of voriconazole-based treatment regimens in invasive S. prolificans infections.

This study assesses cost of illness of metastatic breast cancer (MBC) patients over a specific period of time as observed in Medicare program expenditure data. Incident cases of MBC from 1997 to 1999 were included. Direct care cost data were obtained from Medicare claims from a 5% national sample of program beneficiaries. Costs to the health care system were determined from the date of first diagnosis of MBC to the end of follow-up. A matched case-control study provided comparison of Medicare payments in cancer and non-cancer patients. A total of 397 MBC patients were identified and followed for an average of 16.2 months. The mean total cost was US$ 35,164 per MBC patient and US$ 4176 per person for the control group. Over the follow-up period, the MBC patients averaged 1.7 inpatient admissions per patient and 14.4 inpatient days per admission. The control group averaged 0.3 inpatient admissions per patient and 1.6 inpatient days per admission. Home health aide for MBC averaged one visit every 2 weeks. The direct costs for the older MBC patients were less than the direct costs of the younger MBC group. Multivariate regression analysis showed that as the age increased, the Medicare costs decreased within the MBC cohorts. Less combination treatments were provided for older MBC patients. Cost of illness was inversely proportional to age.

Thirty-four extant pawpaw [Asimina triloba (L.) Dunal] cultivars and advanced selections representing a large portion of the gene pool of cultivated pawpaws were investigated using 71 randomly amplified polymorphic DNA (RAPD) markers to establish genetic identities and evaluate genetic relatedness. All 34 cultivated pawpaws were uniquely identified by as few as 14 loci of eight primers. Genetic diversity of the existing gene pool of cultivated pawpaws, as estimated by Nei's gene diversity (He), was similar to that of wild pawpaw populations. The genetic relatedness among the cultivated pawpaws examined by UPGMA cluster analysis separated 34 cultivars and selections into two distinct clusters, a cluster of PPF (The PawPaw Foundation) selections and a cluster including a majority of the extant cultivars selected from the wild and their derived selections. The results are in general agreement with the known selection history and pedigree information available. The consensus fingerprint profile using the genetically defined RAPD markers is a useful and reliable method for establishing the genetic identities of the pawpaw cultivars and advanced selections. This also proved to be an improved discriminating tool over isozyme markers for the assessment of genetic diversity and relatedness. RAPD profiling of data presented in this study provides a useful reference for germplasm curators engaged in making decisions of sampling strategies, germplasm management and for breeders deciding which parents to select for future breeding efforts.

e17010 Background: Few publications have characterized treatment patterns beyond first-line therapy for patients with metastatic, (Stage IVC) SCCHN. Methods: Surveillance, Epidemiology and End Resu...

You can always count on finding the Mississippi just where you left it last year. But the Missouri is a tawny, restless, brawling flood. It cuts corners, runs around at night, fills itself with snags and traveling sandbars, lunches on levees, and swallows islands and small villages for dessert. Its perpetual dissatisfaction with its bed is the greatest peculiarity of the Missouri.... It makes farming as fascinating as gambling. You never know whether you are going to harvest corn or catfish (Fitch 1907, p. 637).

This report examines whether the Tailored Adaptive Personality Assessment System (TAPAS) may be useful for selecting and classifying recruits into Military Occupational Specialties (MOS) and describes the two broad approaches that were taken to evaluate the measure for these purposes. TAPAS data for this research were collected from Army applicants at the Military Entrance Processing Stations (MEPS) between May 2009 and June 2011. In addition, criterion data were collected in the Tier One Performance Screen (TOPS) program. The total sample size for this research was 151,625. With this data, we first examined the validity of TAPAS scales for predicting outcomes in four high density MOS including 11B, 31B, 68W, and 88M. Next, we examined whether the TAPAS scales could be used to differentiate high performers in each MOS from those that would perform better in a different occupation. Using composites of the TAPAS scales, results indicated that some individuals might perform better in an MOS other than the one they were assigned to. Therefore, TAPAS may be useful as a supplement to the current procedures for MOS qualification and classification.

The U.S. Army Research Institute for the Behavioral and Social "STAY: Strategies to Enhance Retention." The enlisted portion of the STAY project identified factors influencing enlisted Soldiers' career continuance decisions, developed a model of the decision process, generated an extensive list of attrition and retention interventions, and evaluated two of them. Interviews and focus groups across Training and Doctrine Command (TRADOC) and Forces Command (FORSCOM) were conducted during FY06 and FY07 to identify factors influential to both enlisted attrition and retention. The FY06 Trainee Inventory and Soldier Inventory were developed and administered to further inform model development. The resulting career continuance model for enlisted Soldiers accounted for growth and development of Soldiers, influential experiences, individual characteristics, and Family and organizational influences; it also drove the intervention development. A multi-phase process was used to develop and pilot-test interventions for decreasing attrition and improving enlisted Soldier career continuance. Promising interventions were identified based on feedback from ARI and Subject Matter Expert (SME) advisory panels on feasibility and potential success. Two interventions (Soldier Transition Survey and Unit Retention Climate Feedback System) were further investigated. The Soldier Transition Survey provided useful empirical information on factors driving career continuance decisions and demonstrated the value of alternate sources (i.e., proxies) for capturing this information. The Unit Retention Climate Feedback System examined shared unit-level perceptions influencing decisions to reenlist or leave the Active Army, and provides an approach for feeding that information back to unit leaders.

The U.S. Army Research Institute for the Behavioral and Social Sciences (ARI) initiated a three-year research program titled "STAY: Strategies to Enhance Retention." The goals of this effort were to develop and test a conceptual model of the career continuance process, and to identify, implement, and evaluate promising interventions that encourage Army reenlistment among first-term Soldiers. To achieve these broad objectives, this report reviews past and ongoing interventions that support, either directly or indirectly, Army enlisted Soldier retention efforts. The review is based on a number of sources, including a literature search, interviews and focus groups with Army personnel, and anecdotal reports from subject matter experts. We also review the limited amount of research available that has evaluated the impact of Army initiatives on reenlistment decisions and related attitudes. The majority of initiatives discussed in this paper have not been formally evaluated, and the evaluations that do exist need updating. While this information adds to our knowledge about Army initiatives, more research is necessary. The Army would benefit from more recent research assessing whether relationships exist between use of specific Army programs or incentives and reenlistment intentions/decisions.

This report describes the job analysis performed by The U.S. Army Research Institute for the Behavioral and Social Sciences Rotary Wing Aviation Research Unit (ARI RWARU). It was part of a larger research project to develop and validate a selection system for U.S. Army rotary wing aviators, called Selection Instrument for Flight Training (SIFT). The activities performed by Army aviators and the personal attributes required to perform those activities were examined. This job analysis helped identify predictor measures subsequently used to validate the prototype SIFT test battery.

Childhood injuries lead to increased morbidity and result in significant costs to public insurance programs. People with mental retardation, most of whom are covered by Medicaid, are at high risk for injury, which has implications for community inclusion, a central policy goal. Medicaid data from inpatient, outpatient, and long-term care settings represent an important new resource for injury surveillance in this population. Injury prevalence for 8.4 million Medicaid-eligible children in 26 states was measured using 1999 eligibility and claims data; 36.9% Medicaid beneficiaries ages 1 to 20 with mental retardation had at least one injury claim as compared with 23.5% of those without mental retardation. Prevalence rates are reported by gender and age for a variety of injury types.

Claims for injury care provided to aged fee-for-service (FFS) beneficiaries cost Medicare more than $8 billion in 1999, almost 6 percent of Medicare claims spending for elders. More than one-fifth of aged FFS beneficiaries had an injury that resulted in a claim. Fractures, which were experienced by one in seventeen aged beneficiaries, were responsible far 67 percent of total injury claims expenses. Medicare could realize substantial savings if these injuries could be prevented; the program should consider underwriting effective prevention activities.

This study compared graduates of a course taught through the Sergeants Major Academy by distance learning with graduates of the same course taught in residence, as usual. Unlike previous evaluations of distance learning, the measures used to compare groups were not students' immediate reactions to the course nor their end-of-course test scores but measures delayed until the graduates were on the job: (1) a written test of their job knowledge, and (2) job performance ratings by their supervisors. Special care was taken to insure these measures were reliable and valid; the 42-item written test included only material covered in the course and the supervisors were motivated and trained on the technique of making accurate performance ratings. Knowledge test scores for a total of 172 NCOs and performance ratings for a total of 145 NCOs were collected from 8 sites. Results indicate that the different formats for the course, distance learning versus residence, had no reliable effect on either measure. NCOs received nearly the same knowledge test scores and supervisory ratings, on average, regardless of how the course was presented, supporting the conclusion that distance learning technology, as an alternative to residence-based training, does not involve a sacrifice of graduate quality.

This report describes research to explore the feasibility of developing a computer-based career guidance system for displaced workers. The initial system was designed for displaced civilian workers associated with the air force. The project began with a needs assessment using focus groups of a representative sample of workers. The proposed system capitalizes on the capabilities of the Occupational Information Network (O*NET). The project focused on aspects of the proposed system not currently available in existing career information systems. These included the development of worker assessment tools and advanced person-job matching algorithms. Regarding worker assessment, a skill self-assessment inventory was developed and tested along with a taxonomy of non-work activities linked to O*NET skills. A computer demo was developed to demonstrate how these components could be incorporated into a complete career guidance system.

Objective Although the global rate of multiple sclerosis (MS) is low, a few studies have documented high costs. Costs are highly variable depending on MS stage. This study was designed to assess the economic burden of Medicare-eligible patients by MS type in the United States using a claims-based classification algorithm to examine cost variation by disease stage. Methods A sample of 2003 to 2006 Medicare patients was selected. Cases were classified as pre-existing progressive MS or pre-existing relapsing-remitting MS (RRMS); the latter were further subdivided into relapsing, remitting, or stable. Results The sample had 5044 MS subjects, of whom 34.4% had prevalent progressive MS and 65.6% had prevalent RRMS. There were many chronic, comorbid conditions. The mean all-cause Medicare expenditures (not including self-administered medications) per person-year for MS in 2006 were $23,630 for prevalent progressive patients and $5887 for prevalent RRMS patients. Within the RRMS type, Medicare expenditures per person per month in 2006 were $1418 for relapsing patients, $608 for remitting patients, and $331 for stable patients. Conclusions There are substantial cost advantages to Medicare for keeping RRMS patients in a stable health state and in keeping them from advancing in disability severity. The overall cost advantage would be diminished by the large cost burden of comorbidity, which would likely remain fixed with improved MS therapies.

The development of a series of detectors for planar radiochromatography is described (sensitivities are quoted as dpm of carbon-14). The RITA is a position sensitive proportional counter with a resolution of 0.5mm and a sensitivity of a few tens of dpm. This detector may be used, with suitable software, to analyze two dimensional thin-layer chromatography (TLC) plates. TRACY is a multiwire proportional detector which has been developed especially for two dimensional planar chromatography. This detector has a resolution of 1mm with a sensitivity of about 25dpm for an analysis time of 15 minutes. BERTA is a spark chamber which also has been developed for two dimenional radio-detection. The spark chamber has a resolution of 1mm with a sensitivity of about 10dpm in 40 minutes. One of the major disadvantages of such spark chambers has been the lack of any digital information. This has been solved by development of EVA, an optical reading system for the BERTA where a special diode array matrix is used in conjunction with a very fast Motorola 68000 CPU.

Background The burden experienced by spouses of patients with Alzheimer’s disease (AD) may have negative consequences for their physical health. We describe here a method for analyzing United States Medicare records to determine the changes in health service use and costs experienced by spouses after their marital partner receives an AD diagnosis. Methods We initially identified all beneficiaries in the 2001–2005 Medicare 5% sample who had multiple claims listing the ICD-9 diagnostic code for AD, 331.0. The 5% sample includes spouses who share a Medicare account with their marital partners because they lack a sufficient work history for full eligibility on their own. A matched cohort study assessed incremental health costs in the spouses of AD patients versus a control group of spouses of non-AD patients. Longitudinal and cross-sectional analyses tracked the impact of a patient’s AD diagnosis on his or her spouse’s healthcare costs. Results Our method located 54,593 AD patients of whom 11.5% had spouses identifiable via a shared Medicare account. AD diagnosis in one member of a couple was associated with significantly higher monthly Medicare payments for the other member’s healthcare. The spouses’ elevated costs commenced 2 to 3 months before their partners’ AD diagnosis and persisted over the follow-up period. After 31 months, the cumulative additional Medicare reimbursements totaled a mean $4,600 in the spouses of AD patients. This excess was significant even after accounting for differences in baseline health status between the cohorts. Conclusion The study methodology provides a framework for comprehensively evaluating medical costs of both chronically ill patients and their spouses. This method also provides monthly data, which makes possible a longitudinal evaluation of the cost effects of specific health events. The observed correlations provide a coherent demonstration of the interdependence between AD patients’ and spouses’ health. Future research should examine caregiving burden and other possible factors contributing to the AD spouses’ health outcomes. It should also extend the method presented here to evaluations of other chronic diseases of the elderly.