Medicaid Dental Benefits for Pregnant People and Dental Care Use Among Very Young Children.

OBJECTIVES: The aim of this study was to examine the association between Medicaid dental benefits for pregnant people and dental care use among very young children in Medicaid. We hypothesized that children living in states with more generous dental benefits for Medicaid-enrolled pregnant people would be more likely to have a recent dental visit. METHODS: This national cross-sectional study used pooled 2017-2019 data from the National Survey of Children's Health, as well as state Medicaid policy data. The study sample included children aged 0-2 enrolled in Medicaid. Multivariable logistic regression models estimated the association between Medicaid dental benefit generosity for pregnant people and the child having a dental visit in the past year. RESULTS: Children in states with emergency-only dental coverage for pregnant people were 2.5 times as likely to have had a dental visit than children in states with extensive coverage (OR 2.48, 95% CI 1.35-4.53). In supplemental analyses excluding children living in Texas, there was no longer an association between dental coverage for pregnant people and dental utilization among young children (OR 1.52, 95% CI 0.82-2.83). CONCLUSIONS FOR PRACTICE: Young children in states that provided emergency-only dental benefits for pregnant people in Medicaid had significantly higher odds of dental utilization than young children in states with more generous dental benefits for pregnant people. This relationship disappeared after excluding the state Texas, which had the highest rate of child dental utilization in the country and provided emergency-only dental benefits for pregnant people in Medicaid.

Molecular Mechanisms of Winter Survival.

Winter provides many challenges for insects, including direct injury to tissues and energy drain due to low food availability. As a result, the geographic distribution of many species is tightly coupled to their ability to survive winter. In this review, we summarize molecular processes associated with winter survival, with a particular focus on coping with cold injury and energetic challenges. Anticipatory processes such as cold acclimation and diapause cause wholesale transcriptional reorganization that increases cold resistance and promotes cryoprotectant production and energy storage. Molecular responses to low temperature are also dynamic and include signaling events during and after a cold stressor to prevent and repair cold injury. In addition, we highlight mechanisms that are subject to selection as insects evolve to variable winter conditions. Based on current knowledge, despite common threads, molecular mechanisms of winter survival vary considerably across species, and taxonomic biases must be addressed to fully appreciate the mechanistic basis of winter survival across the insect phylogeny.

Association of Medicaid expansion with dental emergency department visits overall and by states' Medicaid dental benefits provision.

BACKGROUND: Evidence on the association of Medicaid expansion with dental emergency department (ED) utilization is limited, while even less is known on policy-related changes in dental ED visits by Medicaid programs' dental benefits generosity. The objective of this study was to estimate the association of Medicaid expansion with changes in dental ED visits overall and by states' benefits generosity. METHODS: We used the Healthcare Cost and Utilization Project's Fast Stats Database from 2010 to 2015 for non-elderly adults (19 to 64 years of age) across 23 States, 11 of which expanded Medicaid in January 2014 while 12 did not. Difference-in-differences regression models were used to estimate changes in dental-related ED visits overall and further stratified by states' dental benefit coverage in Medicaid between expansion and non-expansion States. RESULTS: After 2014, dental ED visits declined by 10.9 [95% confidence intervals (CI): -18.5 to -3.4] visits per 100,000 population quarterly in states that expanded Medicaid compared to non-expansion states. However, the overall decline was concentrated in Medicaid expansion states with dental benefits. In particular, among expansion states, dental ED visits per 100,000 population declined by 11.4 visits (95% CI: -17.9 to -4.9) quarterly in states with dental benefits in Medicaid compared to states with emergency-only or no dental benefits. Significant differences between non-expansion states by Medicaid's dental benefits generosity were not observed [6.3 visits (95% CI: -22.3 to 34.9)]. CONCLUSIONS: Our findings suggest the need to strengthen public health insurance programs with more generous dental benefits to curtail costly dental ED visits.

Dentist-reported differences in services provided to patients with public vs. private dental insurance.

INTRODUCTION: Variation in dentists' provision of types of dental services based on patients' insurance may impact population access to comprehensive care. The aim of this study was to describe differences in the types of services provided to adult patients with Medicaid versus private insurance among private practice general dentists. METHODS: The data source was a 2019 survey of private practice dentists in Iowa, and the study sample included general dentists with current or recent participation in Iowa's Medicaid program for adults (n = 264). Bivariate analyses were used to compare differences in the types of services provided to privately insured and publicly insured patients. RESULTS: Dentists reported the greatest differences in services provided to patients with public versus private insurance for prosthodontic procedures, including complete dentures, removable partial dentures, and crown and bridge services. Endodontic services were the least frequently provided category of services provided by dentists for both patient groups. Patterns were generally similar among both urban and rural providers. CONCLUSION: Access to dental care for Medicaid members should be evaluated not only on the proportion of dentists who see new Medicaid patients but also on the types of services dentists provide to this population.

The impact of clinical simulation on the development of advanced practice skills.

This article considers the findings of a qualitative research study into the impact of simulation on the development of advanced clinical practitioners' skills and knowledge. STUDY AIM: To explore simulated learning through the eyes of trainee and trained advanced clinical practitioners (ACPs) and consider its potential in supporting their development. METHOD: This qualitative research study explored the experiences of trained and trainee ACP volunteers undertaking a structured simulated event provided by a local acute hospital trust simulation team. A questionnaire (n=10) and a focus group (n=4) acted as the data gathering tools. RESULTS: Although simulation can be daunting for the participants, the overwhelming outcome was positive. Participants stated that they gained confidence and suggested that simulation offered a safe place to practise the challenging scenarios that occur in the clinical environment. Additionally, they emphasised that simulation provided a place to network and receive constructive feedback that was non-judgemental, and which helped them to develop clinical knowledge and appreciate their limitations. CONCLUSION: Simulation is a valuable addition to the education and development of ACPs. It should be considered for inclusion within the educational curriculum as a supplement to theoretical knowledge and to the structured clinical supervision provided within the clinical environment.

Evolutionary transition from blood feeding to obligate nonbiting in a mosquito.

The spread of blood-borne pathogens by mosquitoes relies on their taking a blood meal; if there is no bite, there is no disease transmission. Although many species of mosquitoes never take a blood meal, identifying genes that distinguish blood feeding from obligate nonbiting is hampered by the fact that these different lifestyles occur in separate, genetically incompatible species. There is, however, one unique extant species with populations that share a common genetic background but blood feed in one region and are obligate nonbiters in the rest of their range: Wyeomyia smithii Contemporary blood-feeding and obligate nonbiting populations represent end points of divergence between fully interfertile southern and northern populations. This divergence has undoubtedly resulted in genetic changes that are unrelated to blood feeding, and the challenge is to winnow out the unrelated genetic factors to identify those related specifically to the evolutionary transition from blood feeding to obligate nonbiting. Herein, we determine differential gene expression resulting from directional selection on blood feeding within a polymorphic population to isolate genetic differences between blood feeding and obligate nonbiting. We show that the evolution of nonbiting has resulted in a greatly reduced metabolic investment compared with biting populations, a greater reliance on opportunistic metabolic pathways, and greater reliance on visual rather than olfactory sensory input. W. smithii provides a unique starting point to determine if there are universal nonbiting genes in mosquitoes that could be manipulated as a means to control vector-borne disease.

Transitioning to an ACP: a challenging journey with tribulations and rewards.

Julie Reynolds and Gerri Mortimore discuss the difficulties advanced clinical practitioners face when taking on this new role, and how drawing on their transferable skills can help them make the transition.

From expert to advanced clinical practitioner and beyond.

This article considers the potential development of advanced clinical practitioners (ACPs) and consultant practitioners, beyond the 'expert' status as defined by Pat Benner in 1984. The suggested Derby Model: 7 Levels of Practice Advancement, adapted from Benner's From Novice to Expert, recognises Health Education England's four pillars of advanced practice and how they can be implemented and enhanced within these senior roles, and what that means in a 21st century healthcare system.

Distinct microRNA and mRNA responses elicited by ecdysone, diapause hormone and a diapause hormone analog at diapause termination in pupae of the corn earworm, Helicoverpa zea.

Ecdysone, diapause hormone and a diapause hormone analog are all capable of breaking pupal diapause and prompting initiation of adult development in the cotton earworm, Helicoverpa zea. In this study we asked whether these three chemically-distinct diapause terminators elicit the same effect on expression of a collection of microRNAs and transcripts encoding components of the ecdysone signaling pathway. Injection of all three endocrine agents resulted in downregulation of one miRNA, miR-277-3p, a miRNA previously linked to the insulin/FOXO signaling pathway, and all three agents promoted upregulation of spook, a member of the ecdysone biosynthesis pathway, and iswi, an ecdysone-responsive transcript. Other miRNA and mRNA responses varied depending on the agent used to terminate diapause, thus suggesting that different endocrine pathways and mechanisms can lead to the same final developmental response.

A tale of two public dental benefit programs: Iowa dentist participation in traditional Medicaid versus a Medicaid expansion program.

BACKGROUND: In Iowa from 2014 to 2017, there were 2 separate public dental benefit programs for Medicaid-enrolled adults: one for the Medicaid expansion population called the Dental Wellness Plan (DWP), and one for the traditional, non-expansion adult Medicaid population. The programs differed with respect to reimbursement, administration, and benefit structure. This study explored differences in patterns and predictors of dentist participation in the two programs. METHODS: Authors sent a survey to all private practice dentists in Iowa (n = 1301) 2 years after DWP implementation. Descriptive, bivariate, and logistic regression analyses were used to examine patterns and predictors of dentist participation in Medicaid and DWP. RESULTS: Overall rates of dentists' acceptance of new Medicaid and DWP patients were 45 and 43%, respectively. However, Medicaid participants were much more likely than DWP participants to place limits on patient acceptance. Adjusting for other factors, practice busyness was the only significant predictor of DWP participation, and practice location was the only significant predictor of Medicaid participation. Dentists who were not busy enough were more than twice as likely to participate in DWP compared to others, and dentists in rural areas were almost twice as likely to participate in Medicaid compared to dentists in urban areas. CONCLUSIONS: Dentist participation in Medicaid is an ongoing concern for states aiming to ensure access to dental care for low-income populations. We found distinct participation patterns and predictors between a traditional Medicaid dental program and the DWP, suggesting different motivations for participation between the two programs.

"Baby? Baby Not?": Exploring Women's Narratives About Ambivalence Towards an Unintended Pregnancy.

Unintended pregnancy among adult women is a significant public health challenge in the United States. Research has identified ambivalence as a risk factor for not using contraceptives. The qualitative study presented here examined women's narratives about ambivalence toward unintended pregnancy. In-depth interviews were conducted in 2012 with 28 women aged 20-45 years old who were recruited primarily via flyers in family planning clinics in a rural, Midwestern state. The interviews were coded for salient themes. Almost 40 percent of the women said that they had experienced an unintended pregnancy. All but two women expressed ambivalence, stating that they had both good and bad feelings about getting pregnant unintentionally. Women expressed if a pregnancy did occur, they would just have to step up and "deal with it." They recognized a baby was something special but not without negative aspects. Those who were less ambivalent (and more negative) had compelling reasons why, but even those women expressed some positive feelings. At times, ambivalence was expressed by negative reactions about having a child that coincided with believing that becoming a parent or having another child would have a positive impact on themselves. This study provides an examination of women's narratives about ambivalence toward pregnancy. Overall, women's narratives constructed ambivalence as arising from both positive and negative emotions, as well as beliefs about costs and benefits, associated with unintended pregnancy. Given its association with a lack of contraceptive use, understanding the components of ambivalence (e.g., feelings, beliefs) is important to bolstering interventions aimed toward decreasing ambivalence and increasing contraceptive use.

Eliminating Medicaid dental benefits and early-stage oral cancer diagnoses.

BACKGROUND: Despite the importance of regular dental visits for detecting oral cancer, millions of low-income adults lack access to dental services. In July 2009, California eliminated adult Medicaid dental benefits. We tested if this impacted oral cancer detection for Medicaid enrollees. METHODS: We analyzed Surveillance, Epidemiology, and End Results-Medicaid data, which contains verified Medicaid enrollment status, to estimate a difference-in-differences model. Our design compares the change in early-stage (Stages 0-II) diagnoses before and after dropping dental benefits in California with the change in early-stage diagnoses among eight states that did not change Medicaid dental benefits. Patients were grouped by oropharyngeal cancer (OPC) and non-OPC (oral cavity cancer), type, and the length of Medicaid enrollment. We also assessed if the effect of dropping dental benefits varied by the number of dentists per capita. RESULTS: Dropping Medicaid dental benefits was associated with a 6.5%-point decline in early-stage diagnoses of non-OPC (95% CI = -14.5, -3.2, p = 0.008). This represented a 20% relative reduction from baseline rates. The effect was highest among beneficiaries with 3 months of continuous Medicaid enrollment prior to diagnosis who resided in counties with more dentists per capita. Specifically, dropping dental coverage was associated with a 1.25%-point decline in the probability of early-stage non-OPC diagnoses for every additional dentist per 5000 population (p = 0.006). CONCLUSIONS: Eliminating Medicaid dental benefits negatively impacted early detection of cancers of the oral cavity. Continued volatility of Medicaid dental coverage and provider shortages may be further delaying oral cancer diagnoses. Alternative approaches are needed to prevent advanced stage OPC.

Deep sequencing reveals complex mechanisms of diapause preparation in the invasive mosquito, Aedes albopictus.

Seasonal environments present fundamental physiological challenges to a wide range of insects. Many temperate insects surmount the exigencies of winter by undergoing photoperiodic diapause, in which photoperiod provides a token cue that initiates an alternative developmental programme leading to dormancy. Pre-diapause is a crucial preparatory phase of this process, preceding developmental arrest. However, the regulatory and physiological mechanisms of diapause preparation are largely unknown. Using high-throughput gene expression profiling in the Asian tiger mosquito, Aedes albopictus, we reveal major shifts in endocrine signalling, cell proliferation, metabolism, energy production and cellular structure across pre-diapause development. While some hallmarks of diapause, such as insulin signalling and stress response, were not important at the transcriptional level, two genes, Pepck and PCNA, appear to show diapause-induced transcriptional changes across insect taxa. These processes demonstrate physiological commonalities between Ae. albopictus pre-diapause and diapause strategies across insects, and support the idea of a genetic 'toolkit' for diapause. Observations of gene expression trends from a comparative developmental perspective suggest that individual physiological processes are delayed against a background of a fixed morphological ontogeny. Our results demonstrate how deep sequencing can provide new insights into elusive molecular bases of complex ecological adaptations.

RNA-Seq reveals early distinctions and late convergence of gene expression between diapause and quiescence in the Asian tiger mosquito, Aedes albopictus.

Dormancy is a crucial adaptation allowing insects to withstand harsh environmental conditions. The pre-programmed developmental arrest of diapause is a form of dormancy that is distinct from quiescence, in which development arrests in immediate response to hardship. Much progress has been made in understanding the environmental and hormonal controls of diapause. However, studies identifying transcriptional changes unique to diapause, rather than quiescence, are lacking, making it difficult to disentangle the transcriptional profiles of diapause from dormancy in general. The Asian tiger mosquito, Aedes albopictus, presents an ideal model for such a study, as diapausing and quiescent eggs can be staged and collected for global gene expression profiling using a newly developed transcriptome. Here, we use RNA-Seq to contrast gene expression during diapause with quiescence to identify transcriptional changes specific to the diapause response. We identify global trends in gene expression that show gradual convergence of diapause gene expression upon gene expression during quiescence. Functionally, early diapause A. albopictus show strong expression differences of genes involved in metabolism, which diminish over time. Of these, only expression of lipid metabolism genes remained distinct in late diapause. We identify several genes putatively related to hormonal control of development that are persistently differentially expressed throughout diapause, suggesting these might be involved in the maintenance of diapause. Our results identify key biological differences between diapausing and quiescent pharate larvae, and suggest candidate pathways for studying metabolism and the hormonal control of development during diapause in other species.

Motivations and experiences among dentists in rural private practice: A qualitative study.

OBJECTIVES: Despite the critical importance of access to dental care for rural residents and concerns about a shrinking rural dentist workforce, few studies have examined rural dentist motivations to practice in rural areas. The aim of this study was to explore practicing rural dentists' motivations and experiences qualitatively through semi-structured interviews to help inform and guide recruitment and retention efforts in rural areas. METHODS: Dentists were included in the sample frame if they were general dentists in private practice and had a primary practice located in a rural Iowa county. Rural dentists with publicly available email addresses were contacted by email to participate. Semi-structured interviews were administered to 16 private practice general dentists. All interviews were audio recorded, transcribed, and coded using pre-set and emergent codes. RESULTS: Participants were most commonly male (75%), under age 35 (44%), white (88%), and practiced in a partnership arrangement (44%). The main codes regarding dentists' experiences and motivations to practice in a rural area included familiarity with a rural area, community, financial factors, and clinical care delivery. Having been raised in a rural area was a major influence in most dentists' decisions about where to locate. CONCLUSIONS: The importance of rural upbringing in this study underscores the need to consider rural upbringing in dental student admissions. Additional findings, such as financial benefits of a rural practice and other practice-related factors can be used to inform recruitment efforts.

Access to dental insurance and oral health inequities in the United States.

While the oral health status of the United States (U.S.) population has improved over the years, racial/ethnic inequities are pervasive with Black Americans carrying a greater burden of oral diseases in most measured outcomes. Access to dental care is a major structural and societal determinant of oral health inequities rooted in structural racism. From post-Civil War-era to present day, this essay presents a series of examples of racist policies that have shaped access to dental insurance for Black Americans both directly and indirectly. Additionally, this essay explains the unique challenges of Medicare and Medicaid highlighting the specific disparities that these public insurance programs face, and proposes policy recommendations aimed to reduce racial/ethnic inequities in dental coverage and access to advance the nation's oral health with comprehensive dental benefits in public insurance programs.

Dentist attitudes toward an annual benefit maximum in Iowa's adult Medicaid program.

OBJECTIVES: The Dental Wellness Plan (DWP) provides dental coverage for adult Medicaid enrollees in Iowa. In September 2018, a $1000 annual benefit maximum (ABM) was implemented in the DWP program. The aim of this study was to explore private dentists' attitudes toward ABMs and factors associated with ABM attitudes. METHODS: The data source was a mailed survey administered in spring 2019 to all private practice dentists in Iowa. The two dependent variables were (1) attitude toward the $1000 ABM and (2) attitude toward any ABM generally. Independent variables included demographic and practice-related factors, and participation in and attitudes toward the DWP. Descriptive, bivariate, and multivariable analyses were conducted. RESULTS: While over half (56%) of providers reported a positive attitude toward "Any ABM," less than half (40%) reported a positive attitude toward the "$1000 ABM." Attitudes toward both "$1000 ABM" and "Any ABM" were significantly and positively associated with attitudes toward DWP overall and toward DWP structure. Independent variables that were significantly associated with both the "$1000 ABM" and "Any ABM" included overall attitude toward the DWP, attitude toward DWP structure, and practice busyness. CONCLUSIONS: Utilizing an ABM, particularly one set at $1000 for a Medicaid program, elicits mixed attitudes among dentists. Future research should evaluate the impact of Medicaid ABMs on long term dentist participation and patient's ability to receive needed care.