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Provider networks for mental health are narrower than for other medical specialties. Providers' influence on access to care is potentially greater in Medicaid because enrollees are generally limited to contracted providers, without out-of-network options for nonemergency mental health care. The authors used claims-based metrics to examine variation in specialty mental health provider networks.In a cross-sectional analysis of 2018 Oregon Medicaid claims data, claims from adults ages 18-64 years (N=100,515) with a psychiatric diagnosis were identified. In-network providers were identified as those associated with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a health plan (coordinated care organization [CCO]) during the study period. Specialty mental health providers were categorized as prescribers (psychiatrists and mental health nurse practitioners) and nonprescribers (therapists, counselors, clinical nurse specialists, psychologists, and social workers). Measures of network composition, provider-to-population ratio, continuity, and concentration of care were calculated at the CCO level; the correlation between these measures was estimated to describe the degree to which they capture unique dimensions of provider networks.Across 15 CCOs, the number of prescribing providers per 1,000 patients was relatively stable. CCOs that expanded their networks did so by increasing the number of nonprescribing providers. Moderately negative correlations were found between the nonprescriber provider-to-population ratio and proportions of visits with prescribers as well as with usual provider continuity.This analysis advances future research and policy applications by offering a more nuanced view of provider network measurement and describing empirical variation across networks.

Ampullary neuroendocrine tumors (NETs) make up

Complications after pancreatoduodenectomy are common, and range widely in timing of presentation, relation to pancreatobiliary pathology, and necessity of operative intervention. We present a case of a 74-year-old male with history of pancreatoduodenectomy for pancreatic adenocarcinoma who presented 11 months after index operation with cecal volvulus and required emergent right hemicolectomy. Prior history of pancreatoduodenectomy with mobilization of the right colon likely predisposed him to development of this surgical emergency. Patients have altered gastrointestinal anatomy after pancreatoduodenectomy and special care is necessary to protect the afferent biliopancreatic limb during intraoperative exploration, and particularly if right colectomy is necessary.

This article aims to explore whether ICT-enabled real-time data (RTD) systems can help to improve the operationalisation of adaptive management of international development programmes. Using a qual...

Ampullary neuroendocrine tumors (NETs) make up 1% of all gastroenteropancreatic NETs, and information is limited to case series. This study compares patients with ampullary, duodenal, and pancreatic head NETs.The National Cancer Database (2004-2016) was queried for patients with ampullary, duodenal, and pancreatic head NETs. Survival was evaluated using Kaplan-Meier analysis and Cox regression.Overall, 872, 9692, and 6561 patients were identified with ampullary, duodenal, and pancreatic head NETs, respectively. Patients with ampullary NETs had more grade 3 tumors (n = 149, 17%) than patients with duodenal (n = 197, 2%) or pancreatic head (n = 740, 11%) NETs. Patients with ampullary NETs had more positive lymph nodes (n = 297, 34%) than patients with duodenal (n = 950, 10%) or pancreatic head (n = 1513, 23%) NETs. On multivariable analysis for patients with ampullary NETs, age (hazard ratio [HR] 1.03, p 0.0001), Charlson-Deyo score of 2 (HR 2.3, p = 0.001) or ≥3 (HR 2.9, p = 0.013), grade 2 (HR 1.9, p = 0.007) or grade 3 tumors (HR 4.0, p 0.0001), and metastatic disease (HR 2.0, p = 0.001) were associated with decreased survival. At 5 years, the overall survival (OS) for patients with ampullary, duodenal, and pancreatic head NETs was 59%, 71%, and 50%, respectively (p 0.0001), whereas the 5-year OS for patients with ampullary, duodenal, and pancreatic head NETs who underwent surgery was 62%, 78%, and 76%, respectively (p 0.0001).Ampullary NETs were more likely to present with high-grade tumors and lymph node metastases. Based on the clinicopathologic and survival data, ampullary NETs have a unique underlying biology compared with duodenal and pancreatic head NETs.

Vertaisarvioitu. Digitalisaation myötä terveydenhuollon toiminnot muuttuvat nopeasti, ja sähköiset työkalut sekä palvelut ovat jo arkipäivää. Vaikutukset näkyvät koulutustarpeena, koska terveydenhuollon ammattilaisten digiosaaminen tulee turvata. Lääkärien peruskoulutuksen tulisi sisältää etälääketiedettä ja sähköisen terveydenhuollon palveluja (e-health) koskevaa opetusta. Kansallisessa MEDigi-hankkeessa määriteltiin suomalaisen e-health-opetuksen aihealueet ja tehtiin niille ydinainesanalyysi. Työryhmän työn perusteella määräytyi kaksitoista e-health-opetukseen soveltuvaa aihealuetta lääketieteen ja hammaslääketieteen peruskoulutuksessa. Niiden sisältämien opetusaiheiden keskeisyys määriteltiin kolmiportaisesti. Tuloksia sovellettiin pilottina Oulun yliopistossa lääketieteen viidennen vuosikurssin opiskelijoille toteutettuun teemapäivään, jonka opetussisältö muokattiin vastaamaan ydinainesanalyysin tuloksia. Opetus toteutettiin koronapandemian takia kokonaan etäopetuksena. Jatkossa tavoitteena on kansallisesti integroida ydinainesanalyysiin perustuva e-health-opetus suomalaiseen lääkärikoulutukseen.

Background The Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion. Objective To examine the association of the ACA expansion on health care access and utilization for adults ages 18–64 years who have qualified for Supplemental Security Income (SSI) in Oregon. Methods We used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits. Results The Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon’s counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p Conclusions We did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.

Ampullary neuroendocrine tumors (NETs) make up

Imatinib mesylate (Gleevec) is a cellular protein tyrosine kinase inhibitor that inhibits the BCR-ABL tyrosine kinase. This form of targeted therapy has been used for renal cell cancer, chronic myeloid leukemia, and gastrointestinal stromal tumors (GIST). Acute kidney injury, hypophosphatemia, and tumor lysis syndrome have been reported with this agent. We present a 76-year-old woman with a GIST tumor treated with imatinib mesylate. Shortly following the start of treatment, the patient developed acute kidney injury with a serum creatinine of 1.7 mg/dL. A kidney biopsy revealed an acute drug-induced tubular injury. Withholding the agent improved the renal function. Given the extent of her disease, the dose was reduced and she was maintained on treatment. Eight months later there was no radiographic evidence of disease and her renal function remained stable at 1.6 mg/dL. In this paper, we also review the known renal toxicities associated with imatinib. With the increasing use of imatinib and other novel targeted agents for various cancers, it is essential to understand its short- and long-term renal side effects. The acute kidney injury and chronic kidney disease experienced tends to be mild, but the monitoring of serum creatinine is an important part of treatment, especially within the first 3 months. In addition, patients on imatinib need to be monitored for its rarer effects on bone metabolism, such as hypocalcemia and hypophosphatemia.

Major depressive disorder is a frequent and disabling disease and can be treated with antidepressant drugs. When faced with severe or resistant major depressive disorder, however, psychiatrists may resort to electroconvulsive therapy (ECT). Although very effective, the response falls short of 100%. A recent meta-analysis established clinical and biological predictive factors of the response to ECT. We decided to explore neuroimaging biomarkers that could be predictors of the ECT response.We performed a systematic literature review up to January 1, 2018, using a Boolean combination of MeSH terms. We included 19 studies matching our inclusion criteria.Lower hippocampal, increased amygdala, and subgenual cingulate gyrus volumes were predictive for a better ECT response. Functional magnetic resonance imaging also found that the connectivity between the dorsolateral prefrontal cortex and posterior default-mode network is predictive of increased efficacy. Conversely, deep white matter hyperintensities in basal ganglia and Virchow-Robin spaces, medial temporal atrophy, ratio of left superior frontal to left rostral middle frontal cortical thickness, cingulate isthmus thickness asymmetry, and a wide range of gray and white matter anomalies were predictive for a poorer response.Our review addresses the positive or negative predictive value of neuroimaging biomarkers for the ECT response, indispensable in a personalized medicine dynamic. These data could reduce the risk of nonresponders or resistance with earlier effective management. It might also help researchers elucidate the complex pathophysiology of depressive disorders and the functioning of ECT.

ObjectivesElectroconvulsive therapy (ECT) is a safe and validated technique used to treat various psychiatric conditions. It triggers an artificially-induced seizure. This seizure is defined using several parameters such as the amount of energy, duration, frequency, pulse width and intensity. Efficacy and adverse events depend on the amount of energy delivered. Due to technical control, the amount of energy delivered by our unit’s ECT device was limited to 614 mC, 60% of the maximum possible output of the device. We wondered if lowering the dose would lead to better seizure quality among maintenance ECT patients.MethodsWe assessed seizure quality based on the EEG, using a validated tool created by MacPherson. Two evaluators independently rated the seizures. Pre- and post-control scores were compared using Student’s t-test for paired samples.ResultsWe analysed data from 15 patients. Mean age was 65 years old. Twelve had depressive disorder, two had schizophrenia and one had schizo-affective disorder. Mean duration of seizure before control was 41.1 s [95% confidence interval (95CI)=26.1, 51.1]. The mean MacPherson’s score was 20.3 (95CI=16.2, 24.4). After control, the mean MacPherson’s score was 28.2 (23.1, 33.3), showing a significant difference with the pre-control dataset (p=0.032; t=−2.4; df=14). Specifically, peak mid-ictal amplitude increased from 6.9 (95CI=5.1, 8.7) to 10.0 (95CI=7.2, 12.8). Other sub-scores remained unchanged.ConclusionLowering the energy delivered led to an overall increase of seizure quality among our sample. This highlights the necessity and utility of retitration during ECT maintenance, possibly leading to better management of our patients.

INTRODUCTION: The anti-PD-1 monoclonal antibody nivolumab, used in metastatic melanoma, renal carcinoma, and advanced non-small cell lung cancer, may be used off-label in some PD-L1 positivite tumors. We report the first use (to our knowledge) of nivolumab in metastatic carcinoma of unknown primary with hepatoid features, with subsequent loss of PD-L1 expression on the tumor. CASE PRESENTATION: A 62-year old man complained of worsening back and right thigh pain. X-rays revealed an L3 compression fracture, which was managed non-operatively. He developed worsening right hip pain. Imaging revealed a right iliac mass, associated pathologic fracture, and multiple osteoblastic and osteolytic metastases. RESULTS: Iliac mass biopsy showed cords and nests of malignant epithelial cells with abundant eosinophilic cytoplasm, irregular nuclear contours, and prominent nucleoli. HepPar, Cam5.2, and PAX-8 (focal) immunohistochemical stains were positive, suggesting hepatic carcinoma. PD-L1 positivity was high (> 25% but < 50%). Genomic sequencing showed NF2, MLL2, and SETD2 mutations. Workup showed no hepatic involvement, so stage IV hepatoid carcinoma of unknown primary was diagnosed. TREATMENT: Several bony lesions were radiated. Nivolumab (240 mg every 2 weeks) and denosumab (monthly) were started. PROGRESSION: Seven months later he developed left ptosis and proptosis from a sellar/left cavernous sinus mass. Histology was similar to the previous iliac biopsy, but with more aggressive features (mitoses, atypical nuclei). Cam5.2 and synaptophysin immunohistochemical stains were positive; PD-L1 expression was

Because of its ability to reduce inhibitions and increase sexual drive, an emerging body of research has repeatedly identified crystal methamphetamine as a key variable in explaining new HIV transmissions among men who have sex with men (MSM). The implications of which have included the development of HIV prevention policies and public health campaigns centered on curbing methamphetamine use in urban gay centers throughout the United States. Data collected from a diverse sample of gay and bisexual men attending large-scale gay, lesbian, and bisexual community events in New York City (n=738) indicated that 10.2% of men used methamphetamine recently (i.e.

A time of fluidity, a time of consolidation, adolescence is fundamentally a time of becoming. It is a period of life most distinguished by energy, creativity and self-consciousness (in all senses of the term) and accompanied by a renegotiation with the world of adults, both in the home and outside of it. This article examines the problematic relationship between diagnosis and adolescent development, looking especially at eating disorders, substance abuse, and psychiatric illness. It describes what is problematic both for the individuals who are diagnosed and in the use of common diagnostic nomenclature for adolescents, who may best be described in different terms from those of children or adults. It concludes with implications for treatment and a suggestion that new categories for adolescent diagnoses may need to be developed to characterize more adequately adolescent disorders.

Objective: To evaluate the safety and feasibility of cognitive-behavioral therapy (CBT) for depression in physically ill adolescents. Method: In an open trial, 11 adolescents (12–17 years) with inflammatory bowel disease and either major or minor depression underwent 12 sessions of a manual-based CBT enhanced by social skills, physical illness narrative, and family psychoeducation components. Standardized instruments assessed pre- to posttreatment changes in depression, physical health, global psychological functioning, and social functioning. Perceived helpfulness and satisfaction with CBT were assessed. Results: There were significant reductions in DSM-IV depression diagnoses and depressive symptoms and improvements in global psychological and social functioning. Adolescents’ perceptions of their general health and physical functioning improved, although illness severity measures were unchanged. High subject satisfaction and helpfulness ratings for CBT were found along with no adverse events and high subject adherence. Conclusions: A manual-based CBT approach adapted to treat depression in physically ill adolescents appears to be a safe, feasible, and promising intervention.

OBJECTIVES This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics. METHODS One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment. RESULTS Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05). CONCLUSIONS These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.

The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy.Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded.We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient cohort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure.In patients undergoing hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgical proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

In the poster proposal, we briefly describe the nature of ongoing doctoral dissertation research and describe why this project may be of particular interest to the conference attendees. This is a qualitative study designed to expand our current view of e-government in small municipalities in Pennsylvania (PA) and it is guided by a combination of sociotechnical theory and grounded theory approach. This research is aimed at discovering whether and/or how existing and emerging ICTs (including social media) facilitate citizen engagement in local government decision-making process.

Objective: To describe the location of, primary reason for, and time between the first positive HIV test and AIDS diagnosis in a sample of persons with newly diagnosed AIDS. Design: Interviews supplementing information routinely collected through AIDS case reporting. Setting: Eleven US states and cities. Patients: Persons with AIDS (2441) diagnosed between january 1990 and December 1992. Main outcome measures: Location of first positive HIV test, primary reason for testing, and time interval between first positive HIV test and AIDS diagnosis. Results: Overall, persons were tested late in their course of HIV infection: 36% were tested for HIV within 2 months and 51% within 1 year of their AIDS diagnosis. Sixty-five per cent were HIV-tested in acute health-care settings: 33% in hospitals, 28% in physicians'offices, and 4% in emergency departments. Testing during hospitalization was most common among injecting drug users (43%) and persons infected through heterosexual contact (50%). Persons primarily sought HIV testing because of illness (58%); other reasons included being in a known risk group (13%) and having had a known HIV-infected sex partner (8%). Testing because of being in a known risk group was least common among persons infected through heterosexual contact (1%). Among persons in these exposure categories, testing differed by race/ethnicity. Conclusion: Most persons with AIDS were tested relatively late in their course of HIV infection, in acute health-care settings, and because of illness. Not knowing one's serostatus precludes early medical intervention and may increase transmission

To characterize the socioeconomic status of persons with acquired immunodeficiency syndrome (AIDS), 11 U.S. state and city health departments interviewed 2,898 persons ≥18 years of age reported with AIDS between June 1, 1990, and January 31, 1993. Among men who have sex with men, white men reported the lowest percentage (9%), and Central/South American and Mexican men (40%) reported the highest percent¬ages not completing 12 years of school. Among intravenous drug users (IDUs), 35% of white men, 64% of black men, 67% of Puerto Rican men, 29% of white women, and 63% of black women had not completed 12 years of school. Overall, 77% of the men and 90% of the women were unemployed; we also found racial/ethnic differences by employment but to a lesser degree than differences in education. Among women, but not among men, differences in household income by race and ethnicity were marked; 76% of white and 91% of black female IDUs reported a household income of $10,000. Human immunodeficiency virus (HIV) prevention programs must be targeted toward the educational level of the populations served, and HIV services must adapt to the financial circumstances of their clientele. [Am J Prev Med 1994;10:217–22]

Bedbugs (Cimex lectularius or Cimex hemipterus) are cosmopolite hematophagus insects, and recent outbreaks have been reported in all major occidental countries. Although they are suspected of transmitting more than 40 infectious agents, no report has yet definitively demonstrated that capacity., Bedbugs are brown and flat hematophagous insects. The 2 cosmopolite species, Cimex lectularius and Cimex hemipterus, feed on humans and/or domestic animals, and recent outbreaks have been reported in occidental countries. Site assessment for bedbug eradication is complex but can be assured, despite emerging insecticide resistance, by hiring a pest-control manager. The common dermatological presentation of bites is an itchy maculopapular wheal. Urticarial reactions and anaphylaxis can also occur. Bedbugs are suspected of transmitting infectious agents, but no report has yet demonstrated that they are infectious disease vectors. We describe 45 candidate pathogens potentially transmitted by bedbugs, according to their vectorial capacity, in the wild, and vectorial competence, in the laboratory. Because of increasing demands for information about effective control tactics and public health risks of bedbugs, continued research is needed to identify new pathogens in wild Cimex species (spp) and insecticide resistance.

Research on lesbian and bisexual women has documented various biological and behavioral differences between butch and femme women. However, little research has examined whether differences exist in sexual identity development (i.e., the coming-out process). The present study examined longitudinally potential butch/femme differences in sexual identity formation and integration among an ethnically diverse sample of 76 self-identified lesbian and bisexual young women (ages 14–21 years). A composite measure of butch/femme identity classified 43% as butch and 51% as femme. Initial comparisons found butch/femme differences in sexual identity (i.e., nearly all butches identified as lesbian, but about half of femmes identified as bisexual), suggesting the need to examine this confound. Comparisons of lesbian butches, lesbian femmes, and bisexual femmes found that lesbian butches and femmes generally did not differ on sexual identity formation, but they differed from bisexual femmes. Lesbian butches and femmes had sexual behaviors and a cognitive sexual orientation that were more centered on women than those of bisexual femmes. With respect to sexual identity integration, lesbian butches were involved in more gay social activities, were more comfortable with others knowing about their homosexuality, and were more certain, comfortable, and accepting of their sexual identity than were bisexual femmes. Fewer differences were found between lesbian femmes and bisexual femmes or between lesbian butches and lesbian femmes. The findings suggest that sexual identity formation does not differ between butch or femme women, but differences are linked to sexual identity as lesbian or bisexual. Further, the findings that lesbian femmes sometimes differed from lesbian butches and at other times from bisexual femmes on sexual identity integration suggest that neither sexual identity nor butch/femme alone may explain sexual identity integration. Research examining the intersection between sexual identity and butch/ femme is needed.

OBJECTIVE To describe the sociodemographic characteristics and sexual and drug use behaviors of men with AIDS who engage in bisexual activity. METHODS We interviewed 2120 men aged > or = 18 years who were reported with AIDS in 11 states and cities. Men were considered bisexual if they reported having had sex with a man and a woman in the previous 5 years. RESULTS Of the 2020 men with AIDS who reported being sexually active in the previous 5 years, 1150 (57%) had had male partners only, 522 (26%) had had female partners only and 348 (17%) had had both. White men were least likely to report bisexual behavior (15%; 161 out of 1071). Men of Latin American descent were most likely to report bisexual behavior (24%; 37 out of 155), especially those born outside the United States who had lived there for < or = 10 years (38%; 11 out of 29). Bisexual Latin American men, regardless of birthplace, were more likely to be currently married than all other bisexual men (22 versus 7%; P < 0.05). HIV risk behaviors differed between men reporting bisexual and those reporting exclusively homosexual or heterosexual activity. Injecting drug use in the previous 5 years was more common among bisexual than homosexual men (12 versus 6%; P < 0.05). Bisexual men were more likely (P < 0.05) to have received money for sex (11%) than homosexual (4%) or heterosexual men (4%). This difference was even greater among injecting drug users receiving money for sex: bisexual (29%), homosexual (13%), heterosexual (3%). CONCLUSIONS Demographics and HIV risk behaviors of bisexual men with AIDS differ from those of homosexual and heterosexual men with AIDS. These findings indicate that special efforts are needed to prevent sexual transmission of HIV among bisexual men.

In the search for causes of bronchial asthma in infants and children, tobacco smoke is rarely considered. Therefore the following case report should be of interest. REPORT OF CASE A one year old white male infant was first seen in the office on Oct. 8, 1948, with a history of nasal discharge and asthma for the past 10 days. The delivery of the baby was normal; he was the first child of healthy parents. The mother had a history of urticaria from several foods, and the paternal grandfather had asthma. The baby did well until he was two months of age, when a skin rash was noted which cleared when wool was avoided. The child was breast fed until he was three months of age and was then given evaporated milk. About one week later, diarrhea and croup developed. These subsided in a few days, after a change to evaporated