Pent-up demand for care among dual-eligible victims of elder financial exploitation in Maine

Elder financial exploitation (EFE), the misuse of a vulnerable adult's property or resources for personal gain, is a form of elder abuse. This study addresses whether dual-eligible EFE victims were experiencing pent-up demand for health services alleviated through investigation by Adult Protective Services (APS). A quasi-experimental design addressed health service utilization and costs for 131 dual-eligible Maine APS clients over age 60 with substantiated allegations of EFE relative to comparable non-APS controls. APS case files spanning 2007-2012 were linked to 2006-2014 Medicare and Medicaid claims data. Service utilization and costs were analyzed 1 year prior, during, and 2 years after the initial APS investigation. Difference in differences logistic regression and generalized linear models addressed the likelihood of incurring costs and expenditure levels relative to matched controls, respectively. Victims of EFE had higher overall odds of using inpatient and long-term services and supports (LTSS) and higher odds of using LTSS post-investigation than controls. Higher overall levels of outpatient and prescriptions expenditures and higher inpatient expenditures during the APS event year contributed toward APS clients incurring $1,142 higher PMPM total costs than controls. Victims of EFE were experiencing significant pent-up demand for health services post-APS involvement.

Characterising radium-226 particles from legacy contamination to support radiation dose assessments

Radioactive particles are physically discrete sources of radioactivity that have been released into the environment as a result of past emergencies, events and practices. As the release of radioactive particles is often unplanned, the source term has not been characterised, and the potential radiation doses have not been prospectively assessed. If a plausible exposure pathway exists, radioactive particles in the environment may present a hazard to the public depending on their radiological, physical and chemical characteristics. Given their physically discrete nature, standard assessment approaches such as dispersion and transfer modelling of liquid and gaseous radioactive releases, are not appropriate for radioactive particles. The challenge for national regulatory authorities is to calculate potential radiation doses from unplanned releases of radioactive particles into the environment, assess whether the doses are relevant to radiological protection and decide whether actions are required to reduce potential doses. To address this challenge, this paper presents the approach being adopted to radiologically, physically and chemically characterise Ra-226 particles from a contaminated legacy site using gamma spectrometry, optical macroscopy and SEM-EDS. The use of particle characterisation data to support radiation dose assessments is discussed and consideration is given to radioactive particles in the context of radiological protection.

Validity of the activPAL3 activity monitor in people moderately affected by Multiple Sclerosis

Walking is the primary form of physical activity performed by people with Multiple Sclerosis (MS), therefore it is important to ensure the validity of tools employed to measure walking activity. The aim of this study was to assess the criterion validity of the activPAL3 activity monitor during overground walking in people with MS. Validity of the activPAL3 accelerometer was compared to video observation in 20 people moderately affected by MS. Participants walked 20-30m twice along a straight quiet corridor at a comfortable speed. Inter-rater reliability of video observations was excellent (all intraclass correlations >0.99). The mean difference (activPAL3- mean of raters) was -4.70±9.09, -4.55s±10.76 and 1.11s±1.11 for steps taken, walking duration and upright duration respectively. These differences represented 8.7%, 10.0% and 1.8% of the mean for each measure respectively. The activPAL3 tended to underestimate steps taken and walking duration in those who walked at cadences of ≤38 steps/min by 60% and 47%, respectively. The activPAL3 is valid for measuring walking activity in people moderately affected by MS. It is accurate for upright duration regardless of cadence. In participants with slow walking cadences, outcomes of steps taken and walking duration should be interpreted with caution.

Facilitators and barriers to the increased supervisory role of senior charge nurses: a qualitative study

AIMS

To explore the experiences of senior charge nurses provided with 'increased supervisory hours'.

BACKGROUND

Designated supervisory time is essential for senior charge nurses to provide effective clinical leadership. It is important to explore the impact arises of such an increase.

METHODS

An online questionnaire collected exploratory data from senior charge nurses (n = 60). Semi-structured interviews gathered in-depth qualitative data (n = 12). Findings were analysed for common themes associated with implementation of the increased senior charge nurse supervisory role.

RESULTS

The majority of senior charge nurses were unable to use their full allocation of supervisory time. They struggled to accomplish leadership goals because of managing staffing levels, increased workload, time constraints and limited support. Factors that facilitated the role included preparation and support, adequate staff capacity, effective leadership skills and availability of supervisory time. The senior charge nurses took pride in providing clinical leadership, promoting staff development and delivering patient care. Support, in terms of preparation, capacity building and ongoing mentoring, was a key factor for achieving senior charge nurse goals.

CONCLUSION

Senior charge nurses should be supported to maximise supervisory time through the provision of an induction programme, formal coaching and ongoing training and development.

IMPLICATIONS FOR NURSING MANAGEMENT

Preparation and support is essential for senior charge nurses to deliver enhanced clinical leadership through increased supervisory time.

The radium legacy: Contaminated land and the committed effective dose from the ingestion of radium contaminated materials

The manufacture and use of radium in the early to mid-20th century within industrial, medicinal and recreational products have resulted in a large number of contaminated sites across a number of countries with notable examples in the USA and Europe. These sites, represent a significant number of unregulated sources of potential radiological exposure that have collectively and hitherto not been well characterised. In 2007, the Radioactive Contaminated Land (RCL) Regulations came into force in the UK, providing the statutory guidance for regulators to classify and deal with RCL. Here we report on results derived from digestion experiments to estimate committed effective dose, a key aspect of the RCL Regulations, from the ingestion of radium contaminated sources that can be found in the environment. This case study includes particles, clinker and artefacts that arise from past military activities on a site that was once an airfield at Dalgety Bay on the Firth of Forth, UK. Since 2011 the number of radium contaminated finds has increased by one order of magnitude on the foreshore areas of Dalgety Bay. The increase in finds may in large part be attributed to a change in monitoring practice. A subsample of sixty sources was selected, on the basis of their activity and dimensions, and subjected to digestion in simulated stomach and lower intestine solutions. The study demonstrated that more radium-226 ((226)Ra) and lead-210 ((210)Pb; driven by Polonium solubility) are dissolved from sources in artificial 'stomach' solutions compared with 'lower intestine' solutions. The combined 'gut' solubility for (226)Ra and apparent (210)Pb varied from less than 1% to up to 35% ICRP 72 conversion factors were used to convert the activities measured in solution to committed effective dose. A little over 10% of the sources tested dissolved sufficient radioactivity to result in 100mSv committed effective dose to an infant. Using the solubility of 35% as a worst case, minimum source activities necessary to deliver 100mSv to the full age range of users of the foreshore were estimated. All the estimated activities have been detected and recovered through routine monitoring.

Incentives and barriers to research participation and brain donation among African Americans

Successful African American recruitment for aging research requires sensitivity to factors that influence participation. In this work, a structured face-to-face educational interview was used to recruit African Americans for a longitudinal aging study and to collect information about attitudes related to research. The interview was designed to build trust and respect for research and to educate participants about the need for minority participants. Of the 91 African Americans aged 65 and older who completed interviews, 65 (71%) agreed to participate in the longitudinal study and approximately half agreed to brain donation. Those who enrolled and consented to brain donation were more likely to consider benefit to themselves or direct family unit as the main motivator for participation (P < .01). The study also found a significant increase in agreement to brain donation across enrollment periods (P = .0005).

African American participation in Alzheimer's disease research that includes brain donation

Historically, minority groups have been underrepresented in research and clinical trials. The lack of participation by minorities has been attributed to a variety of factors including a mistrust of the predominately white research establishments and a lack of education about the purpose of research. The current study was designed to determine African American interest in Alzheimer's disease (AD) research and to recruit African Americans as normal controls in current AD studies with the goal of eventually gaining consent for brain donation upon death. Participants were 46 African Americans aged 65 or older, who were interviewed about the knowledge of medical procedures and experience with research. After initial recruitment interviews, 31.7% of participants agreed to yearly testing with eventual brain donation. Study findings suggest a moderate relationship between participants' knowledge of medical procedures used to prolong life and willingness to donate one's brain.

Outcomes of the peer-taught 12-week family-to-family education program for severe mental illness

OBJECTIVE

Family-to-Family Education Program (FFEP) is a 12-week course for family members of adults with serious mental illness (SMI). This study evaluates the effectiveness of FFEP for several family member outcomes.

METHOD

The FFEP enrollees on a > or =3-month waiting list were eligible; 95 consenting family members agreed to four interviews (waitlist, pre-FFEP, post-FFEP, and 6 months post-FFEP) regarding subjective and objective burden, empowerment, and depression. Mixed effects ANOVA models tested hypotheses of decreased burden and increased empowerment after FFEP.

RESULTS

The FFEP was associated with reduced subjective burden (P < 0.01) and increased empowerment (P < 0.01) without changes in objective burden. Knowledge about SMI, understanding the mental health system, and self-care also improved. There was no significant decay at 6-month followup.

CONCLUSION

This study provides evidence that FFEP is helpful to relatives of persons with SMI by reducing subjective burden and worry, and increasing empowerment, knowledge about SMI, understanding the mental health system, and self-care.

A comparative study of neurogenesis in the retinal ciliary marginal zone of homeothermic vertebrates

The retina of many fish and amphibians grows throughout life, roughly matching the overall growth of the animal. The new retinal cells are continually added at the anterior margin of the retina, in a circumferential zone of cells, known as the ciliary marginal zone, or CMZ. Recently, Fischer and Reh [Dev. Biol. 220 (2000) 197] have found that new neurons are added to the retina of the chicken via proliferation and subsequent differentiation of neurons and glia at the retinal margin in a zone highly reminiscent of the CMZ of lower vertebrates. In addition, other groups have reported that putative retinal stem cells could be isolated from the ciliary margin of the adult mouse. In light of these findings, we have re-investigated the eyes of three additional species to determine whether other homeothermic vertebrates also possess CMZ cells and whether we could detect evidence for addition of neurons at the retinal margin in mature animals. We examined one additional avian species, the quail, one marsupial, the opposum, and one mammal, the mouse. We find that the CMZ cells have been gradually diminished during vertebrate evolution. The quail has a reduced CMZ as compared to the chicken, while the opposum has only a few cells likely related to the CMZ and we failed to find evidence of CMZ cells at the margin of the mouse retina.

Mouse histamine N-methyltransferase: cDNA cloning, expression, gene cloning and chromosomal localization

OBJECTIVE

Histamine N-methyltransferase (HNMT) catalyzes the Ntau-methylation of histamine. We set out to clone a mouse liver HNMT cDNA and the mouse HNMT gene as steps toward characterizing molecular genetic mechanisms involved in the regulation of this important histamine-metabolizing enzyme.

DESIGN

A PCR-based strategy was used to clone both the mouse HNMT cDNA and the gene encoding that cDNA, Hnmt. The cDNA was used both to express recombinant mouse HNMT and to determine the chromosomal localization of Hnmt.

RESULTS

The mouse liver HNMT cDNA was 1657 bp in length with an 888 bp open reading frame (ORF) that encoded a 296 amino acid protein with a predicted Mr value of approximately 32.5 kDa. The amino acid sequence of the encoded protein was 84% identical to that of human kidney HNMT. Mouse HNMT was expressed in COS-1 cells, and its apparent Km values for histamine and S-adenosyl-L-methionine (Ado-Met), the two cosubstrates for the reaction, were 5.3 and 5.8 microM, respectively. The mouse HNMT gene, Hnmt, spanned approximately 25 kb and had 7 exons. Its structure differed from that of the human gene primarily by the presence of an additional exon at the 5'-terminus. Hnmt mapped to mouse chromosome 2 in an area of conserved synteny to human chromosome 2q, the location of the human gene (2q22) on the basis of fluorescence in situ hybridization.

CONCLUSIONS

Cloning and functional characterization of the mouse HNMT cDNA and gene will now make it possible to study in the mouse molecular genetic mechanisms involved the regulation of this important histamine-metabolizing enzyme.

Recruitment strategies in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: the first six years

The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial has a total enrollment goal of almost 150,000 participants. These participants are being recruited at ten screening centers across the United States. All screening centers tested recruitment methodologies during a 1-year pilot phase. The main phase of recruitment was planned to take place over a 3-year period. The majority of participants are being recruited during the main phase of the study. Each of the screening centers tailors recruitment to its individual catchment area. Recruitment strategies in the PLCO trial are described. As the trial began, several protocol changes were made to help to increase enrollment. The National Cancer Institute (NCI) initiated recruitment efforts at the national level. The individual screening centers describe some of the specific recruitment experiences encountered. As the study progressed, the NCI implemented special initiatives to increase the enrollment of minority participants.

Convergent and discriminant validity of the CVLT (dementia version). California Verbal Learning Test

This study investigated the convergent and discriminant validity of the 9-item "dementia version'' of the California Verbal Learning Test (CVLT-9) in a sample of 130 geriatric patients evaluated for memory complaints. Moderate correlations were observed between the CVLT-9 sum of words recalled for trials 1-5 (Trial 1-5 Recall) and Long-Delay Free Recall (LDFR) measures and the immediate and delayed Logical Memory (LM I and LM II) and Visual Reproduction (VR I and VR II) subtests from the Wechsler Memory Scale-Revised (WMS-R). However, the CVLT-9 Trial 1-5 Recall and VR I measures demonstrated significant correlations with a number of additional measures of language and visuospatial ability. The CVLT-9 LDFR, and the WMS-R LM I, LM II, and VR II showed less overlap with non-episodic memory functioning. A principal components analysis yielded a three-component solution consisting of a general or "g'' component, a specific memory component, and a mood component. The CVLT-9 Trial 1-5 Recall and VR I loaded on both the "g'' and the memory components, whereas LM I, LM II, and VR II loaded on only the memory component. We conclude that the CVLT-9 Trial 1-5 Recall and VR I demonstrate low discriminant validity, suggesting diminished specificity as memory measures.

State-sponsored programs for the uninsured: is there adverse selection?

Risk contracting by states for coverage of previously uninsured populations has been hampered by uncertainty regarding likely claims experience. This study reports on the utilization experience of two state programs offering subsidized coverage in commercial managed care organizations to low-income and previously uninsured people. Program participants used services similarly to people enrolled through large employer benefit plans. There was no evidence of pent-up demand or an unusual level of chronic illness. Similarly, there was little evidence of underutilization, although dissatisfaction and reported barriers to service were more frequent among nonwhite enrollees.

A CNS integrated health care delivery system model

The more complicated a client's health needs are, the higher the risk for inappropriate utilization of services, fragmentation of care and delays in system access. The challenge is to ensure that patients move appropriately from one access point to another in the most efficient, effective manner. The Integrated Health Care Delivery System is designed to meet this challenge.

Evaluation of a mass media campaign on smoking and pregnancy

Two surveys were conducted among pregnant women throughout England, before (n = 625) and after (n = 607) a mass media campaign on smoking and pregnancy targeted at women aged 15-24 years, in the social grade C2DE. The majority of the post-campaign sample recalled having seen at least one of the campaign's series of press advertisements. There was a significant increase among this sample in those considering smoking to be very dangerous to the unborn child, in those understanding the term passive smoking and in those considering passive smoking to be very dangerous. During the campaign there was a 14% increase in the number of calls to a cessation helpline from pregnant women. Over the campaign there were no significant changes in smoking prevalence and consumption among pregnant women or partners or in the numbers of partners offering suggestions to pregnant women about their smoking behaviour.

Health at work in the NHS feature

Almost 20 million people are in paid employment in England today, spending up to 60 per cent of their waking hours in their places of work, many for 40 years or more. Workplaces are, therefore, a major influence on health and provide an invaluable setting for health promotion.

Effect of prospective reimbursement on nursing home costs

OBJECTIVE

This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients.

DATA SOURCES/STUDY SETTING

The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system.

STUDY DESIGN

This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs.

PRINCIPAL FINDINGS

Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients.

CONCLUSIONS

Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

HIB. Assessing information needs

Planning the launch of the new Haemophilus influenzae b vaccine in October of this year has challenged health educators involved with child immunisation, writes Christine McGuire of the Health Education Authority (HEA). Here she outlines the findings from initial research commissioned to explore parental and professional information needs.

Evaluation of a PACS workstation for assessment of body CT studies

Conventional hardcopy images from 266 body CT studies were compared with those provided at a commercially available picture archiving communication system (PACS) workstation. Unprocessed PACS images were larger but otherwise precisely duplicated hardcopy images. The PACS images were evaluated before and after application of various image processing/display features. Approximately three-quarters of the cases were depicted equally well with PACS and hardcopy, but in one quarter of the cases, diagnostic features were judged to be shown more clearly at the PACS workstation. When PACS images were viewed first, change in diagnosis after subsequent hardcopy inspection was infrequent (confidence change: 4%; different findings: 2%). Conversely, when hardcopy images were viewed first, change in diagnosis after subsequent PACS inspection was more frequent (confidence change: 19%; different findings: 8%). Specialized image manipulation available on PACS was critical for its performance. Review of cases with new findings discovered during the second inspection showed the majority of them to be clinically significant, true-positives discovered by PACS. We conclude that PACS is a useful modality for interpretation of body CT images.

Plesiomonas shigelloides septic arthritis complicating rheumatoid arthritis

A patient with severe seropositive rheumatoid arthritis and hepatic cirrhosis developed septic arthritis of his knees. Plesiomonas shigelloides was isolated from joint fluid, blood, and also from the gut. The patient's joint symptoms responded to treatment with oral trimethoprim-sulphamethoxazole, but he died of uncontrolled gastrointestinal bleeding five days later.

Clinical reading and writing skills of junior medical students

A three-year study was designed to assess general reading and writing skills of 231 entering medical students and to compare these scores with those of clinically oriented reading and writing skills in the same cohort of students three years later. Standardized reading and writing tests were administered to all entering freshmen in the class of 1982. Clinical reading and writing examinations were developed by the authors and members of the faculty. The reading test consisted of 16 multiple-choice questions in response to three short discussions in medical journals. Clinical writing was assessed through scoring each student's latter of referral to another physician after he read a "mock" chart of a patient's hospital care. The results showed that entry-level reading comprehension and clinical reading had a significant association as did entry-level English composition and clinical writing. Regression analysis showed that the entry-level reading and writing scores were better predictors of clinical reading and writing skills than any other prematriculation variables. The implications of these findings for medical education are discussed.

A Discrimination Model For Multivariate Q Representations

The proposed discrimination model for Q representation is a generalization of the method of unfolding in an algebraic rather than a geometric field. Placements of Q statements relative to one another in joint space so as to form a quasi-normal distribution of the q stimulus items are assigned Q values which form a bounded set of symbols with specified order in arithmetic progression; for example, a finite set from "one" to "nine" wherein "five" is the midpoint of an ordered metric within persons. An algebraic theory of numbers permits mathematical operations to be carried out with sets of sets of such symbols. Using illustrative data, a mathematical model is developed for the analysis of Q values, each of which represents the intersect of two or more dimensions of behavior structured into a Q set, and for testing its stability, consistency, and reliability. The Q check procedures permit comparisons among individuals and subsamples of population samples.