Mixotrophic denitrification of waste activated sludge fermentation liquid as an alternative carbon source for nitrogen removal: Reducing N2O emissions and costs.

Heterotrophic-sulfur autotrophic denitrification (HAD) has been proposed to be a prospective nitrogen removal process. In this work, the potential of fermentation liquid (FL) from waste-activated sludge (WAS) as the electron donor for denitrification in the HAD system was explored and compared with other conventional carbon sources. Results showed that when FL was used as a carbon source, over 99% of NO3--N was removed and its removal rate exceeded 14.00 mg N/g MLSS/h, which was significantly higher than that of methanol and propionic acid. The produced sulfate was below the limit value and the emission of N2O was low (1.38% of the NO3--N). Microbial community analysis showed that autotrophic denitrifiers were predominated in the HAD system, in which Thiobacillus (16.4%) was the dominant genus. The economic analysis showed the cost of the FL was 0.062 €/m3, which was 30% lower than that in the group dosed with methanol. Our results demonstrated the FL was a promising carbon source for the HAD system, which could reduce carbon emission and cost, and offer a creative approach for waste-activated sludge resource reuse.

The value of lung function assessment and Testin expression detection in clinicopathological features and prognosis of NSCLC patients.

OBJECTIVE: The aim of this study is to investigate the clinical value and potential prognostic significance of lung function assessment and Testin expression in non-small cell lung cancer (NSCLC) patients. METHODS: The NSCLC patients were classified into three groups according to lung function: group of normal lung function, group of PRISm (preserved ratio impaired spirometry) (FEV1, forced expiratory volume during the first second < 80% predicted and FEV1/FVC (forced vital capacity) ≥ 70%) and group of COPD (chronic obstructive pulmonary disease) (FEV1/FVC < 70%). The pre-operational clinicopathological characteristics of these patients were recorded and the markers of systemic inflammatory response, including neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), platelet to lymphocyte ratio (PLR) and eosinophils (EOS), were compared between three groups. The expression of Testin in NSCLC samples was detected by IHC and we further explored the correlation between Testin expression and clinicopathological characteristics and prognosis of NSCLC patients. Finally, Cox regression analysis was conducted to study the prognostic factors of NSCLC patients. RESULTS: Of the 158 NSCLC patients, percentages of normal lung function, PRISm and COPD were 41.4%, 22.8% and 36.1%, respectively. Patients with tumor in the left lung were more likely to have pulmonary dysfunction (PRISm and COPD) than the right lung. The markers of systemic inflammatory response showed differences to various degree in the three groups and NSCLC patients with PRISm or COPD presented more unfavorable prognosis than patients with normal function. The expression of Testin correlated with lymph node metastasis, TNM stage and tumor invasion of NSCLC patients. Moreover, patients with low Testin expression exhibited poorer disease-free survival and overall survival than those with high Testin expression. In Cox regression analysis, we found that PRISm, COPD and Testin expression served as prognostic factors in NSCLC patients. CONCLUSIONS: The presence of COPD or PRISm influenced systemic inflammatory response and prognosis of NSCLC patients. Testin expression correlated with clinicopathological features and could be potentially used as a prognostic marker in NSCLC.

Buprenorphine dispensing before and after the April 2021 X-Waiver exemptions: An interrupted time series analysis.

BACKGROUND: Until the end of 2022, a special registration, known as the X-waiver, was required to prescribe buprenorphine in the US. Before its removal, US federal regulations trialed an X-waiver exemption, initiated on April 28, 2021, which permitted buprenorphine prescribing for up to 30 patients without additional training. We aimed to understand if these regulatory changes impacted buprenorphine dispensing. METHODS: We conducted an interrupted time series analysis to understand changes in buprenorphine dispensing during the 26 weeks after the X-waiver exemption compared to the expected baseline trend established in the 26 weeks before using the IQVIA Longitudinal Prescription claims database. The primary outcome was number of new buprenorphine prescribers nationwide (defined as no prior buprenorphine prescription dispensed in the last 26 weeks). Segmented regression estimated relative changes in buprenorphine dispensing at 1, 13, and 26 weeks post-X-waiver change. RESULTS: A total of 15,517,525 prescriptions filled for 1,328,172 patients (43.4 % female) ordered by 62,312 providers were included for analysis. At 26 weeks post-X-waiver change, there was no change in the number of new prescribers compared to the expected baseline trend (-2.7 % [95 % CI:-8.3,2.9]). The number of new (15.2 % [4.6,25.8]) and existing (1.7 % [0.9,2.4]) patients and patients per prescriber (4.3 % [3,5.6]) increased. Buprenorphine prescriptions reimbursed by Medicaid increased (7.5 % [6.6,8.4]) while commercial fills decreased (-3.4 % [-5.3,-1.5]). CONCLUSIONS: The number of new prescribers did not increase six months post-X-waiver exemption while new patients continued to enter treatment at higher-than-expected rates. These findings suggest that additional interventions beyond the recent X-waiver removal may be needed to increase access to buprenorphine.

Developing a risk assessment tool for cancer-related venous thrombosis in China: a modified Delphi-analytic hierarchy process study.

OBJECTIVE: To develop a Risk Assessment Tool for Cancer-related Venous Thrombosis in China. METHODS: A modified two-round Delphi method was employed to establish consensus within a field to reach an agreement via a questionnaire or by interviewing a multidisciplinary panel of experts by collecting their feedback to inform the next round, exchanging their knowledge, experience, and opinions anonymously, and resolving uncertainties. Furthermore, The AHP (Analytic Hierarchy Process) was used to determine the final quality indicators' relative importance. RESULTS: The expert's positive coefficient was 85.19% in the first round and 82.61% in the second round, with authoritative coefficients of 0.89 and 0.92 in the respective surveys. The P-value of Kendall's W test was all less than 0.001 for each round, and the W-value for concordance at the end of the two rounds was 0.115. The final Risk Assessment Tool for Cancer-related Venous Thrombosis consisted of three domains, ten subdomains, and 39 indicators, with patient factors weighing 0.1976, disease factors weighing 0.4905, and therapeutic factors weighing 0.3119. CONCLUSION: The tool is significantly valid and reliable with a strong authority and coordination degree, and it can be used to assess the risk of cancer-related VTE and initiate appropriate thrombophylactic interventions in China.

Analysis of renewable energy consumption and economy considering the joint optimal allocation of "renewable energy + energy storage + synchronous condenser".

As renewable energy becomes increasingly dominant in the energy mix, the power system is evolving towards high proportions of renewable energy installations and power electronics-based equipment. This transition introduces significant challenges to the grid's safe and stable operation. On the one hand, renewable energy generation equipment inherently provides weak voltage support, necessitating improvements in the voltage support capacity at renewable energy grid points. This situation leads to frequent curtailments and power limitations. On the other hand, the output of renewable energy is characterized by its volatility and randomness, resulting in substantial power curtailment. The joint intelligent control and optimization technology of "renewable energy + energy storage + synchronous condenser" can effectively enhance the deliverable capacity limits of renewable energy, boost its utilization rates, and meet the demands for renewable energy transmission and consumption. Initially, the paper discusses the mechanism by which distributed synchronous condensers improve the short-circuit ratio based on the MRSCR (Multiple Renewable Energy Station Short-Circuits Ratio) index. Subsequently, with the minimum total cost of system operation as the optimization objective, a time-series production simulation optimization model is established. A corresponding optimization method, considering the joint configuration of "renewable energy + energy storage + synchronous condenser," is proposed. Finally, the effectiveness of the proposed method is verified through common calculations using BPA, SCCP, and the production simulation model, considering a real-world example involving large-scale renewable and thermal energy transmission through an AC/DC system. The study reveals that the joint intelligent control and optimization technology can enhance both the sending and absorbing capacities of renewable energy while yielding favorable economic benefits.

The role of segmental bioelectrical impedance technique in the assessment of intraperitoneal ultrafiltration volume with peritoneal dialysis patients.

OBJECTIVE: To investigate the role of segmental bioelectrical impedance technique (SBIA) in the assessment of intraperitoneal ultrafiltration volume with peritoneal dialysis patients. METHOD: We selected the patients at the Department of Nephrology of the First Affiliated Hospital of Zhengzhou University and measured the segmental bioelectrical impedance by a German Fresenius body composition analyzer (the Fresenius whole body composition measurement (BCM) machine was used as a segmental machine in this study). An alternating current (5 kHz, 0.05-0.7 mA) was continuously released during the measurement. The released current penetrated the peritoneal cavity on both sides of the body, from which the segmental resistance at a frequency of 5 kHz was obtained from the multifrequency data (R5/Ω). Baseline BIA measurements were initiated after the patient entered the supine position for 5-10 min, then dialysate was instilled into the peritoneal cavity. BIA measurements were performed at 10-min intervals during the retention of dialysate in the abdomen and finally ended when dialysate drainage was complete. Real-time intraperitoneal volume estimated by SBIA (IPVSBIA)and ultrafiltration volume estimated by SBIA(UFVSBIA) was calculated. At the same time, the actual ultrafiltration volume at the end of peritoneal dialysis was weighed and measured (UFVMEA). RESULTS: A total of 30 patients were included in the study, 9 patients withdrew from the study due to subjective factors during the measurement process, and 21 patients completed the study. The correlation coefficient R2 of UFVSBIA and UFVMEA was 0.21 (p < 0.05). Bland-Altman analysis showed that the bias of UFVSBIA to the actual UFVMEA was 0.12 L, and the 95% agreement limit was between -0.5 L and 0.74 L, which confirmed that UFVSBIA measured by electrical impedance method and UFVMEA measured by weighing method were in good agreement. The time required to reach the maximum ultrafiltration volume (UFVSBIA) was 108 ± 68 min, and the mean value of the maximum ultrafiltration volume (Max UFVSBIA) was 1.16 ± 0.60 L. CONCLUSION: The segmental bioelectrical impedance technique can be used to assess the intraperitoneal ultrafiltration volume of peritoneal dialysis patients in real-time and effectively. This method may guide the dialysis fluid retention time and the maximum ultrafiltration volume in PD patients.

A Longitudinal Assessment of a Physician Performance Enhancement Program Using Health Data, to Improve Quality of Care and Facilitate Lifelong Learning.

The Personal Quality Index (PQI) provides individual annual reports of benchmarked clinical data to inform practice development. This 5-year longitudinal retrospective study of PQI performance indicators also surveyed department members (n = 104) on utility, using t test, and Wilcoxon test. Technicity increased from 59% in 2014 to 72% in 2018 (P < 0.001). The vaginal birth after cesarean delivery rate did not improve, but the combined forceps/vacuum delivery rate decreased for sites and physicians (P < 0.001). Survey response was 35%. Most physicians (62%) found it valuable, and it informed professional development in 23% of cases. Nevertheless, 42% did not trust the data, and 39% found the process provoked anxiety.

Evaluation of Out-of-Pocket Costs and Treatment Intensification With an SGLT2 Inhibitor or GLP-1 RA in Patients With Type 2 Diabetes and Cardiovascular Disease.

Importance: The latest guidelines continue to recommend sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for patients with type 2 diabetes (T2D) and established cardiovascular disease (CVD). Despite this, overall use of these 2 drug classes has been suboptimal. Objective: To assess the association of high out-of-pocket (OOP) costs and the initiation of an SGLT2 inhibitor or GLP-1 RA among adults with T2D and established CVD who are treated with metformin-treated. Design, Setting, and Participants: This retrospective cohort study used 2017 to 2021 data from the Optum deidentified Clinformatics Data Mart Database. Each individual in the cohort was categorized into quartiles of OOP costs for a 1-month supply of SGLT2 inhibitor and GLP-1 RA based on their health plan assignment. Data were analyzed from April 2021 to October 2022. Exposures: OOP cost for SGLT2 inhibitors and GLP-1 RA. Main Outcomes and Measures: The primary outcome was treatment intensification, defined as a new dispensing (ie, initiation) of either an SGLT2 inhibitor or GLP-1 RA, among patients with T2D previously treated with metformin monotherapy. For each drug class separately, Cox proportional hazards models were used to adjust for demographic, clinical, plan, clinician, and laboratory characteristics to estimate the hazard ratios of treatment intensification comparing the highest vs the lowest quartile of OOP costs. Results: Our cohort included 80 807 adult patients (mean [SD] age, 72 [9.5] years, 45 129 [55.8%] male; 71 128 [88%] were insured with Medicare Advantage) with T2D and established CVD on metformin monotherapy. Patients were followed for a median (IQR) of 1080 days (528 to 1337). The mean (SD) of OOP costs in the highest vs lowest quartile was $118 [32] vs $25 [12] for GLP-1 RA, and $91 [25] vs $23 [9] for SGLT2 inhibitors. Compared with patients in plans with the lowest quartile (Q1) of OOP costs, patients in plans with the highest quartile (Q4) of costs were less likely to initiate a GLP-1 RA (adjusted HR, 0.87 [95% CI, 0.78 to 0.97]) or an SGLT2 inhibitor (adjusted HR, 0.80 [95% CI, 0.73 to 0.88]). The median (IQR) number of days to initiating a GLP-1 RA was 481 (207-820) days in Q1 and 556 (237-917) days in Q4 of OOP costs and 520 (193-876) days in Q1 vs 685 (309-1017) days in Q4 for SGLT2 inhibitors. Conclusions and Relevance: In this cohort study of more than 80 000 older adults with T2D and established CVD covered by Medicare Advantage and commercial plans, those in the highest quartile of OOP cost were 13% and 20% less likely to initiate a GLP-1 RA or SGLT2 inhibitor, respectively, when compared with those in the lowest quartile of OOP costs.

Value assessment of PD-1/PD-L1 inhibitors in the treatment of oesophageal and gastrointestinal cancers.

Background: Evidence of efficacy and safety of programmed cell death 1 (PD-1) and programmed death ligand-1 (PD-L1) checkpoint inhibitors in oesophageal cancer (EC), gastric cancer (GC) and colorectal cancer (CRC) was inconsistent, obscuring their clinical application and decision-making. The aim of this study was to comprehensively evaluate the value of PD-1/PD-L1 inhibitors in EC, GC and CRC to select valuable PD-1/PD-L1 inhibitors, and to assess the association between the value and cost of PD-1/PD-L1 inhibitors. Methods: A comprehensive search of trials of PD-1/PD-L1 inhibitors in EC, GC and CRC was performed in Chinese and English medical databases with a cut-off date of 1 July 2022. Two authors independently applied the ASCO-VF and ESMO-MCBS to assess the value of PD-1/PD-L1 inhibitors. A receiver operating characteristic (ROC) curve was generated to establish the predictive value of the ASCO-VF score to meet the threshold of the ESMO-MCBS grade. Spearman's correlation was used to calculate the relationship between the cost and value of drugs. Results: Twenty-three randomized controlled trials were identified: ten (43.48%) in EC, five (21.74%) in CRC, and eight (34.78%) in GC or gastroesophageal junction cancer (GEJC). For advanced diseases, ASCO-VF scores ranged from -12.5 to 69, with a mean score of 26.5 (95% CI 18.4-34.6). Six (42.9%) therapeutic regimens met the ESMO-MCBS benefit threshold grade. The area under the ROC curve was 1.0 (p = 0.002). ASCO-VF scores and incremental monthly cost were negatively correlated (Spearman's ρ = -0.465, p = 0.034). ESMO-MCBS grades and incremental monthly cost were negatively correlated (Spearman's ρ = -0.211, p = 0.489). Conclusion: PD-1/PD-L1 inhibitors did not meet valuable threshold in GC/GEJC. Pembrolizumab met valuable threshold in advanced microsatellite instability-high CRC. The value of camrelizumab and toripalimab may be more worth paying in EC.

An SPRI beads-based DNA purification strategy for flexibility and cost-effectiveness.

BACKGROUND: Current solid-phase reversible immobilization (SPRI) beads technology is widely used in molecular biology due to its convenience for DNA manipulation. However, the high performance commercial SPRI beads have no price advantage over our method. Furthermore, the use of commercially available SPRI beads standards does not provide the flexibility required for a number of specific nucleic acid handling scenarios. RESULTS: We report an efficient DNA purification strategy by combining home-made beads-suspension buffer with SPRI beads. The method tests the critical concentrations of polyethylene glycol (PEG) 8000 and beads to maximise recovery. And the composition of the SPRI beads DNA purification system (SDPS) was determined at 20% PEG 8000, 2 M NaCl and 16.3 mM MgCl2, and 1.25 mg/ml beads (1/8th original concentration). Then, we tested the DNA recovery of the SDPS, and the result showed that it was comparable to the control (AMPure XP beads). In the study, we have also developed an adjustment SPRI beads DNA purification system (ASDPS), the volume of ASDPS per reaction is 0.6× reaction volume (beads/samples). The performance of ASDPS is similar to SDPS and the control. But the cost of our methods is only about 1/24th of the control. To further assess its performance, we prepare the DNA-seq libraries to evaluate the yield, library quality, capture efficiency and consistency. We have compared all these results with the performance of the control and confirmed its efficiency. CONCLUSION: We have proposed an alternative DNA purification approach with great flexibility, allowing researchers to manipulate DNA in different conditions. And ultimately, its application will benefit molecular biology research in the future.

Value assessment of NMPA-approved new cancer drugs for solid cancer in China, 2016-2020.

Background: Whether the high cost of cancer drugs is commensurate with their value to patients, which has become the focus of public concern. We aimed to assess the value of new cancer drugs approved for solid cancer in China and to explore the association between price and value of drugs. Methods: We identified all new drugs for solid tumor that approved by the China's National Medical Products Administration (NMPA) between 2016 and 2020. The value of these drugs was assessed according to the American Society of Clinical Oncology Value Framework (ASCO-VF) and the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). We calculated Cohen's κ statistic to describe agreement between the two frameworks. Spearman's correlation coefficient was used to evaluate the correlation between price and value of drugs. Results: Between 2016 and 2020, 37 new drugs were approved by the NMPA for solid tumor and we could evaluate the value of 28 drugs (76%). Eight (29%) of drugs were approved for non-small-cell lung cancer and 6 (21%) for breast cancer. ASCO-VF scores had a range of -20 to 110.1, and the median score was 43.3 (inter-quartile range 27.1-58.35). Only seven drugs (25%) met the ASCO-VF cutoff score. By the ESMO-MCBS, 13 drugs showed a meaningful value. Agreement between these two frameworks thresholds was only fair (κ = 0.515, P < 0.05). We found no statistically significant correlation between launch price of drugs and clinical benefit according to both frameworks. Conclusions: Not all NMPA-approved new cancer drugs had meaningful value as measured by ASCO-VF or ESMO-MCBS. There was no significant correlation between drug price and the level of clinical benefit.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers.

BACKGROUND: Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited. OBJECTIVE: To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering. DESIGN: and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020. MAIN MEASURES: Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates. KEY RESULTS: Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered. CONCLUSIONS: In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Where Do Real-Time Prescription Benefit Tools Fit in the Landscape of High US Prescription Medication Costs? A Narrative Review.

The problem of unaffordable prescription medications in the United States is complex and can result in poor patient adherence to therapy, worse clinical outcomes, and high costs to the healthcare system. While providers are aware of the financial burden of healthcare for patients, there is a lack of actionable price transparency at the point of prescribing. Real-time prescription benefit (RTPB) tools are new electronic clinical decision support tools that retrieve patient- and medication-specific out-of-pocket cost information and display it to clinicians at the point of prescribing. The rise in US healthcare costs has been a major driver for efforts to increase medication price transparency, and mandates from the Centers for Medicare & Medicaid Services for Medicare Part D sponsors to adopt RTPB tools may spur integration of such tools into electronic health records. Although multiple factors affect the implementation of RTPB tools, there is limited evidence on outcomes. Further research will be needed to understand the impact of RTPB tools on end results such as prescribing behavior, out-of-pocket medication costs for patients, and adherence to pharmacologic treatment. We review the terminology and concepts essential in understanding the landscape of RTPB tools, implementation considerations, barriers to adoption, and directions for future research that will be important to patients, prescribers, health systems, and insurers.

Neuroimaging Assessment of Pain.

Pain is an unpleasant sensory and emotional experience. Understanding the neural mechanisms of acute and chronic pain and the brain changes affecting pain factors is important for finding pain treatment methods. The emergence and progress of non-invasive neuroimaging technology can help us better understand pain at the neural level. Recent developments in identifying brain-based biomarkers of pain through advances in advanced imaging can provide some foundations for predicting and detecting pain. For example, a neurologic pain signature (involving brain regions that receive nociceptive afferents) and a stimulus intensity-independent pain signature (involving brain regions that do not show increased activity in proportion to noxious stimulus intensity) were developed based on multivariate modeling to identify processes related to the pain experience. However, an accurate and comprehensive review of common neuroimaging techniques for evaluating pain is lacking. This paper reviews the mechanism, clinical application, reliability, strengths, and limitations of common neuroimaging techniques for assessing pain to promote our further understanding of pain.

Cost Function Determination for Human Lifting Motion via the Bilevel Optimization Technology.

Investigating the optimal control strategy involved in human lifting motion can provide meritorious insights on designing and controlling wearable robotic devices to release human low-back pain and fatigue. However, determining the latent cost function regarding this motion remains challenging due to the complexities of the human central nervous system. Recently, it has been discovered that the underlying cost function of a biological motion can be identified from an inverse optimization control (IOC) issue, which can be handled via the bilevel optimization technology. Inspired by this discovery, this work is dedicated to studying the underlying cost function of human lifting tasks through the bilevel optimization technology. To this end, a nested bilevel optimization approach is developed by integrating particle swarm optimization (PSO) with the direction collocation (DC) method. The upper level optimizer leverages particle swarm optimization to optimize weighting parameters among different predefined performance criteria in the cost function while minimizing the kinematic error between the experimental data and the result predicted by the lower level optimizer. The lower level optimizer implements the direction collocation method to predict human kinematic and dynamic information based on the human musculoskeletal model inserted into OpenSim. Following after a benchmark study, the developed method is evaluated by experimental tests on different subjects. The experimental results reveal that the proposed method is effective at finding the cost function of human lifting tasks. Thus, the proposed method could be regarded as a paramount alternative in the predictive simulation of human lifting motion.

Projected Impact of the Medicare Part D Senior Savings Model on Diabetes-Related Health and Economic Outcomes Among Insulin Users Covered by Medicare.

OBJECTIVE: The Medicare Part D Senior Savings Model (SSM) took effect on 1 January 2021. In this study we estimated the number of beneficiaries who would benefit from SSM and the long-term health and economic consequences of implementing this new policy. RESEARCH DESIGN AND METHODS: Data for Medicare beneficiaries with diabetes treated with insulin were extracted from the 2018 Medical Expenditure Panel Survey. A validated diabetes microsimulation model estimated health and economic impacts of the new policy for the 5-year initial implementation period and a 20-year extended policy horizon. Costs were estimated from a health system perspective. RESULTS: Of 4.2 million eligible Medicare beneficiaries, 1.6 million (38.3%) would benefit from the policy, and out-of-pocket (OOP) costs per year per beneficiary would decrease by 61% or $500 on average. Compared with non-White subgroups, the White population subgroups would have a higher proportion of SSM enrollees (29.6% vs. 43.7%) and a higher annual OOP cost reduction (reduction of $424 vs. $531). Among the SSM enrollees, one-third (605,125) were predicted to have improved insulin adherence due to lower cost sharing and improved health outcomes. In 5 years, the SSM would 1) avert 2,014 strokes, 935 heart attacks, 315 heart failure cases, and 344 end-stage renal disease cases; 2) gain 3,220 life-years and 3,381 quality-adjusted life-years (QALY); and 3) increase insulin cost and total medical cost by $3.5 billion and $2.8 billion. In 20 years, the number of avoided clinical outcomes, number of life-years and QALY gained, and the total and insulin cost would be larger. CONCLUSIONS: The Medicare SSM may reduce the OOP costs for approximately one-third of the Medicare beneficiaries treated with insulin, improving health outcomes via increased insulin adherence. However, the SSM will also increase overall Medicare spending for insulin and overall medical costs, which may impact future premiums and benefits. Our findings can inform policy makers about the potential impact of the new Medicare SSM.

Assessment of Drying Kinetics, Textural and Aroma Attributes of Mentha haplocalyx Leaves during the Hot Air Thin-Layer Drying Process.

Since Mentha haplocalyx leaves are rich in bioactive constitutes, particularly volatile compounds, there are higher demands for high-quality dried medicinal and aromatic peppermint products. This study aimed to assess the drying kinetics of hot air thin layer drying Mentha haplocalyx leaves and exploring the effects of hot air-drying temperatures on the textural properties and sensory quality. According to our results, the Midilli model is the best model representing the hot air-drying process. The effective moisture diffusivity (Deff) and activation energy (Ea) of the hot air-drying process were determined as 7.51 × 10-9-3.03 × 10-8 m2/s and 57.98 KJ/moL, respectively. The changes of textural and aromatic profiles of dried Mentha haplocalyx leaves were subsequently evaluated by the SEM, GC-MS and E-nose technology. Changes in leaf cellular membrane structures were observed in this study, indicating that the loss of moisture content induced the shrinkage of leaf cells during the hot air-drying process. Moreover, the altered profile of volatile compounds was identified at the different drying temperatures. As a result of the GC-MS analysis, increasing the content of D-carvone from 61.89%, 69.25% and 78.2% resulted in drying temperatures of 35 °C, 45 °C and 55 °C, respectively; while a decreasing trend of other volatile compounds, including D-Limonene, cineole and l-caryophyllene was detected as drying temperature elevated. Finally, the aromatic profile was evaluated by E-nose, and results of the flavor radar fingerprint and PCA showed that aromatic profiles were significantly altered by the drying process. The overall results elucidated that the hot air thin layer drying at 35 °C efficiently improved the final quality of dried Mentha haplocalyx leaves by maintaining flavor properties.