Incidence of Lyme Disease Diagnosis in a Maryland Medicaid Population, 2004-2011.

The epidemiology of Lyme disease has been examined utilizing insurance claims from privately insured individuals; however, it is unknown whether reported patterns vary among the publicly insured. We examined trends in incidence rates of first Lyme disease diagnosis among 384,652 Maryland Medicaid recipients enrolled from July 2004 to June 2011. Age-, sex-, county-, season-, and year-specific incidence rates were calculated, and mixed-effects multiple logistic regression models were used to study the relationship between Lyme disease diagnosis and these variables. The incidence rate in our sample was 97.65 cases per 100,000 person-years (95% confidence interval (CI): 91.53, 104.06), and there was a 13% average annual increase in the odds of a Lyme disease diagnosis (odds ratio = 1.13, 95% CI: 1.09, 1.17; P < 0.001). Incidence rates for males and females were not significantly different, though males were significantly more likely to be diagnosed during high-season months (relative risk (RR) = 1.24, 95% CI: 1.06, 1.44) and less likely to be diagnosed during low-season months (RR = 0.63, 95% CI: 0.46, 0.87) than females. Additionally, adults were significantly more likely than children to be diagnosed during low-season months (RR = 1.59, 95% CI: 1.19, 2.12). While relatively rare in this study sample, Lyme disease diagnoses do occur in a Medicaid population in a Lyme-endemic state.

Seasonal variability of respiratory syncytial virus infection in the Top End of the Northern Territory (2012-2014).

AIM: To determine the prevalence of respiratory syncytial virus (RSV) in the Top End of the Northern Territory and investigate potential drivers of seasonality including rainfall and humidex (humidity and heat index). METHODS: We performed a retrospective audit of laboratory confirmed cases of RSV from January 2012 to August 2014. Demographic details including age, sex and ethnicity were examined. RSV cases were correlated with monthly rainfall and humidex. RESULTS: There were 272 positive isolates detected from 4305 clinical samples (positivity rate 6.3%). The majority of cases occurred in children <12 months (n = 151, 55.5%), with a higher burden of disease seen in Indigenous compared to non-Indigenous infants in this age category (P < 0.005). The prevalence of RSV in the 0-5 years age category was 58/10 000 children per annum. Indigenous patients had higher prevalence rates (88.8/10 000 population per annum) and younger onset of infection (7.5 months; Interquartile range (IQR) 3-19 months compared to 13 months for non-Indigenous children; IQR 5 months to 2.4 years). RSV cases correlated most strongly with rainfall in the preceding month (r = 0.72). CONCLUSIONS: The Top End of the Northern Territory has a distinct RSV season that correlates with rainfall and humidex, which differs from Southern Australian disease patterns.

Assessment of Annual Diabetic Eye Examination Using Telemedicine Technology Among Underserved Patients in Primary Care Setting.

CONTEXT: Digital retinal imaging with the application of telemedicine technology shows promising results for screening of diabetic retinopathy in the primary care setting without requiring an ophthalmologist on site. AIMS: We assessed whether the establishment of telemedicine technology was an effective and efficient way to increase completion of annual eye examinations among underserved, low-income (Medicaid) diabetic patients. SETTINGS AND DESIGN: A cross-sectional study in a primary care setting. SUBJECTS AND METHODS: Health care claims data were collected before the establishment of telemedicine technology in 2010 and after its implementation in 2012 for Medicaid patients at East Baltimore Medical Center (EBMC), an urban health center that is part of Johns Hopkins Health System. STATISTICAL ANALYSIS USED: The primary outcome measure was the compliance rate of patients with diabetic eye examinations; calculated as the number of diabetic patients with a completed telemedicine eye examination, divided by the total number of diabetic patients. RESULTS: In 2010, EBMC treated 213 Medicaid diabetic patients and in 2012 treated 228 Medicaid patients. In 2010, 47.89% of patients completed their annual diabetic eye examination while in 2012 it was 78.07% (P < 0.001). After adjustment for age, gender, HgBA1C, disease severity, using resource utilization band score as a proxy, and medication possession ratio; telemedicine technology significantly increased the compliance (odds ratio: 4.98, P < 0.001). CONCLUSIONS: Adherence to annual eye examinations is low in the studied Medicaid diabetic population. Telemedicine technology in a primary care setting can increase compliance with annual eye examinations.

Effect of ultrasound-enhanced fat separation on whey powder phospholipid composition and stability.

Fat from freshly pasteurized liquid whey was partially separated by gravity for 5, 10, and 30min, with and without simultaneous application of ultrasound. Ultrasound treatments were carried out at 400 and 1,000 kHz at different specific energy inputs (23-390 kJ/kg). The fat-enriched top layers (L1) and the fat-depleted bottom layers (L2) were separately removed and freeze-dried. Nonsonicated and sonicated L2 powders were stored for 14d at ambient temperature to assess their oxidative stability. Creaming was enhanced at both frequencies and fat separation increased with higher ultrasonic energy, extended sonication, or both. The oxidative volatile compound content decreased in defatted whey powders below published odor detection threshold values for all cases. Sonication had a minor influence on the partitioning of phospholipids with fat separation. The current study suggested that ultrasonication at high frequency enhanced fat separation from freshly pasteurized whey while improving whey powder oxidative stability.

Annual diabetic eye examinations in a managed care Medicaid population.

OBJECTIVES: To assess how well a managed care organization performed annual diabetic eye screening in a Medicaid population, and to identify barriers to completion. STUDY DESIGN: Cross-sectional study. METHODS: Healthcare claims data for all Medicaid patients with diabetes covered by Priority Partners Managed Care Organization in 2010 and 2012 were collected, and the annual rates for diabetic eye exams in those years were reported. Predictors of completion of the diabetic eye exam in primary care clinics in 2010 and 2012 were assessed using a logistic regression model. RESULTS: We identified 8902 Medicaid patients with a diagnosis of diabetes using the Healthcare Effectiveness Data and Information Set codes: 3838 patients in 2010 and 5064 patients in 2012. In 2010 and 2012, 46% and 64% of patients, respectively, had completed their annual diabetic eye exam. The increase in participation in annual eye exams from 2010 to 2012 was statistically significant (P < .001). Among the factors increasing the likelihood of completion of an annual diabetic eye exam among the Medicaid population were access to a nonmydriatic fundoscopic camera in the primary care clinic, compliance with glycated hemoglobin measurement based on the recommended guidelines, incentives offered to primary care offices, and higher resource utilization band score. Financial incentives to patients, however, lowered the completion rate. CONCLUSIONS: Annual diabetic eye exam completion is low among the Medicaid population. Detecting high-risk patients and adjusting for factors that play a role in nonadherence both increase the rate of annual diabetic eye exams among underserved populations such as Medicaid patients.

The relationship between a worksite wellness clinic and hospital emergency department visits.

OBJECTIVE: To assess the relationship between the provision of episodic medical care at the worksite and nonadmission emergency department (ED) visits. METHODS: A historical cohort design was used to study the differences of nonadmission ED visits among insurance plan participants employed at two acute care hospitals, one with a worksite wellness clinic and one without over an 8-year period. RESULTS: A significant reduction in the risk of an insurance plan member visiting the ED in the time period after the clinic was opened among plan members with access to a worksite wellness clinic was observed. No significant reduction was noted in ED visits for insurance plan members without access to a worksite clinic. CONCLUSIONS: A wellness clinic rendering episodic medical care is associated with significant reductions in ED visits and insured employees who use an ED.

Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial.

BACKGROUND: Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN: We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION: Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.

Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans.

African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.

Encapsulation of mixtures of tuna oil, tributyrin and resveratrol in a spray dried powder formulation.

Spray dried emulsions are effective for carrying and stabilising combinations of fish oil and tributyrin, fish oil and resveratrol, or fish oil, tributyrin and resveratrol in one formulation. The encapsulation efficiencies were >99% for all three bioactives when a heated mixture of sodium caseinate: glucose: dried glucose syrup matrix (Encapsulant matrix 1) was used. When a heated sodium caseinate: glucose: processed starch matrix (Encapsulant matrix 2) was used, the encapsulation efficiencies were 90-92% for tributyrin and approximately 98% for resveratrol for all formulations but 79-91% for tuna oil where the efficiency was more formulation dependent. There was 84-86% remaining EPA, 85-87% remaining DHA, 85% remaining tributyrin and 94-96% remaining resveratrol after 18 months at 25 °C storage of the spray dried emulsions using Encapsulant matrix 1 across all formulations. In comparison, there was 83-87% remaining EPA and 84-89% remaining DHA, 80-82% remaining tributyrin, and 81-100% remaining resveratrol across all formulations with Encapsulant matrix 2. In vitro studies showed that on sequential exposure to simulated gastric and intestinal fluids, <5% tuna oil was found as triglycerides, but all the tributyrin had been lipolysed. The presence of diglycerides, monoglycerides and free fatty acids in the in vitro digests suggested that lipolysis of tuna oil had occurred. The type of matrix used for encapsulating the bioactives had little effect on the lipolysis of the oils but affected the amount of solvent extractable resveratrol. The ability of delivering mixtures of bioactives within one formulation was demonstrated.

Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members.

INTRODUCTION: We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS: We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS: Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION: African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.

Rapid isolation of omega-3 long-chain polyunsaturated fatty acids using monolithic high performance liquid chromatography columns.

Eicosapentaenoic and docosahexaenoic acids are important bio-active fatty acids in fish oils. Monolithic HPLC columns both in the polymeric cation exchange (silver-ion) and RP formats were compared with corresponding packed columns for the isolation of these acids from tuna oil ethyl esters. Monolithic columns in both formats enabled rapid (typically 5-10 min) separations compared with packed columns (30 min). Polymeric monolithic silver-ion disc column rapidly furnished mixtures of eicosapentaenoic and docosahexaenoic esters (90% purity) within 5-10 min, but was unable to resolve individual esters. A preparative version of the same column (80 mL bed volume) enabled isolation (>88% purity) of 100 mg quantities of eicosapentaenoic and docosahexaenoic esters from esterified tuna oil within 6 min. Baseline separation of eicosapentaenoic and docosahexaenoic esters was achieved on all RP columns. The results show that there is potential to use polymeric monolithic cation exchange columns for scaled-up preparation of eicosapentaenoic and docosahexaenoic ester concentrates from fish oils.

Influenza antiviral resistance in the Asia-Pacific region during 2011.

Despite greater than 99% of influenza A viruses circulating in the Asia-Pacific region being resistant to the adamantane antiviral drugs in 2011, the large majority of influenza A (>97%) and B strains (∼99%) remained susceptible to the neuraminidase inhibitors oseltamivir and zanamivir. However, compared to the first year of the 2009 pandemic, cases of oseltamivir-resistant A(H1N1)pdm09 viruses with the H275Y neuraminidase mutation increased in 2011, primarily due to an outbreak of oseltamivir-resistant viruses that occurred in Newcastle, as reported in Hurt et al. (2011c, 2012a), where the majority of the resistant viruses were from community patients not being treated with oseltamivir. A small number of influenza B viruses with reduced oseltamivir or zanamivir susceptibility were also detected. The increased detection of neuraminidase inhibitor resistant strains circulating in the community and the detection of novel variants with reduced susceptibility are reminders that monitoring of influenza viruses is important to ensure that antiviral treatment guidelines remain appropriate.

Acute post-streptococcal glomerulonephritis in the Northern Territory of Australia: a review of 16 years data and comparison with the literature.

Data relating to acute post-streptococcal glomerulonephritis (APSGN) from the notifiable diseases surveillance system in the Northern Territory of Australia was extracted and analyzed. Isolates of Streptococcus pyogenes from confirmed cases were emm sequence typed. From 1991 to July 2008, there were 415 confirmed cases and 23 probable cases of APSGN notified. Four hundred fifteen (94.7%) of these were Indigenous Australians and 428 (97.7%) were people living in remote or very remote locations. The median age of cases was 7 years (range 0-54). The incidence of confirmed cases was 12.5/100,000 person-years, with an incidence in Indigenous Australian children younger than 15 years of age of 94.3 cases/100,000 person-years. The overall rate ratio of confirmed cases in Indigenous Australians to non-Indigenous Australians was 53.6 (95% confidence interval 32.6-94.8). Outbreaks of disease across multiple communities occurred in 1995 (N = 68), 2000 (N = 55), and 2005 (N = 87 [confirmed cases]). Various emm types of S. pyogenes were isolated from cases of APSGN including some types not previously recognized to be nephritogenic. The widespread outbreak in 2005 was caused by emm55.0 S. pyogenes. Acute post-streptococcal glomerulonephritis continues to occur in remote Indigenous communities in Australia at rates comparable to or higher than those estimated in developing countries. Improvements in preventative and outbreak control strategies are needed.

Characterization of Corynebacterium diphtheriae isolates from infected skin lesions in the Northern Territory of Australia.

Corynebacterium diphtheriae is commonly isolated from cutaneous skin lesions in the Northern Territory of Australia. We prospectively assessed 32 recent isolates from infected skin lesions, in addition to reviewing 192 isolates collected over 5 years for toxin status. No isolates carried the toxin gene. Toxigenic C. diphtheriae is now a rare occurrence in the Northern Territory.

Rapid detection of the H275Y oseltamivir resistance mutation in influenza A/H1N1 2009 by single base pair RT-PCR and high-resolution melting.

INTRODUCTION: We aimed to design a real-time reverse-transcriptase-PCR (rRT-PCR), high-resolution melting (HRM) assay to detect the H275Y mutation that confers oseltamivir resistance in influenza A/H1N1 2009 viruses. FINDINGS: A novel strategy of amplifying a single base pair, the relevant SNP at position 823 of the neuraminidase gene, was chosen to maintain specificity of the assay. Wildtype and mutant virus were differentiated when using known reference samples of cell-cultured virus. However, when dilutions of these reference samples were assayed, amplification of non-specific primer-dimer was evident and affected the overall melting temperature (T(m)) of the amplified products. Due to primer-dimer appearance at >30 cycles we found that if the cycle threshold (C(T)) for a dilution was >30, the HRM assay did not consistently discriminate mutant from wildtype. Where the C(T) was <30 we noted an inverse relationship between C(T) and T(m) and fitted quadratic curves allowed the discrimination of wildtype, mutant and 30∶70 mutant∶wildtype virus mixtures. We compared the C(T) values for a TaqMan H1N1 09 detection assay with those for the HRM assay using 59 clinical samples and demonstrated that samples with a TaqMan detection assay C(T)>32.98 would have an H275Y assay C(T)>30. Analysis of the TaqMan C(T) values for 609 consecutive clinical samples predicted that 207 (34%) of the samples would result in an HRM assay C(T)>30 and therefore not be amenable to the HRM assay. CONCLUSIONS: The use of single base pair PCR and HRM can be useful for specifically interrogating SNPs. When applied to H1N1 09, the constraints this placed on primer design resulted in amplification of primer-dimer products. The impact primer-dimer had on HRM curves was adjusted for by plotting T(m) against C(T). Although less sensitive than TaqMan assays, the HRM assay can rapidly, and at low cost, screen samples with moderate viral concentrations.

Chronic care improvement in primary care: evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.

OBJECTIVE: To examine the effects of an intervention comprising (1) a practice-based care coordination program, (2) augmented by pay for performance (P4P) for meeting quality targets, and (3) complemented by a third-party disease management on quality of care and resource use for older adults with diabetes. DATA SOURCES/STUDY SETTING: Claims files of a managed care organization (MCO) for 20,943 adults aged 65 and older with diabetes receiving care in Alabama, Tennessee, or Texas, from January 2004 to March 2007. STUDY DESIGN: A quasi-experimental, longitudinal study in which pre- and postdata from 1,587 patients in nine intervention primary care practices were evaluated against 19,356 patients in MCO comparison practices (>900). Five incentivized quality measures, two nonincentivized measures, and two resource-use measures were investigated. We examined trends and changes in trends from baseline to follow-up, contrasting intervention and comparison group member results. PRINCIPAL FINDINGS: Quality of care generally improved for both groups during the study period. Only slight differences were seen between the intervention and comparison group trends and changes in trends over time. CONCLUSIONS: This study did not generate evidence supporting a beneficial effect of an on-site care coordination intervention augmented by P4P and complemented by third-party disease management on diabetes quality or resource use.

Examining the effectiveness of hydroxyurea in people with sickle cell disease.

This study investigated hydroxyurea use in people with sickle cell disease (SCD) outside of a research setting. Pharmacy data, outpatient visits, hospital admissions, and length of stay were assessed for all patients with SCD enrolled in a Medicaid managed care organization in Maryland. Three hundred and ninety (390) people with SCD were covered between the years 2001-2005. A large majority (85.9%) never had a claim for a hydroxyurea refill. Hydroxyurea users had higher admission rates than non-hydroxyurea users (5 vs. 1.5, p=.004). Patients who were in the highest tertile of refills of hydroxyurea had significantly fewer hospital admissions than patients in the lowest tertile (2.44 vs. 7.57, p=.043). Patients with the lowest hydroxyurea refill usage had significantly higher mean costs per month enrolled than those with the highest number ($4,553 vs. $2,017, p=.031). Hydroxyurea was underutilized in this patient population. Patients with more regular refills of hydroxyurea had fewer admissions to the hospital and markedly decreased costs.

The course and correlates of high hospital utilization in sickle cell disease: Evidence from a large, urban Medicaid managed care organization.

Although most patients with sickle cell disease (SCD) are hospitalized infrequently and manage painful crises at home, a small subpopulation is frequently admitted to emergency departments and inpatient units. This small group accounts for the majority of health care expenses for patients with SCD. Using inpatient claims data from a large, urban Medicaid MCO for 5 consecutive years, this study sought to describe the course of high inpatient utilization (averaging four or more admissions enrolled per year for at least 1 year) in members with a diagnosis of SCD and a history of hospitalizations for vaso-occlusive crisis. High utilizers were compared with the other members with SCD on demographics, medical and psychiatric comorbidity, and use of other health care resources. Members who were high utilizers had more diagnostic mentions of sickle cell complications than low utilizers. However, the pattern of high inpatient utilization was likely to moderate over successive years, and return to the pattern after moderation was uncommon. Despite this, a small subpopulation engaged in exceptional levels of inpatient utilization over multiple years.

Autoantigens identified by screening a human heart cDNA library with acute rheumatic fever sera.

Acute rheumatic fever (ARF) is an autoimmune sequela of group A streptococcal infection mostly affecting school-aged children. Recurrent episodes of ARF can result in the development of rheumatic heart disease (RHD). One in 40 indigenous Australians in the Northern Territory is affected by RHD. This disease mostly impacts young people; 45% of those who require heart valve surgery in Australia due to RHD are younger than 25 years old. ARF is characterized by autoimmune attack of the heart; therefore, the presence of the autoantibodies involved could potentially be used to diagnose ARF. To this end, a human heart cDNA library was screened with serum from a patient with ARF, and 12 autoreactive human heart antigens were identified. They include five different IgG heavy chains and a range of tissue-specific cell-signaling proteins, species of which have been implicated in other autoimmune diseases. Preliminary ELISA results show that ARF patients have significantly higher levels of antibodies recognizing the cardiac autoantigens than controls. These antigens are promising candidates for the development of a serological assay for the diagnosis of ARF. The nature of the proteins identified has exciting implications for future research into the pathogenesis of ARF.

Chitosan microspheres for encapsulation of alpha-lipoic acid.

Encapsulation of alpha-lipoic acid (LA) was carried out using chitosan as an encapsulant matrix. Placebo and LA-loaded chitosan microspheres were prepared by a spray-drying process. Scanning electron microscopy (SEM) studies confirmed the spherical particle geometry and the smooth surface morphology of LA-loaded particles. The particle size distribution (PSD) analysis of the placebo and LA-loaded microspheres has shown that 50% of the microspheres were less than 3.53 and 7.89 microm, respectively. The structural interactions of the chitosan matrix with the encapsulated LA were studied by Fourier transform infrared spectroscopy (FTIR) and differential scanning calorimetry (DSC) which revealed structural interactions of lipoic acid with the encapsulant matrix. The antioxidant activity of encapsulated lipoic acid was studied using the free-radical scavenging assay. This study demonstrated significant retention of antioxidant activity of lipoic acid (75%) after encapsulation in the chitosan matrix. Encapsulation efficiency of lipoic acid obtained in this study was 55.2% when ethanol and acetic acid (1:1 v/v) was used as incubation/extraction medium.