The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality.

Importance: Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. Objective: To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Design, Setting, and Participants: Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Interventions: Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. Main Outcomes and Measures: The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Results: Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Conclusions and Relevance: Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

Transient translational quiescence in primordial germ cells.

Stem cells in animals often exhibit a slow cell cycle and/or low transcriptional activity referred to as quiescence. Here, we report that the translational activity in the primordial germ cells (PGCs) of the sea urchin embryo (Strongylocentrotus purpuratus) is quiescent. We measured new protein synthesis with O-propargyl-puromycin and L-homopropargylglycine Click-iT technologies, and determined that these cells synthesize protein at only 6% the level of their adjacent somatic cells. Knockdown of translation of the RNA-binding protein Nanos2 by morpholino antisense oligonucleotides, or knockout of the Nanos2 gene by CRISPR/Cas9 resulted in a significant, but partial, increase (47%) in general translation specifically in the PGCs. We found that the mRNA of the translation factor eEF1A is excluded from the PGCs in a Nanos2-dependent manner, a consequence of a Nanos/Pumilio response element (PRE) in its 3'UTR. In addition to eEF1A, the cytoplasmic pH of the PGCs appears to repress translation and simply increasing the pH also significantly restores translation selectively in the PGCs. We conclude that the PGCs of this sea urchin institute parallel pathways to quiesce translation thoroughly but transiently.

Toward a Global Definition and Understanding of Child Sexual Exploitation: The Development of a Conceptual Model.

Child sexual exploitation (CSE) is a serious and persistent global issue affecting up to 5% of the child and youth population worldwide; yet there is no universally accepted definition. To develop a theoretically robust definition of CSE, this review systematically synthesized literature examining CSE definitions aiming to develop a conceptual model and typology. Electronic databases were searched to February 2021, yielding 384 nonduplicative records. Inclusion criteria were peer-reviewed and grey literature investigations of sexual exploitation, with a mean sample age of 18 years or younger, available in the English language. Literature review and data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Sixty-six studies met final inclusion criteria. Two independent reviewers extracted relevant data and used an epistemological approach to thematically analyse meaning and patterns across CSE definitions. Key findings demonstrate that CSE nomenclature is widely inconsistent, and despite growing awareness of this severe form of abuse, language continues to perpetuate stigma and criminalisation, utilising terms such as 'adolescent or child prostitute'. Our findings propose a scientifically and trauma-informed definition and conceptualisation of CSE, based on the following four-dimensional components: (1) A child/young person; (2) sexual acts; (3) abuse; and (4) exploitation (abuse + exchange). In this systematic review, a unified definition and conceptual model aims to advance knowledge and understanding of CSE, contributing to the progression of social norms which embrace nuances of trauma-informed practice and support for the identification and recovery of children, young people and families affected by sexual exploitation.

Fatherhood, Reproductive Health, and Incarcerated Men: A Qualitative Study With Implications for Reentry.

It is important to understand how incarcerated men conceptualize fatherhood for reentry. Sixteen interviews explored attitudes and feelings about parenthood, family planning, and challenges and strengths regarding fatherhood. Transcriptions were analyzed for themes using open coding. Parenting themes: being active in children's lives, financial stability, and giving children better lives. Family planning themes: preventing sexually transmitted infection, creating stable families, importance of family planning, and birth control methods. Men were motivated to be stable fathers and utilize family planning to create stability; men expressed need for better partner communication. Fathers struggled to provide support/stability for children but expressed openness to learning parenting skills and family planning methods. Reentry strategies may address these themes to rehabilitate men and enhance family planning.

Rhabdomyolysis in the Setting of Concomitant Use of Tafamidis, Atorvastatin, and Amiodarone.

An 85-year-old women with transthyretin cardiac amyloidosis presented with generalized weakness, elevated liver function test levels, and creatinine kinase consistent with rhabdomyolysis 1 week after starting tafamidis. She was already taking atorvastatin and amiodarone, raising the possibility of a drug-drug interaction inhibiting the breakdown and excretion of atorvastatin, causing drug-induced rhabdomyolysis. (Level of Difficulty: Intermediate.).

Variation In State Medicaid Implementation Of The ACA: The Case Of Concurrent Care For Children.

More than 55,000 children die each year in the United States, and hospice is used for very few of them at the end of their lives. Nearly one-third of pediatric deaths are a result of chronic, complex conditions, and the majority of these children are enrolled in Medicaid because of disability status or the severity of their disease. Changes in Medicaid/Children's Health Insurance Program regulations under Section 2302 of the Affordable Care Act require all state Medicaid plans to finance curative and hospice services for children. The section enables the option for pediatric patients to continue curative care while enrolled in hospice. We examined state-level implementation of concurrent care for Medicaid beneficiaries and found significant variability in guidelines across the US. The implementation of concurrent care has fostered innovation yet has added barriers to how pediatric concurrent care has been implemented.

Demographic and Psychosocial Factors Associated With Child Sexual Exploitation: A Systematic Review and Meta-analysis.

Importance: Although research has examined factors associated with child sexual exploitation (CSE), consensus is lacking in regard to which factors should be prioritized, thereby hindering policy reform, prevention efforts, and development of early detection and intervention. Objective: To provide a meta-analytic synthesis of studies examining factors associated with CSE and to quantify their relative importance. Data Sources: Electronic databases searched to June 2019 included Medline, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Informit, yielding 396 nonduplicative records. Literature search was performed in July 2019. Study Selection: Inclusion criteria were quantitative investigations of sexual exploitation and mean sample age of 18 years or younger. Data Extraction and Synthesis: Literature review and data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Thirty-seven studies met final inclusion criteria. Two independent reviewers extracted all relevant data. Random-effects meta-analyses were used to derive odds ratios (ORs) for each factor. Data were analyzed from September 1 to October 28, 2019, and prediction intervals calculated in June 2020. Main Outcomes and Measures: Child sexual exploitation, defined as coerced sexual acts between a child or a young person (aged ≤18 years) and an individual or a group in exchange for money, gifts, substances, or other commodities and associated factors. Results: Thirty-seven unique studies were included with a total of 67 453 unique participants (mean [SD] age of 16.2 [2.5] years; 49.9% female). Fifty-two factors associated with CSE were included in the meta-analysis. The strongest factors significantly associated with exposure to sexual exploitation were engagement in sexual risk behaviors (OR, 6.31 [95% CI, 3.12-12.76]; P < .001), having more than 5 sexual partners (OR, 5.96 [95% CI, 1.63-21.87]; P = .007), a diagnosis of posttraumatic stress disorder (OR, 5.29 [95% CI, 3.40-8.22]; P < .001), historical exposure to child pornography (OR, 5.50 [95% CI, 0.99-30.53]; P = .049), and a history of childhood sexual abuse (OR, 3.80 [95% CI, 3.19-4.52]; P < .001). A number of other potentially modifiable factors had moderate to strong associations. Conclusions and Relevance: In this systematic review and meta-analysis, children and adolescents affected by sexual exploitation showed high levels of sexual risk taking, multiple sexual partners, posttraumatic stress disorder, exposure to child pornography, and childhood trauma. Accurate detection of CSE may prevent this type of sexual violence occurring to adolescents and/or provide opportunities for intervention and recovery. Therefore, prevention and intervention efforts will likely benefit from integrating these factors into screening, assessment, and treatment.

Regeneration in bipinnaria larvae of the bat star Patiria miniata induces rapid and broad new gene expression.

BACKGROUND: Some metazoa have the capacity to regenerate lost body parts. This phenomenon in adults has been classically described in echinoderms, especially in sea stars (Asteroidea). Sea star bipinnaria larvae can also rapidly and effectively regenerate a complete larva after surgical bisection. Understanding the capacity to reverse cell fates in the larva is important from both a developmental and biomedical perspective; yet, the mechanisms underlying regeneration in echinoderms are poorly understood. RESULTS: Here, we describe the process of bipinnaria regeneration after bisection in the bat star Patiria miniata. We tested transcriptional, translational, and cell proliferation activity after bisection in anterior and posterior bipinnaria halves as well as expression of SRAP, reported as a sea star regeneration associated protease (Vickery et al., 2001b). Moreover, we found several genes whose transcripts increased in abundance following bisection, including: Vasa, dysferlin, vitellogenin 1 and vitellogenin 2. CONCLUSION: These results show a transformation following bisection, especially in the anterior halves, of cell fate reassignment in all three germ layers, with clear and predictable changes. These results define molecular events that accompany the cell fate changes coincident to the regenerative response in echinoderm larvae.

DO EMPLOYER PENSION CONTRIBUTIONS REFLECT EMPLOYEE PREFERENCES? EVIDENCE FROM A RETIREMENT SAVINGS REFORM IN DENMARK.

This paper studies how firms set contributions to employer-provided 401(k)-type pension plans. Using a reform that decreased the subsidy to contributions to capital pension accounts for Danish workers in the top income tax bracket, we provide strong evidence that employers' contributions are based on their employees' savings preferences. We find an immediate decrease in employer contributions to capital accounts, whose magnitude increased in the share of employees directly affected by the reform. This response was large relative to average employee responses within private IRA-type plans and was accompanied by a similar-magnitude shift of employer contributions to annuity accounts.