Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models

Poult enteritis mortality syndrome

Le syndrome entéritique mortel du dindonneau (SEMD) est une maladie infectieuse, transmissible, d’étiologie mal connue mais probablement virale, caractérisée par une diarrhée avec déshydratation, anorexie, amaigrissement, immunosuppression, arrêt de la croissance (égal ou supérieur à 40%) et un taux de mortalité important pouvant atteindre 100% chez les jeunes dindons. Cette maladie est d’origine multifactorielle. L’action des agents infectieux est sous la dépendance d’autres facteurs liés à l’environnement, l’alimentation et les méthodes d’élevage. Il importe de souligner l’importance des méthodes d’élevage et de la ration alimentaire dans la prévention du SEMD par comparaison avec les méthodes destinées à lutter contre les maladies infectieuses (vaccination, thérapeutiques).Poult enteritis mortality syndrome (PEMS) is an infectious, transmissible disease of incertain, but probable viral etiology, characterized by diarrhea, dehydratation, wheight-loss, anorexia, immunosuppression, growth depression (>40%) and high mortality (approaching 100% in young turkeys). The disease is a multifactorial one. Howewer the effect of infectious agents on the flock is determined by environmental, nutritional, and management factors. Current control strategies primarily involve management (in particular, enhanced biosecurity) and nutrition rather than conventional methods (vaccination and medication) used for infectious diseases

Variation in HIV-1 R5 macrophage-tropism correlates with sensitivity to reagents that block envelope: CD4 interactions but not with sensitivity to other entry inhibitors

<p>Abstract</p> <p>Background</p> <p>HIV-1 R5 viruses cause most of the AIDS cases worldwide and are preferentially transmitted compared to CXCR4-using viruses. Furthermore, R5 viruses vary extensively in capacity to infect macrophages and highly macrophage-tropic variants are frequently identified in the brains of patients with dementia. Here, we investigated the sensitivity of R5 envelopes to a range of inhibitors and antibodies that block HIV entry. We studied a large panel of R5 envelopes, derived by PCR amplification without culture from brain, lymph node, blood and semen. These R5 envelopes conferred a wide range of macrophage tropism and included highly macrophage-tropic variants from brain and non-macrophage-tropic variants from lymph node.</p> <p>Results</p> <p>R5 macrophage-tropism correlated with sensitivity to inhibition by reagents that inhibited gp120:CD4 interactions. Thus, increasing macrophage-tropism was associated with increased sensitivity to soluble CD4 and to IgG-CD4 (PRO 542), but with increased resistance to the anti-CD4 monoclonal antibody (mab), Q4120. These observations were highly significant and are consistent with an increased affinity of envelope for CD4 for macrophage-tropic envelopes. No overall correlations were noted between R5 macrophage-tropism and sensitivity to CCR5 antagonists or to gp41 specific reagents. Intriguingly, there was a relationship between increasing macrophage-tropism and increased sensitivity to the CD4 binding site mab, b12, but decreased sensitivity to 2G12, a mab that binds a glycan complex on gp120.</p> <p>Conclusion</p> <p>Variation in R5 macrophage-tropism is caused by envelope variation that predominantly influences sensitivity to reagents that block gp120:CD4 interactions. Such variation has important implications for therapy using viral entry inhibitors and for the design of envelope antigens for vaccines.</p

Electronic patient-reported outcomes from home in patients recovering from major gynecologic cancer surgery: A prospective study measuring symptoms and health-related quality of life

We previously reported on the feasibility of a Web-based system to capture patient-reported outcomes (PROs) in the immediate postoperative period. The purpose of this study was to update the experience of these patients and assess patient and provider satisfaction and feedback regarding the system

Enduring Mental Health Morbidity and Social Function Impairment in World Trade Center Rescue, Recovery, and Cleanup Workers: The Psychological Dimension of an Environmental Health Disaster

Background The World Trade Center (WTC) attacks exposed thousands of workers to hazardous environmental conditions and psychological trauma. In 2002, to assess the health of these workers, Congress directed the National Institute for Occupational Safety and Health to establish the WTC Medical Monitoring and Treatment Program. This program has established a large cohort of WTC rescue, recovery, and cleanup workers. We previously documented extensive pulmonary dysfunction in this cohort related to toxic environmental exposures. Objectives Our objective in this study was to describe mental health outcomes, social function impairment, and psychiatric comorbidity in the WTC worker cohort, as well as perceived symptomatology in workers’ children. Methods Ten to 61 months after the WTC attack, 10,132 WTC workers completed a self-administered mental health questionnaire. Results Of the workers who completd the questionnaire, 11.1% met criteria for probable post-traumatic stress disorder (PTSD), 8.8% met criteria for probable depression, 5.0% met criteria for probable panic disorder, and 62% met criteria for substantial stress reaction. PTSD prevalence was comparable to that seen in returning Afghanistan war veterans and was much higher than in the U.S. general population. Point prevalence declined from 13.5% to 9.7% over the 5 years of observation. Comorbidity was extensive and included extremely high risks for impairment of social function. PTSD was significantly associated with loss of family members and friends, disruption of family, work, and social life, and higher rates of behavioral symptoms in children of workers. Conclusions Working in 9/11 recovery operations is associated with chronic impairment of mental health and social functioning. Psychological distress and psychopathology in WTC workers greatly exceed population norms. Surveillance and treatment programs continue to be needed

Medication affordability gains following Medicare Part D are eroding among elderly with multiple chronic conditions

Elderly Americans, especially those with multiple chronic conditions, face difficulties paying for prescriptions, which results in worse adherence to and discontinuation of therapy, called cost-related medication nonadherence. Medicare Part D, implemented in January 2006, was supposed to address issues of affordability for prescriptions. We investigated whether the gains in medication affordability attributable to Part D persisted during the six years that followed its implementation. Overall, we found continued incremental improvements in medication affordability in the period 2007–09 that eroded during the period 2009–11. Among elderly beneficiaries with four or more chronic conditions, we observed an increase in the prevalence of cost-related nonadherence from 14.4 percent in 2009 to 17.0 percent in 2011, reversing previous downward trends. Similarly, the prevalence among the sickest elderly of forgoing basic needs to purchase medicines decreased from 8.7 percent in 2007 to 6.8 percent in 2009 but rose to 10.2 percent in 2011. Our findings highlight the need for targeted policy efforts to alleviate the persistent burden of drug treatment costs on this vulnerable population

Understory Cover Responses to Piñon-Juniper Treatments Across Tree Dominance Gradients in the Great Basin

Piñon (Pinus spp.) and juniper (Juniperus spp.) trees are reduced to restore native vegetation and avoid severe fires where they have expanded into sagebrush (Artemisia tridentata Nutt.) communities. However, what phase of tree infilling should treatments target to retain desirable understory cover and avoid weed dominance? Prescribed fire and tree felling were applied to 8–20-ha treatment plots at 11 sites across the Great Basin with a tree-shredding treatment also applied to four Utah sites. Treatments were applied across a tree infilling gradient as quantified by a covariate tree dominance index (TDI=tree cover/[tree+shrub+tall perennial grass cover]). Mixed model analysis of covariance indicated that treatment x covariate interactions were significant (P 0.4). Fire increased cheatgrass (Bromus tectorum L.) cover by an average of 4.2% for all values of TDI. Cutting or shredding trees generally produced similar responses and increased total perennial herbaceous and cheatgrass cover by an average of 10.2% and 3.8%, at TDIs ≥ 0.35 and ≥ 0.45. Cheatgrass cover estimated across the region was < 6% after treatment, but two warmer sites had high cheatgrass cover before (19.2% and 27.2%) and after tree reduction (26.6% and 50.4%). Fuel control treatments are viable management options for increasing understory cover across a range of sites and tree cover gradients, but should be accompanied by revegetation on warmer sites with depleted understories where cheatgrass is highly adapted. Shrub and perennial herbaceous cover can be maintained by mechanically treating at lower TDI. Perennial herbaceous cover is key for avoiding biotic and abiotic thresholds in this system through resisting weed dominance and erosion.Keywords: brush control, state and transition, prescribed fire, resilience, thresholds, mechanical treatments, masticatio

ENIGMA and global neuroscience: A decade of large-scale studies of the brain in health and disease across more than 40 countries.

This review summarizes the last decade of work by the ENIGMA (Enhancing NeuroImaging Genetics through Meta Analysis) Consortium, a global alliance of over 1400 scientists across 43 countries, studying the human brain in health and disease. Building on large-scale genetic studies that discovered the first robustly replicated genetic loci associated with brain metrics, ENIGMA has diversified into over 50 working groups (WGs), pooling worldwide data and expertise to answer fundamental questions in neuroscience, psychiatry, neurology, and genetics. Most ENIGMA WGs focus on specific psychiatric and neurological conditions, other WGs study normal variation due to sex and gender differences, or development and aging; still other WGs develop methodological pipelines and tools to facilitate harmonized analyses of "big data" (i.e., genetic and epigenetic data, multimodal MRI, and electroencephalography data). These international efforts have yielded the largest neuroimaging studies to date in schizophrenia, bipolar disorder, major depressive disorder, post-traumatic stress disorder, substance use disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism spectrum disorders, epilepsy, and 22q11.2 deletion syndrome. More recent ENIGMA WGs have formed to study anxiety disorders, suicidal thoughts and behavior, sleep and insomnia, eating disorders, irritability, brain injury, antisocial personality and conduct disorder, and dissociative identity disorder. Here, we summarize the first decade of ENIGMA's activities and ongoing projects, and describe the successes and challenges encountered along the way. We highlight the advantages of collaborative large-scale coordinated data analyses for testing reproducibility and robustness of findings, offering the opportunity to identify brain systems involved in clinical syndromes across diverse samples and associated genetic, environmental, demographic, cognitive, and psychosocial factors