Measuring Value in Primary Care: Enhancing Quality or Checking the Box?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109581/1/hesr12256-sup-0001-AuthorMatrix.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/109581/2/hesr12256.pd

Costs of liver transplantation: Primum non obfuscare

The costs and benefits of liver transplantation in adult patients at the University of Pittsburgh were reviewed for the period from 1981 through 1984. Indirect costs such as those to support the surgical and hepatology programs, the operating rooms and the clinical pathology department were ignored, and only those costs generated by the liver transplant program were considered in this analysis. Benefits to the patients are survival itself. Over 8.5% of those who leave the hospital return to full-time employment or other useful activity, including normal, albeit complicated, pregnancies. Most deaths occur during the first 3 months, after which there is a slow decline during the first year. Costs to the patient and/or the third party payers are enormous, and include evaluation as a transplant candidate, procurement of the donor liver, the transplantation itself and lifelong medical-surgical follow-up and immunosuppression plus the management of the undesirable consequences of the whole procedure. Laboratory tests alone average over $52,000 per patient. The consumption of blood and blood products is great and averages 30 units per patient. Duration of hospital admissions averaged about 55 days per patient, of which about 10 were in intensive care units. Total dollar costs were not calculated, however. The benefits to medicine are considerable in the acquisition of new knowledge and skills applicable to other disorders and other patients. The authors conclude that with further experience, the costs will decrease and the benefits will increase.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/38330/1/1840060643_ftp.pd

Under Pressure: Financial Effect of the Hospital‐Acquired Conditions Initiative–A Statewide Analysis of Pressure Ulcer Development and Payment

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/112254/1/jgs13475.pd

Small area analysis of hospital discharges for musculoskeletal diseases in Michigan: The influence of socioeconomic factors,

The rise in health care costs has occasioned a number of initiatives in an attempt to reduce the rate of increase. Despite the growth of health maintenance organizations and preferred provider organizations and the introduction of Medicare's prospective payment system, health care costs have continued to increase. Coincident with these efforts, a number of researchers have shown that there exists wide variation in age-adjusted hospital discharge rates, which translate into significant variation in per capita expenditures. Much of the focus on the reasons for hospital admission variability has been on physician practice variation. If most of the variation in hospital discharge rates is due to physician practice style, then payment systems can be developed (e.g., capitation) that limit physician practice variation without harming patients. We examined socioeconomic factors in Michigan communities to assess their association with hospital discharge rates for patients with musculoskeletal diseases. Data on hospital discharges from 1980 and 1987 were taken from the Michigan Inpatient Data Base. All admissions from the major diagnostic category 8, diagnosisrelated group (DRG) 209-256 were included. Zip code-specific hospitalization data were grouped into small geographic areas or hospital market communities (HMCs). Discharge rates were calculated, and profiles of the socioeconomic characteristics of each of the HMCs were developed. A Poisson regression model with an extrasystematic component of variance was used to analyze the association of HMC socioeconomic characteristics with age-adjusted hospital use. We found that four socioeconomic variables, average annual income per capita, percent of the population with four years of college, percent of the population living in an urban area, and percent of families with incomes below the poverty line, explained 26.6% (R2) of the variation in overall hospital discharge rates (p Socioeconomic factors play a significant role in explaining the observed variation in hospital discharge rates for musculoskeletal diseases. Models utilizing only physician practice variation to account for the populationbased differences in discharge rates are overly simplistic. In order to ensure that vulnerable subsets of the population are not harmed by the introduction of cost-containment strategies based on simplistic models, more attention must be paid to the socioeconomic and epidemiologic factors related to hospital use.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29190/1/0000243.pd

Mobility and other predictors of hospitalization for urinary tract infection: a retrospective cohort study

Abstract Background Many hospitalizations for residents of skilled nursing facilities are potentially avoidable. Factors that could prevent hospitalization for urinary tract infection (UTI) were investigated, with focus on patient mobility. Methods A retrospective cohort study was conducted using 2003–2004 data from the Centers for Medicare and Medicaid Services. The study included 408,192 residents of 4267 skilled nursing facilities in California, Florida, Michigan, New York, and Texas. The patients were followed over time, from admission to the skilled nursing facility to discharge or, for those who were not discharged, for 1 year. Cox proportional hazards regression was conducted with hospitalization for UTI as the outcome. Results The ability to walk was associated with a 69% lower rate of hospitalization for UTI. Maintaining or improving walking ability over time reduced the risk of hospitalization for UTI by 39% to 76% for patients with various conditions. For residents with severe mobility problems, such as being in a wheelchair or having a missing limb, maintaining or improving mobility (in bed or when transferring) reduced the risk of hospitalization for UTI by 38% to 80%. Other potentially modifiable predictors included a physician visit at the time of admission to the skilled nursing facility (Hazard Ratio (HR), 0.68), use of an indwelling urinary catheter (HR, 2.78), infection with Clostridium difficile or an antibiotic-resistant microorganism (HR, 1.20), and use of 10 or more medications (HR, 1.31). Patient characteristics associated with hospitalization for UTI were advancing age, being Hispanic or African-American, and having diabetes mellitus, renal failure, Parkinson's disease, dementia, or stroke. Conclusion Maintaining or improving mobility (walking, transferring between positions, or moving in bed) was associated with a lower risk of hospitalization for UTI. A physician visit at the time of admission to the skilled nursing facility also reduced the risk of hospitalization for UTI.http://deepblue.lib.umich.edu/bitstream/2027.42/112369/1/12877_2008_Article_125.pd

Hrs and SNX3 Functions in Sorting and Membrane Invagination within Multivesicular Bodies

After internalization, ubiquitinated signaling receptors are delivered to early endosomes. There, they are sorted and incorporated into the intralumenal invaginations of nascent multivesicular bodies, which function as transport intermediates to late endosomes. Receptor sorting is achieved by Hrs—an adaptor-like protein that binds membrane PtdIns3P via a FYVE motif—and then by ESCRT complexes, which presumably also mediate the invagination process. Eventually, intralumenal vesicles are delivered to lysosomes, leading to the notion that EGF receptor sorting into multivesicular bodies mediates lysosomal targeting. Here, we report that Hrs is essential for lysosomal targeting but dispensable for multivesicular body biogenesis and transport to late endosomes. By contrast, we find that the PtdIns3P-binding protein SNX3 is required for multivesicular body formation, but not for EGF receptor degradation. PtdIns3P thus controls the complementary functions of Hrs and SNX3 in sorting and multivesicular body biogenesis

The 2016 UK Space Agency Mars Utah Rover Field Investigation (MURFI)

The 2016 Mars Utah Rover Field Investigation (MURFI) was a Mars rover field trial run by the UK Space Agency in association with the Canadian Space Agency's 2015/2016 Mars Sample Return Analogue Deployment mission. MURFI had over 50 participants from 15 different institutions around the UK and abroad. The objectives of MURFI were to develop experience and leadership within the UK in running future rover field trials; to prepare the UK planetary community for involvement in the European Space Agency/Roscosmos ExoMars 2020 rover mission; and to assess how ExoMars operations may differ from previous rover missions. Hence, the wider MURFI trial included a ten-day (or ten-‘sol’) ExoMars rover-like simulation. This comprised an operations team and control centre in the UK, and a rover platform in Utah, equipped with instruments to emulate the ExoMars rovers remote sensing and analytical suite. The operations team operated in ‘blind mode’, where the only available data came from the rover instruments, and daily tactical planning was performed under strict time constraints to simulate real communications windows. The designated science goal of the MURFI ExoMars rover-like simulation was to locate in-situ bedrock, at a site suitable for sub-surface core-sampling, in order to detect signs of ancient life. Prior to “landing”, the only information available to the operations team were Mars-equivalent satellite remote sensing data, which were used for both geologic and hazard (e.g., slopes, loose soil) characterisation of the area. During each sol of the mission, the operations team sent driving instructions and imaging/analysis targeting commands, which were then enacted by the field team and rover-controllers in Utah. During the ten-sol mission, the rover drove over 100 m and obtained hundreds of images and supporting observations, allowing the operations team to build up geologic hypotheses for the local area and select possible drilling locations. On sol 9, the team obtained a subsurface core sample that was then analyzed by the Raman spectrometer. Following the conclusion of the ExoMars-like component of MURFI, the operations and field team came together to evaluate the successes and failures of the mission, and discuss lessons learnt for ExoMars rover and future field trials. Key outcomes relevant to ExoMars rover included a key recognition of the importance of field trials for (i) understanding how to operate the ExoMars rover instruments as a suite, (ii) building an operations planning team that can work well together under strict time-limited pressure, (iii) developing new processes and workflows relevant to the ExoMars rover, (iv) understanding the limits and benefits of satellite mapping and (v) practicing efficient geological interpretation of outcrops and landscapes from rover-based data, by comparing the outcomes of the simulated mission with post-trial, in-situ field observations. In addition, MURFI was perceived by all who participated as a vital learning experience, especially for early and mid-career members of the team, and also demonstrated the UK capability of implementing a large rover field trial. The lessons learnt from MURFI are therefore relevant both to ExoMars rover, and to future rover field trials

Transcriptome profiling of sheep granulosa cells and oocytes during early follicular development obtained by Laser Capture Microdissection

<p>Abstract</p> <p>Background</p> <p>Successful achievement of early folliculogenesis is crucial for female reproductive function. The process is finely regulated by cell-cell interactions and by the coordinated expression of genes in both the oocyte and in granulosa cells. Despite many studies, little is known about the cell-specific gene expression driving early folliculogenesis. The very small size of these follicles and the mixture of types of follicles within the developing ovary make the experimental study of isolated follicular components very difficult.</p> <p>The recently developed laser capture microdissection (LCM) technique coupled with microarray experiments is a promising way to address the molecular profile of pure cell populations. However, one main challenge was to preserve the RNA quality during the isolation of single cells or groups of cells and also to obtain sufficient amounts of RNA.</p> <p>Using a new LCM method, we describe here the separate expression profiles of oocytes and follicular cells during the first stages of sheep folliculogenesis.</p> <p>Results</p> <p>We developed a new tissue fixation protocol ensuring efficient single cell capture and RNA integrity during the microdissection procedure. Enrichment in specific cell types was controlled by qRT-PCR analysis of known genes: six oocyte-specific genes (<it>SOHLH2</it>, <it>MAEL</it>, <it>MATER</it>, <it>VASA</it>, <it>GDF9</it>, <it>BMP15</it>) and three granulosa cell-specific genes (<it>KL</it>, <it>GATA4</it>, <it>AMH</it>).</p> <p>A global gene expression profile for each follicular compartment during early developmental stages was identified here for the first time, using a bovine Affymetrix chip. Most notably, the granulosa cell dataset is unique to date. The comparison of oocyte vs. follicular cell transcriptomes revealed 1050 transcripts specific to the granulosa cell and 759 specific to the oocyte.</p> <p>Functional analyses allowed the characterization of the three main cellular events involved in early folliculogenesis and confirmed the relevance and potential of LCM-derived RNA.</p> <p>Conclusions</p> <p>The ovary is a complex mixture of different cell types. Distinct cell populations need therefore to be analyzed for a better understanding of their potential interactions. LCM and microarray analysis allowed us to identify novel gene expression patterns in follicular cells at different stages and in oocyte populations.</p

TLR1/2 Activation during Heterologous Prime-Boost Vaccination (DNA-MVA) Enhances CD8+ T Cell Responses Providing Protection against Leishmania (Viannia)

Leishmania (Viannia) are the predominant agents of leishmaniasis in Latin America. Given the fact that leishmaniasis is a zoonosis, eradication is unlikely; a vaccine could provide effective prevention of disease. However, these parasites present a challenge and we do not fully understand what elements of the host immune defense prevent disease. We examined the ability of vaccination to protect against L. (Viannia) infection using the highly immunogenic heterologous prime-boost (DNA-modified vaccinia virus) modality and a single Leishmania antigen (TRYP). Although this mode of vaccination can induce protection against other leishmaniases (cutaneous, visceral), no protection was observed against L. (V.) panamensis. However, we found that if the vaccination was modified and the innate immune response was activated through Toll-like receptor1/2(TLR1/2) during the DNA priming, vaccinated mice were protected. Protection was dependent on CD8 T cells. Vaccinated mice had higher CD8 T cell responses and decreased levels of cytokines known to promote infection. Given the long-term persistence of CD8 T cell memory, these findings are encouraging for vaccine development. Further, these results suggest that modulation of TLR1/2 signaling could improve the efficacy of DNA-based vaccines, especially where CD8 T cell activation is critical, thereby contributing to effective and affordable anti parasitic vaccines