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Companionship refers to one's being in the presence of another individual. For adults, acquiring a new language is a highly social activity that often involves learning in the context of companionship. However, the effects of companionship on new language learning have gone relatively underexplored, particularly with respect to word learning. Using a within-subject design, the current study employs electroencephalography to examine how two types of companionship (monitored and co-learning) affect word learning (semantic and lexical) in a new language. Dyads of Chinese speakers of English as a second language participated in a pseudo-word-learning task during which they were placed in monitored and co-learning companionship contexts. The results showed that exposure to co-learning companionship affected the early attention stage of word learning. Moreover, in this early stage, evidence of a higher representation similarity between co-learners showed additional support that co-learning companionship influenced attention. Observed increases in delta and theta interbrain synchronization further revealed that co-learning companionship facilitated semantic access. In all, the similar neural representations and interbrain synchronization between co-learners suggest that co-learning companionship offers important benefits for learning words in a new language., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Background: Insufficient clinicians' auscultation ability delays the diagnosis and treatment of valvular heart disease (VHD); artificial intelligence provides a solution to compensate for the insufficiency in auscultation ability by distinguishing between heart murmurs and normal heart sounds. However, whether artificial intelligence can automatically diagnose VHD remains unknown. Our objective was to use deep learning to process and compare raw heart sound data to identify patients with VHD requiring intervention., Methods: Heart sounds from patients with VHD and healthy controls were collected using an electronic stethoscope. Echocardiographic findings were used as the gold standard for this study. According to the chronological order of enrollment, the early-enrolled samples were used to train the deep learning model, and the late-enrollment samples were used to validate the results., Results: The final study population comprised 499 patients (354 in the algorithm training group and 145 in the result validation group). The sensitivity, specificity, and accuracy of the deep-learning model for identifying various VHDs ranged from 71.4 to 100.0%, 83.5-100.0%, and 84.1-100.0%, respectively; the best diagnostic performance was observed for mitral stenosis, with a sensitivity of 100.0% (31.0-100.0%), a specificity of 100% (96.7-100.0%), and an accuracy of 100% (97.5-100.0%)., Conclusions: Based on raw heart sound data, the deep learning model effectively identifies patients with various types of VHD who require intervention and assists in the screening, diagnosis, and follow-up of VHD., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Purpose: The purpose of this study was to assess the left ventricular function effects of permanent left bundle branch pacing (LBBP) versus traditional right ventricular pacing (RVP)., Patients and Methods: Consecutive patients receiving pacemaker implantation were included and divided into left bundle branch block (LBBB) group and right ventricular pacing (RVP) group. Baseline characteristics were collected, and they received 1-year follow-up. Electrocardiogram (ECG) characteristics and pacing parameters were assessed before and after implantation. Cardiac function parameters such as left ventricular ejection fraction (LVEF) and tricuspid regurgitation (TR) were recorded and compared., Results: Of 78 patients included, 45 patients received LBBP (mean age, 72.7 ± 12.2 years; male, 55.6%) and 33 patients underwent RVP (mean age 72.9 ± 11.8 years; male, 63.6%). The pacing parameters were satisfactory during the implantation and remained stable during mid-term follow-up. During the follow-up period, LBBP patients had a greater decrease in LVEDD and LVESD. The TR in the LBBP group was significantly improved as compared to the RVP group ( P =0.016)., Conclusion: Permanent LBBP achieves favorable cardiac hemodynamic effects with good stability and safety. LBBP may reduce severe TR at 1-year follow-up, and LBBP may be an option for patients with severe TR., Competing Interests: The authors report no conflicts of interest in this work., (© 2023 Mao et al.)

A photo-induced transition-metal-free regioselective hydroborylation of α,β-unsaturated carbonyl compounds is developed. The PhSSPh reagent was employed as the photocatalyst, and NHC-BH 3 was used as the boron source. This transformation shows a broad substrate scope and provides a wide range of α-borylcarbonyl molecules in good to excellent yields.

A series of glasses with composition 60NaPO 3 -(40- x )CdF 2 - x YF 3 - y Er 2 O 3 were synthesized via melt-quenching methods and subsequently heat-treated to obtain upconversion luminescent glass ceramics containing NaYF 4 :Er crystals. Hexagonal and/or cubic NaYF 4 crystals were controlled to be bred in the glasses by changing the glass composition. The structure evolution driven by crystallization was characterized using advanced solid-state nuclear magnetic resonance (SSNMR) techniques. The SSNMR results reveal that the Y/Na ratio determines the crystalline phases of NaYF 4 precipitated in this glass system. Y 3+ attracts extra F - ions from P 5+ and Cd 2+ during crystallization because of its stronger ability to attract F - ions, leading to most Y 3+ ions being crystallized into the NaYF 4 crystals. The paramagnetic broadening effect of the Er 3+ ions on NMR signals as well as the upconversion luminescence results indicate that, before crystallization, most Er 3+ ions are surrounded by oxygen within the glasses; however, after crystallization, almost all of them enter the NaYF 4 crystals. On the basis of this local structure investigation, a composition design strategy is developed to obtain highly efficient upconversion luminescent glass ceramics.

Auscultation of heart sounds is an important method for the diagnosis of heart conditions. For most people, the audible component of heart sound are the first heart sound (S1) and the second heart sound (S2). Different diseases usually generate murmurs at different stages in a cardiac cycle. Segmenting the heart sounds precisely is the prerequisite for diagnosis. S1 and S2 emerges at the beginning of systole and diastole, respectively. Locating S1 and S2 accurately is beneficial for the segmentation of heart sounds. This paper proposed a method to classify the S1 and S2 based on their properties, and did not take use of the duration of systole and diastole. S1 and S2 in the training dataset were transformed to spectra by short-time Fourier transform and be feed to the two-stream convolutional neural network. The classification accuracy of the test dataset was as high as 91.135%. The highest sensitivity and specificity were 91.156% and 92.074%, respectively. Extracting the features of the input signals artificially can be avoid with the method proposed in this article. The calculation is not complicated, which makes this method effective for distinguishing S1 and S2 in real time.

Atrial fibrillation (AF) is the most common type of heart arrhythmia. Currently, the pathogenesis of AF is not fully understood yet. A growing body of evidence highlighted the strong association between inflammation and the pathogenesis of AF. C-reactive protein (CRP) is an inflammation marker with increased expression in AF. Therefore, the aim of this study was to determine if CRP promotes inflammation, which may sequentially mediate the onset of AF and the concurrent atrial fibrosis, through TLR4/NF-κB/TGF-β pathway. HL-1 cells were treated with either 25 or 50 μg/ml recombinant human CRP. TGF-β1 and NF-κB inhibitors were given either solely or together to the 50 μg/ml CRP-treated cells. Cell proliferation, apoptosis, the expression of apoptotic factors and TLR4, IL-6, TGF-β1, Smad2, and the phosphorylation of Smad2 were determined. Data showed that CRP induced dose-dependent inhibition on cell proliferation and promoted cell apoptosis, which was induced through both intrinsic and extrinsic pathways. Such effects were reversed by inhibiting TGF-β1 and/or NF-κB. Inhibition of TGF-β1 and/or NF-κB also reduced the expression of TLR4 and IL-6. Inhibition of NF-κB alone weakened the expression of TGF-β1 and phosphorylation of Smad2. Our study demonstrated that CRP is not only a marker, but also an important mediator in the induction of inflammation and likely the pathogenesis of AF. We for the first time reported CRP-induced activation and cross-talk between TLR4 and NF-κB/TGF-β1 signaling pathway in a cardiomyocyte model. Reducing CRP and targeting TLR4/NF-κB/TGF-β1 pathway may provide new insights in the therapeutic interventions to inflammation-induced AF., (© 2019 The Author(s).)

A retrospective cross-sectional analysis of Veterans Health Administration (VHA) administrative and Medicare fee-for-service (FFS) claims data was used to evaluate the association between body mass index (BMI) categories and expenditures among elderly VHA users with diabetes. The study sample included respondents to the 1999 Large Health Survey of Veteran Enrollees who were diagnosed with diabetes in fiscal year 1999, age 65 or older, and enrolled in Medicare FFS (N = 79,934). Types of expenditures included inpatient, outpatient, and a summation of the 2 in the fiscal year 1999. VHA expenditures were from the Health Economics Resource Center Average Cost Database and Medicare expenditures were the paid amounts recorded in the claims. BMI was grouped into 4 exclusive categories: normal (18.5-24.9), overweight (25-29.9), obese (30-34.9), and morbidly obese (> or =35). Generalized linear models with the log-link function were used to examine the association between BMI categories and expenditures, controlling for sociodemographic factors, diabetes duration, health status, and health behavior. Almost half of the study sample was overweight (47.6%), followed by obese (22.6%), normal (20.7%), and morbidly obese (9.1%). Patients with normal BMI had the highest average total expenditures ($10,470) followed by overweight ($7526). Total expenditure was not significantly different between obese and morbidly obese BMI groups ($6597 vs. $6772). After controlling for all other variables, normal weight patients with diabetes had greater total, inpatient, and outpatient expenditures. The study showed that elderly diabetes patients with normal weight incur much higher costs than obese or morbidly obese patients. Further research is needed to examine the causes of high cost among normal weight patients with diabetes to better understand resource needs and to improve resource allocations.

Aims: To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system., Methods: We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors., Results: In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value., Conclusions: Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.

Objective: Metabolic decompensations (MD) are hospitalizations considered preventable with appropriate ambulatory care. We tested for associations between diabetes care and MD., Research Design: We retrospectively compared care between cases (MD; n = 2714) and controls (without MD; n = 10,856) using merged Veterans Health Administration and Medicare data. Logistic regression tested for associations between MD and diabetes care controlling for patient characteristics., Subjects: Veterans Health Administration users with diabetes stratified into high [hemoglobin A1c (HA1c) > or =9%; n = 2532] and low (HA1c <9%; n = 6176) risk groups., Measures: The outcome was hospitalization for MD. Care was defined as quarterly or semiannual diabetes visits and HA1c testing during individualized 12-month baseline periods., Results: : Cases averaged more diabetes visits and HA1c tests than controls (P < 0.001 for both) in the 12-month baseline period. Among the high-risk, 29.8% of cases made 4 quarterly visits compared with 29.6% of controls (P = 0.004); among the low-risk, there was no difference in semiannual visits. Among the high-risk, models showed having no visit was associated with higher odds of MD (adjusted odds ratio: 3.05; 95% confidence interval: 1.69-5.49) compared with 4 visits; individuals with 1-4 visits had similar odds of MD. More HA1c testing was weakly associated with higher odds of MD., Conclusions: MD was associated with more diabetes care, even controlling for patient characteristics. This inconsistency with the theoretical association between appropriate ambulatory care and lower MD rates indicates that MD rates may not accurately reflect diabetes care quality.

Objective: To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage., Data Sources: The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File., Study Design: We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care)., Principal Findings: VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect., Conclusions: Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.

This study examined care patterns among stroke patients with diabetes who were dually eligible for Department of Veterans Affairs (VA) and Medicare services. We investigated the location (VA hospital or community-based hospital reimbursed by Medicare) of initial and postacute stroke care during a 1-year follow-up period. We used logistic regression to identify the factors associated with the locations of initial and subsequent stroke care. Of the 6,699 patients studied, 76% received their initial care at a Medicare-reimbursed hospital ("Medicare-first" patients) and 24% at a VA hospital ("VA-first" patients). Patients who were white, married, female, or living farther from the VA were more likely to be Medicare-first patients. During the follow-up period, Medicare-first patients were more likely not only to seek further care but also to use the dual systems than were VA-first patients (71% vs 49%, respectively). The high rates of dual-system use highlight the need for care coordination across systems to address issues of care duplication and continuity.

Background: Although alcohol problems are common in human immunodeficiency virus (HIV)-infected patients, their impact on health care services use in HIV-infected patients is not well understood., Objective: We sought to examine the association between alcohol problems and health care services use in HIV-infected and HIV-uninfected patients., Design, Setting, and Subjects: We undertook a prospective analysis of 16,048 HIV-infected veterans and 32,096 age-, race-, gender-, and region-matched HIV-uninfected controls identified through the national Veterans Affairs electronic administrative medical record database. We identified subjects with alcohol problems using ICD-9-CM codes for alcohol diagnoses and/or alcohol-related complications., Main Outcome Measures: We measured outpatient visits, emergency department visits, and inpatient hospitalizations over 12 months of follow-up., Results: In adjusted analyses, HIV-infected veterans with alcohol problems were significantly more likely than HIV-uninfected veterans without alcohol problems to have at least 1 outpatient visit and at least 1 inpatient hospitalization and, among those with any health services use, to have significantly greater rates for outpatient visits (Incidence rate ratio [IRR] 2.17; 95% confidence interval [CI] 2.06-2.28; P < 0.001), emergency department visits (IRR 1.46; 95% CI 1.35-1.58; P < 0.001), and inpatient hospitalizations (IRR 1.46; 95% CI 1.30-1.64; P < 0.001). The incidence rates for outpatient visits, mental health visits, emergency department visits, and inpatient hospitalizations were significantly higher in HIV-infected veterans with alcohol problems than in HIV-infected veterans without alcohol problems. We did not find a consistent interaction effect between alcohol problems and HIV status., Conclusion: Alcohol problems are associated with greater outpatient, emergency department, and inpatient health care utilization in HIV-infected and HIV-uninfected veterans. However, alcohol does not appear to have a stronger effect on health services use in HIV-infected veterans compared with HIV-uninfected veterans.

This study examined the association between Veterans Administration (VA)-Medicare dual beneficiaries' HMO enrollment and factors including sociodemographics, access/attachment to VA, self-reported health status, and characteristics of Medicare HMO markets. The results showed that availability of Medicare HMOs and less access to VA care were the major predictors of VA-Medicare dual beneficiaries' HMO enrollment. Other significant predictors of HMO enrollment were age (65-69), having no college education, VA priority status (low income; less than 50 percent service disability). There was some evidence of favorable selection measured by self-reported health status. The identified HMO enrollment profile can position VA better in attracting and managing the care of these beneficiaries and in meeting potentially large shifts in their need for VA care if Medicare benefits or policies change markedly.

Objectives: We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts., Methods: We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence., Results: Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors., Conclusions: When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.

Objectives: To assess the severity level of acute inpatient care in the Veterans Health Administration (VA) using the 3M All Patient Refined Diagnosis Related Groups (APR-DRGs) Grouper and compare severity levels in the six study sites with other Veterans Affairs Medical Centers., Methods: Acute inpatient stays were generated based on bedsection movement information in VA Inpatient Medical SAS data sets from federal fiscal years 1997 and 1998. All nonacute bedsections were excluded. The APR-DRG Grouper generated APR-DRG and severity level for each acute inpatient stay using relevant VA data in a fixed format. Severity and length of stay (LOS) within each major APR-DRG (those accounting for at least 0.5% of all acute inpatient stays or days) were compared between study sites and other centers using z scores., Results: Of 315 APR-DRGs, 63 major groups accounted for more than two thirds of all stays and days of care in both years. The study sites were similar in average patient severity and LOS to other centers for most APR-DRGs. For those with significant differences, the six centers had shorter LOS and higher severity. The magnitude of differences was large in LOS and small in severity., Conclusions: The study sites are generally representative of the overall VA acute inpatient stays. Some adjustments were needed to reflect that the six sites had relatively sicker patients and lower LOS in some of APR-DRGs when resource utilization estimations in the six sites were generalized to the entire VA system. The severity measure of the 3M APR-DRG Grouper can be adapted to the VA controlling for the complicated nature of VA inpatient care.

The authors examined health care coverage for Veterans' Health Administration (VHA) enrollees and how their reliance on VHA care varies by coverage, using the largest and most detailed survey of veterans using VHA services ever conducted. The results showed that a majority of veterans who use VHA services have alternative health care coverage and that most of them use both VHA and non-VHA health care. The findings have important implications for quality of care and coordination of care.

Objective: To investigate whether a performance-based contracting (PBC) system provides incentives for nonprofit providers of substance abuse treatment to select less severe clients into treatment., Data Sources: The Maine Addiction Treatment System (MATS) standardized admission and discharge data provided by the Maine Office of Substance Abuse (OSA) for fiscal years 1991-1995, provides demographic, substance abuse, and social functional information on clients of programs receiving public funding., Study Design: We focused on OSA clients (i.e., those patients whose treatment cost was covered by the funding from OSA) and Medicaid clients in outpatient programs. Clients were identified as being "most severe" or not. We compared the likelihood for OSA clients to be "most severe" before PBC and after PBC using Medicaid clients as the control. Multivariate regression analysis was employed to predict the marginal effect of PBC on the probability of OSA clients being most severe after controlling for other factors., Principal Findings: The percentage of OSA outpatient clients classified as most severe users dropped by 7 percent (p < = 0.001) after the innovation of performance-based contracting compared to the increase of 2 percent for Medicaid clients. The regression results also showed that PBC had a significantly negative marginal effect on the probability of OSA clients being most severe., Conclusions: Performance-based contracting gave providers of substance abuse treatment financial incentives to treat less severe OSA clients in order to improve their performance outcomes. Fewer OSA clients with the greatest severity were treated in outpatient programs with the implementation of PBC. These results suggest that regulators, or payers, should evaluate programs comprehensively taking this type of selection behavior into consideration.

Conventional risk adjustment, which sets capitation payments equal to the average cost of individuals with similar observable characteristics, is not optimal if health plans can use private information to select low-cost enrollees. "Cost-minimizing risk adjustment" minimizes the sum of capitated HMO premiums plus FFS costs by balancing the gains from HMO cost efficiency against the overpayments that result from HMO selection. Estimations using privately-insured data suggest that cost-minimizing risk adjusted premiums reduce total sponsor costs as much as 25.6% below conventional risk adjustment premiums.

To mitigate selection triggered by capitation payments, risk-adjustment models bring capitation payments closer on average to individuals' expected expenditure. We examine the maximum potential profit that plans could hypothetically gain by using their own private information to select low-cost enrollees when payments are made using four commonly used risk adjustment models. Simulations using a privately insured sample suggest that risk selection profits remain substantial. The magnitude of potential profit varies according to the risk adjustment model and the private information plans can employ to identify profitable enrollees., (Copyright 2002 John Wiley & Sons, Ltd.)