Financial assistance and payment plans for underinsured patients shopping for "shoppable" hospital services.

Recent price transparency laws are designed to better inform patients as they compare hospital options and "shop" for health care services. In addition to prices, underinsured patients seeking care need information on financial assistance, discounts, payment plans, and upfront payment requirements to compare the affordability of care across hospitals. Little is known about the availability of this information and the experience of prospective patients seeking it. We contacted a random sample of 10% of general short-term hospitals across the United States in this "secret shopper" telephone study to assess financial options and navigation challenges faced by underinsured patients in need of a non-emergency procedure. The administrative friction was substantial. Most hospitals have 3 siloed offices for (1) financial assistance, (2) payment plans and discounts, and (3) upfront payment requirements. All relevant offices were unreachable in 3 attempted calls at 18.1% of hospitals. Among hospitals with available information, the majority have financial options for patients: 86.7% of hospitals offer financial assistance and 97.0% of hospitals offer payment plans to underinsured patients for non-emergency care. The length and terms of payments plans varied widely for hospital-administered and third-party financing arrangements. Upfront payments were sometimes required, potentially posing barriers for patients without cash or credit access.

The effect of human-machine interface modality, specificity, and timing on driver performance and behavior while using vehicle automation.

The effectiveness of the human-machine interface (HMI) in a driving automation system during takeover situations is based, in part, on its design. Past research has indicated that modality, specificity, and timing of the HMI have an impact on driver behavior. The objective of this study was to examine the effectiveness of two HMIs, which vary by modality, specificity, and timing, on drivers' takeover time, performance, and eye glance behavior. Drivers' behavior was examined in a driving simulator study with different levels of automation, varying traffic conditions, and while completing a non-driving related task. Results indicated that HMI type had a statistically significant effect on velocity and off-road eye glances such that those who were exposed to an HMI that gave multimodal warnings with greater specificity exhibited better performance. There were no effects of HMI on acceleration, lane position, or other eye glance metrics (e.g., on road glance duration). Future work should disentangle HMI design further to determine exactly which aspects of design yield between safety critical behavior.

Coincidence measurements of photodouble ionization of benzene and thiophene.

Photodouble ionization (PDI) triple-differential cross sections (TDCSs) of benzene and thiophene have been measured in electron-electron coincidence experiments under 10-10 eV and 20-20 eV equal energy sharing conditions. A multi-Gaussian fit method has been employed to characterize the TDCSs. The trends and features observed for benzene and thiophene do highlight differences with helium most likely from molecular PDI contributions to the TDCS. A comparison with the well-known helium PDI TDCS for equal energy sharing conditions [Avaldi and Huetz J. Phys. B: At. Mol. Opt. Phys., 2005, 38, S861-S891] supported the validity of the multi-Gaussian fitting method and contextualized the benzene and thiophene fits. The molecular targets and energy sharing conditions were chosen to provide insight into the unexpected resonances observed in aromatic hydrocarbons but not aromatic heterocyclic molecules [Wehlitz et al., Phys. Rev. Lett., 2012, 109, 193001]. Contrary to the work of [Wehlitz et al., Phys. Rev. Lett., 2012, 109, 193001], no significant differences between benzene and thiophene were found.

Prevalence of Medical Payment Products Promoted on US Hospitals' Websites.

This cross-sectional study examines the prevalence of hospital-promoted medical payment products (MPPs) by whether hospitals offered any MPP or an interest-bearing MPP.

Characterization of the hoof bacterial communities in feedlot cattle affected with digital dermatitis, foot rot or both using a surface swab technique.

BACKGROUND: Lameness is defined as altered or abnormal gait due to dysfunction of the locomotor system, and is a health issue of feedlot cattle, having major economic, labour, and welfare implications. Digital dermatitis (DD-a lesion of the plantar surface of the foot) and foot rot (FR-affects the interdigital cleft) are common infectious causes of lameness in feedlots. These hoof lesions can occur alone or in combination (DD + FR) in the same hoof. A total of 208 hoof swabs were collected from three commercial feedlots located in southern Alberta. Every lesion sample was matched with a corresponding control skin sample taken from a healthy contralateral foot. Control skin samples were also collected from cattle with no lesion on any feet. Bacterial communities of three types of hoof lesions (DD, DD + FR, FR) and healthy skin were profiled using 16S amplicon sequencing. RESULTS: Alpha diversity analysis revealed a lower bacterial diversity on DD and FR lesions compared to control skin. Beta diversity analysis showed that bacterial communities of DD, FR, and DD + FR lesions were distinct from those of the control skin. While the impact of feedlot was minimal, lesion type contributed to 22% of the variation observed among bacterial communities (PERMANOVA-R = 0.22, P < 0.01). Compared to the corresponding control skin, there were 11, 12, and 3 differentially abundant (DA) bacterial genera in DD, DD + FR, and FR lesions, respectively. CONCLUSIONS: The bacterial community description of a DD + FR lesion is a novel finding. Not only did lesions lead to altered bacterial communities when compared to healthy skin, but the composition of those communities also differed depending on the hoof lesion. The 16S amplicon sequencing of surface swabs has significant value as a research tool in separating different hoof lesions and can provide additional insights to the polybacterial etiology of DD and FR in feedlot cattle.

Post-incident psychosocial interventions after a traumatic incident in the workplace: a systematic review of current research evidence and clinical guidance.

Background: After a traumatic incident in the workplace organisations want to provide support for their employees to prevent PTSD. However, what is safe and effective to offer has not yet been established, despite many organisations offering some form of intervention after a traumatic event.Objective: To systematically review the evidence for post-incident psychosocial interventions offered within one month of a workplace trauma, and to compare the content, effectiveness and acceptability of these interventions. Given the lack of a yet clearly established evidence-base in this field, we sought to examine both published empirical research as well as guidelines published by expert groups working with staff in high-risk roles.Methods: We conducted systematic searches for empirical research across bibliographic databases and searched online for clinical practice guidelines to April 2023. We were also referred to potentially relevant literature by experts in workplace trauma. Both empirical research and clinical guidelines were appraised for their quality.Results: A total of 80 research studies and 11 clinical practice guidelines were included in the review. Interventions included Critical Incident Stress Debriefing (CISD), Critical Incident Stress Management (CISM), unspecified Debriefing, Trauma Risk Management (TRiM), Psychological First Aid (PFA), EMDR, CBT and group counselling. Most research and guidance were of poor quality. The findings of this review do not demonstrate any harm caused by CISD, CISM, PFA, TRiM, EMDR, group counselling or CBT interventions when delivered in a workplace setting. However, they do not conclusively demonstrate benefits of these interventions nor do they establish superiority of any specific intervention. Generic debriefing was associated with some negative outcomes. Current clinical guidelines were inconsistent with the current research evidence base. Nevertheless, interventions were generally valued by workers.Conclusions: Better quality research and guidance is urgently needed, including more detailed exploration of the specific aspects of delivery of post-incident interventions.

Organisations often seek to provide some form of psychosocial intervention after a traumatic event in the workplace.Previous reviews have contraindicated particular forms of 'debriefing', however, the evidence for post-incident psychosocial interventions in the workplace has not previously been systematically reviewed.Research evidence was generally of poor quality with limited evidence of effectiveness and clinical guidelines were inconsistent with the evidence. Nevertheless, research did not demonstrate harm from most established interventions and support was valued by workers.

Co-crystallisation and humanisation of an anti-HER2 single-domain antibody as a theranostic tool.

Human epidermal growth factor receptor-2 (HER2) is a well-recognised biomarker associated with 25% of breast cancers. In most cases, early detection and/or treatment correlates with an increased chance of survival. This study, has identified and characterised a highly specific anti-HER2 single-domain antibody (sdAb), NM-02, as a potential theranostic tool. Complete structural description by X-ray crystallography has revealed a non-overlapping epitope with current anti-HER2 antibodies. To reduce the immunogenicity risk, NM-02 underwent a humanisation process and retained wild type-like binding properties. To further de-risk the progression towards chemistry, manufacturing and control (CMC) we performed full developability profiling revealing favourable thermal and physical biochemical 'drug-like' properties. Finally, the application of the lead humanised NM-02 candidate (variant K) for HER2-specific imaging purposes was demonstrated using breast cancer HER2+/BT474 xenograft mice.

UHRF1/UBE2L6/UBR4-mediated ubiquitination regulates EZH2 abundance and thereby melanocytic differentiation phenotypes in melanoma.

Cellular heterogeneity in cancer is linked to disease progression and therapy response, although mechanisms regulating distinct cellular states within tumors are not well understood. We identified melanin pigment content as a major source of cellular heterogeneity in melanoma and compared RNAseq data from high-pigmented (HPCs) and low-pigmented melanoma cells (LPCs), suggesting EZH2 as a master regulator of these states. EZH2 protein was found to be upregulated in LPCs and inversely correlated with melanin deposition in pigmented patient melanomas. Surprisingly, conventional EZH2 methyltransferase inhibitors, GSK126 and EPZ6438, had no effect on LPC survival, clonogenicity and pigmentation, despite fully inhibiting methyltransferase activity. In contrast, EZH2 silencing by siRNA or degradation by DZNep or MS1943 inhibited growth of LPCs and induced HPCs. As the proteasomal inhibitor MG132 induced EZH2 protein in HPCs, we evaluated ubiquitin pathway proteins in HPC vs LPCs. Biochemical assays and animal studies demonstrated that in LPCs, the E2-conjugating enzyme UBE2L6 depletes EZH2 protein in cooperation with UBR4, an E3 ligase, via ubiquitination at EZH2's K381 residue, and is downregulated in LPCs by UHRF1-mediated CpG methylation. Targeting UHRF1/UBE2L6/UBR4-mediated regulation of EZH2 offers potential for modulating the activity of this oncoprotein in contexts in which conventional EZH2 methyltransferase inhibitors are ineffective.

Evaluation of international guidance for the community treatment of 'personality disorders': A systematic review.

BACKGROUND: Guidelines for the treatment and management of 'personality disorders' have been introduced to provide guidance on best practice based on evidence and views of key stakeholders. However, guidance varies and there is yet to be an overall, internationally recognised consensus on the best mental health care for people with 'personality disorders'. AIMS: We aimed to identify and synthesise recommendations made by different mental health organisations from across the world on community treatment for people with 'personality disorders'. METHODS: This systematic review consisted of three stages: 1. systematic literature and guideline search, 2. quality appraisal, and 3. data synthesis. We combined a search strategy involving both systematic searching of bibliographic databases and supplementary search methods of grey literature. Key informants were also contacted to further identify relevant guidelines. Codebook thematic analysis was then conducted. The quality of all included guidelines was assessed and considered alongside results. RESULTS: After synthesising 29 guidelines from 11 countries and 1 international organisation, we identified four main domains, with a total of 27 themes. Important key principles on which there was consensus included continuity of care, equity of access, accessibility of services, availability of specialist care, taking a whole systems approach, trauma informed approaches, and collaborative care planning and decision making. CONCLUSIONS: Existing international guidelines shared consensus on a set of principles for the community treatment of 'personality disorders'. However, half of the guidelines were of lower methodological quality, with many recommendations not backed by evidence.

In Vivo Screening Unveils Pervasive RNA-Binding Protein Dependencies in Leukemic Stem Cells and Identifies ELAVL1 as a Therapeutic Target.

Acute myeloid leukemia (AML) is fueled by leukemic stem cells (LSC) whose determinants are challenging to discern from hematopoietic stem cells (HSC) or uncover by approaches focused on general cell properties. We have identified a set of RNA-binding proteins (RBP) selectively enriched in human AML LSCs. Using an in vivo two-step CRISPR-Cas9 screen to assay stem cell functionality, we found 32 RBPs essential for LSCs in MLL-AF9;NrasG12D AML. Loss-of-function approaches targeting key hit RBP ELAVL1 compromised LSC-driven in vivo leukemic reconstitution, and selectively depleted primitive malignant versus healthy cells. Integrative multiomics revealed differentiation, splicing, and mitochondrial metabolism as key features defining the leukemic ELAVL1-mRNA interactome with mitochondrial import protein, TOMM34, being a direct ELAVL1-stabilized target whose repression impairs AML propagation. Altogether, using a stem cell-adapted in vivo CRISPR screen, this work demonstrates pervasive reliance on RBPs as regulators of LSCs and highlights their potential as therapeutic targets in AML. SIGNIFICANCE: LSC-targeted therapies remain a significant unmet need in AML. We developed a stem-cell-adapted in vivo CRISPR screen to identify key LSC drivers. We uncover widespread RNA-binding protein dependencies in LSCs, including ELAVL1, which we identify as a novel therapeutic vulnerability through its regulation of mitochondrial metabolism. This article is highlighted in the In This Issue feature, p. 171.

Neurological Survivorship Following Surgery for Degenerative Cervical Myelopathy: A Longitudinal Study on 195 Patients.

BACKGROUND: Long-term data on postoperative neurological survivorship for patients with degenerative cervical myelopathy (DCM) undergoing decompressive surgery are limited. The purposes of this study were to assess neurological survivorship after primary decompressive surgery for DCM and to identify predictors for postoperative deterioration. METHODS: A longitudinal clinical data set containing surgical details, medical comorbidities, and radiographic features was assembled for 195 patients who underwent a surgical procedure for DCM between 1999 and 2020, with a mean period of observation of 75.9 months. Kaplan-Meier curves were plotted, and a log-rank test was performed for the univariate analysis of factors related to neurological failure. Lasso regression facilitated the variable selection in the Cox proportional hazards model for multivariate analysis. RESULTS: The overall neurological survivorship was 89.3% at 5 years and 77.3% at 10 years. Cox multivariate analysis following lasso regression identified elevated hazard ratios (HRs) for suture laminoplasty (HR, 4.76; p < 0.001), renal failure (HR, 4.43; p = 0.013), T2 hyperintensity (HR, 3.34; p = 0.05), and ossification of the posterior longitudinal ligament (OPLL) (HR, 2.32; p = 0.032). Subgroup analysis among subjects with OPLL demonstrated that the neurological failure rate was significantly higher in the absence of fusion (77.8% compared with 26.3%; p = 0.019). CONCLUSIONS: Overall, patients who underwent a surgical procedure for DCM exhibited an extended period with neurological improvement. Cervical fusion was indicated in OPLL to reduce neurological failure. Our findings on predictors for early deterioration facilitate case selection, prognostication, and counseling as the volume of primary cervical spine surgeries and reoperations increases globally. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Associations between living in localities with e-cigarette sales restrictions and e-cigarette use change among young adults in Los Angeles County.

INTRODUCTION: Local e-cigarette sales restrictions (ESRs) may impact e-cigarette use. This study examined the associations between living in localities with various ESR policies and changes in e-cigarette use among young adults in Los Angeles (LA) County, California, USA. METHODS: Data were from a cohort of LA County young adults (18-21 years; n=2100) who completed two waves of surveys (Fall 2018-Summer 2019 and Summer-Fall 2020). Local flavoured (n=9) and comprehensive (n=2) ESRs in LA County implemented between June 2019 and May 2020 were identified, coded and merged with the baseline data. Multivariable logistic regressions were used to examine the associations between living in ESR localities and e-cigarette use at follow-up, controlling for covariates and stratified by cigarette smoking at baseline. RESULTS: Overall, 20.9% and 14.3% of participants lived in localities with flavoured and comprehensive ESRs, respectively. Participants who were non-Hispanic, had higher socioeconomic statuses and were currently using e-cigarettes were generally more likely to live in ESR localities than their counterparts. The associations between living in ESR localities and e-cigarette use at follow-up were not found among baseline non-e-cigarette users regardless of their cigarette smoking status; a positive relationship was found among baseline e-cigarette users who also smoked cigarettes but not among non-smokers. DISCUSSION: Participants who lived in localities with various ESR policies were different in their baseline e-cigarette use and socioeconomic backgrounds. Future research examining the potential impact of ESRs on e-cigarette use change should consider the localities' overall sociodemographic and tobacco-using characteristics and individuals' cigarette smoking histories.

Tissue-specific mitochondrial HIGD1C promotes oxygen sensitivity in carotid body chemoreceptors.

Mammalian carotid body arterial chemoreceptors function as an early warning system for hypoxia, triggering acute life-saving arousal and cardiorespiratory reflexes. To serve this role, carotid body glomus cells are highly sensitive to decreases in oxygen availability. While the mitochondria and plasma membrane signaling proteins have been implicated in oxygen sensing by glomus cells, the mechanism underlying their mitochondrial sensitivity to hypoxia compared to other cells is unknown. Here, we identify HIGD1C, a novel hypoxia-inducible gene domain factor isoform, as an electron transport chain complex IV-interacting protein that is almost exclusively expressed in the carotid body and is therefore not generally necessary for mitochondrial function. Importantly, HIGD1C is required for carotid body oxygen sensing and enhances complex IV sensitivity to hypoxia. Thus, we propose that HIGD1C promotes exquisite oxygen sensing by the carotid body, illustrating how specialized mitochondria can be used as sentinels of metabolic stress to elicit essential adaptive behaviors.

Exploring the hypothetical impact of flavored cigar sales restrictions among black young adult cigar smokers: a semi-structured in-depth interview investigation.

This study assessed the hypothetical impact of flavored cigar sales restrictions on cigar smoking among Black young adult cigar smokers (ages 21-29). Forty in-depth interviews were conducted in 2020. Interviews were independently coded and analyzed using thematic analysis. When asked how they would smoke cigars given a flavor sales restriction, half of participants reported they would smoke in the same way, a third would stop or reduce smoking, and a few were unsure of what they would do. Cigar smoking outcome expectancies, preference for flavors, and perceived addictiveness of cigar products may predict cigar smoking change given flavor sales restrictions.

Gut-derived short-chain fatty acids modulate skin barrier integrity by promoting keratinocyte metabolism and differentiation.

Barrier integrity is central to the maintenance of healthy immunological homeostasis. Impaired skin barrier function is linked with enhanced allergen sensitization and the development of diseases such as atopic dermatitis (AD), which can precede the development of other allergic disorders, for example, food allergies and asthma. Epidemiological evidence indicates that children suffering from allergies have lower levels of dietary fibre-derived short-chain fatty acids (SCFA). Using an experimental model of AD-like skin inflammation, we report that a fermentable fibre-rich diet alleviates systemic allergen sensitization and disease severity. The gut-skin axis underpins this phenomenon through SCFA production, particularly butyrate, which strengthens skin barrier function by altering mitochondrial metabolism of epidermal keratinocytes and the production of key structural components. Our results demonstrate that dietary fibre and SCFA improve epidermal barrier integrity, ultimately limiting early allergen sensitization and disease development.The Graphical Abstract was designed using Servier Medical Art images ( https://smart.servier.com ).

Oncogenic ZMYND11-MBTD1 fusion protein anchors the NuA4/TIP60 histone acetyltransferase complex to the coding region of active genes.

A recurrent chromosomal translocation found in acute myeloid leukemia leads to an in-frame fusion of the transcription repressor ZMYND11 to MBTD1, a subunit of the NuA4/TIP60 histone acetyltransferase complex. To understand the abnormal molecular events that ZMYND11-MBTD1 expression can create, we perform a biochemical and functional characterization comparison to each individual fusion partner. ZMYND11-MBTD1 is stably incorporated into the endogenous NuA4/TIP60 complex, leading to its mislocalization on the body of genes normally bound by ZMYND11. This can be correlated to increased chromatin acetylation and altered gene transcription, most notably on the MYC oncogene, and alternative splicing. Importantly, ZMYND11-MBTD1 expression favors Myc-driven pluripotency during embryonic stem cell differentiation and self-renewal of hematopoietic stem/progenitor cells. Altogether, these results indicate that the ZMYND11-MBTD1 fusion functions primarily by mistargeting the NuA4/TIP60 complex to the body of genes, altering normal transcription of specific genes, likely driving oncogenesis in part through the Myc regulatory network.

Blood T-cell profiling in metastatic melanoma patients as a marker for response to immune checkpoint inhibitors combined with radiotherapy.

BACKGROUND: The addition of stereotactic ablative radiotherapy (SABR) to immune checkpoint inhibitors (ICIs) has the potential to significantly improve outcomes in the treatment of metastatic melanoma. We analysed peripheral blood immune cells of patients receiving combination SABR and ICI to detect the effect of treatment and identify potential biomarkers that predict outcome. METHODS: 24 polymetastatic melanoma patients participated in the SABR IMPACT trial, receiving standard dose immunotherapy with anti-PD-1 and/or anti-CTLA-4 and stereotactic ablative radiotherapy to one site. Comprehensive immunophenotyping of T-cells was performed with flow cytometry on blood samples from 13 patients at baseline and following the first 4 cycles of treatment. RESULTS: Following four cycles of immunotherapy and SABR, the proportion of naïve subsets were reduced within both the CD4 and CD8 T-cell lineages. Independently, SABR resulted in increased expression of PD-1 (p = 0.019) and ICOS (p = 0.046) on the CD8+ T-cells, accompanied by a reduction in regulatory T-cell frequencies (p = 0.048). A multivariate discriminant analysis revealed a baseline signature of lower levels of CD8+ naive T-cells and higher expression of TIM-3 on regulatory T-cells and memory T-cells better predicted response. CONCLUSION: The combination of immunotherapy and SABR changed the immunophenotype of blood T cells, with some shifts attributable to SABR. Importantly, we identified a T-cell signature at baseline that best predicted response. Validation of these findings in an independent cohort could confirm these as biomarkers at baseline or early during treatment, and whether these can be utilised to stratify patients for high or low intensity treatment to reduce toxicity.

A systems approach discovers the role and characteristics of seven LysR type transcription factors in Escherichia coli.

Although Escherichia coli K-12 strains represent perhaps the best known model bacteria, we do not know the identity or functions of all of their transcription factors (TFs). It is now possible to systematically discover the physiological function of TFs in E. coli BW25113 using a set of synergistic methods; including ChIP-exo, growth phenotyping, conserved gene clustering, and transcriptome analysis. Among 47 LysR-type TFs (LTFs) found on the E. coli K-12 genome, many regulate nitrogen source utilization or amino acid metabolism. However, 19 LTFs remain unknown. In this study, we elucidated the regulation of seven of these 19 LTFs: YbdO, YbeF, YcaN, YbhD, YgfI, YiaU, YneJ. We show that: (1) YbdO (tentatively re-named CitR) regulation has an effect on bacterial growth at low pH with citrate supplementation. CitR is a repressor of the ybdNM operon and is implicated in the regulation of citrate lyase genes (citCDEFG); (2) YgfI (tentatively re-named DhfA) activates the dhaKLM operon that encodes the phosphotransferase system, DhfA is involved in formate, glycerol and dihydroxyacetone utilization; (3) YiaU (tentatively re-named LpsR) regulates the yiaT gene encoding an outer membrane protein, and waaPSBOJYZU operon is also important in determining cell density at the stationary phase and resistance to oxacillin microaerobically; (4) YneJ, re-named here as PtrR, directly regulates the expression of the succinate-semialdehyde dehydrogenase, Sad (also known as YneI), and is a predicted regulator of fnrS (a small RNA molecule). PtrR is important for bacterial growth in the presence of L-glutamate and putrescine as nitrogen/energy sources; and (5) YbhD and YcaN regulate adjacent y-genes on the genome. We have thus established the functions for four LTFs and identified the target genes for three LTFs.