Healthcare Utilization And Expenditure Patterns Among Older Adults With Functional And Medical Decline

Purpose. As the aged population of this country grows, the U.S. healthcare system will face increased pressure to provide long-term care services and supports to increasing numbers of elderly Medicare beneficiaries. Studies have indicated that unmet long-term care need can lead to increased, unnecessary utilization of the healthcare system, thus further taxing the Medicare system. Little is known about how type of long-term care, as well as how long-term care policies—specifically payment policies—affect health care utilization. The objective of this original dissertation research was to examine the effects of place of residence (community versus residential long-term care facility) and long-term care payer type (private pay versus Medicaid) on Medicare-funded healthcare utilization in terms of both risk of potentially preventable hospitalization (PPH) and Medicare expenditures. Methods. This study utilized data from the 5% sample of 2013 Medicare claims and enrollment data from the Centers for Medicare and Medicaid Services (CMS) merged with data from the Areas Health Resource File (AHRF). A retrospective cohort analysis examined the healthcare utilization and expenditure patterns of Medicare beneficiaries for whom, based on clinical and demographic factors, the provision of formal, comprehensive long-term care would be appropriate, among four cohorts: Medicare-only beneficiaries residing in the community; Medicare-only beneficiaries residing in long-term care facilities; Medicare/Medicaid dual eligible beneficiaries residing in the community; and Medicare/Medicaid dual eligible beneficiaries residing in long-term care facilities. Results. This study found a significantly higher risk of both PPH and having Medicare expenditures in the top 90th percentile among both Medicare-only long-term care facility residents and dual eligible community residents as compared to dual eligible long-term care facility residents, yet Medicare-only long-term care facility residents had significantly lower per capita Medicare expenditures than did their dual eligible counterparts residing in long-term care facilities. The results of this study also indicate that state Medicaid bed hold policies had no statistically significant effect on either risk of PPH or on Medicare expenditures. Conclusion. The finding that Medicare-only residents of long-term care facilities are less expensive to the Medicare system, on average, than their dual eligible long-term care facility resident peers, yet are more likely to be hospitalized for a preventable condition and are more likely to be among the most expensive Medicare beneficiaries, could indicate differential patterns of intensity of medical response to similar clinical conditions between the two groups. That state Medicaid bed hold policies were not associated with any of the measures of healthcare utilization in our study seems to suggest that this Medicaid policy does not provide the perverse incentive toward higher utilization that some studies suggest

Lipid Accumulation by Rhodococcus Rhodochrous

Oleaginous microbes can accumulate over 20% of their cell dry weight as lipids that are stored as intracellular energy reserves. The characterization of other oleaginous bacteria creates opportunities for the development of alternative feedstocks and technologies. Rhodococcus rhodochrous is a gram-positive bacterium known for its biodegradation capabilities, but little is known about its ability to accumulate lipids. As R. rhodochrous is capable of degrading hydrocarbon gasses and other aromatics, this study aims to investigate any associated lipid production during the conversion of waste and nontraditional carbon sources, such as model lignocellulosic inhibitors. Lignocellulosic biomass is the most abundant and renewable organic material in the world and is composed of cellulose, hemicellulose, and lignin, which can be pretreated to release sugars from the complex, and often recalcitrant, lignin polymer for microbial fermentation. R. rhodochrous was cultivated with various carbon sources, including glucose, xylose, acetic acid, furfural, phenol, vanillic acid, hydroxybenzoic acid, and propane. The results suggest that R. rhodochrous can survive in the presence of these compounds, achieving almost 7g/L cell dry weight after 168 hours and still accumulate up to 40-50% of cell dry weight as lipid in glucose supplemented media. Furthermore, the aromatic compounds are undetected after 48 hours indicating that R. rhodochrous was able to tolerate these compounds and accumulate lipids. Fatty acid methyl ester profiles show a prevalence of palmitic and oleic methyl esters. Overall, these studies are contributing to a better understanding and characterization of another oleaginous Rhodococcus species, Rhodococcus rhodochrous

Comparison of Methods for Determining Aerobic Exercise Intensity Using Heart Rate in Acute Leukemia Patients Prior to Induction Chemotherapy

Cardiopulmonary exercise testing (CPET), the gold standard of cardiopulmonary evaluation, is used to determine VO2 levels at different aerobic exercise training intensities; however, it may not be feasible to conduct CPET in all clinical settings

Mismatch Repair Proteins Initiate Epigenetic Alterations during Inflammation-Driven Tumorigenesis

Aberrant silencing of genes by DNA methylation contributes to cancer, yet how this process is initiated remains unclear. Using a murine model of inflammation-induced tumorigenesis, we tested the hypothesis that inflammation promotes recruitment of epigenetic proteins to chromatin, initiating methylation and gene silencing in tumors. Compared with normal epithelium and noninflammation-induced tumors, inflammation-induced tumors gained DNA methylation at CpG islands, some of which are associated with putative tumor suppressor genes. Hypermethylated genes exhibited enrichment of repressive chromatin marks and reduced expression prior to tumorigenesis, at a time point coinciding with peak levels of inflammation-associated DNA damage. Loss of MutS homolog 2 (MSH2), a mismatch repair (MMR) protein, abrogated early inflammation-induced epigenetic alterations and DNA hypermethylation alterations observed in inflammation-induced tumors. These results indicate that early epigenetic alterations initiated by inflammation and MMR proteins lead to gene silencing during tumorigenesis, revealing a novel mechanism of epigenetic alterations in inflammation-driven cancer. Understanding such mechanisms will inform development of pharmacotherapies to reduce carcinogenesis

Explore, Exploit or Listen: Combining Human Feedback and Policy Model to Speed up Deep Reinforcement Learning in 3D Worlds

We describe a method to use discrete human feedback to enhance the performance of deep learning agents in virtual three-dimensional environments by extending deep-reinforcement learning to model the confidence and consistency of human feedback. This enables deep reinforcement learning algorithms to determine the most appropriate time to listen to the human feedback, exploit the current policy model, or explore the agent's environment. Managing the trade-off between these three strategies allows DRL agents to be robust to inconsistent or intermittent human feedback. Through experimentation using a synthetic oracle, we show that our technique improves the training speed and overall performance of deep reinforcement learning in navigating three-dimensional environments using Minecraft. We further show that our technique is robust to highly innacurate human feedback and can also operate when no human feedback is given

Gendered Working Environments as a Determinant of Mental Health Inequalities:A Protocol for a Systematic Review

Both gender and employment are critical and intersecting social determinants of mental and physical health. This paper describes the protocol used to conduct a systematic literature review of the relationship between “gendered working environments„ and mental health. Gendered working environments (GWE) are conceptualised as involving: (1) differences in selection into work, and more specifically, occupations; (2) variation in employment arrangements and working hours; (3) disparities in psychosocial exposures at work, and; (4) differences in selection out of work. Methods/design: The review will adhere to a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search procedure. Key words will be identified that are specific to each of the four domains of GWE. The databases used for the search will be Scopus, Pubmed, Proquest, and Web of Science. Keywords will be adapted for the specific requirements of each electronic database. Inclusion criteria are: Using a validated scale to measure mental health (outcome); including exposures related to the four domains of GWE; reporting estimates for both men and women; and use of a cohort, case-control, or cross-sectional design. Studies will be excluded if they were published more than 10 years ago, are not in English or do not present extractable data on the relationship between GWE and mental health. Discussion: The proposed review will provide evidence about the numerous and complex ways in which employment and gender intersect (and are reinforced) to influence mental health over the life course

Optical Lightcurve & Cooling Break of GRB 050502A

We present lightcurves of the afterglow of GRB050502A, including very early data at t-t_{GRB} < 60s. The lightcurve is composed of unfiltered ROTSE-IIIb optical observations from 44s to 6h post-burst, R-band MDM observations from 1.6 to 8.4h post-burst, and PAIRITEL J H K_s observations from 0.6 to 2.6h post-burst. The optical lightcurve is fit by a broken power law, where t^{alpha} steepens from alpha = -1.13 +- 0.02 to alpha = -1.44 +- 0.02 at \~5700s. This steepening is consistent with the evolution expected for the passage of the cooling frequency nu_c through the optical band. Even in our earliest observation at 44s post-burst, there is no evidence that the optical flux is brighter than a backward extrapolation of the later power law would suggest. The observed decay indices and spectral index are consistent with either an ISM or a Wind fireball model, but slightly favor the ISM interpretation. The expected spectral index in the ISM interpretation is consistent within 1 sigma with the observed spectral index beta = -0.8 +- 0.1; the Wind interpretation would imply a slightly (~2 sigma) shallower spectral index than observed. A small amount of dust extinction at the source redshift could steepen an intrinsic spectrum sufficiently to account for the observed value of beta. In this picture, the early optical decay, with the peak at or below 4.7e14 Hz at 44s, requires very small electron and magnetic energy partitions from the fireball.Comment: 22 pages, including 3 tables and 1 figure, Accepted by Ap

The coronal line regions of planetary nebulae NGC6302 and NGC6537: 3-13um grating and echelle spectroscopy

We report on advances in the study of the cores of NGC6302 and NGC6537 using infrared grating and echelle spectroscopy. In NGC6302, emission lines from species spanning a large range of ionization potential, and in particular [SiIX]3.934um, are interpreted using photoionization models (including CLOUDY), which allow us to reestimate the central star's temperature to be about 250000K. All of the detected lines are consistent with this value, except for [AlV] and [AlVI]. Aluminium is found to be depleted to one hundredth of the solar abundance, which provides further evidence for some dust being mixed with the highly ionized gas (with photons harder than 154eV). A similar depletion pattern is observed in NGC6537. Echelle spectroscopy of IR coronal ions in NGC6302 reveals a stratified structure in ionization potential, which confirms photoionization to be the dominant ionization mechanism. The lines are narrow (< 22km/s FWHM), with no evidence of the broad wings found in optical lines from species with similar ionization potentials, such as [NeV]3426A. We note the absence of a hot bubble, or a wind blown bipolar cavity filled with a hot plasma, at least on 1'' and 10km/s scales. We also provide accurate new wavelengths for several of the infrared coronal lines observed with the echelle.Comment: Accepted for publication in MNRA