A profile of children with complex chronic conditions at end of life among Medicaid beneficiaries: Implications for health care reform

Background: As the United States braces for full implementation of health care reform, the eyes of the nation are on Medicaid. The large number of newly eligible Medicaid beneficiaries may challenge health care resources and ultimately impact quality of care. This is a special concern among current Medicaid beneficiaries such as children with complex chronic conditions (CCCs) who have significant health care needs, especially at end of life (EOL). Yet, a comprehensive profile of these children is lacking. Objective: To understand the demographic and health characteristics, health care utilization, and expenditures among Medicaid children with CCCs at EOL. Methods: Our study used a retrospective cohort design with data from the 2007 and 2008 California Medicaid data files. Descriptive statistics were used to profile children in the last year of life. Results: We found a diverse group of children who suffered with serious, multiple chronic conditions, and who accessed comprehensive, multidisciplinary care. Most children had neuromuscular conditions (54%), cardiovascular conditions (46%), and cancer (30%). A majority (56%) had multiple CCCs. Children with CCCs received comprehensive care including hospital inpatient (67%), primary (82%), ancillary (87%), and other acute care services (83%); however, few children utilized hospice and home health care services (26%). Significant age differences existed among the children. Conclusions: The current California Medicaid system appears to provide comprehensive care for children at EOL. The underutilization of hospice and home health services, however, represents an opportunity to improve the quality of EOL care while potentially reducing or remaining budget neutral

Management of Fluid Status in Haemodialysis Patients: The Roles of Technology and Dietary Advice, Technical Problems in Patients on Hemodialysis

The kidneys play a vital role in maintaining normal tissue hydration and serum sodium level. In haemodialysis patients, with impaired or absent kidney function, fluid status is managed by removing excess fluid using ultrafiltration and by restricting dietary sodium intake. Ideally, haemodialysis patients should remain close to normal hydration throughout the interdialytic period, with minimal periods of excessive dehydration or fluid overload and with no fluid–related co-morbidity. Optimal fluid management is achieved by adjusting the post-dialysis ‘target’ weight and, where necessary, limiting the fluid gained between dialysis sessions. While clinical history and examination remain the basis for prescribing the target weight, technology can provide useful objective information especially where the clinical indications are ambiguous. A simple non-invasive test can now be carried out when a patient attends for dialysis enabling staff to pick up changes in body composition so that their target weight can be adjusted to maintain optimal fluid status. In most patients, interdialytic fluid gain (IDFG) is directly related to sodium intake. Acceptable fluid gains can usually be achieved by limiting salt intake to the recommended daily allowance for the general population and avoiding unnecessary sodium loading during dialysis. Low pre-dialysis serum sodium levels can help identify patients with other causes of high IDFG, such as high blood sugar or social drinking, who need additional counselling. For the patients, lowering sodium intake may also improve blood pressure control and reduce requirements for antihypertensive medication. Staff education, and preferably participation, is vital when implementing salt restriction in a haemodialysis unit

IDWG, salt and water – an audit of dialysis staff. British Journal of Renal Medicine.

Our haemodialysis service comprises two teaching hospital-based centres and six satellite units, which merged some years ago. The teaching hospitals were traditionally managed by separate groups of dietitians and dialysis staff. Consequently, there were differences in practice within the service, including the methods used to determine an acceptable interdialytic weight gain (IDWG). High IDWG is regarded as a negative factor due to associated intradialytic hypotension, interdialytic hypertension and cardiovascular disease.1 As such, patients with excessive IDWG are frequently advised to limit their daily fluid intake and may be encouraged to reduce their salt intake because of the association between salt intake and thirst.2 Different members of the multidisciplinary team (MDT) act as advisors in this area. This may lead to confusion and non-compliance if the information is conflicting or provided in a negative manner.3 We undertook an audit throughout the haemodialysis service to standardise the advice given to patients. This article reports the results of a questionnaire used to determine how staff respond to excessive IDWG. It also examined their knowledge of the salt and fluid content of common foods

Plausibility functions and exact frequentist inference

In the frequentist program, inferential methods with exact control on error rates are a primary focus. The standard approach, however, is to rely on asymptotic approximations, which may not be suitable. This paper presents a general framework for the construction of exact frequentist procedures based on plausibility functions. It is shown that the plausibility function-based tests and confidence regions have the desired frequentist properties in finite samples---no large-sample justification needed. An extension of the proposed method is also given for problems involving nuisance parameters. Examples demonstrate that the plausibility function-based method is both exact and efficient in a wide variety of problems.Comment: 21 pages, 5 figures, 3 table

Minimum Decision Cost for Quantum Ensembles

For a given ensemble of $N$ independent and identically prepared particles, we calculate the binary decision costs of different strategies for measurement of polarised spin 1/2 particles. The result proves that, for any given values of the prior probabilities and any number of constituent particles, the cost for a combined measurement is always less than or equal to that for any combination of separate measurements upon sub-ensembles. The Bayes cost, which is that associated with the optimal strategy (i.e., a combined measurement) is obtained in a simple closed form.Comment: 11 pages, uses RevTe

Treating and Preventing Influenza in Aged Care Facilities: A Cluster Randomised Controlled Trial

PMCID: PMC3474842This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Spontaneous CP Violation at the Electroweak Scale

Utilizing results on the cosmology of anomalous discrete symmetries we show that models of spontaneous CP violation can in principle avoid the domain wall problem first pointed out by Zel'dovich, Kobzarev and Okun. A small but nonzero $\theta_{QCD}$ explicitly breaks CP and can lift the degeneracy of the two CP conjugate vacua through nonperturbative effects so that the domain walls become unstable, but survive to cosmologically interesting epochs. We explore the viability of spontaneous CP violation in the context of two Higgs models, and find that the invisible axion solution of the strong CP problem cannot be implemented without further extensions of the Higgs sector.Comment: 10 page

A probabilistic approach for acoustic emission based monitoring techniques: with application to structural health monitoring

It has been demonstrated that acoustic-emission (AE), inspection of structures can offer advantages over other types of monitoring techniques in the detection of damage; namely, an increased sensitivity to damage, as well as an ability to localise its source. There are, however, numerous challenges associated with the analysis of AE data. One issue is the high sampling frequencies required to capture AE activity. In just a few seconds, a recording can generate very high volumes of data, of which a significant portion may be of little interest for analysis. Identifying the individual AE events in a recorded time-series is therefore a necessary procedure to reduce the size of the dataset. Another challenge that is also generally encountered in practice, is determining the sources of AE, which is an important exercise if one wishes to enhance the quality of the diagnostic scheme. In this paper, a state-of-the-art technique is presented that can automatically identify AE events, and simultaneously help in their characterisation from a probabilistic perspective. A nonparametric Bayesian approach, based on the Dirichlet process (DP), is employed to overcome some of the challenges associated with these tasks. Two main sets of AE data are considered in this work: (1) from a journal bearing in operation, and (2) from an Airbus A320 main landing gear subjected to fatigue testing