Medicaid Expenditures among Children with Documented Obesity.

Background: Obesity rates continue to rise among children, but knowledge regarding medical expenditures of Medicaid enrollees with documented obesity is lacking. We aim to describe Medicaid expenditure patterns among children with documented obesity and determine the degree to which specific clinical characteristics and conditions contribute to high expenditures. Methods: We performed a retrospective cross-sectional analysis of children aged 2-17 years with a diagnosis code of obesity continuously enrolled in the 2017 Medicaid MarketScan database. Children were grouped based on annual expenditure percentiles: <80th, 80 to <95th, 95 to <99th, and ≥99th. Inpatient, outpatient, and pharmacy expenditures were analyzed. Covariates included demographics, common obesity comorbid conditions (e.g., hypertension), complex chronic conditions (CCCs), and mental health conditions (MHCs). Logistic regression assessed demographic and clinical characteristics associated with high-spending groups (≥95th%). Results: We identified 300,286 children with a diagnosis of obesity. The 1% of children with the highest spending accounted for 25.4% of annual expenditures among children with documented obesity. Annual expenditures in the highest spending groups were driven primarily by inpatient and outpatient mental health services. Characteristics associated with high-spending groups included the following: age 12-17 years, obesity comorbid conditions, and having ≥1 CCC or MHC. These associations increased with increasing number of CCCs or MHCs. Conclusions: Inpatient and outpatient mental health expenditures made up a large proportion of spending among Medicaid-enrolled children with documented obesity. Important drivers of cost in this population were medical complexity and comorbid MHCs. Future research is needed to determine if some of these costs are avoidable in children with obesity.

Specificity of isokinetic assessment in noncontact knee injury prevention screening: A novel assessment procedure with relationships between variables in amateur adult agility-sport athletes.

OBJECTIVES: To present a new knee isokinetic assessment procedure linked to noncontact knee injury mechanisms and examine correlations between variables relevant to noncontact knee injury prevention screening (peak torque [PT, Nm], time-to-peak torque [TTPT, ms], angle-of-peak torque [APT, °], mean PT [MPT, Nm]). DESIGN: Cross-sectional. SETTING: Sports medicine laboratory. PARTICIPANTS: Thirty-four agility-sport athletes (male/female n = 18/16, age 24.1 ± 3.5yr, height 171.8 ± 9.6 cm, mass 70.6 ± 12 kg). MAIN OUTCOME MEASURES: Pearson's/Spearman's correlation (r/rs), coefficient of determination (r2/rs2). RESULTS: Most correlations were statistically non-significant or statistically-significant with only weak-to-moderate coefficients. For both knee extension and flexion, PT and MPT were significantly and strongly correlated (r = 0.99, r2 = 0.98, p = 0.001). Graphical analyses revealed two datapoint clusters for knee flexion TTPT and APT. One cluster indicated some participants could generate knee flexor PT rapidly (<150 ms) at low knee flexion angles (<45°) and the other cluster indicated that other participants could not (>200 ms, >50°). CONCLUSIONS: In this study, most isokinetic variables represented distinct knee neuromuscular characteristics. For both knee extension and flexion, only PT or MPT need be used to represent isokinetic maximal strength. Knee flexion TTPT and APT may have utility in noncontact knee injury prevention screening with amateur adult agility-sport athletes.

Variations in Sedated Echocardiography and Association With Repeat Echocardiography in Nonrefractory Kawasaki Disease.

OBJECTIVES: Echocardiography performed under sedation allows for better coronary artery visualization in children with Kawasaki disease. We sought to describe hospital-level variability in the percentage of sedated echocardiography (SE) among children with nonrefractory Kawasaki disease (NRKD) and then test its association with repeat echocardiography, length of stay (LOS), and costs. METHODS: We identified children in the Pediatric Health Information System <36 months of age hospitalized with NRKD from March 2010 to February 2017. Hospital-level percentage of SE was the primary outcome. Secondary outcomes were repeat echocardiography during the same hospitalization, LOS, and costs. We used χ2 and Wilcoxon rank tests to compare differences in repeat echocardiography between SE and nonsedated echocardiography. Pearson correlation was used to test associations between SE and repeat echocardiography, LOS, and costs. RESULTS: There were 2887 NRKD hospitalizations from 40 children's hospitals. Initial SE varied from 0.0% to 87.0% (median 5.9%; interquartile range 1.4%-21.1%). Of initial echocardiographies, 22.4% were sedated and 10.1% of all hospitalizations had a repeat echocardiography. Use of SE at the hospital level was associated with a lower likelihood for repeat echocardiography (r = -0.32; 95% confidence interval -0.58 to -0.01; P = .042). Absolute risk reduction was 3.5% and the number needed to sedate was 29. Initial SE was not associated with LOS or hospital-level costs but was associated with increased patient-level costs. CONCLUSIONS: Significant variation exists in the use of SE for children <36 months of age with NRKD at children's hospitals. Our results suggest that determination of SE should not be driven by concern for repeat echocardiography or LOS considerations.

Mapping Schistosoma mansoni endemicity in Rwanda: a critical assessment of geographical disparities arising from circulating cathodic antigen versus Kato-Katz diagnostics.

BACKGROUND: Schistosomiasis is a neglected tropical disease caused by Schistosoma parasites. Intervention relies on identifying high-risk regions, yet rapid Schistosoma diagnostics (Kato-Katz stool assays (KK) and circulating cathodic antigen urine assays (CCA)) yield different prevalence estimates. We mapped S. mansoni prevalence and delineated at-risk regions using a survey of schoolchildren in Rwanda, where S. mansoni is an endemic parasite. We asked if different diagnostics resulted in disparities in projected infection risk. METHODS: Infection data was obtained from a 2014 Rwandan school-based survey that used KK and CCA diagnostics. Across 386 schools screened by CCA (N = 19,217). To allow for uncertainty when interpreting ambiguous CCA trace readings, which accounted for 28.8% of total test results, we generated two presence-absence datasets: CCA trace as positive and CCA trace as negative. Samples (N = 9,175) from 185 schools were also screened by KK. We included land surface temperature (LST) and the Normalized Difference Vegetation and Normalized Difference Water Indices (NDVI, NDWI) as predictors in geostatistical regressions. FINDINGS: Across 8,647 children tested by both methods, prevalence was 35.93% for CCA trace as positive, 7.21% for CCA trace as negative and 1.95% for KK. LST was identified as a risk factor using KK, whereas NDVI was a risk factor for CCA models. Models predicted high endemicity in Northern and Western regions of Rwanda, though the CCA trace as positive model identified additional high-risk areas that were overlooked by the other methods. Estimates of current burden for children at highest risk (boys aged 5-9 years) varied by an order of magnitude, with 671,856 boys projected to be infected by CCA trace as positive and only 60,453 projected by CCA trace as negative results. CONCLUSIONS: Our findings show that people in Rwanda's Northern, Western and capital regions are at high risk of S. mansoni infection. However, variation in identification of environmental risk factors and delineation of at-risk regions using different diagnostics likely provides confusing messages to disease intervention managers. Further research and statistical analyses, such as latent class analysis, can be used to improve CCA result classification and assess its use in guiding treatment regimes.

Unravelling changing interspecific interactions across environmental gradients using Markov random fields.

Inferring interactions between co-occurring species is key to identify processes governing community assembly. Incorporating interspecific interactions in predictive models is common in ecology, yet most methods do not adequately account for indirect interactions (where an interaction between two species is masked by their shared interactions with a third) and assume interactions do not vary along environmental gradients. Markov random fields (MRF) overcome these limitations by estimating interspecific interactions, while controlling for indirect interactions, from multispecies occurrence data. We illustrate the utility of MRFs for ecologists interested in interspecific interactions, and demonstrate how covariates can be included (a set of models known as Conditional Random Fields, CRF) to infer how interactions vary along environmental gradients. We apply CRFs to two data sets of presence-absence data. The first illustrates how blood parasite (Haemoproteus, Plasmodium, and nematode microfilaria spp.) co-infection probabilities covary with relative abundance of their avian hosts. The second shows that co-occurrences between mosquito larvae and predatory insects vary along water temperature gradients. Other applications are discussed, including the potential to identify replacement or shifting impacts of highly connected species along climate or land-use gradients. We provide tools for building CRFs and plotting/interpreting results as an R package.

Public health alternatives to incarceration for drug offenders.

Drug users are vastly overrepresented in prison populations. Once inside they face increased risks of acquiring infections such as HIV, hepatitis and TB, and on release they face an elevated risk of fatal overdose. Relapse and recidivism are the norm following release from prison. The implementation of evidence-based drug treatment programmes in prison is rare, yet drug treatment in prison reduces the transmission of infections, recidivism and fatal overdose on release. Recognising the negative returns associated with incarceration, many jurisdictions have begun to consider alternatives such as depenalisation of the personal use of illicit drugs, provision of treatment and social reintegration of drug offenders, and a shift in focus from supply reduction to demand and harm reduction measures in the community and in prison. Women with drug problems are twice as likely to have been imprisoned for a drug offence as incarcerated men. Similarly, HIV prevalence is higher among female inmates. Serious attention should be paid to implementation of non-custodial sentences for women, particularly during pregnancy and those with young children.

Proprioception in musculoskeletal rehabilitation. Part 2: Clinical assessment and intervention.

INTRODUCTION: Proprioception can be impaired in gradual-onset musculoskeletal pain disorders and following trauma. Understanding of the role of proprioception in sensorimotor dysfunction and methods for assessment and interventions is of vital importance in musculoskeletal rehabilitation. In Part 1 of this two-part Masterclass we presented a theory-based overview of the role of proprioception in sensorimotor control, causes and findings of altered proprioception in musculoskeletal conditions, and general principles of assessment and interventions. PURPOSE: The aim of this second part is to present specific methods for clinical assessment and interventions to improve proprioception in the spine and extremities. IMPLICATIONS: Clinical assessment of proprioception can be performed using goniometers, inclinometers, laser-pointers, and pressure sensors. Manual therapy, taping, and bracing can immediately enhance proprioception and should be used to prepare for exercise interventions. Various types of exercise (active joint repositioning, force sense, co-ordination, muscle performance, balance/unstable surface, plyometric, and vibration training) should be employed for long-term enhancement of proprioception.

Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions.

INTRODUCTION: Impaired proprioception has been reported as a feature in a number of musculoskeletal disorders of various body parts, from the cervical spine to the ankle. Proprioception deficits can occur as a result of traumatic damage, e.g., to ligaments and muscles, but can also occur in association with painful disorders of a gradual-onset nature. Muscle fatigue can also adversely affect proprioception and this has implications for both symptomatic and asymptomatic individuals. Due to the importance of proprioception for sensorimotor control, specific methods for assessment and training of proprioception have been developed for both the spine and the extremities. PURPOSE: The aim of this first part of a two part series on proprioception in musculoskeletal rehabilitation is to present a theory based overview of the role of proprioception in sensorimotor control, assessment, causes and findings of altered proprioception in musculoskeletal disorders and general principles of interventions targeting proprioception. IMPLICATIONS: An understanding of the basic science of proprioception, consequences of disturbances and theories behind assessment and interventions is vital for the clinical management of musculoskeletal disorders. Part one of this series supplies a theoretical base for part two which is more practically and clinically orientated, covering specific examples of methods for clinical assessment and interventions to improve proprioception in the spine and the extremities.

Structures of TraI in solution.

Bacterial conjugation, a DNA transfer mechanism involving transport of one plasmid strand from donor to recipient, is driven by plasmid-encoded proteins. The F TraI protein nicks one F plasmid strand, separates cut and uncut strands, and pilots the cut strand through a secretion pore into the recipient. TraI is a modular protein with identifiable nickase, ssDNA-binding, helicase and protein-protein interaction domains. While domain structures corresponding to roughly 1/3 of TraI have been determined, there has been no comprehensive structural study of the entire TraI molecule, nor an examination of structural changes to TraI upon binding DNA. Here, we combine solution studies using small-angle scattering and circular dichroism spectroscopy with molecular Monte Carlo and molecular dynamics simulations to assess solution behavior of individual and groups of domains. Despite having several long (>100 residues) apparently disordered or highly dynamic regions, TraI folds into a compact molecule. Based on the biophysical characterization, we have generated models of intact TraI. These data and the resulting models have provided clues to the regulation of TraI function.

Small-angle neutron scattering study of a monoclonal antibody using free-energy constraints.

Monoclonal antibodies (mAbs) contain hinge-like regions that enable structural flexibility of globular domains that have a direct effect on biological function. A subclass of mAbs, IgG2, have several interchain disulfide bonds in the hinge region that could potentially limit structural flexibility of the globular domains and affect the overall configuration space available to the mAb. We have characterized human IgG2 mAb in solution via small-angle neutron scattering (SANS) and interpreted the scattering data using atomistic models. Molecular Monte Carlo combined with molecular dynamics simulations of a model mAb indicate that a wide range of structural configurations are plausible, spanning radius of gyration values from ∼39 to ∼55 Å. Structural ensembles and representative single structure solutions were derived by comparison of theoretical SANS profiles of mAb models to experimental SANS data. Additionally, molecular mechanical and solvation free-energy calculations were carried out on the ensemble of best-fitting mAb structures. The results of this study indicate that low-resolution techniques like small-angle scattering combined with atomistic molecular simulations with free-energy analysis may be helpful to determine the types of intramolecular interactions that influence function and could lead to deleterious changes to mAb structure. This methodology will be useful to analyze small-angle scattering data of many macromolecular systems.

Increased efficiency of endocrine procedures performed in an ambulatory operating room.

BACKGROUND: Thyroid and parathyroid procedures historically have been viewed as inpatient procedures. Because of the advancements in surgical techniques, these procedures were transferred from the inpatient operating room (OR) to the outpatient OR at a single academic institution approximately 7 y ago. The goal of this study was to determine whether this change has decreased turnover times and maximized OR utilization. METHODS: We performed a retrospective review of 707 patients undergoing thyroid (34%) and parathyroid (66%) procedures by a single surgeon at our academic institution between 2005 and 2008. Inpatient and outpatient groups were compared using Student t-test, chi-square test, or the Kruskal-Wallis test where appropriate. Multiple regression analysis was used to determine how patient and hospital factors influenced turnover times. RESULTS: Turnover times were significantly lower in the outpatient OR (mean 18 ± 0.7 min) when compared with the inpatient OR (mean 36 ± 1.4 min) (P < 0.001). When compared by type of procedure, all turnover times remained significantly lower in the outpatient OR. Patients in both ORs were similar in age, gender, and comorbidities. However, inpatients had a higher mean American Society of Anesthesiologists score (2.30 versus 2.13, P < 0.001) and were more likely to have an operative indication of cancer (23.1% versus 9.2%, P < 0.001). Using multiple regression, the inpatient OR remained highly significantly associated with higher turnover times when controlling for these small differences (P < 0.001). CONCLUSIONS: Endocrine procedures performed in the outpatient OR have significantly faster turnover times leading to cost savings and greater OR utilization for hospitals.

A short-stay unit for thyroidectomy patients increases discharge efficiency.

BACKGROUND: Patients traditionally recover overnight on a general surgery ward after a thyroidectomy; however, these units often lack the efficiency and focus for rapid discharge, which is the goal of a short-stay (SS) unit. Using an SS unit for thyroidectomy patients, who are often discharged in <24 h, may reduce the duration of hospital stay and subsequently decrease associated costs and increase hospital bed and resource availability. METHODS: A retrospective review of 400 patients undergoing thyroidectomy at a single academic hospital. We analyzed postoperative discharge information and hospital cost data. Adult patients who stayed a single night in the hospital were included. We compared patients staying on a designated SS unit versus a general surgery (GS) ward. RESULTS: A total of 223 patients were admitted to SS, and 177 to GS. Trends of admission location were blocked based on time period, with most patients per time period going to the same location. Discharge times were significantly quicker for patients admitted to SS (P < 0.001). A total of 70% of SS patients were discharged before noon, versus 40% of GS patients (P < 0.001). Many variances were identified to account for these differences. Direct costs were significantly lower with SS, owing to savings in pharmacy, recovery room, and nursing expenses (all P < 0.01). CONCLUSIONS: A designated short-stay hospital unit is an effective model for increasing the efficiency of discharge for thyroidectomy patients compared with those admitted to a general surgery ward. It also serves to increase bed availability, which decreases hospital cost and may improve patient flow.