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Objectives: Bone marrow evaluation plays a critical role in the diagnosis, staging, and monitoring of many diseases. Although there are standardized guidelines for assessing bone marrow specimen quality, there is a lack of evidence-based tools to perform such assessments. The objective was to monitor bone marrow sample quality in real time by standardizing the basic components of a synoptic report and incorporating it into a bone marrow report template., Materials and Methods: A relational database of bone marrow quality parameters was developed and incorporated into our laboratory information system bone marrow report template, with data entry completed during specimen sign out. Data from multiple reports created within a date range were extracted by Structured Query Language query, and summarized in tabular form. Reports generated from these data were utilized in quality improvement efforts., Results: The synoptic reporting system was routinely used to record the quality of bone marrow specimens from adult patients. Data from 3189 bone marrow aspirates, 3302 biopsies, and 3183 biopsy touch imprints identified hemodilution as the principal issue affecting bone marrow aspirate quality, whereas aspiration artifact and fragmentation affected bone marrow biopsy quality., Conclusions: The bone marrow synoptic reporting process was easy to use, readily adaptable, and has proved a useful component of the overall quality assurance process to optimize bone marrow quality., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Pathology Informatics.)

Background: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited., Methods: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership., Results: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition., Conclusions: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.)., (Copyright © 2020 Massachusetts Medical Society.)

D-dimers are formed by the breakdown of fibrinogen and fibrin during fibrinolysis. D-dimer analysis is critical for the diagnosis of deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation. Modern assays for D-dimer are monoclonal antibody based. The enzyme-linked immunosorbent assay (ELISA) is the reference method for D-dimer analysis in the central clinical laboratory, but is time consuming to perform. Recently, a number of rapid, point-of-care D-dimer assays have been developed for acute care settings that utilize a variety of methodologies. In view of the diversity of D-dimer assays used in central laboratory and point-of-care settings, several caveats must be taken to assure the proper interpretation and clinical application of the results. These include consideration of preanalytical variables and interfering substances, as well as patient drug therapy and underlying disease. D-dimer assays should also be validated in clinical studies, have established cut-off values, and reported according to the reagent manufacturers recommendations., (© American Society for Clinical Pathology, 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We compared a lateral flow immunoassay (LFA) to a currently used enzyme immunoassay for detection of cryptococcal antigen in 396 sera and 651 cerebrospinal fluid specimens. We found 97% concordance between the 2 assays. The LFA detected an additional 22 positives. Overall, the LFA had sensitivity of 100% and specificity of 99.6% for the diagnosis of cryptococcosis. The LFA is rapid, accurate, and easy to perform, and it is suitable for routine patient care testing., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Analyses of ownership in the US hospice sector have focused on the growth of for-profit hospice care and on aggregate differences in patient populations and service use patterns between for-profit and not-for-profit agencies. Such comparisons, although useful, do not offer insights about the types of organizations within the hospice sector, including the emergence of multiagency chains. Using Medicare cost report data for the period 2000-11, we tracked the evolution of the US hospice industry. We not only describe the market's composition by profit status but also provide new information about the roles of regional and national chains. Almost half of all Medicare hospice enrollees in 2011 received hospice services from a multiagency chain. A handful of companies play a prominent role, although the presence of smaller for-profit and not-for-profit hospice chains also has grown in recent years. By focusing on the role of the diverse organizations that provide hospice care, our analyses can help inform efforts to monitor and assure quality of care, to assess payment adequacy and options for reform, and to facilitate greater transparency and accountability within the hospice marketplace., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Geographic variations in use of medical services have been interpreted as indirect evidence of wasteful care. Less overuse of services, however, may not be reliably associated with less geographic variation., Objective: To compare average use and geographic variation in use of cancer-related imaging between fee-for-service Medicare and the Department of Veterans Affairs (VA) health care system., Design: Observational analysis of cancer-related imaging from 2003 to 2005 using Medicare and VA utilization data linked to cancer registry data. Multilevel models, adjusted for sociodemographic and tumor characteristics, were used to estimate mean differences in annual imaging use between cohorts of Medicare and VA patients within geographic areas and variation in use across areas for each cohort., Setting: 40 hospital referral regions., Patients: Older men with lung, colorectal, or prostate cancer, including 34,475 traditional Medicare beneficiaries (Medicare cohort) and 6835 VA patients (VA cohort)., Measurements: Per-patient count of imaging studies for which lung, colorectal, or prostate cancer was the primary diagnosis (each study weighted by a standardized price), and a direct measure of overuse-advanced imaging for prostate cancer at low risk for metastasis., Results: Adjusted annual use of cancer-related imaging was lower in the VA cohort than in the Medicare cohort (price-weighted count, $197 vs. $379 per patient; P < 0.001), as was annual use of advanced imaging for prostate cancer at low risk for metastasis ($41 vs. $117 per patient; P < 0.001). Geographic variation in cancer-related imaging use was similar in magnitude in the VA and Medicare cohorts., Limitation: Observational study design., Conclusion: Use of cancer-related imaging was lower in the VA health care system than in fee-for-service Medicare, but lower use was not associated with less geographic variation. Geographic variation in service use may not be a reliable indicator of the extent of overuse., Primary Funding Source: Doris Duke Charitable Foundation and Department of Veterans Affairs Office of Policy and Planning.

Objective: Medicare Advantage prescription drug plans (MA-PDs) and standalone prescription drug plans (PDPs) face different incentives for plan design resulting from the scope of covered benefits (only outpatient drugs for PDPs versus all drug and nondrug services for Medicare Advantage [MA]/MA-PDs). The objective is to begin to explore how MA-PDs and PDPs may be responding to their different incentives related to benefit design., Study Design: We compared 2012 PDP and MA-PD average formulary coverage, prior authorization (PA) or step therapy use, and copayment requirements for drugs in 6 classes used commonly among Medicare beneficiaries., Data: We primarily used 2012 Prescription Drug Plan Formulary and Pharmacy Network Files and MA enrollment data. 2011 Truven Health MarketScan claims were used to estimate drug prices and to compute drug market share. Average coverage and PA/step rates, and average copayment requirements, were weighted by plan enrollment and drug market share., Results: MA-PDs are generally more likely to cover and less likely to require PA/step for brand name drugs with generic alternatives than PDPs, and MA-PDs often have lower copayment requirements for these drugs. For brands without generics, we generally found no differences in average rates of coverage or PA/step, but MA-PDs were more likely to cover all brands without generics in a class., Conclusions: We found modest, confirmatory evidence suggesting that PDPs and MA-PDs respond to different incentives for plan design. Future research is needed to understand the factors that influence Medicare drug plan design decisions.

Importance: Fostering accountability in the Medicare Accountable Care Organization (ACO) programs may be challenging because traditional Medicare beneficiaries have unrestricted choice of health care providers, are attributed to ACOs based on utilization, and often receive fragmented care., Objective: To measure 3 related constructs relevant to ACO incentives and their capacity to manage care: stability of patient assignment, leakage of outpatient care, and contract penetration., Design, Setting, and Participants: Using 2010-2011 Medicare claims and rosters of physicians in organizations participating in ACO programs, we examined these constructs among 524,246 beneficiaries hypothetically assigned to 145 ACOs prior to the start of the Medicare ACO programs. We compared estimates by patient complexity, ACO size, and the primary care orientation of ACO specialty mix., Main Outcomes and Measures: Three related construct measurements: stability of assignment, defined as the proportion of patients whose assignment to an ACO in 2010 was unchanged in 2011; leakage of outpatient care, defined as the proportion of office visits for an assigned population that occurred outside of the contracting organization; and contract penetration, defined as the proportion of Medicare outpatient spending billed by an ACO that was devoted to assigned patients., Results: Of beneficiaries assigned to an ACO in 2010, 80.4% were assigned to the same ACO in 2011. Of those assigned to an ACO in 2010 or 2011, 66.0% were consistently assigned in both years. Unstable assignment was more common among beneficiaries with fewer conditions and office visits but also among those in several high-cost categories, including the highest decile of per-beneficiary spending. Among ACO-assigned beneficiaries, 8.7% of office visits with primary care physicians were provided outside of the assigned ACO, and 66.7% of office visits with specialists were provided outside of the assigned ACO. Leakage of outpatient specialty care was greater for higher-cost beneficiaries and substantial even among specialty-oriented ACOs (54.6% for lowest quartile of primary care orientation). Of Medicare spending on outpatient care billed by ACO physicians, 37.9% was devoted to assigned beneficiaries. This proportion was higher for ACOs with greater primary care orientation (60.0% for highest quartile vs 33.6% for lowest)., Conclusions and Relevance: Care patterns among beneficiaries served by ACOs suggest distinct challenges in achieving organizational accountability in Medicare. Continued monitoring of these patterns may be important to determine the regulatory need for enhancing ACOs' incentives and their ability to improve care efficiency.

An outbreak of fungal infections has been identified in patients who received epidural injections of methylprednisolone acetate that was contaminated with environmental molds. In this report, we present the mycological and histopathological findings in an index case of Exserohilum meningitis and vasculitis in an immunocompetent patient, who received a cervical spine epidural steroid injection for chronic neck pain 1 week before the onset of fulminant meningitis with subsequent multiple brain and spinal cord infarcts. The fungus was recovered from two separate cerebrospinal fluid specimens collected before initiation of antifungal therapy and at autopsy on standard bacterial and fungal culture media. The mold was identified phenotypically as Exserohilum species. DNA sequencing targeting the internal transcribed spacer region and D1/D2 region of 28S ribosomal DNA enabled further speciation as E. rostratum. Gross examination at autopsy revealed moderate brain edema with bilateral uncal herniation and a ventriculostomy tract to the third ventricle. The brainstem, cerebellum, and right orbitofrontal cortex were soft and friable, along with hemorrhages in the cerebellar vermis and thalamus. Microscopic examination demonstrated numerous fungi with septate hyphae invading blood vessel walls and inducing acute necrotizing inflammation. The leptomeninges were diffusely infiltrated by mixed inflammatory cells along with scattered foci of fungal elements. This is the first report of iatrogenic E. rostratum meningitis in humans. This report describes the microbiological procedures and histopathological features for the identification of E. rostratum (a pigmented vascularly invasive fungi), the cause of a current nationwide outbreak of fatal fungal meningitis.

Chronic recurrent multifocal osteomyelitis (CRMO) is an aseptic inflammatory disorder of unknown cause occurring in children and adolescents. It is characterized by multifocal bone lesions with pain and swelling recurring over months to years. Lesions usually involve the metaphyses of the long bones and involvement of the jaw is rare. The clinical presentation, radiographic appearance and histology of a case of CRMO involving the mandible in an 8-year-old girl are documented. The radiographic appearance of another three cases is also described.

Hyperion, Saturn's eighth largest icy satellite, is a body of irregular shape in a state of chaotic rotation. The surface is segregated into two distinct units. A spatially dominant high-albedo unit having the strong signature of H2O ice contrasts with a unit that is about a factor of four lower in albedo and is found mostly in the bottoms of cup-like craters. Here we report observations of Hyperion's surface in the ultraviolet and near-infrared spectral regions with two optical remote sensing instruments on the Cassini spacecraft at closest approach during a fly-by on 25-26 September 2005. The close fly-by afforded us the opportunity to obtain separate reflectance spectra of the high- and low-albedo surface components. The low-albedo material has spectral similarities and compositional signatures that link it with the surface of Phoebe and a hemisphere-wide superficial coating on Iapetus.

Remote sensing of the surface of Europa with near-infrared instruments has suggested the presence of hydrated materials, including sulfate salts. Attention has been focused on these salts for the information they might yield regarding the evolution of a putative interior ocean, and the evaluation of its astrobiological potential. These materials exhibit distinct infrared absorption features due to bound water. The interactions of this water with the host molecules lead to fine structure that can be used to discriminate among these materials on the basis of their spectral behavior. This fine structure is even more pronounced at the low temperatures prevalent on icy satellites. Examination of hydrated sulfate salt spectra measured under cryogenic temperature conditions provides realistic constraints for future remote-sensing missions to Europa. In particular, it suggests that a spectrometer system capable of 2-5 nm spectral resolution or better, with a spatial resolution approaching 100 m, would be able to differentiate among proposed hydrated surface materials, if present, and constrain their distributions across the surface. Such information would provide valuable insights into the evolutionary history of Europa.

The possibility of an ocean within the icy shell of Jupiter's moon Europa has established that world as a primary candidate in the search for extraterrestrial life within our Solar System. This paper evaluates the potential to detect evidence for microbial life by comparing laboratory studies of terrestrial microorganisms with measurements from the Galileo Near Infrared Imaging Spectrometer (NIMS). If the interior of Europa at one time harbored life, some evidence may remain in the surface materials. Examination of laboratory spectra of terrestrial extremophiles measured at cryogenic temperatures reveals distorted, asymmetric nearinfrared absorption features due to water of hydration. The band centers, widths, and shapes of these features closely match those observed in the Europa spectra. These features are strongest in reddish-brown, disrupted terrains such as linea and chaos regions. Narrow spectral features due to amide bonds in the microbe proteins provide a means of constraining the abundances of such materials using the NIMS data. The NIMS data of disrupted terrains exhibit distorted, asymmetric near-infrared absorption features consistent with the presence of water ice, sulfuric acid octahydrate, hydrated salts, and possibly as much as 0.2 mg cm(-3) of carbonaceous material that could be of biological origin. However, inherent noise in the observations and limitations of spectral sampling must be taken into account when discussing these findings.

Spatially resolved infrared and ultraviolet wavelength spectra of Europa's leading, anti-jovian quadrant observed from the Galileo spacecraft show absorption features resulting from hydrogen peroxide. Comparisons with laboratory measurements indicate surface hydrogen peroxide concentrations of about 0.13 percent, by number, relative to water ice. The inferred abundance is consistent with radiolytic production of hydrogen peroxide by intense energetic particle bombardment and demonstrates that Europa's surface chemistry is dominated by radiolysis.

1. The solubility of d-valine in water has been determined over a range of 0-60 degrees . 2. The solubility of this amino acid varies with the mode of crystallization, indicating a dependence of solubility on the crystal form.