Cost of Care for Newborns With Neonatal Abstinence Syndrome in a State Medicaid Program.

Importance: Neonatal abstinence syndrome (NAS) is a medical condition among neonates experiencing substance withdrawal due to the mother's substance use during pregnancy. While previous studies suggest that the overall incidence and annual costs of NAS are increasing, to date, the long-term costs have yet to be demonstrated in Medicaid populations. Objective: To examine the demographic differences and long-term costs of care for neonates diagnosed with vs not diagnosed with NAS. Design, Setting, and Participants: This cohort study used claims data from the Alabama Medicaid Agency for neonates born to Medicaid-eligible mothers between January 1, 2010, and December 31, 2020. Data were analyzed in June 2022. Exposure: A diagnosis of NAS within 30 days of birth. Main Outcomes and Measures: Rate of NAS by demographic and birth characteristics, long-term costs attributable to NAS status and demographic and birth characteristics, and distribution of this expenditure over the enrollment period. Results: A total of 346 259 neonates with Medicaid eligibility were born during the study period (mean [SD] gestational age, 38.4 [2.2] weeks; 50.5%, male), 4027 (1.2%) of whom had an NAS diagnosis within 30 days of birth. A larger percentage of neonates with an NAS diagnosis were male (52.7%) than in the group without NAS (50.5%). Neonates with NAS also weighed less at birth (mean difference, -212.0 g; 95% CI, -231.1 to -192.8 g) and had older mothers (mean difference, 3.4 years; 95% CI, 2.6-4.2 years). An NAS diagnosis had an estimated additional cost of $17 921 (95% CI, $14 830-$21 012) over the enrollment period, and this cost was not evenly distributed over that period. Conclusions and Relevance: In this cohort study of neonates born into the Alabama Medicaid population, those with an NAS diagnosis had a different demographic profile and a higher cost to state Medicaid agencies than those without NAS. These findings warrant further effort to reduce the occurrence of NAS.

Examining Psychological and Knowledge Barriers to Colorectal Cancer Screening in Rural Appalachian Kentucky.

While recent rates of colorectal cancer (CRC) screening have improved in Appalachian Kentucky due to public health efforts, they remain lower compared to both KY as a whole, and the USA. Suboptimal screening rates represent a missed opportunity to engage in early detection and prevention. The purpose of this study is to determine the impact that lack of knowledge has on psychological barriers (e.g., fear and embarrassment) to CRC screening as well as the potential effect of a psychosocial intervention to reduce these barriers. Participants were recruited through faith-based organizations and other community sites. After randomizing participants to either an early or delayed group, a faith-based group education and motivational interviewing intervention was administered. Existing and pilot tested instruments were used to assess knowledge and potential psychological barriers. Data were analyzed using paired t tests and linear regression. We hypothesized that (1) psychological barriers are associated with inadequate knowledge and (2) the intervention, by improving knowledge, could reduce these barriers and increase screening rates. There was a small but significant reduction in psychological barriers (-0.11, p value = 0.015) and moderate increases in CRC knowledge scores (+0.17, p value = 0.06). There was no evidence that the intervention affected these measures (+0.10, p value = 0.58). The relationship between lower barrier scores and increased knowledge was significant at follow up (-0.05, 95% CI (-0.09, -0.00)). An increase in CRC knowledge was correlated with a small but significant decrease in psychological barriers, although there was no evidence that these changes were associated with one another. Future cognitive-based interventions may be effective in increasing CRC knowledge and reducing barriers, but new intervention approaches should be considered.

Health Care Utilization and Medicaid Spending in Children with Type 1 Diabetes in the Alabama Medicaid Program.

There are limited data on health service use and cost in low-income children with type 1 diabetes. This study examined the pattern of use and cost of health care services among low-income children diagnosed with type 1 diabetes in the state of Alabama Medicaid program. The authors performed descriptive analysis and examined factors that influence cost and health service utilization. Results showed that 5638 children with type 1 diabetes were enrolled in the Medicaid program over 7 years. Direct medical costs for patients with type 1 diabetes increased at a rate substantially higher than total Medicaid spending. White children with type 1 diabetes were found to have significantly higher Medicaid spending and service utilization than Black children with type 1 diabetes, while Hispanic children had the lowest costs. Further, older children with type 1 diabetes were found to have significantly higher Medicaid spending and service utilization than younger children with type 1 diabetes.

Palliative Care Conversations for Heart Failure Nurses: A Pilot Education Intervention.

INTRODUCTION: Heart failure is a progressive condition affecting 6.2 million Americans. The use of palliative and supportive care for symptom management and improved quality of life is recommended for persons with heart failure. However, 91% of nurses believe they need further training to have palliative care conversations. The purpose of this pilot education intervention was to determine if providing nurses with education on the timing and content of palliative care conversations would improve their perceived skill and knowledge. METHODS: This was a pilot study of an online educational intervention. Data were electronically collected from 13 participants using validated questionnaires delivered via Qualtrics. Participants completed a demographic survey and End-of-Life Professional Caregiver Survey (EPCS) before and after completing an online, asynchronous education module. RESULTS: Mean scores were higher on all posttest measures. Independent samples t-tests revealed statistically significant differences on the Effective Care Delivery (ECD) scale (t[32] = -2, p = .05) and total EPCS scale scores (t[32] = -2.2, p = .03) from pre- to posttest. CONCLUSION: Scores increased on all dimensions pretest to posttest with statistically significant differences in ECD and total scores. Providing asynchronous online education on timing and content of palliative care conversations to nurses caring for people with heart failure is a feasible and effective way to improve perceived knowledge and skill of palliative care conversations.

Efficacy and safety of ultrasound-guided high-intensity focused ultrasound for uterine fibroids: a preliminary experience.

The objective of this prospective cohort study was to evaluate the therapeutic efficacy and safety of ultrasound-guided high-intensity focussed ultrasound (HIFU) in the treatment of uterine fibroids. Twenty premenopausal women with symptomatic fibroids underwent ultrasound-guided HIFU therapy. Twenty-two fibroids with a median baseline volume of 127.0 cm3 (range 18.5-481.2 cm3) were treated. The percentages fibroid volume reduction were 46.9 (range -8.8-73.1) at 1-month, 57.4 (-51.5-95.2) at 3-month, 60.1 (-18.9-97.8) at 6-month and 75.9 (-33.7-99.3) at 12-month, after treatment. The modified Uterine Fibroid Symptom and Quality of Life (UFS-QOL) scores were reduced by 40.7% (0-59.3%) at 3-month, 45.5% (0-70.4%) at 6-month and 44.9% (0-71.4%) at 12-month after treatment. Three patients required subsequent surgical interventions. No significant complications were encountered. Ultrasound-guided HIFU appears to be effective and safe for the treatment of symptomatic uterine fibroids in selected patients. Impact statement What is already known on this subject? Ultrasound-guided high-intensity focussed ultrasound (HIFU) is a relatively new uterine-sparing treatment for fibroids. Most clinical reports are from China, which suggest that this treatment is a safe and effective modality. However, in many other countries, HIFU treatment for fibroids, especially using ultrasound as image guidance, is still considered novel with limited clinical experience. What do the results of this study add? This preliminary report adds to our limited local experience on HIFU and provides reassurance on our continual utilisation of this treatment modality for fibroids. With the increasing demand of uterine-sparing alternatives, experiences shared among different countries are important to make this treatment modality generalisable and universally acceptable. What are the implications of these findings for clinical practice and/or further research?Ultrasound-guided HIFU (USgHIFU) can potential be offered as an alternative treatment modality for women with fibroids.

Recommendations for the post-operative management of an existing Warfarin therapy after lower limb joint arthroplasty.

BACKGROUND: Warfarin administration after lower limb joint replacements is associated with a high bleeding risk, creating the circumstances for periprosthetic joint infections, increased treatment costs and prolonged Length of Stay (L.o.S). We believe that previously warfarinized patients can be treated safely and discharged without delays, if appropriate policies are established and adhered to. METHODS: This is a retrospective cohort study. We have collected and analyzed data from an audit cycle between 2012 and 2015 on: 1) the post-operative Warfarin reloading protocol, identifying 4 distinct patterns: usual dose, 1.5 times or double the usual dose for 2 days and overloading, 2) timing of reloading: Evening of Surgery vs post-op Day 1, 3) frequency of INR testing: daily vs intermittent, 4) time required to reach a therapeutic INR value ≥2.0, 5) rate of INR variations ≥4.0 and 6) bleeding complications, 7) and the overall L.o.S. RESULTS: We found a significant difference in the time required to reach an INR ≥2.0 between reloading with the usual dose and all other protocols (p < 0.001) without abolishing adverse sequelae. Daily INR testing reduced bleeding complications and INR variations at a significant (p < 0.001) and non-significant level respectively, while timing of restarting showed no significant effect. We found a correlation between INR variations and bleeding complications (odds ratio: 4.65, C.I: 0.59-30.87). 41% of the cohort was discharged on the day their INR turned therapeutic with an average L.o.S of 6.5 days. CONCLUSION: We recommend to: 1) restart Warfarin at double (or in exceptional cases 1.5 times) the patient's maintenance dose for the first two doses, 2) starting on the Evening of Surgery, 3) with daily INR monitoring after the second loading dose, 4) using point of care testing devices, 5) and dosing thereafter to be guided by an anticoagulation service or computer assistance.

Ovarian Reserve After Ultrasound-Guided High-Intensity Focused Ultrasound for Uterine Fibroids: Preliminary Experience.

OBJECTIVE: To determine the effect on ovarian reserve of ultrasound-guided high-intensity focused ultrasound (HIFU) in the treatment of uterine fibroids. METHODS: We performed a mid-study analysis of markers of ovarian reserve using data from a prospective cohort study evaluating the safety of ultrasound-guided HIFU for uterine fibroids. Blood samples obtained from 12 women with uterine fibroids less than one week before treatment were used for measurement of serum anti-Mullerian hormone (AMH), and this testing was repeated in the first, third, sixth, and 12th month after ultrasound-guided HIFU treatment. RESULTS: Fourteen fibroids from 12 patients were treated using ultrasound-guided HIFU. The median baseline fibroid volume was 101.2 cm(3) (range 18.5 to 349.2 cm(3)). The median treatment time was 140.5 minutes (46 to 192 minutes), and median sonication time was 1449 seconds (range 541 to 2445 seconds). The median energy delivered was 575 521.5 joules (range 216 400 to 898 273 joules). The median AMH levels (ng/mL) before treatment and at one, three, six, and 12 months after treatment were 0.3 (range 0.01 to 1.94), 0.47 (0.01 to 1.43), 0.205 (0.01 to 1.81), 0.26 (0 to 2.37), and 0.06 (0.02 to 1.04), respectively. There was no significant difference between the AMH levels before and at any time after treatment. No patient became amenorrheic or reported symptoms suggestive of menopause after treatment. CONCLUSION: Our preliminary experience suggests that ovarian reserve does not seem to be affected by ultrasound-guided HIFU in the treatment of uterine fibroids.

Survival analysis of high-intensity focused ultrasound therapy vs. transarterial chemoembolization for unresectable hepatocellular carcinomas.

BACKGROUND & AIMS: High-intensity focused ultrasound (HIFU) ablation is a non-invasive treatment for unresectable hepatocellular carcinomas (HCCs), but long-term survival analysis is lacking. This study was to analyse its outcome compared to that of transarterial chemoembolization (TACE). METHODS: From October 2003 to September 2010, 113 patients received HIFU ablation as a treatment of HCCs at our hospital. Twenty-six patients had HCCs sized 3-8 cm. Fifty-two patients with matched tumour characteristics having TACE as primary treatment were selected for comparison. Short-term outcome and long-term survival were analysed. RESULTS: In the HIFU group (n = 26), 46 tumours were ablated. The median age of the patients was 69 (49-84) years. The median tumour size was 4.2 (3-8) cm. In the TACE group (n = 52), the median age of the patients was 67 (44-84) years. The median tumour size was 4.8 (3-8) cm. There was no hospital mortality in any of the groups. In the HIFU group, the rates of complete tumour response, partial tumour response, stable disease and progressive disease were 50%, 7.7%, 25.6% and 7.7% respectively, according to the modified Response Evaluation Criteria in Solid Tumours. The TACE group had the corresponding rates at 0%, 21.2%, 63.5% and 15.4% respectively (P < 0.0001). The 1-year, 3-year and 5-year survival rates were 84.6%, 49.2% and 32.3% respectively, in the HIFU group and 69.2%, 29.8% and 2.3% respectively, in the TACE group (P = 0.001). CONCLUSION: HIFU ablation is a safe and effective method for unresectable HCCs. A survival benefit is observed over sole TACE.

High-intensity focused ultrasound ablation: an effective bridging therapy for hepatocellular carcinoma patients.

AIM: To analyze whether high-intensity focused ultrasound (HIFU) ablation is an effective bridging therapy for patients with hepatocellular carcinoma (HCC). METHODS: From January 2007 to December 2010, 49 consecutive HCC patients were listed for liver transplantation (UCSF criteria). The median waiting time for transplantation was 9.5 mo. Twenty-nine patients received transarterial chemoembolization (TACE) as a bringing therapy and 16 patients received no treatment before transplantation. Five patients received HIFU ablation as a bridging therapy. Another five patients with the same tumor staging (within the UCSF criteria) who received HIFU ablation but not on the transplant list were included for comparison. Patients were comparable in terms of Child-Pugh and model for end-stage liver disease scores, tumor size and number, and cause of cirrhosis. RESULTS: The HIFU group and TACE group showed no difference in terms of tumor size and tumor number. One patient in the HIFU group and no patient in the TACE group had gross ascites. The median hospital stay was 1 d (range, 1-21 d) in the TACE group and two days (range, 1-9 d) in the HIFU group (P < 0.000). No HIFU-related complication occurred. In the HIFU group, nine patients (90%) had complete response and one patient (10%) had partial response to the treatment. In the TACE group, only one patient (3%) had response to the treatment while 14 patients (48%) had stable disease and 14 patients (48%) had progressive disease (P = 0.00). Seven patients in the TACE group and no patient in the HIFU group dropped out from the transplant waiting list (P = 0.559). CONCLUSION: HIFU ablation is safe and effective in the treatment of HCC for patients with advanced cirrhosis. It may reduce the drop-out rate of liver transplant candidate.

Survival analysis of high-intensity focused ultrasound ablation in patients with small hepatocellular carcinoma.

BACKGROUND: High-intensity focused ultrasound (HIFU) ablation is a non-invasive treatment for hepatocellular carcinoma (HCC). At present, data on the treatment's long-term outcome are limited. This study analysed the survival outcome of HIFU ablation for HCCs smaller than 3 cm. PATIENTS AND METHODS: Forty-seven patients with HCCs smaller than 3 cm received HIFU treatment between October 2006 and September 2010. Fifty-nine patients who received percutaneous radiofrequency ablation (RFA) were selected for comparison. The two groups of patients were compared in terms of pre-operative variables and survival. RESULTS: More patients in the HIFU group patients had Child-Pugh B cirrhosis (34% versus 8.5%; P = 0.001). The 1- and 3-year overall survival rates of patients whose tumours were completely ablated in the HIFU group compared with the RFA group were 97.4% versus 94.6% and 81.2% versus 79.8%, respectively (P = 0.530). The corresponding 1- and 3-year disease-free survival rates were 63.6% versus 62.4% and 25.9% versus 34.1% (P = 0.683). CONCLUSIONS: HIFU ablation is a safe and effective method for small HCCs. It can achieve survival outcomes comparable to those of percutaneous RFA and thus serves as a good alternative ablation treatment for patients with cirrhosis.

Long-term survival analysis of pure laparoscopic versus open hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a single-center experience.

INTRODUCTION: Laparoscopic liver resection has been reported as a safe and effective approach to the management of liver cancer. However, studies of long-term outcomes regarding tumor recurrence and patient survival in comparison with the conventional open approach are limited. The aim of this study was to analyze the survival outcome of laparoscopic liver resection versus open liver resection. PATIENTS AND METHODS: Between October 2002 and September 2009, 32 patients underwent pure laparoscopic liver resection for hepatocellular carcinoma (HCC). Case-matched control patients (n = 64) who received open liver resection for HCC were included for comparison. Patients were matched in terms of cancer stage, tumor size, location of tumor, and magnitude of resection. Immediate operation outcomes, operation morbidity, disease-free survival, and overall survival were compared between groups. RESULTS: With the laparoscopic group compared with the open resection group, operation time was 232.5 minutes versus 204.5 minutes (P = 0.938), blood loss was 150 mL versus 300 mL (P = 0.001), hospital stay was 4 days versus 7 days (P < 0.0001), postoperative complication was 2 (6.3%) versus 12 (18.8%) (P = 0.184), disease-free survival was 78.5 months versus 29 months (P = 0.086), and overall survival was 92 months versus 71 months (P = 0.142). The disease-free survival for stage II HCC was 22.1 months versus 12.4 months (P = 0.075). CONCLUSIONS: Laparoscopic liver resection for HCC is associated with less blood loss, shorter hospital stay, and fewer postoperative complications in selected patients with no compromise in survival.

Tolerance of high-intensity focused ultrasound ablation in patients with hepatocellular carcinoma.

BACKGROUND: High-intensity focused ultrasound (HIFU) ablation is a relatively new, noninvasive way of ablation for treating hepatocellular carcinoma (HCC). Emerging evidence has shown that it is effective for the treatment of HCC, even in patients with poor liver function. There is currently no data on the safety limit of HIFU ablation in patients with cirrhosis. However, this information is vital for the selection of appropriate patients for the procedure. We analyzed HCC patients who had undergone HIFU ablation and determined the lower limit of liver function and other patient factors with which HCC patients can tolerate this treatment modality. METHODS: Preoperative variables of 100 patients who underwent HIFU ablation for HCC were analyzed to identify the risk factors in HIFU intolerance in terms of stress-induced complications. Factors that may contribute to postablation complications were compared. RESULTS: Thirteen (13 %) patients developed a total of 18 complications. Morbidity was mainly due to skin and subcutaneous tissue injuries (n = 9). Five patients had first-degree skin burn, one had second-degree skin burn, and three had third-degree skin burn. Four complications were grade 3a in the Clavien classification and 14 were below this grade. Univariate analysis showed that age (p = 0.022) was the only independent factor in HIFU intolerance. CONCLUSIONS: HIFU ablation is generally well tolerated in HCC patients with cirrhosis. It is safe for Child-Pugh A and B patients and selected Child-Pugh C patients. With this new modality, HCC patients who were deemed unsalvageable by other surgical means in the past because of simultaneous Child-Pugh B or C disease now have a new hope.

Genomic islands link secondary metabolism to functional adaptation in marine Actinobacteria.

Genomic islands have been shown to harbor functional traits that differentiate ecologically distinct populations of environmental bacteria. A comparative analysis of the complete genome sequences of the marine Actinobacteria Salinispora tropica and Salinispora arenicola reveals that 75% of the species-specific genes are located in 21 genomic islands. These islands are enriched in genes associated with secondary metabolite biosynthesis providing evidence that secondary metabolism is linked to functional adaptation. Secondary metabolism accounts for 8.8% and 10.9% of the genes in the S. tropica and S. arenicola genomes, respectively, and represents the major functional category of annotated genes that differentiates the two species. Genomic islands harbor all 25 of the species-specific biosynthetic pathways, the majority of which occur in S. arenicola and may contribute to the cosmopolitan distribution of this species. Genome evolution is dominated by gene duplication and acquisition, which in the case of secondary metabolism provide immediate opportunities for the production of new bioactive products. Evidence that secondary metabolic pathways are exchanged horizontally, coupled with earlier evidence for fixation among globally distributed populations, supports a functional role and suggests that the acquisition of natural product biosynthetic gene clusters represents a previously unrecognized force driving bacterial diversification. Species-specific differences observed in clustered regularly interspaced short palindromic repeat sequences suggest that S. arenicola may possess a higher level of phage immunity, whereas a highly duplicated family of polymorphic membrane proteins provides evidence for a new mechanism of marine adaptation in Gram-positive bacteria.

Effects of norepinephrine during intra-abdominal hypertension on renal blood flow in bacteremic dogs.

OBJECTIVE: Intraabdominal hypertension reduces organ blood flow. Restoring abdominal perfusion pressure (APP) may restore renal blood flow, especially when sepsis is present. The effects of intra-abdominal pressure (IAP), followed by restoration of APP with norepinephrine, on renal blood flow were determined. DESIGN: Longitudinal study with bacteremia after nonbacteremic (control) conditions. SETTING: University animal laboratory. SUBJECTS: Ten anesthetized mongrel dogs. INTERVENTIONS: IAP was raised to 10, 20, and 30 mm Hg, using intra-abdominal bags filled with saline. After each intervention, decompression was achieved by emptying the bag. Bacteremia was induced by injection of Escherichia coli. Cardiac output and renal blood flow were measured using surgically placed flow probes. Norepinephrine infusion was used to restore the mean arterial pressure to baseline at each IAP. A hypervolemic circulation was maintained throughout by infusing saline. MEASUREMENTS AND MAIN RESULTS: Induction of bacteremia resulted in significant decreases in blood pressure, cardiac output, and renal blood flow (p < .01). Serial increases in IAP decreased cardiac output and renal blood flow both in control and bacteremic dogs (p < .001). These decreases were substantially corrected by abdominal decompression. In nonbacteremic control conditions, restoring APP back to baseline with norepinephrine did not fully restore cardiac output and renal blood flow (p < .001). However, in bacteremic conditions, norepinephrine was able to substantially restore cardiac output and renal blood flow to bacteremic baseline at all levels of IAP. In bacteremic conditions, the renal perfusion fraction returned to bacteremic baseline levels after correction of APP with norepinephrine and after decompression. CONCLUSIONS: Restoration of APP using norepinephrine improves renal blood flow in bacteremic animals with IAPs up to 30 mm Hg, and maintaining a therapeutic APP may preserve renal blood flow in patients with intra-abdominal hypertension who are at risk of IAP-induced renal injury but who have yet to meet accepted criteria for surgical decompression.

Activation of AP-1-dependent transcription by a truncated translation initiation factor.

Int6/eIF3e is a highly conserved subunit of eukaryotic translation initiation factor 3 (eIF3) that has also been reported to interact with subunits of the proteasome and the COP9 signalosome. Overexpression of full-length Int6 or a 13-kDa C-terminal fragment, Int6CT, in the fission yeast Schizosaccharomyces pombe causes multidrug resistance that requires the otherwise inessential AP-1 transcription factor Pap1. Here we show for the first time that Int6CT acts to increase the transcriptional activity of Pap1. Microarray hybridization data indicate that Int6CT overexpression resulted in the up-regulation of 67 genes; this expression profile closely matched that of cells overexpressing Pap1. Analysis of the upstream regulatory sequences of these genes showed that the majority contained AP-1 consensus binding sites. Partial defects in ubiquitin-dependent proteolysis have been suggested to confer Pap1-dependent multidrug resistance, but no such defect was seen on Int6CT overexpression. Indeed, none of the previously identified interactions of endogenous Int6 was required for the activation of Pap1 transcription described here. Moreover, Int6CT-induced activation of Pap1-responsive gene expression was independent of the ability of Pap1 to undergo a redox-regulated conformational change which mediates its relocalization to the nucleus and expression of oxidative stress response genes. Int6CT therefore activates Pap1-dependent transcription by a novel mechanism.