San Diego: Major Providers Pursue Countywide Networks and New Patient Care Models

San Diego has long been a geographically well-defined health care market with high managed care penetration and a consolidated provider sector. In recent years, hospital systems have faced increasing cost pressures as commercial health plans have responded to employer demands for more affordable premiums. Safety-net providers expanded capacity to deal with the large Medi-Cal expansion that began in 2014, but continue to grapple with how to provide adequate care for a new enrollee population that is far sicker, with more complex medical and social service needs, than the providers' previous patient base.Key developments include:While the hospital market remained largely stable in recent years, most of the smaller hospitals have been losing volume and struggling financially.Major systems are pursuing population health strategies and increasingly using provider-sponsored health plans to take full risk for more patients.The challenges of independent practice are leading many primary care physicians to choose employment at system-affiliated groups.In the two years since Medicaid eligibility was first expanded under the ACA, San Diego's Medi-Cal managed care enrollment almost doubled to 700,000. Many Medi-Cal enrollees without a regular primary care provider sought care at hospital emergency departments, and access gaps for many kinds of specialty care and behavioral health care were even more severe.San Diego County's commitment to providing health care for low-income residents continues to be limited, although the county Health and Human Services Agency has become more active in fostering collaborations between health and other social services

Orange County: Changing Market Fuels New Models of Provider Collaboration

Since 2010, Orange County has largely recovered from the economic downturn and remains a relatively well-educated community with high rates of private insurance coverage overall. Socioeconomic variation persists in this county, with the number of low-income residents growing and a large jump in the proportion of the population that gained Medi-Cal coverage under the Affordable Care Act (ACA). Other key findings include:The region's major hospital systems are expanding ambulatory services and geographic reach.Orange County physicians are increasingly giving up independence to varying degrees and joining larger physician organizations or hospital-affiliated groups to gain shelter from mounting financial pressures and administrative burdens.Providers are collaborating on new payment arrangements, with some Orange County physician organizations and hospitals working toward assuming more risk for more patients, particularly the growing numbers in preferred-provider organizations (PPOs).The proportion of Orange County residents covered by Medi-Cal has jumped, with a greater proportional increase in Medi-Cal enrollment than other California regions studied.Safety-net provider capacity is tight; private providers are playing a significant role in serving the Medi-Cal expansion population

Development of a Fan for Future Space Suit Applications

NASA's next generation space suit system will place new demands on the fan used to circulate breathing gas through the ventilation loop of the portable life support system. Long duration missions with frequent extravehicular activities (EVAs), the requirement for significant increases in reliability and durability, and a mission profile that imposes strict limits on weight, volume and power create the basis for a set of requirements that demand more performance than is available from existing fan designs. This paper describes the development of a new fan to meet these needs. A centrifugal fan was designed with a normal operating speed of approximately 39,400 rpm to meet the ventilation flow requirements while also meeting the aggressive minimal packaging, weight and power requirements. The prototype fan also operates at 56,000 rpm to satisfy a second operating condition associated with a single fan providing ventilation flow to two spacesuits connected in series. This fan incorporates a novel nonmetallic "can" to keep the oxygen flow separate from the motor electronics, thus eliminating ignition potential. The nonmetallic can enables a small package size and low power consumption. To keep cost and schedule within project bounds a commercial motor controller was used. The fan design has been detailed and implemented using materials and approaches selected to address anticipated mission needs. Test data is presented to show how this fan performs relative to anticipated ventilation requirements for the EVA portable life support system. Additionally, data is presented to show tolerance to anticipated environmental factors such as acoustics, shock, and vibration. Recommendations for forward work to progress the technology readiness level and prepare the fan for the next EVA space suit system are also discussed

Bibliography on HIV/AIDS in Ethiopia and Ethiopians in the Diaspora: The 2004 Update

No Abstract Available Ethiop.J.Health Dev. Vol.19(1) 2005: 65-8

Do genetic structure and landscape heterogeneity impact color morph frequency in a polymorphic salamander?

Landscape heterogeneity plays an important role in population structure and divergence, particularly for species with limited vagility. Here, we used a landscape genetic approach to identify how landscape and environmental variables affect genetic structure and color morph frequency in a polymorphic salamander. The eastern red- backed salamander, Plethodon cinereus, is widely distributed in northeastern North America and contains two common color morphs, striped and unstriped, that are divergent in ecology, behavior, and physiology. To quantify population structure, rates of gene flow, and genetic drift, we amplified 10 microsatellite loci from 648 individuals across 28 sampling localities. This study was conducted in northern Ohio, where populations of P. cinereus exhibit an unusually wide range of morph frequency variation. To test whether genetic distance was more correlated with morph frequency, elevation, canopy cover, waterways, ecological niche or geographic distance, we used resistance distance and least cost path analyses. We then examined whether landscape and environmental variables, genetic distance or geographic distance were correlated with variation in morph frequency. Tests for population structure revealed three genetic clusters across our sampling range, with one cluster monomorphic for the striped morph. Rates of gene flow and genetic drift were low to moderate across sites. Genetic distance was most correlated with ecological niche, elevation and a combination of landscape and environmental variables. In contrast, morph frequency variation was correlated with waterways and geographic distance. Thus, our results suggest that selection is also an important evolutionary force across our sites, and a balance between gene flow, genetic drift and selection interact to maintain the two color morphs

Bibliography on HIV/AIDS in Ethiopia and Ethiopians in the Diaspora: The 2015 Update

No Abstrac

Bibliography on HIV/AIDS in Ethiopia and Ethiopians in the diaspora: The 2016 update

No Abstrac

Pharmacologic management of Mycobacterium ulcerans infection

Introduction: Pharmacological treatment of Buruli ulcer (Mycobacterium ulcerans infection; BU) is highly effective, as shown in two randomized trials in Africa. Areas covered: We review BU drug treatment–in vitro, in vivo and clinical trials (PubMed: ‘(Buruli OR (Mycobacterium AND ulcerans)) AND (treatment OR therapy).’ We also highlight the pathogenesis of M. ulcerans infection that is dominated by mycolactone, a secreted exotoxin, that causes skin and soft tissue necrosis, and impaired immune response and tissue repair. Healing is slow, due to the delayed wash-out of mycolactone. An array of repurposed tuberculosis and leprosy drugs appears effective in vitro and in animal models. In clinical trials and observational studies, only rifamycins (notably, rifampicin), macrolides (notably, clarithromycin), aminoglycosides (notably, streptomycin) and fluoroquinolones (notably, moxifloxacin, and ciprofloxacin) have been tested. Expert opinion: A combination of rifampicin and clarithromycin is highly effective but lesions still take a long time to heal. Novel drugs like telacebec have the potential to reduce treatment duration but this drug may remain unaffordable in low-resourced settings. Research should address ulcer treatment in general; essays to measure mycolactone over time hold promise to use as a readout for studies to compare drug treatment schedules for larger lesions of Buruli ulcer

Altered cellular infiltration and cytokine levels during early Mycobacterium tuberculosis sigC mutant infection are associated with late-stage disease attenuation and milder immunopathology in mice

<p>Abstract</p> <p>Background</p> <p>Mouse virulence assessments of certain <it>Mycobacterium tuberculosis </it>mutants have revealed an immunopathology defect in which high tissue CFU counts are observed but the tissue pathology and lethality are reduced. <it>M. tuberculosis </it>mutants which grow and persist in the mouse lungs, but have attenuated disease progression, have the immunopathology (<it>imp</it>) phenotype. The antigenic properties of these strains may alter the progression of disease due to a reduction in host immune cell recruitment to the lungs resulting in disease attenuation and prolonged host survival.</p> <p>Results</p> <p>In this study we focused on the mouse immune response to one such mutant; the <it>M. tuberculosis </it>Δ<it>sigC </it>mutant. Aerosol infection of DBA/2 and SCID mice with the <it>M. tuberculosis </it>Δ<it>sigC </it>mutant, complemented mutant and wild type strain showed proliferation of mutant bacilli in mouse lungs, but with decreased inflammation and mortality in DBA/2 mice. SCID mice shared the same phenotype as the DBA/2 mice in response to the Δ<it>sigC </it>mutant, however, they succumbed to the infection faster. Bronchoalveolar lavage (BAL) fluid analysis revealed elevated numbers of infiltrating neutrophils in the lungs of mice infected with wild type and complemented Δ<it>sigC </it>mutant strains but not in mice infected with the Δ<it>sigC </it>mutant. In addition, DBA/2 mice infected with the Δ<it>sigC </it>mutant had reduced levels of TNF-α, IL-1β, IL-6 and IFN-γ in the lungs. Similarly, there was a reduction in proinflammatory cytokines in the lungs of SCID mice. In contrast to the mouse model, the Δ<it>sigC </it>mutant had reduced initial growth in guinea pig lungs. A possible mechanism of attenuation in the Δ<it>sigC </it>mutant may be a reduction in neutrophilic-influx in the alveolar spaces of the lungs, and decreased proinflammatory cytokine secretion. In contrast to mouse data, the <it>M. tuberculosis </it>Δ<it>sigC </it>mutant proliferates slowly in guinea pig lungs, a setting characterized by caseating necrosis.</p> <p>Conclusion</p> <p>Our observations suggest that the immunopathology phenotype is associated with the inability to trigger a strong early immune response, resulting in disease attenuation. While macrophages and T cells have been shown to be important in containing <it>M. tuberculosis </it>disease our study has shown that neutrophils may also play an important role in the containment of this organism.</p

Microbiological, histological, immunological, and toxin response to antibiotic treatment in the mouse model of Mycobacterium ulcerans disease.

Mycobacterium ulcerans infection causes a neglected tropical disease known as Buruli ulcer that is now found in poor rural areas of West Africa in numbers that sometimes exceed those reported for another significant mycobacterial disease, leprosy, caused by M. leprae. Unique among mycobacterial diseases, M. ulcerans produces a plasmid-encoded toxin called mycolactone (ML), which is the principal virulence factor and destroys fat cells in subcutaneous tissue. Disease is typically first manifested by the appearance of a nodule that eventually ulcerates and the lesions may continue to spread over limbs or occasionally the trunk. The current standard treatment is 8 weeks of daily rifampin and injections of streptomycin (RS). The treatment kills bacilli and wounds gradually heal. Whether RS treatment actually stops mycolactone production before killing bacilli has been suggested by histopathological analyses of patient lesions. Using a mouse footpad model of M. ulcerans infection where the time of infection and development of lesions can be followed in a controlled manner before and after antibiotic treatment, we have evaluated the progress of infection by assessing bacterial numbers, mycolactone production, the immune response, and lesion histopathology at regular intervals after infection and after antibiotic therapy. We found that RS treatment rapidly reduced gross lesions, bacterial numbers, and ML production as assessed by cytotoxicity assays and mass spectrometric analysis. Histopathological analysis revealed that RS treatment maintained the association of the bacilli with (or within) host cells where they were destroyed whereas lack of treatment resulted in extracellular infection, destruction of host cells, and ultimately lesion ulceration. We propose that RS treatment promotes healing in the host by blocking mycolactone production, which favors the survival of host cells, and by killing M. ulcerans bacilli