Optimization of scanning transmission X-ray microscopy for the identification and quantitation of reinforcing particles in polyurethanes.

The morphology, size distributions, spatial distributions, and quantitative chemical compositions of co-polymer polyol-reinforcing particles in a polyurethane have been investigated with scanning transmission X-ray microscopy (STXM). A detailed discussion of microscope operating procedures is presented and ways to avoid potential artifacts are discussed. Images at selected photon energies in the C 1s, N 1s and O 1s regions allow unambiguous identification of styrene-acrylonitrile-based (SAN) copolymer and polyisocyanate polyaddition product-based (PIPA) reinforcing particles down to particle sizes at the limit of the spatial resolution (50 nm). Quantitative analysis of the chemical composition of individual reinforcing particles is achieved by fitting C 1s spectra to linear combinations of reference spectra. Regression analyses of sequences of images recorded through the chemically sensitive ranges of the C 1s, N 1s and O 1s spectra are used to generate quantitative compositional maps, which provide a fast and effective means of investigating compositional distributions over a large number of reinforcing particles. The size distribution of all particles determined by STXM is shown to be similar to that determined by TEM. The size distributions of each type of reinforcing particle, which differ considerably, were obtained by analysis of STXM images at chemically selective energies.

A model for improving coverage policy decisions.

Reasoned and defensible coverage decisions are essential for a fairer and more efficient healthcare system. Because healthcare resources are finite, coverage decisions should be informed by economic evaluations and made from a perspective that attends to the interests of both individuals and the population enrolled in a plan as a whole. Coverage decisions for all healthcare interventions should follow a 2-step procedure that consists of (1) the relatively impartial and objective assessment of an intervention's eligibility for coverage and (2) the distinctively value-laden determination (for which the enrolled population's values and preferences should take priority) to cover, conditionally cover, or not cover an intervention.

The human B cell response to IL-13 is dependent on cellular phenotype as well as mode of activation.

Normal mature quiescent human B lymphocytes, isolated as a function of buoyant density, require activation for up-regulation of IL-13R constituents. Cell activation through a combination of surface Ig and CD40 receptor ligation leads to the most substantial message production for IL-13Ralpha1. Functional consequences of this receptor variation, in initially quiescent cells, includes demonstrable effects on cellular proliferation in response to ligand exposure. Variations in the method of surface activation, with particular emphasis on the CD40 receptor, reveals that immobilized CD40 ligand may be sufficient, in and of itself, to up-regulate IL-13Ralpha1, which may bear significance for B-lymphocyte bystander proliferation. Regulation of the IL-13Ralpha1 protein and message also differs as a function of cellular phenotype. Although values are greater in memory than naive B cells, as they are initially isolated from extirpated tonsils, variations in the magnitude of message and protein, as a function of surface stimulation, are more substantial in the naive subset. The magnitude of variation in message production in naive cells is associated with a more vigorous proliferative response to IL-13 than seen in memory lymphocytes. The cellular response to IL-13, as a function of activation and phenotype, is the converse of that demonstrated for IL-2. Evaluation of proliferation, receptor message, ligand binding protein production, and the response to putatively synergistic cytokines reveals that IL-2 is the predominant lymphokine utilized by memory cells. This is in contradistinction to IL-13, which along with IL-4, are the predominant moieties for naive lymphocytes.

Value-based formulas for purchasing. Does managed care offer value to society?

To assess whether managed care is, all things considered, a good investment for our society, we can measure its performance relative to five essential health care goals: promote efficiency; expand access; improve quality; preserve freedom of choice; and protect patient advocacy. These goals, which have shaped and continue to shape health care policy, define what is important to us in our health care system. Concerns about managed care's ability to advance these goals and thus to offer value are heightened if recently observed trends continue.

Forecasting physician workforce requirements in Minnesota.

The existing oversupply, specialty imbalance, and geographic maldistribution of clinicians are inconsistent with the goals of health system reform in Minnesota. Health professional workforce projections can help the private and public sectors make informed decisions to assure that the future supply of health professionals reasonably approximates requirements. Appropriate methodologies for projecting national health professional requirements, based on existing HMO staffing patterns, should be applied to Minnesota. In the absence of workforce projections, a variety of assumptions about changes in Minnesota's health care system that will affect workforce supply and requirements can, nonetheless, be made. Limitations on the state's ability to influence the health professional workforce within its borders are noted.

Electronic signature thrives in different environments.

Implementing electronic signature has been a positive experience for both our organizations. The benefits we sought were there, and unforeseen benefits surfaced. Five activities that facilitated the success of electronic signature at our two facilities were (1) flowcharting the electronic signature process prior to purchase and installation; (2) becoming familiar with legal requirements for electronic signature, and assuring that products under consideration meet these requirements; (3) gaining the support of medical staff leadership; (4) using a written agreement of password confidentiality and document responsibility with physicians; and (5) thoroughly training medical records staff, then establishing a positive one-on-one training procedure for physicians with a high degree of staff attention.

For better or worse? The moral and policy lessons of Minnesota's HealthRight legislation.

Minnesota's recently enacted HealthRight legislation places the state at the forefront of American health reform. How did the state manage to overcome the policy gridlock in evidence in other states and at the national level? And how well does the legislation fare under close ethical scrutiny? Among the most important factors that permitted Minnesota to enact reforms were the explicit linkage in the legislative debate of the goal of cost containment to the desire to expand access, the public perception that HealthRight is incremental and consistent with earlier reform efforts in Minnesota, and the lengthy public debate that preceded the enactment of HealthRight. Although it endeavors to create a fair and efficient health care system, it is not at all certain that HealthRight, in its present form, will achieve these normative goals.

Are financial incentives for wellness fair?

Employers have shown considerable enthusiasm for programs that use financial incentives to stimulate health-related changes in employee behavior and lifestyle. This article raises fairness issues in relation to these programs.

Universal basic benefits preempt mandated benefits.

Many states seek to expand health care access to uninsured people. As part of their efforts, states must define a basic level of health services to which all residents would have access. Presumably, this level of services would be leaner than that now covered by most health care policies. As it is, private insurers are already mandated by all states to include certain benefits, which differ widely from state to state. However, simple fairness argues that once a state defines a basic level of health services, that level should function as a floor for everyone and replace the previously mandated benefits (which, nonetheless, may be a useful guide in defining a basic level of health services).

The challenges to physician autonomy and advocacy.

The rapid changes occurring in the organization, delivery and financing of health care has come at the expense of the medical profession. Control of the health care system now appears to have shifted from providers to purchasers and payers.