Competition and Services Offered Among General Hospitals in the Deep South

Hospitals, along with other health care providers, are a central part of every health care system and responsible for a great share of healthcare expenditure. In the United States, the cost of health care is much higher than it is anywhere else. High expenditures for hospital services could reduce the resources available for primary care and other services that could do more for population health. The purpose of this study was to explore the competition among general medical and surgical hospitals in the Deep Southern states of Mississippi, Alabama, Georgia, South Carolina, and Louisiana to determine if increasing the level of competition was associated with more services being offered. The design of the study was a correlational analysis of cross-sectional data, employing multiple regression guided by the Medical Arms Race (MAR) theory. The dependent variable was the total number of services offered, and the primary independent variable was market concentration, as measured by the Herfindahl-Hirschman Index. The covariates were age, poverty level, and urban/rural location. The number of services in each general medical and surgical hospital in Mississippi, Alabama, Georgia, South Carolina, and Louisiana were measured to determine whether increasing levels of competition resulted in more services being offered. The findings of this study strongly support the MAR theory showing that the dependent variable and the primary independent variable were significantly correlated with higher market concentration being associated with fewer services being offered. The results suggest that reducing competition could decrease duplication of hospital services

Social Outcomes Contracting (SOC) in Social Programmes and Public Services: A Mixed-Methods Systematic Review Protocol

Background: Across a range of policy areas and geographies, governments and philanthropists are increasingly looking to adopt a social outcomes contracting (SOC) approach. Under this model, an agreement is made that a provider of services must achieve specific, measurable social and/or environmental outcomes and payments are only made when these outcomes have been achieved. Despite this growing interest, there is currently a paucity of evidence in relation to the tangible improvement in outcomes associated with the implementation of these approaches. Although promising, evidence suggests that there are risks (especially around managing perverse incentives).[1] The growing interest in SOC has been accompanied by research of specific programmes, policy domains or geographies, but there has not been a systematic attempt to synthetise this emerging evidence. To address this gap, this systematic review aims to surface the best evidence on when and where effects have been associated with SOC.  Methods: This mixed-methods systematic review protocol has been prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines (Additional File 2) (Shamseer et al., 2010). The review aims to consult policymakers throughout the evidence synthesis process, by adopting a user-involved research process. This will include the establishment and involvement of a Policy Advisory Group (PAG). The PAG will consist of a large, diverse, international group of policy makers who are or have been actively involved in funding and shaping social outcomes contracts (Additional File 3). The following electronic databases will be searched: ABI/INFORM Global, Applied Social Sciences Index & Abstracts (ASSIA), Scopus, International Bibliography of the Social Sciences (IBSS), PAIS Index, PolicyFile Index, Proquest Dissertations and Theses, ProQuest Social Science, Social Services Abstracts, Web of Science, Worldwide Political Science Abstracts and PsycINFO. We will also conduct a comprehensive search of grey literature sources. Studies will be imported into Covidence and screened (after de-duplication) independently by two reviewers, using explicit inclusion/exclusion criteria. We will conduct risk of bias and quality assessment using recommended tools and we will extract data using a pre-piloted, standardised data extraction form. If meta-synthesis cannot be conducted for the effectiveness component, we will carry out a descriptive narrative synthesis of the quantitative evidence, categorised by type of intervention, type of outcome/s, population characteristics and/or policy sector. The qualitative studies will be synthesised using thematic content analysis (Thomas and Harden 2008). If possible, we will also analyse the available economic data to understand the costs and benefits associated with SOC. Finally, we will conduct a cross-study synthesis, which will involve bringing together the findings from the effectiveness review, economic review and qualitative review. We recognise that the proposed conventional effectiveness review method may lead to inconclusive or partial findings given the complexity of the intervention, the likely degree of heterogeneity and the under-developed evidence base. We see a traditional systematic review as an important foundation to describe the evidence landscape. We will use this formal review as a starting point and then explore more contextually rooted review work in future. Discussion: We will use the systematic review findings to produce accessible and reliable empirical insights on whether, when, and where (and if possible, how) SOC approaches deliver improved impact when compared to more conventional funding arrangements. The outputs will support policymakers to make informed decisions in relation to commissioning and funding approaches. Systematic   review   registration: This   systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), on 20th November 2020 and was last updated on 21 January 2021: (registration number PROSPERO CRD42020215207). [1] A perverse incentive in an outcomes-based contract is an incentive that has unintended and undesirable results. For instance, a poorly designed welfare-to-work scheme could create incentives for service providers to prioritise clients who are easier to help and to ‘park’ those who are harder to assist (NAO 2015)

Using saliva epigenetic data to develop and validate a multivariable predictor of esophageal cancer status

Background: Salivary epigenetic biomarkers may detect esophageal cancer. Methods: A total of 256 saliva samples from esophageal adenocarcinoma patients and matched volunteers were analyzed with Illumina EPIC methylation arrays. Three datasets were created, using 64% for discovery, 16% for testing and 20% for validation. Modules of gene-based methylation probes were created using weighted gene coexpression network analysis. Module significance to disease and gene importance to module were determined and a random forest classifier generated using best-scoring gene-related epigenetic probes. A cost-sensitive wrapper algorithm maximized cancer diagnosis. Results: Using age, sex and seven probes, esophageal adenocarcinoma was detected with area under the curve of 0.72 in discovery, 0.73 in testing and 0.75 in validation datasets. Cancer sensitivity was 88% with specificity of 31%. Conclusion: We have demonstrated a potentially clinically viable classifier of esophageal cancer based on saliva methylation

The LEECH Exoplanet Imaging Survey: Limits on Planet Occurrence Rates Under Conservative Assumptions

We present the results of the largest $L^{\prime}$ ($3.8~\mu$m) direct imaging survey for exoplanets to date, the Large Binocular Telescope Interferometer (LBTI) Exozodi Exoplanet Common Hunt (LEECH). We observed 98 stars with spectral types from B to M. Cool planets emit a larger share of their flux in $L^{\prime}$ compared to shorter wavelengths, affording LEECH an advantage in detecting low-mass, old, and cold-start giant planets. We emphasize proximity over youth in our target selection, probing physical separations smaller than other direct imaging surveys. For FGK stars, LEECH outperforms many previous studies, placing tighter constraints on the hot-start planet occurrence frequency interior to $\sim20$ au. For less luminous, cold-start planets, LEECH provides the best constraints on giant-planet frequency interior to $\sim20$ au around FGK stars. Direct imaging survey results depend sensitively on both the choice of evolutionary model (e.g., hot- or cold-start) and assumptions (explicit or implicit) about the shape of the underlying planet distribution, in particular its radial extent. Artificially low limits on the planet occurrence frequency can be derived when the shape of the planet distribution is assumed to extend to very large separations, well beyond typical protoplanetary dust-disk radii ($\lesssim50$ au), and when hot-start models are used exclusively. We place a conservative upper limit on the planet occurrence frequency using cold-start models and planetary population distributions that do not extend beyond typical protoplanetary dust-disk radii. We find that $\lesssim90\%$ of FGK systems can host a 7 to 10 $M_{\mathrm{Jup}}$ planet from 5 to 50 au. This limit leaves open the possibility that planets in this range are common.Comment: 31 pages, 13 figures, accepted to A

IPSP Scoping Report

In the transition towards Open Access (OA), institutional publishing is challenged by fragmentation and varying service quality, visibility, and sustainability. To address this issue, DIAMAS gathers 23 organisations from 12 European countries, well-versed in OA academic publishing and scholarly communication. The project will: 1. Map the current landscape of Institutional Publishing Service Providers (IPSPs) in 25 countries of the ERA with special attention for IPSPs that do not charge fees for publishing or reading. This will yield a taxonomy of IPSPs and an IPSP landscape report, a basis for the rest of the project. 2. Coordinate and improve the efficiency and quality of IPSPs by developing an Extensible Quality Standard for Institutional Publishing (EQSIP). This quality standard will professionalise, strengthen, and reduce the fragmentation of institutional publishing in Europe. EQSIP will serve as a benchmark for a gap analysis of the data

Novel epigenetic network biomarkers for early detection of esophageal cancer

BACKGROUND: Early detection of esophageal cancer is critical to improve survival. Whilst studies have identified biomarkers, their interpretation and validity is often confounded by cell-type heterogeneity. RESULTS: Here we applied systems-epigenomic and cell-type deconvolution algorithms to a discovery set encompassing RNA-Seq and DNA methylation data from esophageal adenocarcinoma (EAC) patients and matched normal-adjacent tissue, in order to identify robust biomarkers, free from the confounding effect posed by cell-type heterogeneity. We identify 12 gene-modules that are epigenetically deregulated in EAC, and are able to validate all 12 modules in 4 independent EAC cohorts. We demonstrate that the epigenetic deregulation is present in the epithelial compartment of EAC-tissue. Using single-cell RNA-Seq data we show that one of these modules, a proto-cadherin module centered around CTNND2, is inactivated in Barrett's Esophagus, a precursor lesion to EAC. By measuring DNA methylation in saliva from EAC cases and controls, we identify a chemokine module centered around CCL20, whose methylation patterns in saliva correlate with EAC status. CONCLUSIONS: Given our observations that a CCL20 chemokine network is overactivated in EAC tissue and saliva from EAC patients, and that in independent studies CCL20 has been found to be overactivated in EAC tissue infected with the bacterium F. nucleatum, a bacterium that normally inhabits the oral cavity, our results highlight the possibility of using DNAm measurements in saliva as a proxy for changes occurring in the esophageal epithelium. Both the CTNND2/CCL20 modules represent novel promising network biomarkers for EAC that merit further investigation

The He II Emitting Nebula N44C in the LMC: Optical/UV Spectroscopy of the Nebula and its Ionizing Star

We present HST spectroscopy and imaging, along with new ground-based spectroscopy and ROSAT HRI imaging, of the He II emitting nebula N44C and its ionizing star. A GHRS spectrogram of the ionizing star yields a spectral type of about O7 for the star. The lack of P Cygni profiles for Si IV and C IV indicates that the star is not a supergiant. The nebular abundances in the ionized gas are consistent with average abundances for LMC H II regions, with the possible exception that nitrogen may be enhanced. Enrichment by a former evolved companion star is not evident. A long-slit echelle spectrogram in H-alpha + [N II] shows no evidence for high-velocity gas in N44C. This rules out high-velocity shocks as the source of the nebular He II emission. A 108 ks ROSAT HRI image of N44C shows no X-ray point source to a 3-sigma upper limit L(X) < 10^34 erg s^-1 in the 0.1-2.0 keV band. Based on new measurements of the electron density in the He II emitting region, we derive recombination timescales of approximately 20 yrs for He^+2 and approximately 4 yrs for Ne^+4. If N44C is a fossil X-ray ionized nebula, this places severe constraints on when the putative X-ray source could have turned off. The presence of strong [Ne IV] emission in the nebula is puzzling if the ionizing source has turned off. It is possible the system is related to the Be X-ray binaries, although the O star in N44C does not show Be characteristics at the present time. Monitoring of X-rays and He II emission from the nebula, as well as a radial velocity study of the ionizing star, are needed to fully understand the emission line spectrum of N44C.Comment: 37 pages, 7 figures (1 color .gif image); accepted for publication in the 10 Dec 2000 Astrophysical Journal. Complete PostScript and PDF versions can also be obtained at http://ocotillo.as.arizona.edu/~dgarnet

Stability and error analysis for a diffuse interface approach to an advection-diffusion equation on a moving surface

In this paper we analyze a fully discrete numerical scheme for solving a parabolic PDE on a moving surface. The method is based on a diffuse interface approach that involves a level set description of the moving surface. Under suitable conditions on the spatial grid size, the time step and the interface width we obtain stability and error bounds with respect to natural norms. Furthermore, we present test calculations that confirm our analysis

The clinical effectiveness and cost-effectiveness of a ‘stepping into day treatment’ approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial

BACKGROUND: Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a 'step-down' treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation. METHODS: 386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m2 and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden. DISCUSSION: The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision