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Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment.Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed.A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS15: 73.5% vs. 68.7%, p0.001), more frequent surgical intervention (74.8% vs. 64.5%, p0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS16) (vs. ISS15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p0.001) decreased the likelihood of Medicaid sustainment.Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain.Prognostic and Epidemiological; Level IV.

The complexity of diagnostic (surgical) pathology has increased substantially over the last decades with respect to histomorphological and molecular profiling. Pathology has steadily expanded its role in tumor diagnostics and beyond from disease entity identification via prognosis estimation to precision therapy prediction. It is therefore not surprising that pathology is among the disciplines in medicine with high expectations in the application of artificial intelligence (AI) or machine learning approaches given their capabilities to analyze complex data in a quantitative and standardized manner to further enhance scope and precision of diagnostics. While an obvious application is the analysis of histological images, recent applications for the analysis of molecular profiling data from different sources and clinical data support the notion that AI will enhance both histopathology and molecular pathology in the future. At the same time, current literature should not be misunderstood in a way that pathologists will likely be replaced by AI applications in the foreseeable future. Although AI will transform pathology in the coming years, recent studies reporting AI algorithms to diagnose cancer or predict certain molecular properties deal with relatively simple diagnostic problems that fall short of the diagnostic complexity pathologists face in clinical routine. Here, we review the pertinent literature of AI methods and their applications to pathology, and put the current achievements and what can be expected in the future in the context of the requirements for research and routine diagnostics.

This paper quantifies frictions in uptake, tests for adverse selection, and analyzes welfare effects of proposed reforms in natural disaster insurance markets. I find that willingness to pay is remarkably low. In high-risk flood zones, fewer than 60 percent of homeowners purchase flood insurance even though premiums are only two-thirds of own costs. Estimating flood insurance demand and cost elasticities using house-level variation in premiums from recent US congressional reforms reveals that these homeowners select into insurance based on observable differences in adaptation but not private information about risk. These findings change the sign of predicted welfare effects of proposed policies. (JEL D82, G22, Q54)

International audience; Water stress can cause declines in plant function that persist after rehydration. Recent work has defined ‘resilience’ traits characterizing leaf resistance to persistent damage from drought, but whether these traits predict resilience in whole-plant function is unknown. It is also unknown whether the coordination between resilience and ‘resistance’ – the ability to maintain function during drought – observed globally occurs within ecosystems. For eight rainforest species, we dehydrated and subsequently rehydrated leaves, and measured water stress thresholds for declines in rehydration capacity and maximum quantum yield of photosystem II (Fv/Fm). We tested correlations with embolism resistance and dry season water potentials (ΨMD), and calculated safety margins for damage (ΨMD – thresholds) and tested correlations with drought resilience in sap flow and growth. Ψ thresholds for persistent declines in Fv/Fm, indicating resilience, were positively correlated with ΨMD and thresholds for leaf vein embolism. Safety margins for persistent declines in Fv/Fm, but not rehydration capacity, were positively correlated with drought resilience in sap flow.Correlations between resistance and resilience suggest that species' differences in performance during drought are perpetuated after drought, potentially accelerating shifts in forest composition. Resilience to photochemical damage emerged as a promising functional trait to characterize whole-plant drought resilience.

TheE4variant ofAPOEstrongly predisposes individuals to late-onset Alzheimer’s disease. We demonstrate that in response to neutral lipid synthesis, apolipoprotein E (APOE) in astrocytes can avoid translocation into the ER lumen and traffic to lipid droplets (LDs) via membrane bridges at ER-LD contacts.APOEknockdown promotes fewer, larger LDs containing more unsaturated triglyceride. This LD size distribution phenotype was rescued by chimeric APOE that targets only LDs. APOE4-expressing astrocytes also form a small number of large LDs enriched in unsaturated triglyceride. Additionally, the larger LDs inAPOE4cells exhibit impaired turnover and increased sensitivity to lipid peroxidation. Our data indicate that APOE plays a previously unrecognized role as an LD surface protein that regulates LD size and composition.APOE4is a toxic gain of function variant that causes aberrant LD composition and morphology. We propose thatAPOE4astrocytes with large, unsaturated LDs are sensitized to lipid peroxidation or lipotoxicity, which could contribute to Alzheimer’s disease risk.SummaryWindhamet al. discover that APOE in astrocytes can traffic to lipid droplets (LDs), where it modulates LD composition and size. Astrocytes expressing the Alzheimer’s risk variant APOE4 form large LDs with impaired turnover and increased peroxidation sensitivity.

Urbanization is altering landscapes globally at an unprecedented rate. While ecological differences between urban and rural environments often promote phenotypic divergence among populations, it is unclear to what degree these trait differences arise from genetic divergence as opposed to phenotypic plasticity. Furthermore, little is known about how specific landscape elements, such as green corridors, impact genetic divergence in urban environments. We tested the hypotheses that: 1) urbanization, and 2) proximity to an urban green corridor influence genetic divergence inAsclepias syriaca(common milkweed) populations for phenotypic traits. Using seeds from 52 populations along three urban-to-rural subtransects in the Greater Toronto Area, one of which followed a green corridor, we grew ∼1000 plants in a common garden and observed >20 ecologically-important traits associated with plant defense/damage, reproduction, and growth over four years. We found significant heritable variation for eight traits withinA. syriacapopulations and weak phenotypic divergence among populations. However, neither urbanization nor an urban green corridor influenced genetic divergence in individual traits or multivariate phenotype. These findings contrast with the expanding literature demonstrating that urbanization promotes rapid evolutionary change and offer preliminary insights into the eco- evolutionary role of green corridors in urban environments.

There is a paucity of literature describing risk factors for canalicular injury (CI) during periocular Mohs micrographic surgery (Mohs).This study aimed to determine factors associated with CI after Mohs. This information may inform patient counseling and surgical planning.This case-control study compared subjects with canalicular injury after Mohs with subjects requiring ophthalmologic Mohs repair without canalicular injury. All subjects who had CI after Mohs were included in the control group. CI from other causes were excluded.Basal cell carcinoma was the most common etiologic tumor (p.00001). Canalicular injury was associated with infiltrative, morpheaform, and/or micronodular-type basal cell carcinoma. Initial tumor location involving the medial canthus was not statistically different between cases and controls (32% vs 17%, p = .22). Having a final defect involving the medial canthus region was more likely in cases versus controls (55% vs 26%, p = .01952).Although most final defects involved the medial canthal region, a substantial number of tumors resulting in CI did not initially seem to involve the medial canthus. Surgeons cannot rely simply on anatomical location when assessing risk for CI, and anticipation of need for canalicular reconstruction is challenging.

A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs—the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.

IMPORTANCE: The long-term benefits of off-pump (“beating heart”) vs on-pump coronary artery bypass grafting (CABG) remain controversial. OBJECTIVE: To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial. DESIGN, SETTING, AND PARTICIPANTS: From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021. INTERVENTIONS: On-pump and off-pump CABG procedures. MAIN OUTCOMES AND MEASURES: The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects. RESULTS: A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings. CONCLUSIONS AND RELEVANCE: No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01924442

As firing temperatures in gas turbine engines continue to increase to achieve high efficiencies, components in the main gas path must be protected with cooling flows to ensure lifing targets are met. Manufacturing variations, however, influence the performance and life characteristics of components with the same nominal design. This study presents blade flow and overall cooling effectiveness measurements for nine true-scale, aero engine turbine blades with realistic manufacturing variations. Flow measurements were made through each blade at a fixed pressure ratio to determine flow variability between holes and between blades. Infrared thermography was used to capture spatially-resolved temperature measurements reported as overall effectiveness on the same nine blades under high-speed rotating conditions at the Steady Thermal Aero Research Turbine Laboratory. Thermal performance was correlated with blade flow performance indicating substantial blade-to-blade variations resulting from manufacturing differences. Measurements also indicated wide variations in cooling jet trajectories as well as overall cooling effectiveness. Finally, the observed blade-to-blade variations in effectiveness were scaled to engine conditions with lifing estimates showing some blades would be expected to last only half as long as others due to manufacturing variability.

The Global Alliance for Genomics and Health (GA4GH) is a standards-setting organization that is developing a suite of coordinated standards for genomics. The GA4GH Phenopacket Schema is a standard for sharing disease and phenotype information that characterizes an individual person or biosample. The Phenopacket Schema is flexible and can represent clinical data for any kind of human disease including rare disease, complex disease, and cancer. It also allows consortia or databases to apply additional constraints to ensure uniform data collection for specific goals. We present phenopacket-tools, an open-source Java library and command-line application for construction, conversion, and validation of phenopackets. Phenopacket-tools simplifies construction of phenopackets by providing concise builders, programmatic shortcuts, and predefined building blocks (ontology classes) for concepts such as anatomical organs, age of onset, biospecimen type, and clinical modifiers. Phenopacket-tools can be used to validate the syntax and semantics of phenopackets as well as to assess adherence to additional user-defined requirements. The documentation includes examples showing how to use the Java library and the command-line tool to create and validate phenopackets. We demonstrate how to create, convert, and validate phenopackets using the library or the command-line application. Source code, API documentation, comprehensive user guide and a tutorial can be found at https://github.com/phenopackets/phenopacket-tools. The library can be installed from the public Maven Central artifact repository and the application is available as a standalone archive. The phenopacket-tools library helps developers implement and standardize the collection and exchange of phenotypic and other clinical data for use in phenotype-driven genomic diagnostics, translational research, and precision medicine applications.

A Pom-Pom polymer with qa side chains of molecular weight Mw,a at both ends of a backbone chain of molecular weight Mw,b is the simplest branched polymer topology. Ten nearly monodisperse polystyrene Pom-Pom systems synthesized via an optimized anionic polymerization and a grafting-onto method with Mw,b of 100 to 400 kg/mol, Mw,a of 9 to 50 kg/mol, and qa between 9 and 22 are considered. We analyze the elongational rheology of the Pom-Poms by use of the hierarchical multi-mode molecular stress function (HMMSF) model, which has been shown to predict the elongational viscosity of linear and long-chain branched (LCB) polymer melts based exclusively on the linear-viscoelastic characterization and a single material parameter, the so-called dilution modulus GD. For the Pom-Poms considered here, we show that GD can be identified with the plateau modulus $${G}_{N}^{0}={G}_{D}$$ G N 0 = G D , and the modeling of the elongational viscosity of the Pom-Poms does therefore not require any fitting parameter but is fully determined by the linear-viscoelastic characterization of the melts. Due to the high strain hardening of the Pom-Poms, brittle fracture is observed at higher strains and strain rates, which is well described by the entropic fracture criterion. Graphical abstract

BACKGROUND More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING This study was conducted at a Veterans Affairs medical center. SETTING Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL ANTECEDENTES:Mas del 50% de complicaciones postoperatorias de la herida ocurren despues del alta. Es la complicacion postoperatoria mas comun y el motivo mas frecuente de reingreso despues del procedimiento quirurgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida despues del alta quirurgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las caracteristicas de las complicaciones de la herida, identificadas despues del alta hospitalaria, en pacientes sometidos a cirugia colorrectal, en comparacion con las complicaciones intrahospitalarias.DISENO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirurgica de la Administracion de Salud de Veteranos.ENTORNO CLINICO:Administracion de Veteranos.PACIENTES:Pacientes sometidos a reseccion colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACION:Costos de atencion ajustados al alta, 30 dias y 90 dias despues de la cirugia.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicacion de la herida dentro de los 30 dias de la cirugia. (49,2% indice hospitalario, 50,8% despues del alta). En comparacion con los pacientes, del indice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p

Primitive chain network (PCN) and non-equilibrium molecular dynamics (NEMD) simulations indicate that the nonuniversality seen in the elongational rheology of linear polymer melts and concentrated solutions is caused by monomeric friction reduction. We present, in the context of tube models with varying tube diameter, a new constitutive equation based on enhanced relaxation of stretch (ERS) and find good agreement with experimental evidence and with predictions of the extended interchain pressure (EIP) model. The stretch evolution equations of the ERS and the EIP model can be converted in a form, which allows expressing them in terms of monomeric friction reduction. Monomeric friction coefficients obtained from the ERS model and those used in PCN and NEMD simulations show at least qualitative agreement. While the reduction of monomeric friction is incorporated in PCN and NEMD simulations by empirical correlations between friction coefficient and segmental orientation or elongational stress fitted to elongational viscosity data, the EIP and ERS models provide analytical and parameter-free relations of monomeric friction reduction as a function of chain stretch.