THE AFFORDABLE CARE ACT AND INCENTIVIZED HEALTH WELLNESS PROGRAMS--A TALE OF FEDERALISM AND SHIFTING ADMINISTRATIVE BURDEN.

The Patient Protection and Affordable Care Act creates new incentives and builds on existing wellness program policies to promote employer wellness programs and encourage opportunities to support healthier workplaces. The proposed rules are promulgated by the Department of Health and Human Services (HHS), the Department of Labor, and the Treasury Department, and seek to encourage appropriately designed, consumer-protective wellness programs in group health coverage. This legislative landscape raises significant federalism concerns insofar as it largely shifts the responsibility for administration of health incentive programs to the states. Little attention has been paid to the shifting "administrative burden" that would thereby ensue. This paper will address the distribution of power in the American federal system vis-à-vis subnational counterparts in the wake of rampant, recent health care reform efforts. This paper will therefore explore the willingness of the national government to delegate policymaking responsibility to state governments in the context of an important aspect of healthcare reform. This, in turn, can be used to assess the distribution of powers between governmental levels--a subject that has received little systematic inquiry to date. Finally, this paper will explore the degree of administrative burden shifting that may likely occur as a result of these changes in health reform and what potential impacts it may have on individual health.

Prevalence and regional distribution of obstructive sleep apnea in Canada: Analysis from the Canadian Longitudinal Study on Aging.

OBJECTIVES: Obstructive sleep apnea (OSA) is a common chronic condition that is often undiagnosed or diagnosed after many years of symptoms and has an impact on quality of life and several health factors. We estimated the Canadian national prevalence of OSA using a validated questionnaire and physical measurements in participants in the Canadian Longitudinal Study on Aging (CLSA). METHODS: The method used individual risk estimation based upon the validated STOP-BANG scale developed for OSA. This stratified population sample spans Canada to provide regional estimates. RESULTS: In this sample of adults aged 45 to 85 years old, the overall prevalence in 2015 of combined moderate and severe OSA in the 51,337 participants was 28.1% (95% confidence intervals, 27.8‒28.4). The regional prevalence varied statistically between Atlantic Canada and Western Canada (p < 0.001), although clinically the variations were limited. The provincial prevalence for moderate and severe OSA ranged from 27.5% (New Brunswick and British Columbia) to 29.1% (Manitoba). Body mass index (BMI) was the dominant determinant of the variance between provinces (ß = 0.33, p < 0.001). Only 1.2% of participants had a clinical diagnosis of OSA. CONCLUSION: The great majority (92.9%) of the participants at high risk of OSA were unrecognized and had no clinical diagnosis of OSA.

RéSUMé: OBJECTIFS: Le syndrome de l'apnée du sommeil (SAS) est une maladie chronique courante qui est souvent non diagnostiquée ou diagnostiquée plusieurs années après l'apparition de symptômes et qui a un impact sur la qualité de vie ainsi que plusieurs autres facteurs de santé. Nous avons estimé la prévalence nationale canadienne du SAS à l'aide d'un questionnaire validé et de mesures physiques chez les participants de l'Étude longitudinale canadienne sur le vieillissement (ÉLCV). MéTHODES: L'étude mesure l'estimation du risque individuel du SAS basée sur l'échelle validée STOP-BANG qui a été développée pour l'évaluation du SAS. Cet échantillon de population stratifié couvre tout le Canada et permet de fournir des estimations régionales. RéSULTATS: Dans cet échantillon d'adultes âgés de 45 à 85 ans, la prévalence globale du SAS modéré et sévère chez les 51 337 participants était de 28,1 % en 2015 (intervalles de confiance à 95 %: 27,8‒28,4). La prévalence régionale variait statistiquement entre le Canada atlantique et l'ouest du Canada (p < 0,001), bien que les variations cliniques soient limitées. La prévalence provinciale du SAS modéré et sévère variait entre 27,5 % (Nouveau-Brunswick et Colombie-Britannique) et 29,1 % (Manitoba). L'indice de masse corporelle représentait le facteur dominant de la variance entre les provinces (ß = 0,33, p < 0,001). Seulement 1,2 % des participants avaient un diagnostic clinique du SAS. CONCLUSION: La grande majorité (92,9 %) des participants présentant un risque élevé du SAS n'étaient pas identifiés auparavant et n'avaient aucun diagnostic clinique du SAS.

Barriers to hepatitis C diagnosis and treatment in the DAA era: Preliminary results of a community-based survey of primary care practitioners.

Notwithstanding the groundbreaking achievement of hepatitis C curative treatment with direct-acting antiviral therapies, Canada faces an uphill battle in reaching the 2030 goal of viral elimination set forth by the World Health Organization, a goal made more difficult by the COVID-19 pandemic. There is limited understanding of the diagnostic and treatment barriers, and challenges in linkage to care in Canada, especially as it pertains to primary care providers in a community context. Therefore, in this article, the authors conducted a survey study to evaluate the following factors: primary care providers' knowledge of specialist treatment options and the importance of screening and treatment; and patient factors, including transportation, linguistic barriers, and other socio-economic status indicators that impact the screening and management of hepatitis C. The results suggest that public health campaigns that protocolize and/or incentivize screening and referrals may provide solutions to addressing such barriers.

Chronic abdominal pain and Budd-Chiari syndrome: A relentless quest for an underlying neoplastic etiology.

In this article, we report on a 62-year-old non-cirrhotic male presenting to the emergency department (ED) with chronic abdominal pain, anorexia, and weight loss. Upon initial presentation, physical exam was unremarkable, other than for sarcopenia and splenomegaly. Initial imaging studies revealed a large thrombosis from the iliac vein to the right atrium of the heart. Following discharge, the patient re-consulted to the ED four months later and was re-admitted in renal failure and ascites. The diagnosis of Budd-Chiari syndrome (BCS) was established. Positive immunohistochemistry confirmed a neoplastic ideology of epithelial nature. This case offers a unique perspective on the clinical presentation of secondary BCS, necessitating a consideration in the differential diagnosis of a para-vascular cause. In this case, chronic abdominal pain, often overlooked, may necessitate further workup to establish a clinical diagnosis.

WITHDRAWN: The troponin T isoform shift may constitute a protective compensatory mechanism in hypertrophic cardiomyopathy.

This article was withdrawn by the authors before final publication on April 22, 2008.

Myeloperoxidase-mediated lipoprotein carbamylation as a mechanistic pathway for atherosclerotic vascular disease.

There is an emerging and significant body of research that suggests that MPO (myeloperoxidase) may be a critical mediator in dysfunctional lipoprotein formation and, hence, atherogenic initiation and progression. MPO is a haem peroxidase found in leucocytes and is abundant in macrophages surrounding atherosclerotic lesions. Several lines of evidence support the role of MPO-mediated carbamylation of proteins in atherogenesis. The generic mechanism of MPO-mediated protein carbamylation has been elucidated recently and has been identified as a potentially crucial pathway that links smoking, inflammation and atherogenesis. HDL (high-density lipoprotein) exerts a physiologically beneficial effect of reducing arterial cholesterol deposition; however, there are considerable gaps in current understanding of the molecular basis of dysfunctional HDL formation. Especially deserving of attention is a contextual understanding of dysfunctional pro-atherogenic HDL formation in light of inflammatory changes in atheroma. The present review is especially timely in light of the solved structures of nascent and discoidal HDL and integrates the biochemical significance of MPO carbamylation in the context of these structures. Various avenues of experimental investigation are explored which will be crucial in understanding the vascular consequences of dysfunctional HDL formation and the identification of novel mechanistic pathways in vascular disease. It is anticipated that further knowledge on the intricacies of dysfunctional HDL formation, potentially by an MPO-driven pathway, will lead to considerable progress in identifying novel drug targets for atherosclerosis and characterization of the primary atherogenic process.

Revisiting the '6-month' liver transplant rule for alcohol-associated liver disease: It is time for a change but not without a sound policy first.

There is historical reluctance in the medical community to offer liver transplantation to patients with alcoholic liver disease. Transplant programs broadly follow a policy that requires abstention from alcohol for a minimum of 6 months. This policy, however, is at odds with data that supports improved survival in patients with severe acute alcoholic hepatitis (SAAH). Ethicists, the public, and the transplant community must make a concerted effort to forge an updated transplant policy for SAAH that better reflects current scientific evidence for earlier transplant in well-selected recipients without unfair advantage to those of high socioeconomic status.

A photodimerization approach to crosslink and functionalize microgels.

Microgels were prepared within reverse micelles via photocrosslinking. Gelation resulted from the [2+2] photodimerization reaction of nitrocinnamoyl (NC) groups on multi-arm polyethylene glycol (PEG) or gelatin. Because of the potential for biomedical and chemical applications, immobilization capacity within the microgels was investigated. Quantum dots (QDs), for example, share a similar size scale with proteins and can be physically trapped within the microgels. In addition, the optoelectronic properties of QDs could be utilized for analytical, imaging, and therapeutic purposes. Small molecules and recognition sequences (e.g. biotin) can also be covalently immobilized within the microgel networks through the photodimerization reaction. In the presence of biotin-PEG-NC, the resulting microgels added to streptavidin-coated plates. The microgel properties such as biodegradability and degree of swelling may be engineered for particular applications including targeted monitoring and controlled drug delivery systems.

Primary sclerosing cholangitis: diagnostic and management challenges.

Primary sclerosing cholangitis (PSC) is a chronic immune-mediated disease affecting intra- and extrahepatic bile ducts, primarily the large biliary ducts. Clinical manifestations are broad, and the spectrum encompasses asymptomatic cholestasis, icteric cholangitis with pruritis, cirrhosis, and cholangiocarcinoma. Though rare, PSC has a propensity to affect young to middle-aged males and is strongly associated with inflammatory bowel disease. There is an unmet need for effective medical treatments for PSC, and to date, the only curative therapy is liver transplantation reserved for those with end-stage liver disease. This article addresses the diagnostic and management challenges of PSC, with a succinct analysis of existing therapies, their limitations, and a glimpse into the future of the management of this multifaceted pathologic entity.

Transient elastography in Canada: current state and future directions.

BACKGROUND: Transient elastography (TE) is a safe and effective technology to noninvasively assess hepatic fibrosis in patients with numerous liver conditions. TE is not readily available to all Canadians, and data regarding how this technology is incorporated into clinical practice are lacking. OBJECTIVE: To describe TE practices in Canada, and to identify strategies to optimize access and usage. METHODS: All Canadian centres with TE devices were invited to complete a survey after obtaining purchasing data from the national distributor of the device. Descriptive statistics were generated. RESULTS: Forty-two devices were available in Canada as of January 2015. Seventy-one percent are used in academic settings, 74% are hospital based and 26% are in private clinics. The test is performed by trained nurses in 48% of centres, physicians in 19%, technicians in 9.5% and by any member of the health care team in 19%. Nineteen percent of centres provide satellite clinics to perform the test. While the majority of the centres perform the test at no additional cost to patients, 29% charge a variable fee. CONCLUSION: In Canada, most TE devices are used in academic and/or hospital-based settings, thus limiting access to this technology to many patients. A sizeable minority of centres mandate patients pay variable out-of-pocket fees. Satellite clinics offered by some centres could increase access, but are not widespread. The lack of uniformity with TE practices in Canada suggests that a national policy is needed.

Nitrocinnamate-functionalized gelatin: synthesis and "smart"hydrogel formation via photo-cross-linking.

Gelatin having p-nitrocinnamate pendant groups (Gel-NC) was prepared via an efficient one-pot synthesis, yield >87%. (1)H NMR data indicated that 1 mol of gelatin was modified with 18 +/- 6 mol of the photosensitive group. Upon exposure to low-intensity 365 nm UV light and in the absence of photoinitiators or catalysts, Gel-NC cross-linked within minutes into a gelatin-based hydrogel as monitored by UV-vis spectroscopy. The degree of swelling of this biodegradable hydrogel in aqueous solutions responded to changes in Gel-NC concentration levels, the ionic strength of the aqueous solutions, and photo-cross-linking time. Topography changes associated with phase transition resulting from "photocleavage" of the hydrogel network with 254 nm UV light were studied with AFM. Both Gel-NC and its hydrogel expressed low toxicity to human neonatal fibroblast cells. In addition, gelatin-based microgels were prepared via the photo-cross-linking of Gel-NC within inverse micelles.