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Out-of-pocket costs of diabetes medications other than insulin can be quite high for individuals with employer-sponsored health insurance.

Many Medicaid programs and private health plans are implementing new models of maternity care reimbursement, and clinicians face mounting pressure to demonstrate high-quality care at a lower cost. Clinicians will be better prepared to meet these challenges with a fuller understanding of new payment models and the opportunities they present. We describe the structure of maternity care episode payments and recommend 4 ways that clinicians can prepare for success as value-based payment models are implemented: identify opportunities to improve outcomes and experience, measure quality, reduce waste, and work in teams across settings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Investing time and effort to uncover and mitigate today's stressors for employees can help employers avoid tomorrow's more damaging and expensive consequences. A comprehensive assessment of workplace stress can generate a substantial return on this investment, measured in enhanced individual well-being, reduced health care and disability costs and improved company performance. This article discusses the structure of stress diagnostics, the dimensions of those diagnostics, leading and lagging indicators of employee stress and how employers can use diagnostics to take actions that benefit employers and employees alike.

Few adult patients with HIV/AIDS are evaluated for communication disorders. A broad inventory of the communication disorders was obtained in a convenience sample of 82 adult HIV/AIDS patients who presented for medical appointments. Each participant underwent a head and neck exam and a communications skills evaluation. Speech, language, and cognition were assessed using a 10-item test battery. A 14-item hearing test battery was conducted in a separate session. The primary outcomes were the presence and degree of communication disorders. Head and neck exams revealed 40% with ear-related issues. Only 2 participants showed normal findings on all 24 communication skills assessments. Four demonstrated normal findings on all speech-language-cognitive assessments, whereas 8 had normal findings on the complete hearing test battery. A relatively high prevalence of cognitive and language deficits and central auditory disturbances were found. Clinicians must recognize the potential for communication deficits even in a relatively healthy patient with HIV.

Degradation of nuclear DNA is a hallmark of programmed cell death. Epidermal keratinocytes die in the course of cornification to function as the dead building blocks of the cornified layer of the epidermis, nails, and hair. Here, we investigated the mechanism and physiological function of DNA degradation during cornification in vivo. Targeted deletion of the keratinocyte-specific endonuclease DNase1-like 2 (DNase1L2) in the mouse resulted in the aberrant retention of DNA in hair and nails, as well as in epithelia of the tongue and the esophagus. In contrast to our previous studies in human keratinocytes, ablation of DNase1L2 did not compromise the cornified layer of the epidermis. Quantitative PCRs showed that the amount of nuclear DNA was dramatically increased in both hair and nails, and that mitochondrial DNA was increased in the nails of DNase1L2-deficient mice. The presence of nuclear DNA disturbed the normal arrangement of structural proteins in hair corneocytes and caused a significant decrease in the resistance of hair to mechanical stress. These data identify DNase1L2 as an essential and specific regulator of programmed cell death in skin appendages, and demonstrate that the breakdown of nuclear DNA is crucial for establishing the full mechanical stability of hair.

The cornified layer, the stratum corneum, of the epidermis is an efficient barrier to the passage of genetic material, i.e. nucleic acids. It contains enzymes that degrade RNA and DNA which originate from either the living part of the epidermis or from infectious agents of the environment. However, the molecular identities of these nucleases are only incompletely known at present. Here we performed biochemical and genetic experiments to determine the main DNase activity of the stratum corneum. DNA degradation assays and zymographic analyses identified the acid endonucleases L-DNase II, which is derived from serpinB1, and DNase 2 as candidate DNases of the cornified layer of the epidermis. siRNA-mediated knockdown of serpinB1 in human in vitro skin models and the investigation of mice deficient in serpinB1a demonstrated that serpinB1-derived L-DNase II is dispensable for epidermal DNase activity. By contrast, knockdown of DNase 2, also known as DNase 2a, reduced DNase activity in human in vitro skin models. Moreover, the genetic ablation of DNase 2a in the mouse was associated with the lack of acid DNase activity in the stratum corneum in vivo. The degradation of endogenous DNA in the course of cornification of keratinocytes was not impaired by the absence of DNase 2. Taken together, these data identify DNase 2 as the predominant DNase on the mammalian skin surface and indicate that its activity is primarily targeted to exogenous DNA.

The purpose of this study was to examine the relationships between patterns of spelling error and related linguistic abilities of four persons with complex communication needs and physical impairments, compared to younger individuals without disabilities matched by spelling age. All participants completed a variety of spelling and linguistic tasks to determine overall spelling age, patterns of spelling errors, and abilities across phonemic, orthographic, and morphological awareness. Performance of the spelling-age matched pairs was similar across most of the phonemic, orthographic, and morphological awareness tasks. Analysis of the participants' spelling errors, however, revealed different patterns of spelling errors for three of the spelling-age matched pairs. Within these three pairs, the participants with complex communication needs and physical impairments made most of their spelling errors due to phonemic awareness difficulties, while most of the errors on the part of the participants without disabilities were due to orthographic difficulties. The results of this study lend support to the findings of previous investigations that reported difficulties among individuals with complex communication needs and physical impairments evidence when applying phonemic knowledge to literacy tasks.

This article reviews the experience of a large, heterogeneous integrated delivery network that incorporated physician quality metrics into pay-for-performance contracts. The authors present criteria for including measures in pay-for-performance contracts and offer a practical approach to determining withhold return or bonus distribution based on improvement and performance. They demonstrate interventions undertaken to improve performance, including the development of a claims-based registry. Empirical data show that the network performance improved more than the comparable state and national performance during the period of this observational study. The authors conclude that pay-for-performance contracts led to development of medical management programs including a claims-based registry and nonphysician interventions, which helped significantly improve selected HEDIS scores.

Purpose: A large regional health plan in the Northeastern United States noted that its radiology costs were increasing more than it anticipated in its pricing, and noted further that other similar health plans in markets with high managed care penetration had significantly lower expenses for radiology services. This study describes the potential areas of improvement and managed care techniques that were implemented to reduce costs and reform processes., Materials and Methods: We performed an in-depth analysis of financial data, claims logic, contracting with provider units and conducted interviews with employees, to identify potential areas of improvement and cost reduction. A detailed market analysis of the environment, competitors and vendors was accompanied by extensive literature, Internet and Medline search for comparable projects. All data were docu-mented in Microsoft Excel(R) and analyzed by non-parametric tests using SPSS(R) 8.0 (Statistical Package for the Social Sciences) for Windows(R)., Results: The main factors driving the cost increases in radiology were divided into those internal or external to the HMO. Among the internal factors, the claims logic was allowing overpayment due to limitations of the IT system. Risk arrangements between insurer and provider units (PU) as well as the extent of provider unit management and administration showed a significant correlation with financial performance in terms of variance from budget. Among the external factors, shared risk arrangements between HMO and provider unit were associated with more efficient radiology utilization and overall improvement in financial performance. PU with full-time management had significantly less variance from their budget than those without. Finally, physicians with imaging equipment in their offices ordered up to 4 to 5 times more imaging procedures than physicians who did not perform imaging studies themselves., Conclusion: We identified initiatives with estimated potential savings of approximately $ 5.5 million. Some of these initiatives are similar to the reforms to reduce cost and improve quality that are already implemented or proposed within the German healthcare system.

The "family doctor" has been identified as the professional most likely to be contacted by the general public with concerns about communication disorders; yet the family practice physician is unlikely to refer patients with communicative disorders to speech-language pathologists or audiologists for nonmedical evaluation and treatment. The purpose of this study was to determine attitudes of family practice residents about referral patterns for communication disorders using a survey format. Thirty-nine residents estimated that they had referred an average of 1.5 patients to a speech-language pathologist and 2.2 patients to an audiologist during a six-month interval. The findings indicated that these residents did not routinely refer patients to speech-language pathologists. When they did refer, a limited view of communication problems was used.

A 21-year-old man presented in shock after ingesting 2 g of arsenic trioxide. He died within 37 hours despite intensive treatment that included intramuscular dimercaprol and hemodialysis. Hemodynamic and laboratory data are presented illustrating the multisystem toxicities of inorganic arsenic. Hemodialysis, previously described as an effective therapeutic adjunct, was shown to be ineffective in this case.

Casein phosphopeptides (CPP) were produced by tryptic hydrolysis of sodium caseinate and further purified by precipitation and chromatography on QAE-Sephadex A-25. Their physico-chemical properties were compared with the properties of an enzymically dephosphorylated equivalent preparation (DPP). Binding of Ca2+ to the peptides was measured using a Ca selective electrode and was found to increase with pH and to show 1/1 stoicheiometry Ca/Porg in CPP at pH 6.5 and 7.6. Klotz plots indicated equivalent binding sites at these two pH values, but some heterogeneity was seen at pH 3.5. In contrast, DPP did not bind significant amounts of Ca2+. CPP effectively inhibited the formation of insoluble calcium phosphates at different Ca/P ratios. The effective CPP concentration was 10 mg/l and complete stability of calcium phosphate solutions was obtained at about 100 mg/l. This stabilizing effect was dependent on the presence of organic P.

A strong lytic activity against Micrococcus luteus was demonstrated in abomasal secretions from calf, adult cattle, goat and sheep. This bacteriolytic activity was undetectable in other secretions. Bacteriolysis was caused by a glycosidase displaying endo-N-acetylmuramoylhydrolase specificity (EC 3.2.1.17) and was further characterized in the calf. This lysozyme also displayed significant chitinase activity. Immunofluorescence microscopy confirmed the secretion of lysozyme by abomasal gastric glands exclusively. Electrofocusing revealed multiple molecular forms, the predominant one (more than 80%) being characterized by Mr approx. 15,000, pH optimum 5.0, pl 7.5 and remarkable conformational stability. The lytic activity of lysozyme was ionic strength dependent and competitive inhibition was observed with both N-acetyl glucosamine and N-acetyl-muramic acid. Amino-acid analysis demonstrated common characteristics with known lysozymes, i.e. four disulphide bridges, two proline and N-terminal lysine. Structural homology between the three ruminant lysozymes was established by immunological cross-reactivity.