Healthcare utilization and spending by children with cancer on Medicaid

BackgroundChildren with cancer are a unique patient population with high resource, complex healthcare needs. Understanding their healthcare utilization could highlight areas for care optimization.ProcedureWe performed a retrospective, cross‐sectional analysis of the 2014 Truven Marketscan Medicaid Database to explore clinical attributes, utilization, and spending among children with cancer who were Medicaid enrollees. Eligible patients included children (ages 0–18 years) with cancer (Clinical Risk Group 8). Healthcare utilization and spending (per member per month, PMPM) were assessed overall and across specific healthcare services.ResultsChildren with cancer (n = 5,405) represent less than 1% of the 1,516,457 children with medical complexity in the dataset. Children with cancer had high services use: laboratory/radiographic testing (93.0%), outpatient specialty care (83.4%), outpatient therapy/treatment (53.4%), emergency department (43.7%), hospitalization (31.5%), home healthcare (9.5%). PMPM spending for children with cancer was $3,706 overall and$2,323 for hospital care.ConclusionChildren with cancer have high healthcare resource use and spending. Differences in geographic distribution of services for children with cancer and the trajectory of spending over the course of therapy are areas for future investigation aimed at lowering costs of care without compromising on health outcomes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138316/1/pbc26569_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138316/2/pbc26569.pd

Incest avoidance, extrapair paternity, and territory quality drive divorce in a year-round territorial bird

Divorce can be an important behavioral strategy to improve fitness. This is particularly relevant for species that are territorial year-round with continuous partnerships, where individuals face constraints on partner choice due to limited vacancies and dispersal opportunities. We tested several hypotheses for divorce in such a species, the cooperatively breeding bird Malurus coronatus. Based on 9 years of detailed information on dispersal and survival of 317 breeding pairs, we tested whether divorce is driven by inbreeding avoidance, by a better partner or territory, or by social variables (number of subordinates and fidelity of partners). We found that divorce is important to escape incest: incestuous pairs were substantially more likely to divorce (64%) than non-incestuous pairs (14%). However, incestuous pair bonds lasted up to a year, highlighting constraints on breeder dispersal. Non-incestuous pairs also divorced, but here the only predictor for divorce was the presence of extrapair offspring in a previous brood. Although reproductive failure did not trigger divorce, and reproductive success did not improve in the year following divorce, females that dispersed after divorce obtained higher quality territories, unlike females that dispersed after their partner died. Thus, divorce may be a strategy to improve long-term benefits associated with better territories. Some divorces appeared to be forced evictions by older females, although direct evidence for this is limited. Taken together, our findings demonstrate the complexity of factors that affect the occurrence of divorce when partner choice is constrained

Tele-AAC Resolution.

Approximately 1.3% of all people, or about 4 million Americans, cannot rely on their natural speech to meet their daily communication needs. Telepractice offers a potentially cost-effective service delivery mechanism to provide clinical AAC services at a distance to the benefit of underserved populations in the United States and worldwide. Tele-AAC is a unique cross-disciplinary clinical service delivery model that requires expertise in both telepractice and augmentative and alternative communication (AAC) systems. The Tele-AAC Working Group of the 2012 ISAAC Research Symposium therefore drafted a resolution underscoring the importance of identifying and characterizing the unique opportunities and constraints of Tele-AAC in all aspects of service delivery. These include, but are not limited to: needs assessments; implementation planning; device/system procurement, set-up and training; quality assurance, client progress monitoring, and follow-up service delivery. Tele-AAC, like other telepractice applications, requires adherence to the ASHA Code of Ethics and other policy documents, and state, federal, and international laws, as well as a competent technological infrastructure. The Working Group recommends that institutions of higher education and professional organizations provide training in Tele-AAC service provision. In addition, research and development are needed to create validity measures across Tele-AAC practices (i.e., assessment, implementation, and consultation); determine the communication competence levels achieved by Tele-AAC users; discern stakeholders' perceptions of Tele-AAC services (e.g., acceptability and viability); maximize Tele-AAC's capacity to engage multiple team members in AAC assessment and ongoing service; identify the limitations and barriers of Tele-AAC provision; and develop potential solutions

Are rivers just bigstreams? Using a pulse method to measure nitrogen demand in a large river

Given recent focus on large rivers as conduits for excess nutrients to coastal zones, their role in processing and retaining nutrients has been overlooked and understudied. Empirical measurements of nutrient uptake in large rivers are lacking, despite a substantial body of knowledge on nutrient transport and removal in smaller streams. Researchers interested in nutrient transport by rivers (discharge \u3e10000 L/s) are left to extrapolate riverine nutrient demand using a modeling framework or a mass balance approach. To begin to fill this knowledge gap, we present data using a pulse method to measure inorganic nitrogen. (N) transport and removal in the Upper Snake River, Wyoming, USA (seventh order, discharge 12000 L/s). We found that the Upper Snake had surprisingly high biotic demand relative to smaller streams in the same river network for both ammonium (NH4+) and nitrate (NO3-). Placed in the context of a meta-analysis of previously published nutrient uptake studies, these data suggest that large rivers may have similar biotic demand for N as smaller tributaries. We also found that demand for different forms of inorganic N (NH4+ vs. NO3-) scaled differently with stream size. Data from rivers like the Upper Snake and larger are essential for effective water quality management at the scale of river networks. Empirical measurements of solute dynamics in large rivers are needed to understand the role of whole river networks (as opposed to stream reaches) in patterns of nutrient export at regional and continental scales

Characteristics of Children With Cancer Discharged or Admitted From the Emergency Department

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136395/1/pbc25872_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136395/2/pbc25872.pd

More than kin:Subordinates foster strong bonds with relatives and potential mates in a social bird

Social interactions shape relationships between individuals in complex societies. Affiliative interactions are associated with benefits and strengthen social bonds, while aggressive interactions are costly and negatively affect social bonds. Individuals may attempt to reduce aggressive encounters through submissive displays directed at higher-ranking individuals. Thus, fine-scale patterns of affilia-tive, aggressive, and submissive interactions may reflect costly and beneficial social relationships within groups, providing insight into the benefits of group living and the mechanisms of conflict resolution. So far, however, most studies have looked at social interactions and benefits of group living in isolation. We investigated how the strength of social bonds (affiliative vs. aggressive interactions) and submissive displays varied with kin-selected and potential mating benefits, and with reproductive conflict in the cooperatively breeding purple-crowned fairy-wren, Malurus coronatus. Our results revealed that subordinates formed equally strong social bonds with kin and potential mates (unrelated opposite-sex individuals) while they formed antagonistic relationships with reproductive competitors that offered no kin-selected or mating benefits (unrelated same-sex individuals). Submissive displays were directed exclusively at same-sex breeders, regardless of relatedness. Affiliation and submission were associated with reduced foraging time when food was limited, indicating a cost to maintaining positive relationships. Together, our results suggest that the strength of social bonds is determined by (potential) benefits obtained from group members, while submission likely serves to reduce conflict. Our findings highlight the importance of time-costly social interactions for maintaining relationships with group members, providing insight into how social groups of individuals with (partly) divergent interests can remain stable.</p

PCV23: VARIATION IN COSTS OF TREATING HYPERCHOLESTEROLEMIC PATIENTS IN FRANCE

The evolution of male ornamentation has long been the focus of sexual selection studies. However, evidence is accumulating that sexually selected traits can also be lost, although the process is ill-understood. In male fairy-wrens (Malurus spp.), early molt into the seasonal breeding plumage is critical for obtaining extra-pair paternity (EPP), which reaches very high levels in these socially monogamous songbirds. A notable exception is the purple-crowned fairy-wren, Malurus coronatus, which, like its congeners, breeds cooperatively, but where EPP is very rare. Nevertheless, males develop a conspicuous seasonal breeding plumage at highly variable times. Based on 6 years of molt data collected for 137 individuals, we investigated the adaptive significance of pre-breeding molt timing as a sexual signal under (near) genetic monogamy. Molt timing varied between and within individuals with age and climate: molt was completed earlier in older males and after wetter years. Despite its potential to act as a sexual signal of male quality, fitness benefits and costs of early molt appear limited: molt timing did not correlate with 1) the likelihood of gaining a breeding position; 2) female mate preference (EPP/cuckoldry, divorce); 3) female reproductive investment (breeding timing, clutch size, number of clutches); 4) breeding performance (hatching success, fledging success, fledgling survival, annual reproductive success); and 5) male survival. However, although molt timing did not predict which subordinates would become breeders, breeders molted earlier than subordinates. The lack of EPP in this species might imply relaxed sexual selection on early molt with potential to lead to trait disappearance

Scaling Dissolved Nutrient Removal in River Networks: A Comparative Modeling Investigation

Along the river network, water, sediment, and nutrients are transported, cycled, and altered by coupled hydrological and biogeochemical processes. Our current understanding of the rates and processes controlling the cycling and removal of dissolved inorganic nutrients in river networks is limited due to a lack of empirical measurements in large, (nonwadeable), rivers. The goal of this paper was to develop a coupled hydrological and biogeochemical process model to simulate nutrient uptake at the network scale during summer base flow conditions. The model was parameterized with literature values from headwater streams, and empirical measurements made in 15 rivers with varying hydrological, biological, and topographic characteristics, to simulate nutrient uptake at the network scale. We applied the coupled model to 15 catchments describing patterns in uptake for three different solutes to determine the role of rivers in network-scale nutrient cycling. Model simulation results, constrained by empirical data, suggested that rivers contributed proportionally more to nutrient removal than headwater streams given the fraction of their length represented in a network. In addition, variability of nutrient removal patterns among catchments was varied among solutes, and as expected, was influenced by nutrient concentration and discharge. Net ammonium uptake was not significantly correlated with any environmental descriptor. In contrast, net daily nitrate removal was linked to suspended chlorophyll a (an indicator of primary producers) and land use characteristics. Finally, suspended sediment characteristics and agricultural land use were correlated with net daily removal of soluble reactive phosphorus, likely reflecting abiotic sorption dynamics. Rivers are understudied relative to streams, and our model suggests that rivers can contribute more to network-scale nutrient removal than would be expected based upon their representative fraction of network channel length

From ornament to armament or loss of function?:Breeding plumage acquisition in a genetically monogamous bird

The evolution of conspicuous male traits is thought to be driven by female mate choice or male-male competition. These two mechanisms are often viewed as distinct processes, with most studies focusing on female choice. However, both mechanisms of sexual selection can act simultaneously on the same trait (i.e., dual function) and/or interact in a synergistic or conflicting way. Dual-function traits are commonly assumed to originate through male-male competition before being used in female choice; yet, most studies focusing on such traits could not determine the direction of change, lacking phylogenetic information. We investigated the role of conspicuous male seasonal plumage in male-male competitive interactions in the purple-crowned fairy-wren Malurus coronatus, a cooperatively breeding bird. Male breeding plumage in most Malurus species is selected by female choice through extra-pair mate choice, but unlike its congeners, M.coronatus is genetically monogamous, and females do not seem to choose males based on breeding plumage acquisition. Our study shows that, within groups, subordinate males that were older, and therefore higher-ranked in the queue for breeder position inheritance, produced a more complete breeding plumage. In line with this, subordinate males that were older and/or displayed a more complete breeding plumage were more successful in competitively acquiring a breeder position. A role as a signal of competitive ability was experimentally confirmed by presenting models of males: in breeding colours, these received more aggression from resident breeder males than in nonbreeding colours, but elicited limited response from females, consistent with competitors in breeding plumage being perceived as a bigger threat to the breeder male. The role of the conspicuous breeding plumage in mediating male-male interactions might account for its presence in this genetically monogamous species. As phylogenetic reconstructions suggest a past female choice function in M.coronatus, this could represent a sexual trait that shifted functions, or a dual-function trait that lost one function. These evolutionary scenarios imply that intra- and intersexual functions of ornaments may be gained or lost independently and offer new perspectives in understanding the complex dynamics of sexual selection