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Background: An extensive quest for genetic variables impacting the susceptibility for T2DM and other cardiometabolic disorders has been sparked by the global growth in the frequency of those widespread ailments. In Egypt, no previous studies examined the relation between KLF14 rs972283 SNP and the risk of developing T2DM. This study aims to ascertain the genetic influences of KLF14 rs972283 on T2DM in Egypt. Subjects and methods: This study included 50 diabetic patients and 50 healthy subjects. Each individual underwent a clinical assessment and total body examination, laboratory investigations including liver enzymes, FBS, HbA1C, and lipid profile. The DNA Purification Kit was used to separate genomic DNA from the whole blood. Gene polymorphism was detected via the PCR-REFLP method. Results: There was no association between KLF14 (rs972283) gene polymorphism and T2DM among studied people. The distribution of KLF14 rs972283 genotypes in diabetic cases was 9 patients with GG genotype (18%) and 26 with GA (52%) while 15 patients (30%) had homozygous mutant genotype AA. However, in the control group, 7 healthy cases had the GG genotype (14%), 31 (62%) had the GA genotypes, and 12 (24%) had the AA genotype. Concerning the allele frequency, the A allele in the KLF14 rs972283 polymorphism was more frequent in both diabetic and control cases (56% and 55%; respectively), but without significant difference (P=0.887). Conclusion: The present study shows for the first time that rs972283 SNP of the KLF14 gene was not associated with T2DM susceptibility in the Egyptian population. However, this study detects an association between KLF14 rs972283 (GG genotype) and a higher risk for elevated TG and LDL levels in control cases. This could indicate that the presence of the GG genotype even in control cases could be used to predict cardiovascular disease.

Background: Liver inflammation is deliberated a risk factor for the ongoing liver damage including non-alcoholic steatohepatitis, cirrhosis, and hepatoma. CD14, an effectual mediator for the monocytes activation, has been postulated as a marker of liver inflammation and fibrosis. This study is constructed to detect the alterations in the CD14 serum levels in 40 NAFLD cases and 14 healthy controls along with to analyze the role of CD14 polymorphisms in the causation and severity of Non-Alcoholic Fatty Liver Disease (NAFLD). Liver enzymes, glycated hemoglobin, together with lipid profile were estimated in all included subjects. The diagnosis of NAFLD depends largely on ultrasonography. NAFLD fibrosis score and FIB-4 score were calculated. Serum CD14 was quantified by EnzymeLinked Immunosorbent Assay (ELISA) and C14-159C/T SNP was genotyped via Polymerase Chain Reaction (PCR) and Restriction Fragment Length Polymorphisms (RFLP). Results: Serum CD14 was markedly higher in the diabetic subjects either lean or overweight/obese than the controls (P0.676 (P=1.000). Conclusion: The former observations advocate the potential role of CD14 in both the pathogenesis and progression of NAFLD. Yet, it didn't correlate with the NFS, consequently it couldn't forecast the severity of the disease. Furthermore, no association was distinguished linking CD14 C-(159) T polymorphism and the risk of NAFLD occurrence.

In 2019, the COVID-19 pandemic emerged. Variation in COVID-19 patient outcomes between hospitals was later reported.This study aims to determine whether sustainers-hospitals with sustained high performance on Hospital Value-Based Purchasing Total Performance Score (HVBP-TPS)-more effectively responded to the pandemic and therefore had better patient outcomes.We calculated hospital-specific risk-standardized event rates using deidentified patient-level data from the UnitedHealth Group Clinical Discovery Database. HVBP-TPS from 2016 to 2019 were obtained from Centers for MedicareMedicaid Services. Hospital characteristics were obtained from the American Hospital Association Annual Survey Database (2019), and county-level predictors were obtained from the Area Health Resource File. We use a repeated-measures regression model assuming an AR(1) type correlation structure to test whether sustainers had lower mortality rates than nonsustainers during the first wave (spring 2020) and the second wave (October to December 2020) of the pandemic.Sustainers did not have significantly lower COVID-19 mortality rates during the first wave of the pandemic, but they had lower COVID-19 mortality rates during the second wave compared to nonsustainers. Larger hospitals, teaching hospitals, and hospitals with higher occupancy rates had higher mortality rates.During the first wave of the pandemic, mortality rates did not differ between sustainers and nonsustainers. However, sustainers had lower mortality rates than nonsustainers in the second wave, most likely because of their knowledge management capabilities and existing structures and resources that enable them to develop new processes and routines to care for patients in times of crisis. Therefore, a consistently high level of performance over the years on HVBP-TPS is associated with high levels of performance on COVID-19 patient outcomes.Investing in identifying the knowledge, processes, and resources that foster the dynamic capabilities needed to achieve superior performance in HVBP might enable hospitals to utilize these capabilities to adapt more effectively to future changes and uncertainty.

Suzan Gad,1 Mohamed M Sheta,2 Abeer I Al-khalafawi,3 Heba A Abu El-Fadl,1 Maha Anany,1 Shaimaa Sahmoud,1 Mona Karem Amin1 1Pediatrics and Neonatology Department, Suez Canal University Faculty of Medicine, Ismailia, Egypt; 2Pediatrics and Neonatology Department, Mansoura General Hospital, Mansoura, Egypt; 3Neonatology Department, Saqr Hospital, MOH, Ras Alkheima, United Arab EmiratesCorrespondence: Mohamed M ShetaPediatrics and Neonatology Department, Mansoura General Hospital, Mansoura, EgyptTel +971-559-865-166Email sheta99999@yahoo.comBackground: The health benefits of breastfeeding are well known. However, some ill babies including those admitted to the neonatal intensive care unit (NICU) cannot be directly breastfed. In this situation, expressed breast milk (EBM) can be used. However, breast milk is not always sterile and may be contaminated by many microorganisms. EBM contamination is probably attributed to improper technical and hygienic factors and may pose significant threats to the newborn baby. The present study aimed to document the prevalence of EBM contamination in NICU and to uncover the relevant risk factors.Subjects and Methods: The study included 118 mothers who could express breast milk for their own neonates admitted to the NICU. A checklist was used to document the steps the mothers followed during expression of milk and all steps of handling until the EBM reached the NICU. A 1 mL sample of EBM was obtained and sent to the microbiology laboratory within 20 minutes. Data obtained from the present study are expressed as number and percentage or mean ± standard deviation (SD). Statistical calculations were computed using SPSS 25.Results: In the present study, 106 (89.8%) out of the assessed 118 EBM samples were contaminated. Hygienic factors related to EBM contamination included hand only wash, possible recontamination of hands during turning taps off, lack of using cotton pads or cloth piece on nipple and breast cleaning by water only. Other factors related to EBM contamination included container cleaning by water only, fresh milk refrigeration after > 4 hours, adding freshly expressed warm breast milk to refrigerated milk expressed earlier in the same day, milk transport in plastic bags with ice packs and longer transportation time. In the contaminated samples, the most commonly isolated organisms included Staphylococcus aureus (55.7%),Staphylococcus epidermidis (21.7%) and Enterobacter (11.6%).Conclusion: The present study identified bacterial contamination in about 90% of EBM samples delivered to NICU infants. Factors related to EBM contamination include hygienic, storage and transport factors.Keywords: breastfeeding, expressed breast milk, NICU

Most of the published experiments about carbimazole (CMZ)-induced testicular injury are constructed in normal healthy animals, which lakes the translational identification. Despite metformin (MET) having advantageous effects on injured testicles, its impact on thyroid function is arguable. In the current levothyroxine (LT4)/CMZ model, Wistar rats were primed by LT4 for sixty days. CMZ was then given individually or simultaneously with different doses of MET, 100, 200, and 400 mg, daily for thirty days. Serum was assessed for thyroid profile panel, sex hormones, and gonadotropin levels. Testicular tissues were examined for steroidogenesis, spermatogenesis, inflammation, and apoptosis. Histopathology of thyroid and testes were examined, besides thyroidal nuclear factor (NF)-kB expression. MET in a dose-response manner improved the LT4/CMZ-induced testicular toxicity by increasing the steroidogenic acute regulatory protein (StAR), and 17-β-hydroxysteroid dehydrogenase (17βHSD) activities, the proliferating cell nuclear antigen (PCNA), sperm count and motility, sex hormones, and gonadotropin levels. MET-400 mg markedly decreased the elevated NF-kB expressions, tumour necrosis factor (TNF)-α, caspase-3, and BAX, and increased BCL-2. LT4/CMZ could be used as translational animal modelling. MET displayed a dose-dependent ameliorative effect on the LT4/CMZ model without significant harmful effects on thyroid functions. MET-testicular protective roles in diabetics with thyroidal diseases should be explored.

Objective: To assess the BMI among children with Growth Hormone Deficiency (GHD) and Idiopathic Short Stature (ISS) and its correlation to ghrelin, Growth Hormone (GH), and Insulin-like Growth Factor-1 (IGF-1) levels. Methods: A cross-sectional descriptive study in which 42 patients attending the Pediatric endocrine clinic were enrolled, allocated into two groups: group I: GHD children; group II: ISS children. Ghrelin, IGF-1 and GH in both groups were measured. Results: Ghrelin was significantly higher among GHD group (p < 0.001). Overall, there was a strong negative correlation between IGF-1 and ghrelin (r = -0.977, p-value = < 0.001) while a moderate positive correlation between ghrelin and BMI (r = 0.419, p-value = 0.006). There was a weak positive non-significant correlation between IGF-1 and BMI (r = 0.276, p-value = 0.077). In GHD group, there was a weak positive non-significant correlation between ghrelin and GHmax measurement (r = 0.052, p-value = 0.824), while a weak negative non-significant correlation between both variables in ISS group (r = -0.243, p-value = 0.288). In GHD group, there was a moderate positive correlation between ghrelin and BMI (r = 0.500, p-value = 0.021), but weak negative non-significant correlation between both variables in ISS group (r = -0.255, p-value = 0.265). Conclusion: There was a negative feedback loop between ghrelin and IGF-1, whereas a positive feedback between ghrelin and BMI. BMI was more affected in the ISS group but was non-signifi-cantly correlated with ghrelin. There was no significant compensatory response of ghrelin suggesting its contribution to the pathogenesis of ISS.

This article examines the relationship between hospital profitability and efficiency. A cross-section of 1317 U.S. metropolitan, acute care, not-for-profit hospitals for the year 2015 was employed. We use a frontier method, stochastic frontier analysis, to estimate hospital efficiency. Total margin and operating margin were used as profit variables in OLS regressions that were corrected for heteroskedacity. In addition to estimated efficiency, control variables for internal and external correlates of profitability were included in the regression models. We found that more efficient hospitals were also more profitable. The results show a positive relationship between profitability and size, concentration of output, occupancy rate and membership in a multi-hospital system. An inverse relationship was found between profits and academic medical centers, average length of stay, location in a Medicaid expansion state, Medicaid and Medicare share of admissions, and unemployment rate. The results of a Hausman test indicates that efficiency is exogenous in the profit equations. The findings suggest that not-for-profit hospitals will be responsive to incentives for increasing efficiency and use market power to increase surplus to pursue their objectives.

Background Carob (Ceratonia siliqua L.) is one of the important crops in terms of nutritional and medicinal value in the countries of Western Asia and North Africa. Despite the fact that some countries have used Carob in traditional medicines, the modern food industry began to discover the great potential of this plant which differentiates with antioxidant capacity as well as other important medicinal activities. Some of very few studies that have been reported on this important plant were published. Methodology In the present study, micropropagation behavior and biochemical constituents of Ceratonia siliqua L. cultured on MS medium supplemented with different types and concentrations of cytokinins (0.0, 0.5, 1.0, or 1.5 mg/l BA, Kin, or TDZ and 0.2 mg/l NAA) under various light qualities ((white, green, blue, red, and yellow) were examined. Results MS culture medium supplemented with BA produced the highest shootlets number/explants. For light quality, the data showed that green light increased shootlet number/explants, fresh and dry weights. However, yellow light increased shootlet length and leaves number and also caused significant increase in total phenols, flavonoids, and antioxidant capacity (DPPH) as compared to other lights. HPLC analysis showed that yellow light caused the highest accumulation of total phenolic and catechin that were the highest accumulated compounds (509 μg/ml) followed by that were accumulated under green light (412.68 μg/ml). Shootlets grown under white light (control) gave the highest accumulation of p-coumaric acid, rosmarinic acid, and cinnamic acid. Shootlets grown under blue light gave the highest accumulation of gentisic acid and syringic acid. Red light caused the highest accumulation of vanillic acid. However, white light accumulated the highest amount of flavonoid compounds comparing with other light qualities. Conclusion This study had reached to optimize a suitable micropropagation protocol of Ceratonia siliqua L. and characterization of biochemical constituents that can be beneficial for increasing its medical value which will help in food industries for commercial purposes.

Background. The prevalence of childhood obesity has been increasing worldwide. This may explain the emergence of nonalcoholic fatty liver as the leading cause of liver disease. Several previous studies have addressed the association between thyroid function and nonalcoholic fatty liver disease. Objectives. To study the impact of weight reduction through lifestyle modifications in adolescents with obesity. Methods. A prospective cohort study was done on 61 adolescents with obesity. Patients were evaluated at the first visit by the full history, clinical examination, and investigations (thyroid profile, lipid profile, liver function tests, HbA1c, and liver ultrasonography) as basal information. The intervention program included a dietary program, increasing physical activity, and decreasing sedentary activity. A postintervention evaluation was done at the end of six months which included anthropometric measures, laboratory results, and ultrasonographic estimation. Results. It was shown that the mean BMI of the participants had significantly decreased after lifestyle modification from (32.05 ± 3.36 kg/m2) to (28.1 ± 2.77 kg/m2) ( P < 0.001 ). It also showed that the percentage of studied adolescents with elevated TSH decreased from 47.5% to 19.7% after the weight reduction program. Improvement was also achieved in the lipid profile and liver functions. The percentage of studied adolescents with ultrasound appearance of NAFLD decreased from 31.1% to 26.2% after weight reduction. Conclusions. Lifestyle modification positively influences the metabolic derangement in obesity without medical treatment. ΔTSH is a significant predictor of the change in BMI z-score. It is also possible that hepatic steatosis affects thyroid function rather than the other way around.

Objective This study aims to investigate the relationship between RNs and hospital-based medical specialties staffing levels with inpatient COVID-19 mortality rates. Methods We relied on data from AHA Annual Survey Database, Area Health Resource File, and UnitedHealth Group Clinical Discovery Database. In phase 1 of the analysis, we estimated the risk-standardized event rates (RSERs) based on 95,915 patients in the UnitedHealth Group Database 1,398 hospitals. We then used beta regression to analyze the association between hospital- and county- level factors with risk-standardized inpatient COVID-19 mortality rates from March 1, 2020, through December 31, 2020. Results Higher staffing levels of RNs and emergency medicine physicians were associated with lower COVID-19 mortality rates. Moreover, larger teaching hospitals located in urban settings had higher COVID-19 mortality rates. Finally, counties with greater social vulnerability, specifically in terms of housing type and transportation, and those with high infection rates had the worst patient mortality rates. Conclusion Higher staffing levels are associated with lower inpatient mortality rates for COVID-19 patients. More research is needed to determine appropriate staffing levels and how staffing levels interact with other factors such as teams, leadership, and culture to impact patient care during pandemics.

ObjectiveThis study aims to investigate the relationship between registered nurses and hospital-based medical specialties staffing levels with inpatient COVID-19 mortality rates.MethodsWe rely on data from AHA Annual Survey Database, Area Health Resource File, and UnitedHealth Group Clinical Discovery Database. We use linear regression to analyze the association between hospital staffing levels and bed capacity with inpatient COVID-19 mortality rates from March 1, 2020, through December 31, 2020.ResultsHigher staffing levels of registered nurses, hospitalists, and emergency medicine physicians were associated with lower COVID-19 mortality rates. Moreover, a higher number of ICU and skilled nursing beds were associated with better patient outcomes. Hospitals located in urban counties with high infection rates had the worst patient mortality rates.ConclusionHigher staffing levels are associated with lower inpatient mortality rates for COVID-19 patients. A future assessment is needed to establish benchmarks on the minimum staffing levels for nursing and hospital-based medical specialties during pandemics.

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Currently, there are many membrane separation technologies that have been attracted growing interest in dyes removal from water streams and wastewater. In this chapter, we focus on nanofiltration (NF). In comparison with the available membrane techniques, NF is deemed to be the most promising technique due to its higher dye rejection, lower energy consumption, and higher antifouling properties. However, the challenge for feasible NF membranes with enhanced permeate flux, selectivity, and higher antifouling properties is remaining in the commonly used polymeric NF membranes. Therefore, numerous methods have been recently adopted by incorporating specific fillers into the polymeric membranes to fill in these gaps. We investigate the recent types of NF modified membranes based on their merits and limitations. Furthermore, the models of spiral wound NF for dyes removal are presented to explain the underlying mechanisms. Hence, this chapter may help the decision-makers to select the suitable membrane technology for the dye treatment removal using NF-based membranes.

Purpose The purpose of this article was to investigate the organizational and market-level variables associated with sustained superior hospital performance on Value-Based Purchasing total performance scores (TPS). Methodology TPS for 2014 through 2017 was obtained from the Centers for Medicare & Medicaid Services Hospital Compare website. Market-level data were from the 2017 Area Health Resource File, and hospital-level data were from the 2014 American Hospital Association Annual Survey database. We specified a logistic regression model to identify significant predictors of hospitals with sustained superior performance on TPS, that is, "sustainers." Principal findings Only 8.4% of hospitals were classified as sustainers. Hospitals located in rural markets with a high Medicare Advantage penetration had a higher likelihood of being classified as sustainers. High RN staffing levels, lower Medicare share of inpatient days, not-for-profit ownership, and small size were all significant organizational predictors of sustained superior performance. Conclusions Both modifiable characteristics, such as nurse staffing levels, and nonmodifiable characteristics, such as rural markets and small hospital size, are associated with the likelihood of hospitals sustaining superior performance over time. Practice implications Managers need to carefully examine their staffing levels as they pursue interventions to sustain high TPS overtime. Moreover, factors such as Medicare share of inpatient days and size need to be considered when understanding barriers to sustained performance on Value-Based Purchasing domains.

Objective (or study question) To examine the association between hospitalists staffing levels and contract type with CMS Total Performance Score (TPS). Data sources/study setting Total performance scores were obtained from CMS, hospital-level data from the 2015 American Hospital Association Annual Survey Database, and unemployment rates from the Area Resource Health File. Study design We used cluster analysis to classify hospitals based on the distribution of various hospitalist contracts, and we used regression analysis to examine the association between TPS and hospitalist staffing levels and contract distributions. Hospital-level predictors included hospitalists staffing levels, RN staffing levels, and Magnet status. Market-level variables were unemployment rates and competition. Principal findings Higher staffing levels of employed hospitalists or hospitalists with a group contract are associated with higher TPS (with coefficient estimates of 0.85 and 0.83, respectively, and the same standard error of 0.22). Higher staffing levels of hospitalists under individual contract are negatively associated with TPS (with coefficient estimate of -0.43 and standard error of 0.21). Based on the regression analysis using hospital clusters as independent variables, hospitals with individual contracts or without hospitalists providing care had significantly worse TPS compared to hospitals that predominantly employ hospitalists (with coefficient estimate of -1.80 and standard error of 0.61). Magnet status, RN staffing levels, and small and medium size were positively associated with TPS. Medicare share of inpatient days, teaching status, AMCs, and for-profit and public nonfederal ownership were negatively associated with TPS. Conclusions Adequate hospitalist staffing level is important for hospitals to achieve better performance. Hospitals need to consider the mix of arrangements or contracts that they have with hospitalists.

The Chemically enhanced process is considered to be a physicochemical technology for domestic wastewater treatment. The objective of this paper is to improve the efficiency of primary treatment processes and reducing the Hazardous Material and cost of the secondary treatment stage either by eliminating a biological treatment, where conditions and standards allow or by reducing the secondary treatment requirements. Analysis of physicochemical parameters as well as the treatment efficiency of aluminum sulfate (alum), ferric chloride (FeCl3), lime (CaO), and seawater was used. The effect of pH and the coagulant dosages were studied as well as mixing and settling time. Conditions were optimized according to the removal efficiencies measured in terms of reduction in the concentration of total suspended solids (TSS), biological oxygen demand (BOD5), and chemical oxygen demand (COD). The optimum COD removal % was achieved at a settling time of 20 minutes, while at pH~6, alum gave a high turbidity % removal of approximately 90% at the dose of 70 mg/l. FeCl3 gave a high turbidity % removal of approximately 95% at the dose of 40 mg/l. Turbidity removal and TSS removal gave a similar pattern at a settling time of 10-20 minutes, where best results were achieved. The results also showed that at pH~4, FeCl3 gave high COD% removal of approximately 90% at the dose of 40 mg/l. By studying the effect of stirrers’ speed (rpm), the results showed that an increase in the mixing intensity, above 80 rpm decreases the removals of COD, Turbidity and TSS when using alum as a coagulant.

The Chemically enhanced process is considered to be a physicochemical technology for domestic wastewater treatment. The objective of this paper is to improve the efficiency of primary treatment processes and reducing the Hazardous Material and cost of the secondary treatment stage either by eliminating a biological treatment, where conditions and standards allow or by reducing the secondary treatment requirements. Analysis of physicochemical parameters as well as the treatment efficiency of aluminum sulfate (alum), ferric chloride (FeCl3), lime (CaO), and seawater was used. The effect of pH and the coagulant dosages were studied as well as mixing and settling time. Conditions were optimized according to the removal efficiencies measured in terms of reduction in the concentration of total suspended solids (TSS), biological oxygen demand (BOD5), and chemical oxygen demand (COD). The optimum COD removal % was achieved at a settling time of 20 minutes, while at pH~6, alum gave a high turbidity % removal of approximately 90% at the dose of 70 mg/l. FeCl3 gave a high turbidity % removal of approximately 95% at the dose of 40 mg/l. Turbidity removal and TSS removal gave a similar pattern at a settling time of 10-20 minutes, where best results were achieved. The results also showed that at pH~4, FeCl3 gave high COD% removal of approximately 90% at the dose of 40 mg/l. By studying the effect of stirrers’ speed (rpm), the results showed that an increase in the mixing intensity, above 80 rpm decreases the removals of COD, Turbidity and TSS when using alum as a coagulant.

ObjectiveThis study sought to understand the relationship of hospital performance with high-level electronic medical record (EMR) adoption, hospitalists staffing levels, and their potential interaction.Materials and methodsWe evaluated 2,699 non-federal, general acute hospitals using 2016 data merged from four data sources. We performed ordinal logistic regression of hospitals’ total performance score (TPS) on their EMR capability and hospitalists staffing level while controlling for other market- and individual-level characteristics.ResultsHospitalists staffing level is shown to be positively correlated with TPS. High-level EMR adoption is associated with both short-term and long-term improvement on TPS. Large, urban, non-federal government hospitals, and academic medical centers tend to have lower TPS compared to their respective counterparts. Hospitals belonging to medium- or large-sized healthcare systems have lower TPS. Higher registered nurse (RN) staffing level is associated with higher TPS, while higher percentage of Medicare or Medicaid share of inpatient days is associated with lower TPS.DiscussionAlthough the main effects of hospitalists staffing level and EMR capability are significant, their interaction is not, suggesting that hospitalists and EMR act through separate mechanisms to help hospitals achieve better performance. When hospitals are not able to invest on both simultaneously, given financial constraints, they can still reap the full benefits from each.ConclusionHospitalists staffing level and EMR capability are both positively correlated with hospitals’ TPS, and they act independently to bolster hospital performance.

Background and aim Vitamin D is essential for growth, development, and health. It works as a paracrine and autocrine signaling molecule that affects nearly all systems in the body. Vitamin-D deficiency (VDD) may be overlooked due to the variable clinical presentations. This study was conducted to assess vitamin-D status among children and adolescents, and to find out predictors for its deficiency/insufficiency among the studied groups. Patients and methods A cross-sectional analytical study was conducted on 88 patients (47 children and 41 adolescents). All participants were subjected to history, clinical examination, and estimation of serum vitamin D, alkaline phosphatase, calcium, and phosphorous levels. The patients were divided into four groups according to serum vitamin-D level: severely deficient less than 10 ng/ml, deficient 10–less than 20 ng/ml, insufficient 20–30 ng/ml, and sufficient vitamin D more than 30 ng/ml. Results VDD was prevalent in the studied group, where 58% of them showed VDD and 25% showed insufficiency. Children showed 8.6% severe deficiency, 46.8% deficiency, and 31.9% insufficiencies. The adolescents showed 21.1% severe deficiency, 48.8% deficiency, and 17.7% insufficiency. Muscle cramps were significant among children only. Multivariable linear-regression analysis revealed that BMI (P=0.01) and fast food (P=0.016) were associated with the increased risk of deficiency. Conclusions VDD and insufficiency are prevalent in Egyptian children and adolescents among both sexes. The severity of deficiency is associated with muscle cramps. Vitamin-D status was affected by increased BMI and fast-food intake.

The quality of physician-patient communication influences patient health outcomes and satisfaction with healthcare delivery. Yet, little is known about contextual factors that influence physicians' communication with their patients. The main purpose of this article is to examine organizational-level factors that influence patient perceptions of physician communication in inpatient settings. We used the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and American Hospital Association data to determine patients' ratings of physician communication at the hospital level, and to collect information about hospital-level factors that can potentially influence physician communication. Our sample consisted of 2,756 hospitals. We ran a regression analysis to determine the predictors of poor physician communication, measured as the percentage of patients in a hospital who reported that physicians sometimes or never communicated well. In our sample of hospitals, this percentage ranged between 0% and 21%, with 25% of hospitals receiving poor ratings from more than 6% of patients. Three organizational factors had statistically significant negative associations with physician communication: for-profit ownership, hospital size, and hospitalists providing care in the hospital, On the other hand, the number of full-time-equivalent physicians and dentists per 10,000 inpatient days, physician ownership of the hospital, Medicare share of inpatient days, and public ownership were positively associated with patients' ratings of physician communication. Physician staffing levels are an understudied area in healthcare research. Our findings indicate that physician staffing levels affect the quality of physician communication with patients. Moreover, for-profit and larger hospitals should invest more in physician communication given the role that HCAHPS plays in value-based purchasing.

Splenic tuberculosis (splenic TB) is extremely rare. It is likely to be misdiagnosed as carcinoma of spleen, splenic abscess, lymphoma, or others. The misdiagnosis rate is high if there is no tuberculosis history in other organs. We came across a case of 27 years old immunocompetent female from good socioeconomic background who presented with weight loss and pain in left hypochondriac region. Ultrasonography of abdomen revealed multiple hypo echoic lesions in the spleen. MRI chest and abdomen revealed multiple splenic focal lesions with no contrast enhancement and well defined mass in the posterior mediastinum. Splenectomy was performed and sample was sent for histopathological examination and also microbiological analysis. Microscopic examination revealed splenic tissue with multiple variable sized granulomas showing epithelial cells, lymphocytes and Langhan’s giant cells, the larger one showed wide necrosis with nuclear debris and suppuration together with focal increase in plasma cells. This was consistent with the diagnosis of Mycobacterial infection with MRI finding of only mediastinal lymph node involvement in the lungs.

Background Hispanics comprise 17% of the total U.S. population, surpassing African-Americans as the largest minority group. Linguistically, almost 60 million people speak a language other than English. This language diversity can create barriers and additional burden and risk when seeking health services. Patients with Limited English Proficiency (LEP) for example, have been shown to experience a disproportionate risk of poor health outcomes, making the provision of Language Services (LS) in healthcare facilities critical. Research on the determinants of LS adoption has focused more on overall cultural competence and internal managerial decision-making than on measuring LS adoption as a process outcome influenced by contextual or external factors. The current investigation examines the relationship between state policy, service area factors, and hospital characteristics on hospital LS adoption. Methods We employ a cross-sectional analysis of survey data from a national sample of hospitals in the American Hospital Association (AHA) database for 2011 (N= 4876) to analyze hospital characteristics and outcomes, augmented with additional population data from the American Community Survey (ACS) to estimate language diversity in the hospital service area. Additional data from the National Health Law Program (NHeLP) facilitated the state level Medicaid reimbursement factor. Results Only 64%of hospitals offered LS. Hospitals that adopted LS were more likely to be not-for-profit, in areas with higher than average language diversity, larger, and urban. Hospitals in above average language diverse counties had more than 2-fold greater odds of adopting LS than less language diverse areas [Adjusted Odds Ratio (AOR): 2.26, P< 0.01]. Further, hospitals with a strategic orientation toward diversity had nearly 2-fold greater odds of adopting LS (AOR: 1.90, P< 0.001). Conclusion Our findings support the importance of structural and contextual factors as they relate to healthcare delivery. Healthcare organizations must address the needs of the population they serve and align their efforts internally. Current financial incentives do not appear to influence adoption of LS, nor do Medicaid reimbursement funds, thus suggesting that further alignment of incentives. Organizational and system level factors have a place in disparities research and warrant further analysis; additional spatial methods could enhance our understanding of population factors critical to system-level health services research.

Understanding patient perceptions of hospital encounters is crucial for the continuous efforts to improve quality of care in the United States. Abundant research has examined the influence of different service process dimensions on customer satisfaction, but scant research has explored how the organizational context affects customer perceptions of service providers. The authors propose a more comprehensive model of customer satisfaction that moves beyond the service process to incorporate organizational and market factors that affect customer experiences directly and indirectly through their influence on the service process. Three organizational and market factors lie at the center of the health care debate: physician ownership, hospital specialization, and market competition. The authors employ the Hospital Consumer Assessment of Healthcare Providers and Systems to determine patient ratings and the American Hospital Association Annual Survey to determine organizational and market factors. The results show that physician ownership, specialization, and market competition positively affect patient ratings. Dimensions of the service process act as a mediator between organizational and market factors and patient ratings. This study provides new insights into the importance of including both organizational and market factors and service process dimensions when examining customer ratings and offers implications for governance and strategy in service organizations.

In this article, we investigate the diversity of healthcare delivery organizations by comparing the market determinants of hospitals entry rates with those of ambulatory surgery centers (ASCs). Unlike hospitals, ASCs is one of the growing populations of specialized healthcare delivery organizations. There are reasons to believe that firm entry patterns differ within growing organizational populations since these markets are characterized by different levels of organizational legitimacy, technological uncertainty, and information asymmetry. We compare the entry patterns of firms in a mature population of hospitals to those of firms within a growing population of ASCs. By using patient-level datasets from the state of Florida, we break down our explanatory variables by facility type (ASC vs. hospital) and utilize negative binomial regression models to evaluate the impact of niche density on ASC and hospital entry. Our results indicate that ASCs entry rates is higher in markets with overlapping ASCs while hospitals entry rates are less in markets with overlapping hospitals and ASCs. These results are consistent with the notion that firms in growing populations tend to seek out crowded markets as they compete to occupy the most desirable market segments while firms in mature populations such as general hospitals avoid direct competition.

Background Hospitals facing financial uncertainty have sought to reduce nurse staffing as a way to increase profitability. However, nurse staffing has been found to be important in terms of quality of patient care and nursing-related outcomes. Nurse staffing can provide a competitive advantage to hospitals and as a result of better financial performance, particularly in more competitive markets. Purpose In this study, we build on the Resource-Based View of the Firm to determine the effect of nurse staffing on total profit margin in more competitive and less competitive hospital markets in Florida. Methodology/approach By combining a Florida statewide nursing survey with the American Hospital Association Annual Survey and the Area Resource File, three separate multivariate linear regression models were conducted to determine the effect of nurse staffing on financial performance while accounting for market competitiveness. The analysis was limited to acute care hospitals. Findings Nurse staffing levels had a positive association with financial performance (β = 3.3, p = .02) in competitive hospital markets, but no significant association was found in less competitive hospital markets. Practice implications Hospitals in more competitive hospital markets should reconsider reducing nursing staff, as these cost-cutting measures may be inefficient and negatively affect financial performance.

Introduction: Recent research has shown that microRNAs (miRNA) are emerging as important regulators of cellular differentiation. The miR-122 accounts for approximately 70% of all miRNAs in the liver so its presence in the serum is highly indicative of liver processes.

BACKGROUND Medicare ceased payment for some hospital-acquired infections beginning October 1, 2008, following provisions in the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005. OBJECTIVE We examined the association of this policy with declines in rates of vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infection (CAUTI). DATA Discharge data from the Florida Agency for Healthcare Administration from 2007 to 2011. STUDY DESIGN We compared rates of hospital-acquired vascular catheter-associated infections (HA-VCAI) and catheter-associated urinary tract infections (HA-CAUTI) before and after implementation of the new policy (January 2007 to September 2008 vs. October 2008 to September 2011). This pre-post, retrospective, interrupted time series study was further analyzed with a generalized hierarchical logistic regression, by estimating the probability of a patient acquiring these infections in the hospital, post-policy compared to pre-policy. PRINCIPAL FINDINGS Pre-policy, 0.12% of admitted patients were diagnosed with CAUTI; of these, 32% were HA-CAUTI. Similarly, 0.24% of admissions were diagnosed as VCAI; of these, 60% were HA-VCAI. Post-policy, 0.16% of admissions were CAUTIs; of these, 31% were HA-CAUTI. Similarly, 0.3% of admissions were VCAIs and, of these, 45% were HA-VCAI. There was a statistically significant decrease in HA-VCAIs (OR: 0.571 (p < 0.0001)) post-policy, but the reduction in HA-CAUTI (OR: 0.968 (p < 0.4484)) was not statistically significant. CONCLUSIONS The results suggest Medicare non payment policy is associated with both a decline in the rate of hospital-acquired VCAI (HA-VCAI) per quarter, and the probability of acquiring HA-VCAI post- policy. The strength of the association could be overestimated, because of concurrent ongoing infection control interventions.

The quality of physician-patient communication influences patient health outcomes and satisfaction with healthcare delivery. Yet, little is known about contextual factors that influence physicians' communication with their patients. The main purpose of this article is to examine organizational-level factors that influence patient perceptions of physician communication in inpatient settings. We used the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and American Hospital Association data to determine patients' ratings of physician communication at the hospital level, and to collect information about hospital-level factors that can potentially influence physician communication. Our sample consisted of 2,756 hospitals. We ran a regression analysis to determine the predictors of poor physician communication, measured as the percentage of patients in a hospital who reported that physicians sometimes or never communicated well. In our sample of hospitals, this percentage ranged between 0% and 21%, with 25% of hospitals receiving poor ratings from more than 6% of patients. Three organizational factors had statistically significant negative associations with physician communication: for-profit ownership, hospital size, and hospitalists providing care in the hospital, On the other hand, the number of full-time-equivalent physicians and dentists per 10,000 inpatient days, physician ownership of the hospital, Medicare share of inpatient days, and public ownership were positively associated with patients' ratings of physician communication. Physician staffing levels are an understudied area in healthcare research. Our findings indicate that physician staffing levels affect the quality of physician communication with patients. Moreover, for-profit and larger hospitals should invest more in physician communication given the role that HCAHPS plays in value-based purchasing.

Throughout the past 30 years, there has been a lot of controversy surrounding the proliferation of new forms of health care delivery organizations that challenge and compete with general NFP community hospitals. Traditionally, the health care system in the United States has been dominated by general NFP (NFP) voluntary hospitals. With the number of for-profit general hospitals, physician-owned specialty hospitals, and ambulatory surgical centers increasing, a question arises: “Why is the general NFP community hospital the dominant model?” In order to address this question, this paper reexamines the history of the hospital industry. By understanding how the “general NFP hospital” model emerged and dominated, we attempt to explain the current dominance of general NFP hospitals in the ever changing hospital industry in the United States.

PurposeThe volume of international patients has been growing in the past 15 years, with developing countries gaining a larger market share. The international patients market is lucrative, given that hospitals may be able to attract an affluent clientele, and many patients from foreign countries who seek care require complicated procedures and treatments. The purpose of this paper is to build on previous work in the international business and health services fields, to develop a model that predicts a hospital's ability to attract international patients.Design/methodology/approachThe paper is a synthesis of the literature on export ventures and patient choice to predict a hospital's “export” performance.FindingsIt is estimated that around 70,000 foreign patients travel each year to the USA to receive inpatient medical care. These patients not only benefit hospitals and medical professionals but also benefit the local community through money spent in hotels, restaurants, shopping, etc. Strategic management, international business, and health services research fields can help us understand how hospitals can be more competitive in attracting international patients. The authors propose that the following dimensions affect a hospital's export performance: hospital resources (hospital attributes, international competence, management commitment, and strategy); institutional environment; and domestic hospital industry factors.Research limitations/implicationsMore empirical work is required to test the authors' model.Originality/valueMost of the studies done on international patients were descriptive in nature. This is the first paper that builds a conceptual model to help us understand what determines a hospital's performance in the international patients market.

Medicaid is the principal state and federal program that finances the health and medical care of low-income families, some elders, and people with disabilities who meet eligibility requirements, do not have health insurance, and otherwise cannot pay for their health care. In the 2006–2007 fiscal year (FY0607), Florida Medicaid served three million people, with expenditures of approximately U.S.$14 billion (Kaiser Commission on Medicaid and the Uninsured 2007; National Association of Budget Office 2008;). For the 2008–2009 fiscal year (FY0809), Florida Medicaid expenditures are estimated at U.S.$6,619 per eligible enrollee for a total of U.S.$15 billion (Agency for Health Care Administration 2008; Williams 2009;). Given budget challenges in Florida and other states, expansion of Medicaid-managed care is an attractive alternative because it can potentially control costs by ensuring appropriate health care utilization, and, by providing insurance through private health plans, potentially making Medicaid more similar to commercial coverage (LewinGroup 2009). Most studies on the impact of Medicaid-managed care have focused on health care access and utilization (Eberly et al. 2010; Zuckerman et al. 2002; Garrett et al. 2003; Garrett and Zuckerman 2005; Cook 2007; Burns 2009a,b;) and results have been mixed. However, despite the strong belief among policy makers in the ability of managed care to reduce health care costs, its economic impact has not been as well explored. In 2004, the LewinGroup published a report that synthesized findings from 24 studies examining the effect of the implementation of managed care programs on Medicaid savings throughout the United States (LewinGroup 2009). According to this report, the majority of Medicaid-managed care programs resulted in cost savings; however, the savings ranged from only 0.5 to 20 percent. Moreover, Medicaid-managed care programs led to higher enrollee satisfaction and improved access. The report concluded that the savings are generally attributed to reductions in inpatient utilization and prescription drug expenditures. In an attempt to control escalating costs and improve the Medicaid system, the Florida Legislature authorized a demonstration that would become known as “Medicaid Reform” in Senate Bill 838. A Section 1115 waiver was sought and approved in 2005. The demonstration began on July 1, 2006, and was approved for initial pilot implementation in two counties. Broward and Duval counties were selected for the initial pilot implementation because of the large number of Medicaid enrollees in those counties and their willingness to participate in the demonstration. The reforms to Florida's Medicaid program were based on empowering consumers to take control of their health care, providing more choices for consumers, and enhancing the health status of Medicaid enrollees through increased health literacy and incentives to engage in healthy behaviors. Furthermore, a key objective of Florida's Medicaid demonstration included making the delivery of medical care in Medicaid more reflective of the processes and approaches operative in the private sector. The reforms required Medicaid enrollees to choose either a Health Maintenance Organization (HMO) or a Provider Service Network (PSN), which were allowed to offer customized benefit packages. The benefit packages were subject to tests of actuarial equivalency and benefit sufficiency. Medicaid enrollees in the nonreform counties could voluntarily choose between an HMO or fee-for-service (FFS) primary care case management (PCCM) within 30 days of initial enrollment in Medicaid, but they were automatically assigned to either an HMO or PCCM if they had not voluntarily enrolled within 30 days. Medicaid beneficiaries in residential care facilities, children with special health care needs, and enrollees who also received Medicare benefits were not required to select a managed care plan. HMOs participating in the Medicaid demonstration are paid a capitation payment that is risk adjusted to reflect the relative health care status of their enrollees. Reform capitation rates are based on specific principles and policies applied to FFS historical data in identifiable areas. That rate is then risk adjusted to reflect the medical circumstances of a particular plan's enrollees, based on the enrollees' age, gender, and use of prescription medications that serves as an indicator of certain chronic diseases. The technical approach to this adjustment is based on the calculation of risk scores using the Medicaid Rx risk adjustment model devised by researchers at the University of California, San Diego (Gilmore et al. 2001). For the first 2 years of the demonstration, a risk corridor was mandated so that risk adjustment was limited to ± 10 percent of the original base rate. PSNs participating in Florida Medicaid are paid on an FFS basis. In order to facilitate enrollee selection of a health plan, Florida Medicaid created the Choice Counseling process. Choice Counseling is a comprehensive counseling program designed to provide the education and outreach necessary to assist Medicaid enrollees with making a health plan choice that best fits their specific needs and to promote healthy lifestyles in order to reduce minority health disparities. Another key element was the creation of an Enhanced Benefits Rewards (EBR) program, which offered financial incentives to participate in specific health promotion and illness prevention activities such as dental visits, vision exams, wellness visits, PAP screening, mammography screening, and colorectal screening (Agency for Health Care Administration 2009). When enrollees complete an EBR activity, funds are placed in their account and can be utilized for purchasing certain over-the-counter items at any Florida Medicaid participating pharmacy. A key goal of the demonstration has been to achieve greater predictability in Florida's Medicaid expenditures, with the ultimate objective of improved capacity to manage program costs (Agency for Health Care Administration 2005; Snipes 2009;). The objective of this study is to assess the degree to which Florida's Medicaid reform initiative has impacted per member per month (PMPM) expenditures.

BACKGROUND Since the early 1990s, specialty hospitals have been continuously increasing in number. A moratorium was passed in 2003 that prohibited physicians' referrals of Medicare patients to newly established specialty hospitals if the physician has ownership stakes in the hospital. Although this moratorium expired in effect in 2007, many are still demanding that the government pass new policies to discourage the proliferation of specialty hospitals. PURPOSE This study aimed at examining the regulatory and environmental forces that influence specialty hospitals founding rate. Specifically, we use the resource partitioning theory to investigate the relationship between general hospitals closure rates and the market entry of specialty hospitals. This study will help managers of general hospitals in their strategic thinking and planning. METHODOLOGY We rely on secondary data resources, which include the American Hospital Association, Area Resource file, census, and Center for Medicare and Medicaid Services data, to perform a longitudinal analysis of the founding rate of specialty hospital in the 48 states. Specifically, we use the negative binomial generalized estimating equation approach available through Stata 9.0 to study the effect of general hospitals closure rate and environmental variables on the proliferation of specialty hospitals. FINDINGS Specialty hospitals founding rate seems to be significantly related to general hospitals closure rates. Moreover, results indicate that economic, supply, regulatory, and financial conditions determine the founding rate of specialty hospitals in different states. PRACTICE IMPLICATIONS The results from this study indicate that the closure of general hospitals creates market conditions that encourage the market entry of specialized health care delivery forms such as specialty hospitals. Managers of surviving general hospitals have to view the closure of other general hospitals not just as an opportunity to increase market share but also as a threat of competition from new forms of health care organizations.

BACKGROUND The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital-wide all-cause readmission rates, which are key indicators of quality and waste. Understanding hospital characteristics that are associated with lower readmission rates is important. OBJECTIVES The main objective of this article is to identify hospital characteristics associated with lower readmission rates. Specifically, we focus on the relationship between hospitalist staffing levels, the level of physician integration, and physician ownership with hospital-wide all-cause readmissions. METHODS We rely on data from CMS, American Hospital Association Annual Survey Database, and Area Health Resource File. We use ordinary least square regression to assess the association between readmission rates and hospitalist staffing levels, physician integration, physician ownership, and the presence of a medical home model, while controlling for key organizational and market factors such as registered nurse (RN) staffing levels and competition. RESULTS Higher hospitalist staffing levels, the fully integrated physician model, and physician ownership were associated with lower readmission rates. The addition of 1 hospitalist per general and surgical bed was associated with a 0.77 percentage-points decrease in adjusted 30-day all-cause readmission rates. Fully integrated hospitals had adjusted 30-day all-cause readmission rates 0.09 percentage points lower than non–fully integrated hospitals, and hospitals partially or fully owned by physicians had adjusted readmission rates 0.36 percentage points lower than non–physician-owned hospitals. CONCLUSIONS Hospitals should focus on modifiable organizational factors that influence patient outcomes such as hospitalist and RN staffing levels and explore hospital-physician arrangements that result in the greatest alignment between hospital and physician incentives. Journal of Hospital Medicine 2016;11:682–687. © 2016 Society of Hospital Medicine