From research to realization: How a Texas health plan implemented an academic model of care for Alzheimer's disease

MIND at Home is a comprehensive, home-based care coordination intervention for people with Alzheimer's disease or related dementias (A/D) who live in the community and for their family caregivers. Developed by researchers at Johns Hopkins University (JHU), the model has been shown to extend the time a person with A/D remains at home for almost two years, as well as improved quality of life and quality of care and reduced caregiver burden. The MIND at Home pilot at Superior HealthPlan is a collaboration between Centene Corporation, JHU, and Superior HealthPlan (Superior). The goal of the MIND at Home pilot is to adapt, implement, and evaluate the impact of MIND at Home within Superior's Medicaid population. The pilot is structured as an interventional study of the MIND at Home program versus a propensity score-matched (PSM) comparison group receiving standard-of-care. The duration of the pilot is approximately 12 months, with longitudinal follow-up at 18 and 24 months. The pilot population includes Superior HealthPlan Medicaid members (receiving Long-Term Services & Supports) who are community-residing and have a confirmed diagnosis of A/D. The study has enrolled approximately 300 participants who have received the intervention. An analysis of claims data for participants receiving the MIND at Home intervention indicates the program increased primary care utilization (+10.0%) while reducing emergency department (ED) utilization (-15.8%), polypharmacy (-5.0%), and total spend (-1.35%). Consumer survey results indicate high levels of satisfaction among both pilot participants and their family caregivers and case studies anecdotally illustrate the significant impacts the MIND at Home program has had on participant and caregiver quality of life. Preliminary outcomes of the pilot indicate the MIND at Home program reduces high cost healthcare utilization - particularly ED and polypharmacy - and overall participant costs. Additional outcomes illustrate participants are highly satisfied with the MIND at Home program and have experienced dramatic increases in quality of life. This pilot showcases the value of operationalizing this evidence-based academic care model for A/D in a Medicaid population and that collaboration across academic research, industry, and government-sponsored healthcare programs can result in improved outcomes for individuals with A/D.

Virtual Interdisciplinary Collaboration in Statewide Implementation of the MIND at Home Dementia Care Program

MIND at Home, a well-researched holistic, family-centered dementia care coordination program, provides collaborative support to community-dwelling persons living with dementia (PLWD) and their informal care partners (CP). Through comprehensive home-based assessment of 13 memory-care domains covering PLWD and CPs, individualized care plans are created, implemented, monitored, and revised over the course of the illness. Non-clinical Memory Care Coordinators (MCCs) working with an interdisciplinary team provide education and coaching to PLWD and their identified CP, and serve as a critical liaison and resource and between families, medical professional, and formal and informal community resources. This paper will describe a statewide pilot implementation of the program within a health plan across diverse sites in Texas and will present qualitative and quantitative descriptions of a key component of the program's effective translation to practice, the virtual collaborative case-based learning sessions. Health plan teams completed online interactive training modules and an intensive in-person case-based training with the Johns Hopkins team prior to program launch, and then engaged in weekly, hour-long virtual collaborative sessions that included health plan teams (site-based field teams, health plan clinical supervisory and specialty personnel [RNs, pharmacists, a geriatric psychiatrist, behavioral health specialists] and Johns Hopkins MIND program experts and geriatric psychiatrists. To date, the program has enrolled 350 health plan members, conducted 65 virtual collaborative sessions, and provided 423 CME/CEU units to team members. We will provide an overview of virtual collaborative session structure, participant contributions and discussion topics, case complexity, as well as didactic learning topics covered.

Embedding integrated mental health assessment and management in general hospital settings: feasibility, acceptability and the prevalence of common mental disorder

OBJECTIVE

To assess the feasibility and acceptability of routine web-based screening in general hospital settings, and describe the level of common mental disorder.

METHOD

A service development platform to integrate mental and physical healthcare was implemented in six specialties (rheumatology, limb reconstruction, hepatitis C, psoriasis, adult congenital heart disease (ACHD), chronic pain) across three general hospitals in London, UK. Under service conditions, patients completed a web-based questionnaire comprising mental and physical patient-reported outcome measures, whilst waiting for their appointment. Feasibility was quantified as the proportion of patients who completed the questionnaire. Acceptability was quantified as the proportion of patients declining screening, and the proportion requiring assistance completing the questionnaire. The prevalence of probable depression and anxiety was expressed as the percentage of cases determined by the Patient Health Questionnaire-9 and Generalised Anxiety Disorder Questionnaire-7.

RESULTS

The proportion of patients screened varied widely across specialties (40.1-98.2%). The decline rate was low (0.6-9.7%) and the minority required assistance (11.7-40.4%). The prevalence of probable depression ranged from 60.9% in chronic pain to 6.6% in ACHD. The prevalence of probable anxiety ranged from 25.1% in rheumatology to 11.4% in ACHD.

CONCLUSION

Web-based screening is acceptable to patients and can be effectively embedded in routine practice. General hospital patients are at increased risk of common mental disorder, and routine screening may help identify need, inform care and monitor outcomes.

Comparison of partial sequence of the cap binding protein (eIF4E) isolated from Agaricus bisporus and its pathogen Verticillium fungicola

The 3' regions of the gene encoding the cap binding protein eIF4E were successfully isolated from Agaricus bisporus and Verticillium fungicola using a degenerate primer within the eIF4E gene and an anchored oligo d(T) primer. The deduced amino acid sequences contained 173 residues for A. bisporus and 171 residues V. fungicola. Analysis of these sequences shows that despite conserved regions of homology, centering around tryptophan residues, A. bisporus and V. fungicola are very diverse at the amino acid and DNA level. Percentage homology between the two fungi is low at the nucleotide, 35%, and amino acid level, 29%. The highest degree of similarity between the A. bisporus sequence and other published sequences is with the Homo sapiens eIF4E sequence (32%). V. fungicola exhibited highest homology with the eIF4E sequence from Caenorhabditis elegans (34%). Southern analysis of genomic DNA indicated a single copy of the gene within the A. bisporus genome.

Does the menopause influence the risk of bacteriuria?

The objective of this study was to test the hypothesis that the risk of bacteriuria is increased as a result of estrogen deprivation following the menopause. All midstream urine samples (MSU) sent to the King's College Hospital department of microbiology by general practitioners in 1997 were assessed. Bacteriuria was diagnosed when the bacterial count was >10(5) organisms/ml. Logistic regression analysis was performed to investigate the effects of age and sex on the likelihood of having a positive result. Non-linear effects of age were investigated, with interest focusing in particlar on the time around the menopause. There were 15,392 MSU samples analyzed; 11,811 (77%) were from women and 3581 (23%) from men. In both sexes the proportion of positive results increased with increasing age (P<0.0001). The specimens taken from women were significantly more likely to be positive than those taken from a man of the same age (P<0.0001). In women there was no evidence of any non-linear relationship between age and the log odds of a positive result. A plot of the proportion of positive results versus age did not suggest any departure from a linear relationship at or following the menopause. In conclusion, the increased risk of bacteriuria which occurs as women get older appears to happen gradually as a result of the aging process, rather than as the result of pathophysiological changes in the urogenital tract that take place at or following the menopause.

Growth processes in teeth distinguish modern humans from Homo erectus and earlier hominins

A modern human-like sequence of dental development, as a proxy for the pace of life history, is regarded as one of the diagnostic hallmarks of our own genus Homo. Brain size, age at first reproduction, lifespan and other life-history traits correlate tightly with dental development. Here we report differences in enamel growth that show the earliest fossils attributed to Homo do not resemble modern humans in their development. We used daily incremental markings in enamel to calculate rates of enamel formation in 13 fossil hominins and identified differences in this key determinant of tooth formation time. Neither australopiths nor fossils currently attributed to early Homo shared the slow trajectory of enamel growth typical of modern humans; rather, both resembled modern and fossil African apes. We then reconstructed tooth formation times in australopiths, in the approximately 1.5-Myr-old Homo erectus skeleton from Nariokotome, Kenya, and in another Homo erectus specimen, Sangiran S7-37 from Java. These times were shorter than those in modern humans. It therefore seems likely that truly modern dental development emerged relatively late in human evolution.

Inadequate protection against yellow fever of children visiting endemic areas

The guidelines of the World Health Organization call for immunization against yellow fever at least 10 days before travel to endemic areas. The goal of this study was to determine whether these guidelines have been applied in 2 travel clinic settings in teaching hospitals in Israel and the United Kingdom specifically for children traveling to endemic areas. Two groups of children aged 9 months to 15 years (n = 98), who were planning to travel to yellow fever-endemic areas, were evaluated regarding characteristics related to the administration of yellow fever vaccine before travel. Overall, 19 children in both clinics (19.4%; 95% confidence interval, 12.1-28.6) had received their yellow fever vaccination < 10 days before departure (no interclinic difference). Eleven of these children received the vaccine < 7 days before departure. We found that the World Health Organization guidelines for yellow fever vaccination are frequently not followed. An initiative to explain to the public the importance of vaccination well before travel to endemic areas should be undertaken.

How long does it take for antidepressant therapies to act?

OBJECTIVE

To review the proposition that antidepressants have a delayed onset of action by employing measurement and analytic strategies that overcome problems confounding interpretation of many efficacy studies.

METHOD

A subset of patients was recruited to the longitudinal component of the Australasian database study, was assessed at baseline, and then completed measures of depression and anxiety when treatment commenced, and every 3 days over the next 4 weeks. The trajectories of defined 4-week outcome responders and non-responders were compared.

RESULTS

Both groups showed a similar decrease in depression (and anxiety) over the first 3 days. A clear trend break then occurred, with little further improvement in the non-responders, as against distinct and progressive improvement in the responders. Ongoing early improvement (across days 3-6) was a strong predictor of responder status.

CONCLUSIONS

The small sample size limits firm interpretation, although distinct interpretive advantages to the study design are evident. Findings are compatible with a number of recent studies arguing against any extensive delayed onset of action for the antidepressant drugs, but argue for caution in interpreting immediate improvement as predicting likely responder status, and more for examining early and sustained improvement as such a marker.

Comparing frontal cranial profiles in archaic and modern homo by morphometric analysis

Archaic and modern human frontal bones are known to be quite distinct externally, by both conventional visual and metric evaluation. Internally this area of the skull has been considerably less well-studied. Here we present results from a comparison of interior, as well as exterior, frontal bone profiles from CT scans of five mid-Pleistocene and Neanderthal crania and 16 modern humans. Analysis was by a new morphometric method, Procrustes analysis of semi-landmarks, that permits the statistical comparison of curves between landmarks. As expected, we found substantial external differences between archaic and modern samples, differences that are mainly confined to the region around the brow ridge. However, in the inner median-sagittal profile, the shape remained remarkably stable over all 21 specimens. This implies that no significant alteration in this region has taken place over a period of a half-million years or more of evolution, even as considerable external change occurred within the hominid clade spanning several species. This confirms that the forms of the inner and outer aspects of the human frontal bone are determined by entirely independent factors, and further indicates unexpected stability in anterior brain morphology over the period during which modern human cognitive capacities emerged. Anat Rec (New Anat): 257:217-224, 1999.

Rare temporal bone pathology of the Singa calvaria from Sudan

Evidence has recently accumulated that the Singa calvaria from Sudan probably dates from Oxygen Isotope Stage 6 (>130 ka). Morphological studies have indicated a mixture of archaic and more modern human traits, but such analyses are complicated by the possibility that the vault is pathologically deformed, although the exact etiology has not been established. Now computed tomography (CT) has revealed that the right temporal bone lacks the structures of the bony labyrinth. The most likely cause of this rare pathological condition appears to be labyrinthine ossification, in which newly deposited bone obliterates the inner ear spaces following an infectious disease or occlusion of the labyrinthine blood supply. A possible cause of vascular compromise could have been the presence of an expanding acoustic neuroma in the internal acoustic meatus, which is suggested by a significantly wider right meatus compared with the left side. Interestingly, labyrinthine ossification is also consistent with the controversial diagnosis that an anemia caused the characteristic diploic widening at the parietal bosses, because prime etiological factors of ossification are among the common complications of some of these blood diseases. CT examination of the vault and a review of the literature suggest that a blood disorder may well have caused the unusual parietal morphology. Given the nature of these pathological conditions, the Singa individual must have experienced a period of considerable disability. The morphological evidence from the normal bony labyrinth on the left side and from the CT evaluation of the vault is consistent with the interpretation of Singa as a late archaic hominid or an early representative of Homo sapiens drawn from a population which might be directly ancestral to modern humans.

A comparative study of stereolithographically modelled skulls of Petralona and Broken Hill: implications for future studies of middle Pleistocene hominid evolution

Computer generated three-dimensional stereolithographic models of middle Pleistocene skulls from Petralona and Broken Hill are described and compared. The anterior cranial fossae of these models are also compared with that of another middle Pleistocene skull, Arago 21. Stereolithographic modelling reproduces not only the outer surfaces of skulls, but also features within the substance of the bones, and details of the internal braincase. The skulls of Petralona and, to a somewhat lesser degree, Broken Hill are extremely pneumatized. Previously undescribed features associated with pneumatization are detailed, along with their possible functional significance, polarity, and potential for understanding hominid cranial variation. Petralona and Broken Hill also exhibit a dramatic suite of cerebral features that is probably related to extensive pneumatization of the skull, namely frontal lobes that are tilted and located behind rather than over the orbits, laterally flared temporal lobes, marked occipital projection, and basal location of the cerebellum. Comparison of the anterior cranial fossae of Petralona, Broken Hill, and Arago 21 suggests that external resemblance of skulls may not always correlate with endocranial similarity. We believe that stereolithographic reconstructions have the potential for helping to resolve difficult questions about the origins of Neanderthal and anatomically modern people.

Liver biopsy and nursing intervention

A liver biopsy is valuable in evaluating for liver disease. A biopsy is often the determining factor for final diagnosis. The Mengbini Klatskin and Tru-Cut needles are types of biopsy needles used in the GI department at the University of Rochester. The choice is based on the personal preference of the physician or on the type of biopsy. The RN's role in the GI department includes pre- and post-procedure planning, assistance during the procedure, patient and family education, and emotional support. It is important to develop a trusting rapport with patients undergoing a liver biopsy. In addition, confident assistance with the procedure and correct positioning of the patient lead to a successful procedure as well as to an uneventful recovery. In searching the literature, the authors found little current information to assist nurses in the assessment of patients about to undergo a liver biopsy. In this article, the authors present some recommendations from experience to assist others in providing quality patient care for liver biopsy procedures.

CD44 expression on murine tissues

CD44 is a cell surface glycoprotein found on lymphoid and epithelial cells. Its primary function on lymphocytes and macrophages is to mediate interaction with endothelium, while its function on epithelial cells is not known. The protein has many different forms, generated by alternative mRNA splicing and by post-translational modification, which may mediate different functions. During previous work on murine lung tumor cells, mAb 133–13A was isolated and shown to recognize a surface glycoprotein, P100, of 90–100 × 10(3) M(r). Amino acid sequence analysis of purified P100 indicates that it is CD44. Since few data exist to indicate which forms of CD44 are present in different normal tissues, mAb 133–13A was used to analyze CD44 expression in mouse tissue. Quantitative data on the distribution of CD44(P100) in mice show that spleen, thymus, liver, intestine, uterus and choroid of the eye are major sites of expression. In addition, epithelia of adrenals, esophagus and trachea are CD44(P100) positive. Previous work on human cell lines has implicated a high molecular mass (130-160 × 10(3) M(r)) form of the glycoprotein as the form expressed in epithelial cells and carcinomas. Isolation of CD44 proteins from lymphoid tissues in the mouse indicate that, as in human lymphoid tissue, the low molecular mass form (80-90 × 10(3) M(r)) is predominately expressed. These data show that both small (approximately 81 × 10(3) M(r)) and large forms of the glycoprotein are expressed in basal epithelia of esophagus and trachea and in salivary gland, while only the small form is expressed in epithelium of the adrenal cortex and in the murine lung and mammary carcinomas studied. While these data cannot distinguish between specific splice variants, they show that the large forms of CD44 are minor components in normal tissue and seem to be found only in basal epithelium. The CD44 of low M(r) found in epithelial tissues is probably associated with lymphoid cell types in the tissues.

Thrombomodulin is preferentially expressed in Balb/c lung microvessels

Previously, two rat monoclonal antibodies where developed which bind distinct epitopes on a murine glycoprotein, P112, which is expressed primarily in lung capillary endothelium. In this paper we show that P112 is identical to the endothelial anticoagulant protein, thrombomodulin (TM). Several lines of evidence support this conclusion. First, amino acid analysis of P112 shows a high degree of homology to TM, and both molecules exhibit the same mobility in gel electrophoresis. Second, P112 and TM share reactivity for two different monoclonal antibodies. Third, purified P112, like TM, acts as a cofactor for protein C activation. Finally, two cDNA clones identified with P112 polyclonal antiserum contain sequence identity with the known TM cDNA sequence. Quantitative analysis of TM (P112) expression using a two-site monoclonal antibody assay demonstrates that significantly higher levels of TM are found in lung in comparison with other highly vascularized organs, i.e. the kidney and liver. Quantitative Northern blot data coincides with the two-site assay data and demonstrates that the high level of TM expression in lung is not due to preferential binding of the monoclonal antibodies to lung TM but rather to increased production of TM mRNA in the lung relative to other highly vascularized organs. It is suggested that expression of TM is highest in cells from continuous endothelium.