Pharmacy Use by Dual-Eligible Non-Elderly Veterans with Private Healthcare Insurance

The Veterans Health Administration (VHA) is the largest nationally integrated healthcare system in the United States, operating 168 medical centers and more than 1000 community based outpatient clinics. However, many veterans seek care outside the VHA system, particularly when they are also covered by state or federal programs such as Medicare or Medicaid, or have access to private health insurance, often through employment. Concerted efforts have been made to facilitate communication and coordinate care between VHA and private sector healthcare, but concurrent use of these systems adds to an already fragmented U.S health care system

Self-Accleration and Instability of Gravity Wave Packets: 1. Effects of Temporal Localization

An anelastic numerical model is used to explore the dynamics accompanying the attainment of large amplitudes by gravity waves (GWs) that are localized in altitude and time. GW momentum transport induces mean flow variations accompanying a GW packet that grows exponentially with altitude, is localized in altitude, and induces significant GW phase speed, and phase, variations across the GW packet. These variations arise because the GW occupies the region undergoing accelerations, with the induced phase speed variations referred to as “self-acceleration.” Results presented here reveal that self-acceleration of a GW packet localized in time and altitude ultimately leads to stalling of the vertical propagation of the GW packet and accompanying two- and three-dimensional (2-D and 3-D) instabilities of the superposed GW and mean motion field. The altitudes at which these effects occur depend on the initial GW amplitude, intrinsic frequency, and degree of localization in time and altitude. Larger amplitudes and higher intrinsic frequencies yield strong self-acceleration effects at lower altitudes, while smaller amplitudes yield similar effects at higher altitudes, provided the Reynolds number, Re, is sufficiently large. Three-dimensional instabilities follow 2-D “self-acceleration instability” for sufficiently high Re. GW packets can also exhibit self-acceleration dynamics at more than one altitude because of continued growth of the GW packet leading edge above the previous self-acceleration event. --From the publisher\u27s website

Antibiotic stewardship implementation and patient-level antibiotic use at hospitals with and without on-site Infectious Disease specialists.

Many US hospitals lack Infectious Disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist. This retrospective VHA cohort included all acute-care patient-admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy (DOT) per days-present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient-admissions. Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525,451 (95.8%) admissions at ID hospitals and 23,007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use [OR 0.92, (95% CI, 0.85-0.99)]. Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials [OR 0.61 (95% CI, 0.54-0.70)] and higher narrow-spectrum beta-lactam use [OR 1.43 (95% CI, 1.22-1.67)]. Total antibacterial exposure (inpatient plus post-discharge) was lower among patients at ID versus non-ID sites [OR 0.92 (95% CI, 0.86-0.99)]. Patients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship

Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists.

BackgroundMany US hospitals lack infectious disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist.MethodsThis retrospective VHA cohort included all acute-care patient admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy per days present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient admissions.ResultsEighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525 451 (95.8%) admissions at ID hospitals and 23 007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use (odds ratio, 0.92; 95% confidence interval, .85-.99). Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials (0.61; .54-.70) and higher narrow-spectrum β-lactam use (1.43; 1.22-1.67). Total antibacterial exposure (inpatient plus postdischarge) was lower among patients at ID versus non-ID sites (0.92; .86-.99).ConclusionsPatients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship

Effect of molecular filtering and electrolyte composition on the spatial variation in performance of dye solar cells

It is demonstrated that the molecular filtering effect of TiO2 has a significant influence on dye solar cell (DSC) performance. As electrolyte is injected to a DSC, some of the electrolyte components adsorb to the surface TiO2 (here 4-tert-butylpyridine and 1-methyl-benzimidazole) and accumulate near the electrolyte filling hole resulting in varying electrolyte composition and performance across the cell. The spatial performance distribution was investigated with a new method, the segment cell method. Not only is the segmented cell method simple and cheap when compared to the only other method for examining spatial variation (photocurrent mapping), it also has the major advantage of allowing the spatial variation in all other operating parameters to be assessed. Here the molecular filtering effect was to influence the cell performance in case of all the five studied electrolytes causing up to 35% losses in efficiency. Raman spectra indicated that the loss in photocurrent in the electrolyte filling was in correlation with the loss of thiocyanate ligands suggesting that dye regeneration may also be a significant factor in addition to electron injection in some of the cells. There were also shifts in the absorption spectra the photoelectrodes which further supported changes in the thiocyanate ligands. Besides absorption changes, there were additional shifts in the IPCE spectra which may relate to deprotonation of the dye. The efficiency losses were reduced to ∼10% with contemporary electrolyte compositions.Peer reviewe