Financing Long-Term Care in Missouri: Limits and Changes in the Wake of the Deficit Reduction Act of 2005

The expense of long-term care, intensified by an aging population, has contributed to a nationwide financial strain on the Medicaid program, complicating the already difficult tasks of medical and fiscal planning for the elderly. Missouri\u27s elderly population is substantial, the state having ranked 14d\u27 in the country for the number of residents over age 65 in 2000. These senior citizens face the prospect of paying for long-term care, and many of them will rely on Medicaid for all or part of the cost. Medicaid is the primary taxpayer-funded program that finances long-term care. Current projections suggest that the cost of Medicaid will continue to increase exponentially. As a result of this projected increase, both the federal government and the state of Missouri have enacted legislation restricting the availability of Medicaid benefits for long-term care - limits that affect the financial planning of the baby boom generation, especially those in the middle-class

Dinoflagellate abundance in the Laguna Botos, Poás Volcano, Costa Rica

Phytoplankton of the Botos lagoon of Poás volcano is dominated by dinoflagellates. The two species of greatest abundance in March 1979 were Peridinium incospicuum Lemm. and P. volzii Lemm, which represented 96% of total cells. The identity of these species was confirmed by electron microscopy. Both species are cosmopolitan. Without further resealch it is premature to compare Botos Lagoon with similar lakes in Central America

The antimicrobial peptide TAT-RasGAP_317-326 inhibits the formation and expansion of bacterial biofilms in vitro.

Biofilms are structured aggregates of bacteria embedded in a self-produced matrix that develop in diverse ecological niches. Pathogenic bacteria can form biofilms on surfaces and in tissues, causing nosocomial and chronic infections that are difficult to treat. While antibiotics are largely inefficient in limiting biofilm formation and expansion, antimicrobial peptides (AMPs) are emerging as alternative antibiofilm treatments. In this study, we explore the effect of the newly described AMP TAT-RasGAP <sub>317-326</sub> on Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus biofilms. Efficiency of TAT-RasGAP <sub>317-326</sub> on biofilms was tested in vitro. Both viability of bacteria contained in the biofilm as well as biomass of the biofilm were quantified using resazurin and crystal violet staining, respectively. The antibiofilm effect of TAT-RasGAP <sub>317-326</sub> was compared with a selection of classical antibiotics and AMPs. We observe that TAT-RasGAP <sub>317-326</sub> inhibits biofilm formation at concentrations equivalent or two times greater than the minimum inhibitory concentration (MIC) of planktonic bacteria. Moreover, TAT-RasGAP <sub>317-326</sub> limits the expansion of A. baumannii and P. aeruginosa established biofilms at twice the concentration inhibiting biofilm formation. These results underscore the potential use of TAT-RasGAP <sub>317-326</sub> against biofilms and encourage further studies in the development of AMPs to treat biofilm-related infections

A current perspective on cancer immune therapy: Step‑by‑step approach to constructing the magic bullet

Immunotherapy is the new trend in cancer treatment due to the selectivity, long lasting effects, and demonstrated improved overall survival and tolerance, when compared to patients treated with conventional chemotherapy. Despite these positive results, immunotherapy is still far from becoming the perfect magic bullet to fight cancer, largely due to the facts that immunotherapy is not effective in all patients nor in all cancer types. How and when will immunotherapy overcome these hurdles? In this review we take a step back to walk side by side with the pioneers of immunotherapy in order to understand what steps need to be taken today to make immunotherapy effective across all cancers. While early scientists, such as Coley, elicited an unselective but effective response against cancer, the search for selectivity pushed immunotherapy to the side in favor of drugs focused on targeting cancer cells. Fortunately, the modern era would revive the importance of the immune system in battling cancer by releasing the brakes or checkpoints (anti-CTLA-4 and anti-PD-1/PD-L1) that have been holding the immune system at bay. However, there are still many hurdles to overcome before immunotherapy becomes a universal cancer therapy. For example, we discuss how the redundant and complex nature of the immune system can impede tumor elimination by teeter tottering between different polarization states: one eliciting anti-cancer effects while the other promoting cancer growth and invasion. In addition, we highlight the incapacity of the immune system to choose between a fight or repair action with respect to tumor growth. Finally we combine these concepts to present a new way to think about the immune system and immune tolerance, by introducing two new metaphors, the “push the accelerator” and “repair the car” metaphors, to explain the current limitations associated with cancer immunotherapyThis work was supported by NIH R00 CA154605 and Louisiana Board of Regents LEQSF(2016-17)-RD-C-14 (H.L.M.), a Rámon y Cajal Merit Award from the Ministerio de Economía y Competitividad, Spain (B.S.Jr) and a Clinic and Laboratory Integration Program (CLIP) grant from the Cancer Research Institute, NY (B.S.Jr)

The stereotypicality of symptomatic and pragmatic argumentation in consultations about palliative systemic treatment for advanced cancer

Analysis and support of clinical decision makin

Envisioning shared decision making: a reflection for the next decade

Despite the evolving evidence in favor of shared decision making (SDM) and of decades-long calls for its adoption, SDM remains uncommon in routine care. Reflecting on this lack of progress, we sought to reimagine the future of SDM and the path to take us there. In late 2017, a multidisciplinary and international group of six researchers were challenged by a senior SDM scholar to envision the future and, based on a provocatively critical view of the present, to write letters to themselves from the year 2028. Letters were exchanged and discussed electronically. The group then met in person to discuss the letters. Since the letters painted a dystopian picture, they triggered questions about the nature of SDM, who should benefit from SDM, how to measure its contribution to care, and what new ways can be invented to design and test interventions to implement SDM in routine care. Through contrasting the purposefully generated dystopias with an ideal future for SDM, we generated reflections on a research agenda for SDM. These reflections hinged on recognizing SDM's contributing to care, that is, as a way to advance the problematic human situation of patients. These focused on three distinct yet complimentary contributors to SDM: 1) the process of making decisions, 2) humanistic communication, and 3) fit-to-care of the resulting decision. The group then concluded that to move SDM from envisioned to routine practice, and to ensure it reaches all, particularly persons rendered vulnerable by current forms of health care, a substantial investment in implementation research is necessary. Perhaps the discussion of these reflections can contribute to a path forward that will improve the likelihood of the future we dream for SDM.Analysis and support of clinical decision makin

Toma de decisiones compartidas en la atención de pacientes con diabetes mellitus: un desafío para Latinoamérica

Patients with diabetes mellitus often have several medical problems and carry a burden imposed by their illness and treatment. Health care often ignores the values, preferences and context of patients, leading to treatments that do not fit into patients’ overwhelmed lives. Shared Decision Making (SDM) emerges as a way to answer the question: “What’s best for the patient?”. SDM promotes an empathic conversation between patients and clinicians that integrates the best evidence available with their values, preferences and context. We discuss three SDM approaches for patients with diabetes: one focused on sharing information, another on making choices, and a third one on helping patients and clinicians to talk about how to address the problems of living with diabetes and its comorbidities. Despite the benefits demonstrated in studies conducted in the U.S. and Europe, the implementation of SDM continues to be a challenge. In Latin America, healthcare and socio-economic conditions render the implementation of SDM more challenging. Research aimed to respond to this challenge is necessary. Meanwhile, clinicians can practice SDM by sharing evidence-based information, giving voice to patients’ values and preferences in making choices, and creating empathic conversations aimed at decisions aligned with patients’ context, dreams, goals, and life expectations. (Rev Med Chile 2017; 145: 641-649) Key words: Decision Making; Decision Support Techniques; Diabetes Mellitus; Evidence-Based Medicine

Tracking the Late Jurassic apparent (or true) polar shift in U-Pb-dated kimberlites from cratonic North America (Superior Province of Canada)

Different versions of a composite apparent polar wander (APW) path of variably selected global poles assembled and averaged in North American coordinates using plate reconstructions show either a smooth progression or a large (∼30°) gap in mean paleopoles in the Late Jurassic, between about 160 and 145 Ma. In an effort to further examine this issue, we sampled accessible outcrops/subcrops of kimberlites associated with high-precision U-Pb perovskite ages in the Timiskaming area of Ontario, Canada. The 154.9 ± 1.1 Ma Peddie kimberlite yields a stable normal polarity magnetization that is coaxial within less than 5° of the reverse polarity magnetization of the 157.5 ± 1.2 Ma Triple B kimberlite. The combined ∼156 Ma Triple B and Peddie pole (75.5°N, 189.5°E, A95 = 2.8°) lies about midway between igneous poles from North America nearest in age (169 Ma Moat volcanics and the 146 Ma Ithaca kimberlites), showing that the polar motion was at a relatively steady yet rapid (∼1.5°/Myr) pace. A similar large rapid polar swing has been recognized in the Middle to Late Jurassic APW path for Adria-Africa and Iran-Eurasia, suggesting a major mass redistribution. One possibility is that slab breakoff and subduction reversal along the western margin of the Americas triggered an episode of true polar wander