The factors contributing to better workplaces for farmers on pasture-based dairy farms

Herd size expansion, combined with the reduced availability of people to work on farms, has led to an increased focus on techniques that can improve dairy farm social sustainability. Effective work organization is one such entity, which could influence farm social sustainability; focusing on having a productive, flexible and standardized farm workload. The objective of this study was to examine the factors that contribute to better workplaces for the farmer using a survey of representative pasture-based dairy farms in Ireland. Potential contributing factors to better workplaces for farmers were identified, namely; farm and farmer characteristics, working day structure, farmer attitudes, farm facilities, labor efficient practices and human resource management practices. A survey was completed by 313 Irish dairy farmers between 20 November and 3 January 2019 to capture relevant information. One proxy indicator was selected to represent each of productivity, flexibility and standardization within the workplace, and each of the 313 farms were categorized into quartiles based on their ranking for these 3 indicators (1 = most effective quartile to 4 = least effective quartile). The average farmer that completed the survey was 51 years old, milked 125 cows, reported to work 69.6 h/ week, take 10.3 d of holidays/ year and had a finish time of 19:52 in spring. The quartile of farms with the most effective farmer workplace reported reduced hours worked per week (58.6 v 82.6 h per week), more holiday days (16.6 v 5.1 d) and weekends off (8.3 v 2.4) per year, and earlier finish times (18:41 v 21:14 in spring) compared with the least effective quartile. Similarly, the most effective farms reported better facilities, and greater implementation of labor efficient and human resource management practices compared with the least effective farms. The most effective quartile for farmer workplace effectiveness were more positive about the industry's potential to offer an effective work-life balance, would be more likely to encourage young people to pursue careers in dairy, and had more positive attitudes toward attracting and retaining workers compared with the least effective quartile. The study highlighted the range of factors contributing to more effective workplaces for farmers, indicating scope for improvement on many farms, and challenges across all farms when compared with other industries in the case of some indicators (e.g., time-off). The results can support the continued extension of concepts regarding work organization to assist farms in alleviating social sustainability challenges; highlighting the differentiating factors between the most and least effective farmer workplaces.

Topologization of β-antimonene on Bi2Se3 via proximity effects

Topological surface states usually emerge at the boundary between a topological and a conventional insulator. Their precise physical character and spatial localization depend on the complex interplay between the chemical, structural and electronic properties of the two insulators in contact. Using a lattice-matched heterointerface of single and double bilayers of β-antimonene and bismuth selenide, we perform a comprehensive experimental and theoretical study of the chiral surface states by means of microscopy and spectroscopic measurements complemented by first-principles calculations. We demonstrate that, although β-antimonene is a trivial insulator in its free-standing form, it inherits the unique symmetry-protected spin texture from the substrate via a proximity effect that induces outward migration of the topological state. This "topologization" of β-antimonene is found to be driven by the hybridization of the bands from either side of the interface.

Many-body perturbation theory calculations using the yambo code

yambo is an open source project aimed at studying excited state properties of condensed matter systems from first principles using many-body methods. As input, yambo requires ground state electronic structure data as computed by density functional theory codes such as Quantum ESPRESSO and Abinit. yambo's capabilities include the calculation of linear response quantities (both independent-particle and including electron-hole interactions), quasi-particle corrections based on the GW formalism, optical absorption, and other spectroscopic quantities. Here we describe recent developments ranging from the inclusion of important but oft-neglected physical effects such as electron-phonon interactions to the implementation of a real-time propagation scheme for simulating linear and non-linear optical properties. Improvements to numerical algorithms and the user interface are outlined. Particular emphasis is given to the new and efficient parallel structure that makes it possible to exploit modern high performance computing architectures. Finally, we demonstrate the possibility to automate workflows by interfacing with the yambopy and AiiDA software tools.

Electronic structure of the Ge/Si(1 0 5) hetero-interface: an ARPES and DFT study

We present a joint experimental and theoretical study of the electronic properties of the rebonded-step reconstructed Ge/Si(1 0 5) surface which is the main strained face found on Ge/Si(0 0 1) quantum dots and is considered a prototypical model system for surface strain relaxation in heteroepitaxial growth. Using a vicinal surface as a model system for obtaining a stable single-domain film structure with large terraces and rebonded-step surface termination, we realized an extended and ordered Ge/Si planar hetero-junction suitable for direct study with angle-resolved photoemission spectroscopy. At the coverage of four Ge monolayers photoemission spectroscopy reveals the presence of 2D surface and film bands displaying energy-momentum dispersion compatible with the 5  ×  4 periodicity of the system. The good agreement between experiment and first-principles electronic structure calculations confirms the validity of the rebonded-step structural model. The direct observation of surface features within 1 eV below the valence band maximum corroborates previously reported analysis of the electronic and optical behavior of the Ge/Si hetero-interface.

Controlling the Local Electronic Properties of Si(553)-Au through Hydrogen Doping

We propose a quantitative and reversible method for tuning the charge localization of Au-stabilized stepped Si surfaces by site-specific hydrogenation. This is demonstrated for Si(553)-Au as a model system by combining density functional theory simulations and reflectance anisotropy spectroscopy experiments. We find that controlled H passivation is a two-step process: step-edge adsorption drives excess charge into the conducting metal chain "reservoir" and renders it insulating, while surplus H recovers metallic behavior. Our approach illustrates a route towards microscopic manipulation of the local surface charge distribution and establishes a reversible switch of site-specific chemical reactivity and magnetic properties on vicinal surfaces.

Evidence of β-antimonene at the Sb/Bi2Se3 interface

We report a study of the interface between antimony and the prototypical topological insulator Bi2Se3. Scanning tunnelling microscopy measurements show the presence of ordered domains displaying a perfect lattice match with bismuth selenide. Density functional theory calculations of the most stable atomic configurations demonstrate that the ordered domains can be attributed to stacks of β-antimonene.

Manganese exposure induces neuroinflammation by impairing mitochondrial dynamics in astrocytes

Chronic manganese (Mn) exposure induces neurotoxicity, which is characterized by Parkinsonian symptoms resulting from impairment in the extrapyramidal motor system of the basal ganglia. Mitochondrial dysfunction and oxidative stress are considered key pathophysiological features of Mn neurotoxicity. Recent evidence suggests astrocytes as a major target of Mn neurotoxicity since Mn accumulates predominantly in astrocytes. However, the primary mechanisms underlying Mn-induced astroglial dysfunction and its role in metal neurotoxicity are not completely understood. In this study, we examined the interrelationship between mitochondrial dysfunction and astrocytic inflammation in Mn neurotoxicity. We first evaluated whether Mn exposure alters mitochondrial bioenergetics in cultured astrocytes. Metabolic activity assessed by MTS assay revealed an IC₅₀ of 92.68μM Mn at 24h in primary mouse astrocytes (PMAs) and 50.46μM in the human astrocytic U373 cell line. Mn treatment reduced mitochondrial mass, indicative of impaired mitochondrial function and biogenesis, which was substantiated by the significant reduction in mRNA of mitofusin-2, a protein that serves as a ubiquitination target for mitophagy. Furthermore, Mn increased mitochondrial circularity indicating augmented mitochondrial fission. Seahorse analysis of bioenergetics status in Mn-treated astrocytes revealed that Mn significantly impaired the basal mitochondrial oxygen consumption rate as well as the ATP-linked respiration rate. The effect of Mn on mitochondrial energy deficits was further supported by a reduction in ATP production. Mn-exposed primary astrocytes also exhibited a severely quiescent energy phenotype, which was substantiated by the inability of oligomycin to increase the extracellular acidification rate. Since astrocytes regulate immune functions in the CNS, we also evaluated whether Mn modulates astrocytic inflammation. Mn exposure in astrocytes not only stimulated the release of proinflammatory cytokines, but also exacerbated the inflammatory response induced by aggregated α-synuclein. The novel mitochondria-targeted antioxidant, mito-apocynin, significantly attenuated Mn-induced inflammatory gene expression, further supporting the role of mitochondria dysfunction and oxidative stress in mediating astrogliosis. Lastly, intranasal delivery of Mn in vivo elevated GFAP and depressed TH levels in the olfactory bulbs, clearly supporting the involvement of astrocytes in Mn-induced dopaminergic neurotoxicity. Collectively, our study demonstrates that Mn drives proinflammatory events in astrocytes by impairing mitochondrial bioenergetics.

Protein kinase Cδ upregulation in microglia drives neuroinflammatory responses and dopaminergic neurodegeneration in experimental models of Parkinson's disease

Chronic microglial activation has been linked to the progressive degeneration of the nigrostriatal dopaminergic neurons evidenced in Parkinson's disease (PD) pathogenesis. The exact etiology of PD remains poorly understood. Although both oxidative stress and neuroinflammation are identified as co-contributors in PD pathogenesis, signaling mechanisms underlying neurodegenerative processes have yet to be defined. Indeed, we recently identified that protein kinase C delta (PKCδ) activation is critical for induction of dopaminergic neuronal loss in response to neurotoxic stressors. However, it remains to be defined whether PKCδ activation contributes to immune signaling events driving microglial neurotoxicity. In the present study, we systematically investigated whether PKCδ contributes to the heightened microglial activation response following exposure to major proinflammatory stressors, including α-synuclein, tumor necrosis factor α (TNFα), and lipopolysaccharide (LPS). We report that exposure to the aforementioned inflammatory stressors dramatically upregulated PKCδ with a concomitant increase in its kinase activity and nuclear translocation in both BV-2 microglial cells and primary microglia. Importantly, we also observed a marked upregulation of PKCδ in the microglia of the ventral midbrain region of PD patients when compared to age-matched controls, suggesting a role for microglial PKCδ in neurodegenerative processes. Further, shRNA-mediated knockdown and genetic ablation of PKCδ in primary microglia blunted the microglial proinflammatory response elicited by the inflammogens, including ROS generation, nitric oxide production, and proinflammatory cytokine and chemokine release. Importantly, we found that PKCδ activated NFκB, a key mediator of inflammatory signaling events, after challenge with inflammatory stressors, and that transactivation of NFκB led to translocation of the p65 subunit to the nucleus, IκBα degradation and phosphorylation of p65 at Ser536. Furthermore, both genetic ablation and siRNA-mediated knockdown of PKCδ attenuated NFκB activation, suggesting that PKCδ regulates NFκB activation subsequent to microglial exposure to inflammatory stimuli. To further investigate the pivotal role of PKCδ in microglial activation in vivo, we utilized pre-clinical models of PD. We found that PKCδ deficiency attenuated the proinflammatory response in the mouse substantia nigra, reduced locomotor deficits and recovered mice from sickness behavior in an LPS-induced neuroinflammation model of PD. Likewise, we found that PKCδ knockout mice treated with MPTP displayed a dampened microglial inflammatory response. Moreover, PKCδ knockout mice exhibited reduced susceptibility to the neurotoxin-induced dopaminergic neurodegeneration and associated motor impairments. Taken together, our studies propose a pivotal role for PKCδ in PD pathology, whereby sustained PKCδ activation drives sustained microglial inflammatory responses and concomitant dopaminergic neurotoxicity consequently leading to neurobehavioral deficits. We conclude that inhibiting PKCδ activation may represent a novel therapeutic strategy in PD treatment.

Appropriate clinical use of human leukocyte antigen typing for coeliac disease: an Australasian perspective

The past decade has seen human leukocyte antigen (HLA) typing emerge as a remarkably popular test for the diagnostic work-up of coeliac disease with high patient acceptance. Although limited in its positive predictive value for coeliac disease, the strong disease association with specific HLA genes imparts exceptional negative predictive value to HLA typing, enabling a negative result to exclude coeliac disease confidently. In response to mounting evidence that the clinical use and interpretation of HLA typing often deviates from best practice, this article outlines an evidence-based approach to guide clinically appropriate use of HLA typing, and establishes a reporting template for pathology providers to improve communication of results.

ABO incompatible renal transplantation without antibody removal using conventional immunosuppression alone

ABO incompatible living donor renal transplantation (ABOi) can achieve outcomes comparable to ABO compatible transplantation (ABOc). However, with the exception of blood group A2 kidneys transplanted into recipients with low titer anti-A antibody, regimens generally include antibody removal, intensified immunosuppression and splenectomy or rituximab. We now report a series of 20 successful renal transplants across a range of blood group incompatibilities using conventional immunosuppression alone in recipients with low baseline anti-blood group antibody (ABGAb) titers. Incompatibilities were A1 to O (3), A1 to B (2), A2 to O (2), AB to A (2), AB to B (1), B to A1 (9), B to O (1); titers 1:1 to 1:16 by Ortho. At 36 months, patient and graft survival are 100%. Antibody-mediated rejection (AbMR) occurred in one patient with thrombophilia and low level donor-specific anti-HLA antibody. Four patients experienced cellular rejection (two subclinical), which responded to oral prednisolone. This series demonstrates that selected patients with low titer ABGAb can undergo ABOi with standard immunosuppression alone, suggesting baseline titer as a reliable predictor of AbMR. This reduces morbidity and cost of ABOi for patients with low titer ABGAb and increases the possibility of ABOi from deceased donors.

Casting light on the darkening of colors in historical paintings

The degradation of colors in historical paintings affects our cultural heritage in both museums and archeological sites. Despite intensive experimental studies, the origin of darkening of one of the most ancient pigments known to humankind, vermilion (α-HgS), remains unexplained. Here, by combining many-body theoretical spectroscopy and high-resolution microscopic x-ray diffraction, we clarify the composition of the damaged paint work and demonstrate possible physicochemical processes, induced by illumination and exposure to humidity and air, that cause photoactivation of the original pigment and the degradation of the secondary minerals. The results suggest a new path for the darkening process which was never considered by previous studies and prompt a critical examination of their findings.

Induction of tumorigenicity by galectin-3 in a nontumorigenic human breast-carcinoma cell-line

The human galectin-3 is a galactoside-binding protein of 31 kDa which functions as a receptor for glycoproteins containing poly N-acetyllactosamine side chains and as a substrate for matrix metalloproteinases-2 and -9. We studied its expression by flow cytoflourimetry, Western, Northern and Southern analyses, in five cultured human breast carcinoma cell lines previously characterized as nontumorigenic, poorly metastatic or metastatic in nude mice. The expression of galectin-3 correlated with the reported tumorigenicity of the cells. The introduction of recombinant galectin-3 into the null expressing non-tumorigenic BT-549 cells resulted in the acquisition of anchorage-independent growth properties in all and tumorigenicity in 3/4 sense transfected cell clones. The data indicate a relationship between galectin-3 expression and malignancy of human breast carcinoma cell lines.

Integrative mRNA profiling comparing cultured primary cells with clinical samples reveals PLK1 and C20orf20 as therapeutic targets in cutaneous squamous cell carcinoma

Identifying therapeutic targets for cancer treatment relies on consistent changes within particular types or sub-types of malignancy. The ability to define either consistent changes or sub-types of malignancy is often masked by tumor heterogeneity. To elucidate therapeutic targets in cutaneous squamous cell carcinoma (cSCC), the most frequent skin neoplasm with malignant potential, we have developed an integrated approach to gene expression profiling beginning with primary keratinocytes in culture. Candidate drivers of cSCC development were derived by first defining a set of in vitro cancer genes and then comparing their expression in a range of clinical data sets containing normal skin, cSCC and the benign hyper-proliferative condition psoriasis. A small interfering RNA (siRNA) screen of the resulting 21 upregulated genes has yielded targets capable of reducing xenograft tumor volume in vivo. Small-molecule inhibitors for one target, Polo-like kinase-1 (PLK1), are already in clinical trials for other malignancies, and our data show efficacy in cSCC. Another target, C20orf20, is identified as being overexpressed in cSCC, and siRNA-mediated knockdown induces apoptosis in vitro and reduces tumor growth in vivo. Thus, our approach has shown established and uncharacterized drivers of tumorigenesis with potent efficacy as therapeutic targets for the treatment of cSCC.

Successful ABO-incompatible kidney transplantation with antibody removal and standard immunosuppression

ABO-incompatible (ABOi) kidney transplantation is an established therapy, though its implementation to date has been in part limited by the requirement for additional immunosuppression. Here, we describe the outcomes of 37 patients undergoing ABOi kidney transplantation utilizing perioperative antibody depletion and receiving an identical tacrolimus-based immunosuppressive regimen to contemporaneous ABO-compatible (ABOc) recipients, with the exception that mycophenolate was commenced earlier (7-14 days pretransplant). Antibody depletion was scheduled according to baseline anti-ABO antibody titer (tube IAT method: median 1:128, range 1:8 to 1:4096). Patient and graft survival for the 37 ABOi recipients was 100% after a median 26 months (interquartile range [IQR] 18-32). Eight rejection episodes (two antibody-mediated and six cellular) in ABOi recipients were successfully treated with biopsy-proven resolution. Latest median eGFR is 50 mL/min × 1.73 m² (IQR 40-64) for ABOi patients and 54 mL/min × 1.73 m² (IQR 44-66) in the ABOc patients (p = 0.25). We conclude that ABOi transplantation can be performed successfully with perioperative antibody removal and conventional immunosuppression. This suggests that access to ABOi transplantation can include a broader range of end-stage kidney disease patients.

Management of osteoporosis in primary care in Australia

This study reviewed factors influencing osteoporosis management in primary care settings in Australia and examined risk profiles of patients (n = 37,957) for osteoporosis. Only 29.7% of patients with a prior fracture were currently on specific medication for osteoporosis. The results highlight the need for further exploration of barriers to osteoporosis management.

INTRODUCTION

Osteoporosis management in primary care is suboptimal even for high-risk people with a history of prior fracture.

METHODS

This study reviewed factors influencing the management of individuals at risk for osteoporosis in primary care settings in Australia and examined risk profiles of patients for osteoporosis. Patients (n = 37,957, mean age 71) were recruited over a 12-month period (February 2006-Jan 2007) and interviewed.

RESULTS

With regard to risk factors for osteoporosis, 12.6% of patients reported a history of prior minimal trauma fracture, 7.5% reported a family history of osteoporosis, 7.4% reported they were current smokers, 11.4% reported low dietary calcium intake, 31.8% reported no regular weekly physical exercise and 10.3% reported current use of glucocorticoids. Of those with a prior fracture, only 29.7% were currently on specific medication for osteoporosis. Radiography (n = 17,754) demonstrated a prior vertebral fracture in 30.1%, but only 3.8% of the 17,754 patients reported current use of specific osteoporosis medication.

CONCLUSIONS

This study has confirmed low rates of treatment in primary care even in individuals who have already suffered a prior fracture or have other risk factors. This study highlights the need for further exploration of barriers to osteoporosis management in the primary care setting.

Thrombotic thrombocytopenic purpura is associated with a high relapse rate after plasma exchange: a single-centre experience

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is a rare condition characterized by microangiopathic haemolytic anaemia, thrombocytopenia, renal and/or neurological dysfunction secondary to microvascular or macrovascular thrombosis. Despite advances in treatment, TTP remains a serious condition with significant morbidity and mortality.

METHODS

We undertook an audit of patients with TTP over 14 years to assess remission, relapse, survival and factors predictive of outcome using current therapy based on plasma exchange with fresh-frozen plasma.

RESULTS

Forty patients were identified between January 1992 and December 2005. Thirty-one (82%) achieved complete response (CR) to therapy using plasma exchange with fresh-frozen plasma (median 11 exchanges) and steroids. Twelve (37%) relapsed a median of 14 days following cessation of therapy, with multiple relapses occurring in two patients. TTP-related death occurred in four patients during their initial presentation and in two during subsequent relapse. Four patients were only partially responsive to first-line therapy. The absence of neurological features at presentation was the only factor predicting a sustained CR to first-line therapy (P = 0.027, log-rank analysis). The mean duration of inpatient treatment was 18 days (range 4-38 days) with 30% of patients requiring intensive care admission. Thirty-four per cent of patients acquired central venous line infection, with a median of two episodes of line sepsis per patient.

CONCLUSION

Our results indicate the need for better treatments to reduce the high early relapse rate and significant mortality associated with current therapy.

Anti-CD20 antibody in thrombotic thrombocytopenic purpura refractory to plasma exchange

Thrombotic thrombocytopenic purpura is a rare condition characterized by microangiopathic haemolytic anaemia, thrombocytopenia, altered neurology, renal impairment and fever. While plasma exchange has reduced mortality from more than 90% to between 10 and 30%, a proportion of cases fail to respond. Rituximab may be efficacious in the management of refractory cases of thrombotic thrombocytopenic purpura. We present two cases in which rituximab was used with successful outcomes. Treatment resulted in resolution of severe clinical and haematological abnormalities in both patients. There has been no relapse after 16 months follow up. Our experience supports the use of rituximab in difficult cases of TTP. Ongoing evaluation of its use is in progress at our institution.

An unusual complication of thrombolysis--bilateral retro-orbital haematomata

We present a case of bilateral retro-orbital haematomata following thrombolysis of pulmonary embolism in a severely haemodynamically compromised 29-year-old female. The haematomata developed two days post-thrombolysis with marked visual impairment. Visual acuity was restored following bilateral drainage of the superior aspects of the retro-orbital space.

Disability profile and health care costs of Medicare beneficiaries under age sixty-five

Medicare has more than five million beneficiaries with disabilities who are under age sixty-five, and enrollment is rising rapidly. This paper presents a profile of nonelderly beneficiaries in fee-for-service Medicare by major disability category, excluding those with end-stage renal disease. The profile is based on Medicare Current Beneficiary Survey (MCBS) Cost and Use data for 1994-1996. We estimate Medicare costs by service type and health care costs by payer type, and we discuss implications for Medicare reform and related federal disability policy issues.

Medicare beneficiaries' costs of care in the last year of life

This paper profiles Medicare beneficiaries' costs for care in the last year of life. About one-quarter of Medicare outlays are for the last year of life, unchanged from twenty years ago. Costs reflect care for multiple severe illnesses typically present near death. Thirty-eight percent of beneficiaries have some nursing home stay in the year of their death; hospice is now used by half of Medicare cancer decedents and 19 percent of Medicare decedents overall. African Americans have much higher end-of-life costs than others have, an unexpected finding in light of their generally lower health care spending.

Co-administration of drugs and blood products

The addition of a drug to a blood product intravenous line raises the question of physical and chemical compatibility of the drug with the blood and any preservatives or additives in the blood product. This clinical scenario is encountered frequently, however the practice has not been well studied. Protocols at most institutions prohibit the addition of drugs to blood products. We investigated the addition of analgesic drugs used for patient-controlled analgesia (morphine 1 mg/ml, pethidine 10 mg/ml and ketamine 1 mg/ml) to a standard red cell concentrate, resuspended red blood cells. The red cells were analysed by a Blood Transfusion Service Haematologist and subjected to standard quality control tests. The morphology of the red cells in resuspended red blood cell preparations was unchanged by the addition of these drugs at any stage during storage. The drug concentration in the resuspended red blood cell serum was measured at 0 and at 20 minutes and there was no decrease in concentration which showed that there was no loss of free drug in the resuspended red blood cell serum. This study demonstrates that the concern regarding injury to red cells in standard red cell concentrates by addition of these drugs is unjustified.

Hiring of diagnostic radiologists in 1998

OBJECTIVE

We sought to determine the 1998 hiring activities of physician practices with respect to diagnostic radiologists.

MATERIALS AND METHODS

A survey was mailed to a sample of 970 radiology practices in the spring through fall of 1999; 73.0% responded. Responses were weighted to represent all practices in the United States providing diagnostic radiology services. Findings were compared with results of similar surveys from previous years.

RESULTS

In 1998, multiradiologist groups sought to hire 2299 (+/-148 [standard error]) diagnostic radiologists, an increase of 20% from 1977. Positions offered in 1998 were split almost equally between expansion positions and replacements for those who had left a practice. Another 422 (+/-58) positions had been vacated that practices did not seek to refill. In 1998, 621 (+/-57) diagnostic radiologists left active practice, which is more than the usual number of approximately 400 annually but less than the approximately 800 of 1996 and 1997. There was no significant association between hiring activity and the self-perceived effect of managed care on a group.

CONCLUSION

The pace of hiring and turnover of diagnostic radiologists increased in 1998. Positions available continue to exceed radiologists available to fill them; the excess was approximately 330 positions, which is not significantly different from the excess reported for 1997, but is higher than the (not statistically significant) net shortfall of 51 positions estimated for 1996.

The zinc finger protein schnurri acts as a Smad partner in mediating the transcriptional response to decapentaplegic

In Drosophila, a BMP-related ligand Decapentaplegic (Dpp) is essential for cell fate specification during embryogenesis and in imaginal disc development. Dpp signaling culminates in the phosphorylation and nuclear translocation of Mothers against dpp (Mad), a receptor-specific Smad that can bind DNA and regulate the transcription of Dpp-responsive genes. Genetic analysis has implicated Schnurri (Shn), a zinc finger protein that shares homology with mammalian transcription factors, in the Dpp signal transduction pathway. However, a direct role for Shn in regulating the transcriptional response to Dpp has not been demonstrated. In this study we show that Shn acts as a DNA-binding Mad cofactor in the nuclear response to Dpp. Shn can bind DNA in a sequence-specific manner and recognizes sites within a well-characterized Dpp-responsive promoter element, the B enhancer of the Ultrabithorax (Ubx) gene. The Shn-binding sites are relevant for in vivo expression, since mutations in these sites affect the ability of the enhancer to respond to Dpp. Furthermore we find that Shn and Mad can interact directly through discrete domains. To examine the relative contribution of the two proteins in the regulation of endogenous Dpp target genes we developed a cell culture assay and show that Shn and Mad act synergistically to induce transcription. Our results suggest that cooperative interactions between these two transcription factors could play an important role in the regulation of Dpp target genes. This is the first evidence that Dpp/BMP signaling in flies requires the direct interaction of Mad with a partner transcription factor.

Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims

CONTEXT

Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.

OBJECTIVE

To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.

DESIGN

A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.

SETTING AND SUBJECTS

A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.

MAIN OUTCOME MEASURES

Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).

RESULTS

For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).

CONCLUSIONS

This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333.