174 research outputs found

    Geographic Variation Within the Military Health System

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    Background: This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS). Methods: Data for fiscal years 2007 – 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF. Results: Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas. Conclusions: In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare

    Racial Disparities in Emergency General Surgery: Do Differences in Outcomes Persist Among Universally Insured Military Patients?

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    Research Objective: Described as one of the most serious health problems affecting the nation, racial disparities are estimated to account for \u3e83,000 deaths, \u3e$57 billion per year. They have been identified in multiple surgical settings, including differences in outcomes by race among emergency general surgery(EGS) patients. As many minority patients are uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30/90/180day outcomes exist within a universally-insured population of military/civilian-dependent EGS patients and whether differences in outcomes differentially persist in care received at military-vs-civilian hospitals and among sponsors who are enlisted-service members-vs-officers. It also considered longer-term outcomes of care. Study Design: Risk-adjusted survival analyses using Cox proportional-hazards models assessed race-based differences in mortality, major morbidity, and readmission from index-hospital admission (discharge for readmission) through 30/90/180days. Models accounted for hospital clustering and possible biases associated with missing race (reweighted-estimating equations). Sub-analyses considered effects restricted to operative interventions, stratified by 24 EGS-diagnostic categories defined by the American Association for the Surgery of Trauma(AAST), and effect modification related to rank (SES-proxy: officers-vs-enlisted-sponsors) and military-vs-civilian-hospital care. Population Studied: Five years of national TRICARE Prime/Prime-plus data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18y) with primary EGS conditions, defined by the AAST. Patients who did not have an index admission between 01/01/2006-01/07/2010 (minimum 180days follow-up) or who were not continuously enrolled in TRICARE for 180days were excluded. Non-surviving patients were retained while they survived. Principal Findings: A total of 101,011 patients were included: 73.5% White, 14.5% Black, 4.4% Asian, 7.7% other. Risk-adjusted analyses reported equivalent-or-better mortality and readmission outcomes among minority patients at 30/90/180days—even when restricted to civilian hospitals where studies suggest that EGS disparities are found. Readmissions within military hospitals were lower among minority patients. Major morbidity was higher among Black versus White patients (HR[95%CI]): 30day-1.23[1.13-1.35], 90day-1.18[1.09-1.28], 180day-1.15[1.07-1.24]—a finding driven by appendiceal disorders (HR:1.69-1.70). No other diagnostic category-based HR was significant. When considered by rank, significant effects were isolated to enlisted-service members. However, given the relatively small number of patients who were (dependents of) officers, it is difficult to determine whether rank-based findings are a result of social determinants or influenced by the limited number of minority patients. Conclusions: The first of its kind to examine racial disparities in longer-term outcomes of EGS care, this longitudinal analysis of military patients demonstrated apparent mitigation of racial disparities within a universally-insured health system when compared to the overall US health system. Efforts to explain findings based on consideration of care provided in military-vs-civilian hospitals, among specific EGS-diagnostic categories, and based on sponsor rank revealed modification of the association between race and outcomes to some extent for all three. Implications for Policy or Practice: The contrast between results for universally-insured military/civilian-dependent patients and reported disparities among all US civilian patients merits consideration. The data speak to the importance of insurance-coverage in the development of disparities interventions nationwide and will help to inform policy within the DoD

    First record of Eufriesea laniventris (Ducke, 1902) (Hymenoptera, Apidae, Euglossini) in the state of Amazonas, Brazil

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    The first record of Eufriesea laniventris in the state of Amazonas is here reported. Attracted to 1.8 cineole and methyl salicylate fragrances, six specimens were colected in the region of Manaus (2º 36' S 60º 02' W) during the year 2000.", 'enÉ registrada pela primeira vez a ocorrência de Eufriesea laniventris no Amazonas. No ano 2000, foram coletados seis exemplares na região de Manaus (2º 36' S e 60º 02' W) atraídos pelas substâncias odoríferas 1,8 cineol e salicilato de metila

    Lista de gêneros de Hymenoptera (Insecta) do Espírito Santo, Brasil

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    The first checklist of genera of Hymenoptera from Espírito Santo state, Brazil is presented. A total of 973 genera of Hymenoptera is listed, of which 555 (57%) are recorded for the first time from this state. Ichneumonoidea and Chalcidoidea are the two superfamilies with the most genera, 241 and 203 respectively. Braconidae, with 141 genera, are the richest family.The first checklist of genera of Hymenoptera from Espírito Santo state, Brazil is presented. A total of 973 genera of Hymenoptera is listed, of which 555 (57%) are recorded for the first time from this state. Ichneumonoidea and Chalcidoidea are the two superfamilies with the most genera, 241 and 203 respectively. Braconidae, with 141 genera, are the richest family.Fil: Azevedo, Celso O.. Universidade Federal do Espírito Santo; BrasilFil: Molin, Ana Dal. Texas A&M University; Estados UnidosFil: Penteado-Dias, Angelica. Universidade Federal do São Carlos; BrasilFil: Macedo, Antonio C. C.. Secretaria do Meio Ambiente do Estado de São Paulo; BrasilFil: Rodriguez-V, Beatriz. Universidad Nacional Autónoma de México; MéxicoFil: Dias, Bianca Z. K.. Universidade Federal do Espírito Santo; BrasilFil: Waichert, Cecilia. State University of Utah; Estados UnidosFil: Aquino, Daniel Alejandro. Universidad Nacional de La Plata. Facultad de Ciencias Naturales y Museo. División Entomología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Smith, David. Smithsonian Institution; Estados UnidosFil: Shimbori, Eduardo M.. Universidade Federal do São Carlos; BrasilFil: Noll, Fernando B.. Universidade Estadual Paulista Julio de Mesquita Filho; BrasilFil: Gibson, Gary. Agriculture and Agri-Food Canada; CanadáFil: Onody, Helena. Universidade Federal do São Carlos; BrasilFil: Carpenter, James M.. American Museum of Natural History; Estados UnidosFil: Lattke, John. Universidad Nacional de Loja; EcuadorFil: Ramos, Kelli dos S.. Universidade de Sao Paulo; BrasilFil: Williams, Kevin. Florida State Collection of Arthropods; Estados UnidosFil: Masner, Lubomir. Agriculture and Agri-Food Canada; CanadáFil: Kimsey, Lynn. University of California; Estados UnidosFil: Tavares, Marcelo T.. Universidade Federal do Espírito Santo; BrasilFil: Olmi, Massimo. Università degli Studi della Tuscia; ItaliaFil: Buffington, Matthew L.. United States Department of Agriculture; Estados UnidosFil: Ohl, Michael. Staatliches Museum fur Naturkunde Stuttgart; AlemaniaFil: Sharkey, Michael. University of Kentucky; Estados UnidosFil: Johnson, Norman F.. Ohio State University; Estados UnidosFil: Kawada, Ricardo. Universidade Federal do Espírito Santo; BrasilFil: Gonçalves, Rodrigo B.. Universidade Federal do Paraná; BrasilFil: Feitosa, Rodrigo. Universidade Federal do Paraná; BrasilFil: Heydon, Steven. University of California; Estados UnidosFil: Guerra, Tânia M.. Universidade Federal do Espírito Santo; BrasilFil: da Silva, Thiago S. R.. Universidade Federal do Espírito Santo; BrasilFil: Costa, Valmir. Instituto Biológico; Brasi

    Bacteriophage Crosstalk: Coordination of Prophage Induction by Trans-Acting Antirepressors

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    Many species of bacteria harbor multiple prophages in their genomes. Prophages often carry genes that confer a selective advantage to the bacterium, typically during host colonization. Prophages can convert to infectious viruses through a process known as induction, which is relevant to the spread of bacterial virulence genes. The paradigm of prophage induction, as set by the phage Lambda model, sees the process initiated by the RecA-stimulated self-proteolysis of the phage repressor. Here we show that a large family of lambdoid prophages found in Salmonella genomes employs an alternative induction strategy. The repressors of these phages are not cleaved upon induction; rather, they are inactivated by the binding of small antirepressor proteins. Formation of the complex causes the repressor to dissociate from DNA. The antirepressor genes lie outside the immunity region and are under direct control of the LexA repressor, thus plugging prophage induction directly into the SOS response. GfoA and GfhA, the antirepressors of Salmonella prophages Gifsy-1 and Gifsy-3, each target both of these phages' repressors, GfoR and GfhR, even though the latter proteins recognize different operator sites and the two phages are heteroimmune. In contrast, the Gifsy-2 phage repressor, GtgR, is insensitive to GfoA and GfhA, but is inactivated by an antirepressor from the unrelated Fels-1 prophage (FsoA). This response is all the more surprising as FsoA is under the control of the Fels-1 repressor, not LexA, and plays no apparent role in Fels-1 induction, which occurs via a Lambda CI-like repressor cleavage mechanism. The ability of antirepressors to recognize non-cognate repressors allows coordination of induction of multiple prophages in polylysogenic strains. Identification of non-cleavable gfoR/gtgR homologues in a large variety of bacterial genomes (including most Escherichia coli genomes in the DNA database) suggests that antirepression-mediated induction is far more common than previously recognized

    A Toxin–Antitoxin System Promotes the Maintenance of an Integrative Conjugative Element

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    SXT is an integrative and conjugative element (ICE) that confers resistance to multiple antibiotics upon many clinical isolates of Vibrio cholerae. In most cells, this ∼100 Kb element is integrated into the host genome in a site-specific fashion; however, SXT can excise to form an extrachromosomal circle that is thought to be the substrate for conjugative transfer. Daughter cells lacking SXT can theoretically arise if cell division occurs prior to the element's reintegration. Even though ∼2% of SXT-bearing cells contain the excised form of the ICE, cells that have lost the element have not been detected. Here, using a positive selection-based system, SXT loss was detected rarely at a frequency of ∼1×10−7. As expected, excision appears necessary for loss, and factors influencing the frequency of excision altered the frequency of SXT loss. We screened the entire 100 kb SXT genome and identified two genes within SXT, now designated mosA and mosT (for maintenance of SXT Antitoxin and Toxin), that promote SXT stability. These two genes, which lack similarity to any previously characterized genes, encode a novel toxin-antitoxin pair; expression of mosT greatly impaired cell growth and mosA expression ameliorated MosT toxicity. Factors that promote SXT excision upregulate mosAT expression. Thus, when the element is extrachromosomal and vulnerable to loss, SXT activates a TA module to minimize the formation of SXT-free cells

    The Complete Genome Sequence of ‘Candidatus Liberibacter solanacearum’, the Bacterium Associated with Potato Zebra Chip Disease

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    Zebra Chip (ZC) is an emerging plant disease that causes aboveground decline of potato shoots and generally results in unusable tubers. This disease has led to multi-million dollar losses for growers in the central and western United States over the past decade and impacts the livelihood of potato farmers in Mexico and New Zealand. ZC is associated with ‘Candidatus Liberibacter solanacearum’, a fastidious alpha-proteobacterium that is transmitted by a phloem-feeding psyllid vector, Bactericera cockerelli Sulc. Research on this disease has been hampered by a lack of robust culture methods and paucity of genome sequence information for ‘Ca. L. solanacearum’. Here we present the sequence of the 1.26 Mbp metagenome of ‘Ca. L. solanacearum’, based on DNA isolated from potato psyllids. The coding inventory of the ‘Ca. L. solanacearum’ genome was analyzed and compared to related Rhizobiaceae to better understand ‘Ca. L. solanacearum’ physiology and identify potential targets to develop improved treatment strategies. This analysis revealed a number of unique transporters and pathways, all potentially contributing to ZC pathogenesis. Some of these factors may have been acquired through horizontal gene transfer. Taxonomically, ‘Ca. L. solanacearum’ is related to ‘Ca. L. asiaticus’, a suspected causative agent of citrus huanglongbing, yet many genome rearrangements and several gene gains/losses are evident when comparing these two Liberibacter. species. Relative to ‘Ca. L. asiaticus’, ‘Ca. L. solanacearum’ probably has reduced capacity for nucleic acid modification, increased amino acid and vitamin biosynthesis functionalities, and gained a high-affinity iron transport system characteristic of several pathogenic microbes
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