Inequality in healthcare costs between residing and non-residing patients: evidence from Vietnam.

BACKGROUND: Place of residence has been shown to impact health. To date, however, previous studies have only focused on the variability in health outcomes and healthcare costs between urban and rural patients. This study takes a different approach and investigates cost inequality facing non-residing patients - patients who do not reside in the regions in which the hospitals are located. Understanding the sources for this inequality is important, as they are directly related to healthcare accessibility in developing countries. METHODS: The causal impact of residency status on individual healthcare spending is documented with a quasi-experimental design. The propensity score matching method is applied to a unique patient-level dataset (n = 900) collected at public general and specialist hospitals across North Vietnam. RESULTS: Propensity score matching shows that Vietnamese patients who do not reside in the regions in which the hospitals are located are expected to pay about 15 million Vietnamese dongs (approximately 750 USD) more than those who do, a sizable gap, given the distribution of total healthcare costs for the overall sample. This estimate is robust to alternative matching specifications. The obtained discrepancy is empirically attributable to the differences in three potential contributors, namely spending on accompanying relatives, "courtesy funds," and days of hospitalization. CONCLUSIONS: The present study finds that there is significant inequality in healthcare spending between residing and non-residing patients at Vietnamese hospitals and that this discrepancy can be partially explained by both institutional and non-institutional factors. These factors signal practical channels through which policymakers can improve healthcare accessibility.

Reduction in cardiolipin decreases mitochondrial spare respiratory capacity and increases glucose transport into and across human brain cerebral microvascular endothelial cells.

Microvessel endothelial cells form part of the blood-brain barrier, a restrictively permeable interface that allows transport of only specific compounds into the brain. Cardiolipin is a mitochondrial phospholipid required for function of the electron transport chain and ATP generation. We examined the role of cardiolipin in maintaining mitochondrial function necessary to support barrier properties of brain microvessel endothelial cells. Knockdown of the terminal enzyme of cardiolipin synthesis, cardiolipin synthase, in hCMEC/D3 cells resulted in decreased cellular cardiolipin levels compared to controls. The reduction in cardiolipin resulted in decreased mitochondrial spare respiratory capacity, increased pyruvate kinase activity, and increased 2-deoxy-[(3) H]glucose uptake and glucose transporter-1 expression and localization to membranes in hCMEC/D3 cells compared to controls. The mechanism for the increase in glucose uptake was an increase in adenosine-5'-monophosphate kinase and protein kinase B activity and decreased glycogen synthase kinase 3 beta activity. Knockdown of cardiolipin synthase did not affect permeability of fluorescent dextran across confluent hCMEC/D3 monolayers grown on Transwell(®) inserts. In contrast, knockdown of cardiolipin synthase resulted in an increase in 2-deoxy-[(3) H]glucose transport across these monolayers compared to controls. The data indicate that in hCMEC/D3 cells, spare respiratory capacity is dependent on cardiolipin. In addition, reduction in cardiolipin in these cells alters their cellular energy status and this results in increased glucose transport into and across hCMEC/D3 monolayers. Microvessel endothelial cells form part of the blood-brain barrier, a restrictively permeable interface that allows transport of only specific compounds into the brain. In human adult brain endothelial cell hCMEC/D3 monolayers cultured on Transwell(®) plates, knockdown of cardiolipin synthase results in decrease in mitochondrial cardiolipin and decreased mitochondrial spare respiratory capacity. The reduced cardiolipin results in an increased activity of adenosine monophosphate kinase (pAMPK) and protein kinase B (pAKT) and decreased activity of glycogen synthase kinase 3 beta (pGSK3ß) which results in elevated glucose transporter-1 (GLUT-1) expression and association with membranes. This in turn increases 2-dexoyglucose uptake from the apical medium into the cells with a resultant 2-deoxyglucose movement into the basolateral medium.

A regionally tailored epidemiological forecast and monitoring program to guide a healthcare system in the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, analytics and predictive models built on regional data provided timely, accurate monitoring of epidemiological behavior, informing critical planning and decision-making for health system leaders. At Atrium Health, a large, integrated healthcare system in the southeastern United States, a team of statisticians and physicians created a comprehensive forecast and monitoring program that leveraged an array of statistical methods. METHODS: The program utilized the following methodological approaches: (i) exploratory graphics, including time plots of epidemiological metrics with smoothers; (ii) infection prevalence forecasting using a Bayesian epidemiological model with time-varying infection rate; (iii) doubling and halving times computed using changepoints in local linear trend; (iv) death monitoring using combination forecasting with an ensemble of models; (v) effective reproduction number estimation with a Bayesian approach; (vi) COVID-19 patients hospital census monitored via time series models; and (vii) quantified forecast performance. RESULTS: A consolidated forecast and monitoring report was produced weekly and proved to be an effective, vital source of information and guidance as the healthcare system navigated the inherent uncertainty of the pandemic. Forecasts provided accurate and precise information that informed critical decisions on resource planning, bed capacity and staffing management, and infection prevention strategies. CONCLUSIONS: In this paper, we have presented the framework used in our epidemiological forecast and monitoring program at Atrium Health, as well as provided recommendations for implementation by other healthcare systems and institutions to facilitate use in future pandemics.

Assessing Platelet Mitochondrial Dysfunction in a Murine Model of Acute Acetaminophen Toxicity.

INTRODUCTION: Acetaminophen (APAP) toxicity remains a significant cause of adult and pediatric liver failure in North America and Europe. Previous research has evaluated the impaired mitochondrial function associated with APAP toxicity. The primary aim of this study was to evaluate the effects of APAP toxicity on platelet mitochondrial function using platelet oxygen consumption in a murine model in vivo. Our secondary objectives were to determine the effect of 4-MP on platelet mitochondrial function and hepatic toxicity in the setting of APAP overdose, and to correlate platelet mitochondrial function with other markers of APAP toxicity. METHODS: Male C57Bl/6 mice were randomized to receive APAP (300 or 500 mg/kg) or vehicle followed 90 minutes later by either 4-MP (50 mg/kg) or vehicle via intraperitoneal injection. Mice were euthanized 0, 12, or 24 hours later and platelets isolated from cardiac blood and counted. Platelet oxygen consumption (POC) was determined using a closed-system respirometer. Liver injury was assessed by measuring alanine transferase (ALT) and histological evaluation. RESULTS: Injection of 500 mg/kg APAP led to increased POC versus pair-matched control (vehicle) (p < 0.001). Administration of 4-MP did not affect POC in control or 300 mg/kg APAP mice. In mice receiving 500 mg/kg APAP and 4-MP, POC decreased significantly compared to mice receiving 500 mg/kg APAP alone (p < 0.01). Serum and histological analysis confirmed APAP-induced hepatic damage in mice receiving 500 mg/kg APAP and these effects blunted by treatment with 4-MP. CONCLUSIONS: Platelet oxygen consumption as a measure of mitochondrial function may be useful as a biomarker of hepatic APAP toxicity in the setting of moderate to severe overdose. Treatment with 4-MP decreases hepatic necrosis and may mitigate the harmful effects of APAP on platelet mitochondrial function detected via POC.

Oral health in patients scheduled for hematopoietic stem cell transplantation in the Orastem study.

Despite advances in transplant medicine, prevalence of complications after hematopoietic stem cell transplantation (HSCT) remains high. The impact of pre-HSCT oral health factors on the incidence and severity of complications post-HSCT is poorly understood. The aim of this prospective, observational study was to analyze oral health in patients planned for HSCT. Patients ≥18 years requiring HSCT were included from five sites between 2011-2018. General health, oral findings and patient-reported symptoms were registered in 272 patients. Oral symptoms around disease onset were reported by 43 patients (15.9%) and 153 patients (58.8%) reported oral complications during previous chemotherapy. One third of patients experienced oral symptoms at the oral examination before conditioning regimen and HSCT. In total, 124 (46.1%) patients had dental caries, 63 (29.0%) had ≥one tooth with deep periodontal pockets, 147 (75.0%) had ≥one tooth with bleeding on probing. Apical periodontitis was observed in almost 1/4 and partially impacted teeth in 17 (6.3%) patients. Oral mucosal lesions were observed in 84 patients (30.9%). A total of 45 (17.4%) of 259 patients had at least one acute issue to be managed prior to HSCT. In conclusion, oral symptoms and manifestations of oral disease were prevalent in patients planned for HSCT. The extent of oral and acute dental diseases calls for general oral screening of patients pre-HSCT.

Microchimerism in salivary glands after blood- and marrow-derived stem cell transplantation.

Blood- and marrow-derived stem cells (BMDSCs) provide disease-ameliorating effects for cardiovascular and autoimmune diseases. Microchimerism from donor BMDSCs has been reported in several recipient tissues. We hypothesized that this finding suggests a potential use of BMDSCs in the treatment of salivary dysfunctions. We investigated the presence of Y chromosome-positive cells in salivary gland biopsies of 5 females who had received a marrow or blood stem cell transplant from male donors. One to 16 years after transplantation, all recipients exhibited scattered Y chromosome-positive cells in the acini, ducts, and stroma of their salivary glands (mean of 1.01%). Potentially, these cells can be markers of transplantation tolerance, contribute to neoplastic epithelial tissues, or engraft at sites of injury. In addition, transplantation of BMDSCs could be used for treatment of Sjögren's syndrome and salivary glands damaged by therapeutic irradiation for cancers of the head and neck.

Temporal Bet-Hedging in Sand Fly Oviposition: Pharate Phlebotomus papatasi Sand Fly Neonates Regulate Hatching Time in Response to Organic Matter and Proximity to Conspecific Eggs.

In phlebotomine sand fly, the topic of the factors stimulating or inhibiting egg hatching has been largely ignored. In this study, we evaluated the hypothesis that pharate neonate sand flies are able to regulate their hatching time adaptively in response to cues indicative of the presence of food or potential competitors. In this study, we evaluated the independent and combined effects of organic matter (OM) extract and proximity to conspecific eggs on the hatching proportion of Phlebotomus papatasi eggs. In one set of larval rearing jars, we introduced 16 eggs into a small hole in the center of a plaster base of the jar. In another set, we introduced a single egg into each small hole of a 4-by-4 symmetrical array. To one set, we added an aqueous OM extract, and to the other, we added deionized water (DI). OM stimulated egg hatching while egg clustering slightly inhibited egg hatching. Results of this experiment are biologically important because they show, for the first time, that pharate sand fly neonates are able to adaptively regulate their hatching time in response to external cues.

When in America, do as the Americans? The evolution of health behaviors and outcomes across immigrant cohorts.

This study seeks to understand US immigrants' health-related behaviors and outcomes across arrival cohorts. We simultaneously examine risky consumption choices (smoking and drinking) and physical health conditions (asthma, diabetes, vision problems, and coronary heart diseases) using data from the National Health Interview Surveys (1989-2018). We incorporate cohort fixed-effects and the interactions between cohort effects and years since immigration into our empirical framework to capture the dynamics of immigrant health over time. For all health indicators, we find that there are important differences between arriving immigrants and natives. Despite some heterogeneity in the dynamics of unhealthy behaviors, this heterogeneity seems to dissipate as we explore longer-term health outcomes. Overall, our findings provide an interesting outlook on how the integration into the host society affects American immigrants' health. We contribute new results to the immigrant assimilation literature, which has primarily focused on obesity and wages.

Forecasting COVID-19 Hospital Census: A Multivariate Time-Series Model Based on Local Infection Incidence.

BACKGROUND: COVID-19 has been one of the most serious global health crises in world history. During the pandemic, health care systems require accurate forecasts for key resources to guide preparation for patient surges. Forecasting the COVID-19 hospital census is among the most important planning decisions to ensure adequate staffing, number of beds, intensive care units, and vital equipment. OBJECTIVE: The goal of this study was to explore the potential utility of local COVID-19 infection incidence data in developing a forecasting model for the COVID-19 hospital census. METHODS: The study data comprised aggregated daily COVID-19 hospital census data across 11 Atrium Health hospitals plus a virtual hospital in the greater Charlotte metropolitan area of North Carolina, as well as the total daily infection incidence across the same region during the May 15 to December 5, 2020, period. Cross-correlations between hospital census and local infection incidence lagging up to 21 days were computed. A multivariate time-series framework, called the vector error correction model (VECM), was used to simultaneously incorporate both time series and account for their possible long-run relationship. Hypothesis tests and model diagnostics were performed to test for the long-run relationship and examine model goodness of fit. The 7-days-ahead forecast performance was measured by mean absolute percentage error (MAPE), with time-series cross-validation. The forecast performance was also compared with an autoregressive integrated moving average (ARIMA) model in the same cross-validation time frame. Based on different scenarios of the pandemic, the fitted model was leveraged to produce 60-days-ahead forecasts. RESULTS: The cross-correlations were uniformly high, falling between 0.7 and 0.8. There was sufficient evidence that the two time series have a stable long-run relationship at the .01 significance level. The model had very good fit to the data. The out-of-sample MAPE had a median of 5.9% and a 95th percentile of 13.4%. In comparison, the MAPE of the ARIMA had a median of 6.6% and a 95th percentile of 14.3%. Scenario-based 60-days-ahead forecasts exhibited concave trajectories with peaks lagging 2 to 3 weeks later than the peak infection incidence. In the worst-case scenario, the COVID-19 hospital census can reach a peak over 3 times greater than the peak observed during the second wave. CONCLUSIONS: When used in the VECM framework, the local COVID-19 infection incidence can be an effective leading indicator to predict the COVID-19 hospital census. The VECM model had a very good 7-days-ahead forecast performance and outperformed the traditional ARIMA model. Leveraging the relationship between the two time series, the model can produce realistic 60-days-ahead scenario-based projections, which can inform health care systems about the peak timing and volume of the hospital census for long-term planning purposes.