Healthcare.gov: Opportunity out of Disaster

The launch of HealthCare.gov, the website of the Affordable Care Act (AKA Obamacare), was a major public relations disaster for the Obama administration. This case examines some of the factors that contributed to the failure of the launch and then details how Optum, an information technology service provider, considered the opportunity provided by the failure. The case provides examples of both good and bad IT management processes and poses questions for discussion related to the evaluation of risk associated with high profile projects

Biochemical composition of body compartments during the reproductive cycle of the starfish Allostichaster capensis in Patagonia, Argentina

Allostichaster capensis (Perrier, 1875) (= inaequalis) is a fissiparous starfish inhabiting the South Atlantic Ocean coasts. On the Patagonian coast, it displays an annual sexual and asexual reproductive cycle. Fission is most frequent during the austral summer (November-January) and arm regeneration takes place during the rest of the year. In this article, seasonal changes in biochemical composition of body compartments are presented for a population of this fissiparous starfish in Bahia Kaiser, Golfo Nuevo, Chubut, Argentina, from June 2000 to May 2002. During the annual cycle, an inverse relationship between gonad and pyloric caeca indices suggests nutrient transfer. Biochemical analysis revealed that only lipids are translocated from pyloric caeca to gonads at the beginning of gametogenesis.Fil: Rubilar Panasiuk, Cynthia Tamara. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Nacional Patagónico; ArgentinaFil: Díaz de Vivar, María Enriqueta Adela. Universidad Nacional de la Patagonia "San Juan Bosco"; ArgentinaFil: Pastor de Ward, C. T.. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Nacional Patagónico; Argentin

Mismatch negativity/P3a complex in young people with psychiatric disorders : a cluster analysis

Background: We have recently shown that the event-related potential biomarkers, mismatch negativity (MMN) and P3a, are similarly impaired in young patients with schizophrenia- and affective-spectrum psychoses as well as those with bipolar disorder. A data driven approach may help to further elucidate novel patterns of MMN/P3a amplitudes that characterise distinct subgroups in patients with emerging psychiatric disorders. Methods: Eighty seven outpatients (16 to 30 years) were assessed: 19 diagnosed with a depressive disorder; 26 with a bipolar disorder; and 42 with a psychotic disorder. The MMN/P3a complex was elicited using a two-tone passive auditory oddball paradigm with duration deviant tones. Hierarchical cluster analysis utilising frontal, central and temporal neurophysiological variables was conducted. Results: Three clusters were determined: the 'globally impaired' cluster (n = 53) displayed reduced frontal and temporal MMN as well as reduced central P3a amplitudes; the 'largest frontal MMN' cluster (n = 17) were distinguished by increased frontal MMN amplitudes and the 'largest temporal MMN' cluster (n = 17) was characterised by increases in temporal MMN only. Notably, 55% of those in the globally impaired cluster were diagnosed with schizophrenia-spectrum disorder, whereas the three patient subgroups were equally represented in the remaining two clusters. The three cluster-groups did not differ in their current symptomatology; however, the globally impaired cluster was the most neuropsychologically impaired, compared with controls. Conclusions: These findings suggest that in emerging psychiatric disorders there are distinct MMN/P3a profiles of patient subgroups independent of current symptomatology. Schizophrenia-spectrum patients tended to show the most global impairments in this neurophysiological complex. Two other subgroups of patients were found to have neurophysiological profiles suggestive of quite different neurobiological (and hence, treatment) implications

Fast and flexible selection with a single switch

Selection methods that require only a single-switch input, such as a button click or blink, are potentially useful for individuals with motor impairments, mobile technology users, and individuals wishing to transmit information securely. We present a single-switch selection method, "Nomon," that is general and efficient. Existing single-switch selection methods require selectable options to be arranged in ways that limit potential applications. By contrast, traditional operating systems, web browsers, and free-form applications (such as drawing) place options at arbitrary points on the screen. Nomon, however, has the flexibility to select any point on a screen. Nomon adapts automatically to an individual's clicking ability; it allows a person who clicks precisely to make a selection quickly and allows a person who clicks imprecisely more time to make a selection without error. Nomon reaps gains in information rate by allowing the specification of beliefs (priors) about option selection probabilities and by avoiding tree-based selection schemes in favor of direct (posterior) inference. We have developed both a Nomon-based writing application and a drawing application. To evaluate Nomon's performance, we compared the writing application with a popular existing method for single-switch writing (row-column scanning). Novice users wrote 35% faster with the Nomon interface than with the scanning interface. An experienced user (author TB, with > 10 hours practice) wrote at speeds of 9.3 words per minute with Nomon, using 1.2 clicks per character and making no errors in the final text.Comment: 14 pages, 5 figures, 1 table, presented at NIPS 2009 Mini-symposi

A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial

Background Health worker compliance with clinical guidelines is enhanced by digital clinical decision support at the point of care. The Palestinian public health system is implementing a digital maternal and child health eRegistry with clinical decision support. We aimed to compare the quality of antenatal care between clinics using the eRegistry and those using paper-based records. Methods The eRegQual cluster-randomised controlled trial was done in primary health-care clinics offering routine antenatal care in the West Bank, Palestine. The intervention was the eRegistry with clinical decision support for antenatal care, implemented in District Health Information Systems 2 (DHIS2) Tracker software. 133 clinics forming 120 clusters were included and randomised; clusters were randomly assigned (1:1) to either the control (paper-based documentation) or intervention (eRegistry with clinical decision support) groups. The primary process outcomes were appropriate screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring. The primary health outcome at delivery was a composite of moderate or severe anaemia; severe hypertension; large-for-gestational-age baby; malpresentation and small-for-gestational-age baby undetected before delivery. Data were analysed with mixed-effects logistic regression, accounting for clustering within clinics and pregnancies as appropriate. This trial is registered with the ISRCTN registry (ISRCTN18008445). Findings Between Jan 15 and Sept 15, 2017, 3219 pregnant women received care in the intervention clinics (n=60 clusters) and 3148 pregnant women received care in the control primary health-care clinics (n=59 clusters). Compared with the control group, the intervention led to higher guideline adherence for screening and management of anaemia (1535 [28·9%] of 5320 vs 2297 [44·3%] of 5182; adjusted odds ratio [OR] 1·88 [95% CI 1·52–2·32]), hypertension (7555 [94·7%] of 7982 vs 7314 [96·6%] of 7569; adjusted OR 1·62 [95% CI 1·29–2·05]), and gestational diabetes (1726 (39·7%) of 4348 vs 2189 (50·7%) of 4321; adjusted OR 1·45 [95% CI 1·14–1·83]) at eligible antenatal contacts. Only 599 (9·4%) of 6367 women attended the full antenatal care schedule, and better care provision did not translate to fewer adverse health outcomes in the intervention clusters (700 cases; 21·7%) compared to the control clusters (688 cases; 21·9%; adjusted OR 0·99; 95% CI 0·87–1·12). Interpretation Clinical decision support for antenatal care in the eRegistry was superior for most process outcomes but had no effect on the adverse health outcomes. The improvements in process outcomes strengthen the evidence for the WHO guideline for digital client tracking with clinical decision support in lower-middle-income settings. Digital health interventions to address gaps in attendance might help achieve effective coverage of antenatal care.publishedVersio

Men Presenting With Sexual Thoughts of Children or Coercion: Flights of Fancy or Plans for Crime?

Introduction. There is limited evaluation of clinical and theoretical claims that sexual thoughts of children and coercing others facilitate sexual offending. The nature of these thoughts (what they contain) is also unknown. Aims. To examine the relationship between child/coercive sexual thoughts and sexual offending, and to determine the nature of these thoughts and any differences between sexual offending (SO), non-sexual offending (NSO) and non-offending (NO) men. Methods. In a cross-sectional computerized survey, anonymous qualitative and quantitative self-reported sexual thought and experience data were collected from 279 adult volunteers, comprising equal numbers of SO, NSO and NO men recruited from a medium-security UK prison and a community sample of 6081 men. Main Outcome Measures. Computerized Interview for Sexual Thoughts and Computerized Inventory of Sexual Experiences. Results. Three analytical approaches found child sexual thoughts were related to sexual offending; sexual thoughts with coercive themes were not. Latent class analyses identified three types of child sexual thought (primarily differentiated by interpersonal context: the reporting of own emotions, emotions of others or both) and four types of sexual thoughts of coercing others (chiefly discriminated by the other person’s response: no emotional states reported, consent, non-consent, mixed). Type of child sexual thought and participant group were not significantly related. Type of coercive sexual thought and group were marginally related; the consensual type was more common for the NO group, the non-consensual type more common for the SO group, than expected statistically. Conclusions. Child sexual thoughts are a risk factor for sexual offending and should be assessed by clinicians. Generally, sexual thoughts with coercive themes are not a risk factor, though thought type may be important (i.e. thoughts where the other person expresses an enduring lack of consent). Exploring the dynamic risk factors associated with each type of child/coercive thought may lead to more targeted treatment

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Spire, an Actin Nucleation Factor, Regulates Cell Division during Drosophila Heart Development

The Drosophila dorsal vessel is a beneficial model system for studying the regulation of early heart development. Spire (Spir), an actin-nucleation factor, regulates actin dynamics in many developmental processes, such as cell shape determination, intracellular transport, and locomotion. Through protein expression pattern analysis, we demonstrate that the absence of spir function affects cell division in Myocyte enhancer factor 2-, Tinman (Tin)-, Even-skipped- and Seven up (Svp)-positive heart cells. In addition, genetic interaction analysis shows that spir functionally interacts with Dorsocross, tin, and pannier to properly specify the cardiac fate. Furthermore, through visualization of double heterozygous embryos, we determines that spir cooperates with CycA for heart cell specification and division. Finally, when comparing the spir mutant phenotype with that of a CycA mutant, the results suggest that most Svp-positive progenitors in spir mutant embryos cannot undergo full cell division at cell cycle 15, and that Tin-positive progenitors are arrested at cell cycle 16 as double-nucleated cells. We conclude that Spir plays a crucial role in controlling dorsal vessel formation and has a function in cell division during heart tube morphogenesis

Positive Feedbacks in Seagrass Ecosystems – Evidence from Large-Scale Empirical Data

Positive feedbacks cause a nonlinear response of ecosystems to environmental change and may even cause bistability. Even though the importance of feedback mechanisms has been demonstrated for many types of ecosystems, their identification and quantification is still difficult. Here, we investigated whether positive feedbacks between seagrasses and light conditions are likely in seagrass ecosystems dominated by the temperate seagrass Zostera marina. We applied a combination of multiple linear regression and structural equation modeling (SEM) on a dataset containing 83 sites scattered across Western Europe. Results confirmed that a positive feedback between sediment conditions, light conditions and seagrass density is likely to exist in seagrass ecosystems. This feedback indicated that seagrasses are able to trap and stabilize suspended sediments, which in turn improves water clarity and seagrass growth conditions. Furthermore, our analyses demonstrated that effects of eutrophication on light conditions, as indicated by surface water total nitrogen, were on average at least as important as sediment conditions. This suggests that in general, eutrophication might be the most important factor controlling seagrasses in sheltered estuaries, while the seagrass-sediment-light feedback is a dominant mechanism in more exposed areas. Our study demonstrates the potentials of SEM to identify and quantify positive feedbacks mechanisms for ecosystems and other complex systems