The CMS Strategy to Promote Equity in Quality and Value Programs.

This Viewpoint discusses the CMS approach to incentivize excellent care for underserved populations.

Aligned carbon nanotube morphogenesis predicts physical properties of their polymer nanocomposites.

Carbon nanostructure (CNS) based polymer nanocomposites (PNCs) are of interest due to the superior properties of the CNS themselves, scale effects, and the ability to transfer these properties anisotropically to the bulk material. However, measurements of physical properties of such materials are not in agreement with theoretical predictions. Recently, the ability to characterize the 3D morphology of such PNCs at the nanoscale has been significantly improved, with rich, quantitative data extracted from tomographic transmission electron microscopy (TEM). In this work, we use new, nanoscale quantitative 3D morphological information and stochastic modeling to re-interpret experimental measurements of continuous aligned carbon nanotube (A-CNT) PNC properties as a function of A-CNT packing/volume fraction. The 3D tortuosity calculated from tomographic reconstructions and its evolution with volume fraction is used to develop a novel definition of waviness that incorporates the stochastic nature of CNT growth. The importance of using randomly wavy CNTs to model these materials is validated by agreement between simulated and previously-measured PNC elastic moduli. Secondary morphological descriptors such as CNT-CNT junction density and inter-junction distances are measured for transport property predictions. The scaling of the junction density with CNT volume fraction is observed to be non-linear, and this non-linearity is identified as the primary reason behind the previously unexplained scaling of aligned-CNT PNC longitudinal thermal conductivity. By contrast, the measured electrical conductivity scales linearly with volume fraction as it is relatively insensitive to junction density beyond percolation. This result verifies prior hypotheses that electrical conduction in such fully percolated and continuous CNT systems is dominated by the bulk resistivity of the CNTs themselves. This combination of electron tomographic data and stochastic simulations is a powerful method for establishing a predictive capability for nanocomposite structure-property relations, making it an essential aid in understanding and tailoring the next-generation of advanced composites.

The Evolution of Carbon Nanotube Network Structure in Unidirectional Nanocomposites Resolved by Quantitative Electron Tomography.

Carbon nanotube (CNT) reinforced polymers are next-generation, high-performance, multifunctional materials with a wide array of promising applications. The successful introduction of such materials is hampered by the lack of a quantitative understanding of process-structure-property relationships. These relationships can be developed only through the detailed characterization of the nanoscale reinforcement morphology within the embedding medium. Here, we reveal the three-dimensional (3D) nanoscale morphology of high volume fraction (V(f)) aligned CNT/epoxy-matrix nanocomposites using energy-filtered electron tomography. We present an automated phase-identification method for fast, accurate, representative rendering of the CNT spatial arrangement in these low-contrast bimaterial systems. The resulting nanometer-scale visualizations provide quantitative information on the evolution of CNT morphology and dispersion state with increasing V(f), including network structure, CNT alignment, bundling and waviness. The CNTs are observed to exhibit a nonlinear increase in bundling and alignment and a decrease in waviness as a function of increasing V(f). Our findings explain previously observed discrepancies between the modeled and measured trends in bulk mechanical, electrical and thermal properties. The techniques we have developed for morphological quantitation are applicable to many low-contrast material systems.

It's academic: public policy activities among faculty members in a department of medicine.

PROBLEM: To investigate whether and how faculty members in a department of medicine are engaged in public policy activities. APPROACH: Between February and April 2011, the authors conducted a cross-sectional, Web-based survey of all active Department of Medicine faculty members at the University of California, San Francisco. Survey questions covered demographics, academic role, academic rank, and participation in three specific public policy activities during the past five years: (1) policy-related research, (2) expert advice to government officials, and (3) public policy advocacy in collaboration with organizations outside government. OUTCOMES: Two hundred twenty of 553 faculty (40%) responded to the survey. One hundred twenty-four faculty members (56% of respondents and 22% of total active faculty) reported that they were engaged in at least one of the three types of policy-related activities: 51 (23%) conducted policy-related research, 67 (30%) provided expert advice to government officials, and 93 (42%) collaborated with organizations to advocate for public policy. Higher faculty rank was significantly associated with faculty members reporting that they were involved in one or more of the three policy activities (P = .04). NEXT STEPS: Academic departments should identify public policy expertise among their faculty and leverage this expertise by facilitating opportunities to develop a shared faculty awareness of their public policy activities, by supporting the establishment of mentoring relationships for less experienced faculty in the area of public policy, and by incorporating standards of excellence for work in public policy into the promotions process.

Adolescent alcohol use, suicidal ideation, and suicide attempts.

PURPOSE: To examine the association between self-reported alcohol use and suicide attempts among adolescents who did and did not report suicidal ideation during the past year. METHODS: Screening data from 31,953 students attending schools in the United States that implemented the Signs of Suicide (SOS) program in 2001-2002 were used in this analysis. Two types of alcohol use were investigated: heavy episodic drinking, and drinking while down. Self-reported suicide attempts were regressed on suicidal ideation and both measures of alcohol use, controlling for participants' levels of depressive symptoms, and demographic characteristics. RESULTS: Logistic regression analyses indicated that both drinking while down and heavy episodic drinking were significantly associated with self-reported suicide attempts. Analyses examining the conditional association of alcohol use and suicidal ideation with self-reported suicide attempts revealed that drinking while down was associated with significantly greater risk of suicide attempt among those not reporting suicidal ideation in the past year. Heavy episodic drinking was associated with increased risk of suicide attempt equally among those who did and did not report suicidal ideation. CONCLUSIONS: This study identified the use of alcohol while sad or depressed as a marker for suicidal behavior in adolescents who did not report ideating prior to an attempt, and hence, may not be detected by current strategies for assessing suicide risk. Findings from this study should provide further impetus for alcohol screening among clinicians beyond that motivated by concerns about alcohol and substance use.

Assessing barriers to change in drinking behavior: results of an online employee screening program.

BACKGROUND: The impact of alcohol abuse on worker productivity is considerable and appears to be increasing over time. Although early screening and intervention may help prevent or reduce the damaging health and productivity effects of problem drinking, barriers to behavioral change may render broad-based prevention efforts ineffectual. This study examined the correlates of two potential barriers to changes in drinking behavior--underestimation of drinking and lack of knowledge of helping resources--using data from web-based employee alcohol screenings. METHODS: Anonymous screening data from 1185 employees of ten companies participating in the 2003 National Alcohol Screening Day were analyzed. The AUDIT, a 10-item screening instrument developed by the World Health Organization, was used to measure drinking behavior; employees' subjective assessments of their drinking were also obtained. RESULTS: Over 53% of participants subjectively underestimated their drinking relative to their AUDIT results, and 58% of respondents did not know whether their medical insurance included benefits for alcohol treatment. Logistic regression analysis revealed that younger and male respondents tended to have the highest AUDIT scores and also (along with married respondents) were most likely to underestimate their drinking. Younger, unmarried respondents were least likely to be aware of their alcohol treatment insurance benefits. CONCLUSIONS: Current corporate efforts to curtail problem drinking among employees may not adequately address barriers to change. Targeting at-risk employee groups for alcohol screening and dissemination of information about health insurance benefits and treatment options is recommended, as is providing personalized feedback based on screening results to raise awareness of at-risk drinking and available helping resources.

Age variability in the association between heavy episodic drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program.

OBJECTIVE: Alcohol use is a risk factor for suicidal behavior among adolescents, but it is not clear whether this association is consistent during the adolescent period. This study examined the age-specific associations between heavy episodic drinking (HED) and self-reported suicide attempts in a large and diverse sample of adolescents. METHOD: Screening data from 32,217 students, between the ages of 11 and 19 years, in 225 schools were analyzed. Logistic regression analyses estimating the impact of HED on self-reported suicide attempts in the past year were performed. RESULTS: Heavy episodic drinking was significantly associated with self-reported suicide attempts (odds ratio 1.78, p <.05) controlling for depressive symptoms. However, there was substantial age variability in this association, with the association between HED and self-reported attempts stronger among younger adolescents. Among youths aged 13 years and younger, those who reported an episode of HED during the past year were roughly 2.6 times more likely to report an attempt than those who did not report HED in the past year, in contrast to 1.2 times among youths aged 18 years and older. CONCLUSIONS: Heavy episodic drinking is a clear risk factor for suicidal behavior among younger adolescents, beyond the risk conveyed by depressive symptoms. Further research investigating the bases for increased suicide risk among younger adolescents engaging in HED is warranted. Results provide support to AACAP's practice parameters calling for attention to substance abuse in the assessment of suicide risk and suggest that routine screening for HED by physicians may improve the detection of adolescent suicide risk, particularly among younger adolescents.

Screening high school students for eating disorders: results of a national initiative.

INTRODUCTION: Early identification and treatment of disordered eating and weight control behaviors may prevent progression and reduce the risk of chronic health consequences. METHODS: The National Eating Disorders Screening Program coordinated the first-ever nationwide eating disorders screening initiative for high schools in the United States in 2000. Students completed a self-report screening questionnaire that included the Eating Attitudes Test (EAT-26) and items on vomiting or exercising to control weight, binge eating, and history of treatment for eating disorders. Multivariate regression analyses examined sex and racial/ethnic differences. RESULTS: Almost 15% of girls and 4% of boys scored at or above the threshold of 20 on the EAT-26, which indicated a possible eating disorder. Among girls, we observed few significant differences between ethnic groups in eating disorder symptoms, whereas among boys, more African American, American Indian, Asian/Pacific Islander, and Latino boys reported symptoms than did white boys. Overall, 25% of girls and 11% of boys reported disordered eating and weight control symptoms severe enough to warrant clinical evaluation. Of these symptomatic students, few reported that they had ever received treatment. CONCLUSION: Population screening for eating disorders in high schools may identify at-risk students who would benefit from early intervention, which could prevent acute and long-term complications of disordered eating and weight control behaviors.

Irregular menses linked to vomiting in a nonclinical sample: findings from the National Eating Disorders Screening Program in high schools.

PURPOSE: Using data from an eating disorders screening initiative conducted in high schools across the United States, we examined the relationship between vomiting frequency and irregular menses in a nonclinical sample of adolescent females. METHODS: A self-report questionnaire was administered to students from U.S. high schools participating in the National Eating Disorders Screening Program in 2000. The questionnaire included items on frequency of vomiting for weight control in the past 3 months, other eating disorder symptoms, frequency of menses, height, and weight. Multivariable regression analyses were conducted using data from 2791 girls to estimate the risk of irregular menses (defined as menses less often than monthly) associated with vomiting frequency, adjusting for other eating disorder symptoms, weight status, age, race/ethnicity, and school clusters. RESULTS: Girls who vomited to control their weight one to three times per month were one and a half times more likely (risk ratio [RR] = 1.6; 95% confidence interval [CI] = 1.2-2.2), and girls who vomited once per week or more often were more than three times more likely (RR = 3.2; 95% CI = 2.3-4.4), to experience irregular menses than were girls who did not report vomiting for weight control. Vomiting for weight control remained a strong predictor of irregular menses even when overweight and underweight participants were excluded. CONCLUSIONS: Our study adds to the evidence that vomiting may have a direct effect on hormonal function in adolescent girls, and that vomiting for weight control may be a particularly deleterious component of eating disorders.

An evaluation of National Alcohol Screening Day.

AIMS: Although National Alcohol Screening Day (NASD) became the USA's largest and most visible community-based intervention targeting risky drinking over the past decade, its utility in identifying individuals who are at risk for alcohol problems and in catalyzing behaviour change has not been tested in studies including untreated controls. The purpose of this study was to assess changes in alcohol use three months following NASD participation using a quasi-experimental pretest-posttest control group design. METHODS: Participants (N = 713) were recruited from 5 NASD sites in Florida, Massachusetts, and New York, USA. Intervention subjects (N = 318) were recruited at the NASD event; control subjects (N = 395) were recruited at the same locations approximately 1 week after NASD. All participants completed brief surveys at the time of enrollment, and then again 3 months later. RESULTS: Significant decreases in the typical number of drinks consumed per occasion were observed among at-risk drinkers in the intervention group relative to controls in the 3 months following NASD. At-risk NASD participants averaged approximately 5.6 fewer drinks per week than at-risk controls. CONCLUSIONS: Findings suggest that exposure to a brief screening program with provision of feedback can result in significant reductions in alcohol consumption among risky drinkers.

Results of National Alcohol Screening Day: college demographics, clinical characteristics, and comparison with online screening.

OBJECTIVE: The authors evaluated the efficacy of the 2002 college-based National Alcohol Screening Day (NASD) by determining: (1) the demographic and clinical characteristics of the participants that were screened and (2) the degree to which those scoring at hazardous drinking levels received clinical intervention or were referred for further assessment or treatment. PARTICIPANTS: Of 45,368 participants, 23,334 were screened and 14,598 received some form of clinical intervention, defined as advice or referral. METHODS: The authors conducted nonparametric and univariate analyses to test for statistical differences in demographics, clinical-characteristics, and interventions-as a function of-screening mode. RESULTS: Nearly 34% of those screened in person had an AUDIT score of 8 or higher, indicating harmful or hazardous drinking. Of these, only 10% had ever undergone alcohol treatment. More than 58% of those screened online scored 8 or higher, and of this group, fewer than 6% had ever undergone alcohol treatment. CONCLUSIONS: These data suggest that the in-person event and the online interactive program associated with NASD are serving markedly different populations, particularly with regard to clinical indicators.

Application of The APA Practice Guidelines on Suicide to Clinical Practice.

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient's current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient's level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.