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Background: Percent time in therapeutic range (TTR) and international normalized ratio (INR) variability both measure warfarin control and are associated with outcomes independently. Here, we examine the advantages of a warfarin composite measure (WCM), which summarizes the 2 when measuring patient outcomes. We also examine how the measure chosen would affect anticoagulation clinic performance rankings., Methods and Results: We constructed WCM using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability using 103 897 warfarin-experienced patients from 100 anticoagulation clinics. We examined the association of WCM with ischemic stroke, major bleeding, and fatal bleeding, using a subset of patients with atrial fibrillation (n=40 404). We divided patients into quintiles based on their level of control for TTR, log INR variability, and WCM. We calculated the hazard ratios for ischemic stroke, major bleeding, and fatal bleeding stratified by these quintiles. WCM hazard ratios for stroke and fatal bleeding showed the largest difference between excellent control and poorest control quintile compared with TTR and log INR variability, but not for major bleeding. In addition, we compared site rankings obtained using each of our 3 performance measures. Kappa scores for identifying outlier and nonoutlier clinics between WCM and its components were moderate (κ=0.56 for TTR and κ=0.62 for log INR variability) but was weak between TTR and log INR variability (κ=0.13)., Conclusions: WCM produces the largest range of risk for warfarin complications, widening the floor ceiling effects that limit the use of TTR and INR variability as separate measures. Anticoagulation clinics ranking changed considerably according to the anticoagulation measure that was selected.

Artificial food colors (AFCs) are used to color many beverages, foods, and sweets in the United States and throughout the world. In the United States, the Food and Drug Administration (FDA) limits the AFCs allowed in the diet to 9 different colors. The FDA certifies each batch of manufactured AFCs to guarantee purity and safety. The amount certified has risen from 12 mg/capita/d in 1950 to 62 mg/capita/d in 2010. Previously, we reported the amounts of AFCs in commonly consumed beverages. In this article, the amounts of AFCs in commonly consumed foods and sweets are reported. In addition, the amount of sugars in each product is included. Amounts of AFCs reported here along with the beverage data show that many children could be consuming far more dyes than previously thought. Clinical guidance is given to help caregivers avoid AFCs and reduce the amount of sugars in children's diets., (© The Author(s) 2014.)

Background: Omega-3 polyunsaturated fatty acid (PUFA) may benefit humans and animals with chronic inflammatory diseases., Hypothesis: Omega-3 PUFA supplementation improves clinical signs, lung function, and airway inflammation in horses with recurrent airway obstruction (RAO) and inflammatory airway disease (IAD)., Animals: Eight research horses and 35 client-owned horses., Methods: A pilot study examined the dose of PUFA that can alter plasma PUFA composition. Then, a randomized, controlled clinical trial was performed in horses with RAO and IAD. Horses were fed a complete pelleted diet with no hay and randomly assigned to 1 of 3 daily treatments for 2 months: 30 or 60 g of the supplement or 30 g of placebo. Clinical signs, lung function, plasma PUFA composition, and bronchoalveolar lavage fluid (BALF) cytology were evaluated. Data were expressed as median (25-75th percentiles). P < .05 was considered significant., Results: Polyunsaturated fatty acid supplementation resulted in increased plasma docosahexaenoic acid (DHA) that peaked at 4 weeks. Clinical improvement was noted in all horses involved in the clinical trial, but the group that received PUFA had greater improvement in clinical signs (cough score improved 60%), lung function (respiratory effort decreased 48%), and BALF (neutrophils decreased from 23 to 9%) when compared to placebo (cough score improved 33%, respiratory effort decreased 27%, BALF neutrophils increased from 11 to 17%; P < .05)., Conclusions and Clinical Importance: Feeding horses with RAO and IAD a PUFA supplement containing 1.5-3 g DHA for 2 months provides an additional benefit to low-dust diet., (Copyright © 2014 by the American College of Veterinary Internal Medicine.)

Background: Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine., Objective: Describe APPs role in inpatient medicine., Design: Observational cross-sectional cohort study., Setting: One hundred twenty-four Veterans Health Administration (VHA) hospitals., Participants: Chiefs of medicine (COMs) and nurse managers., Measurements: Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses., Results: One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers., Conclusions: NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs., (© 2014 Society of Hospital Medicine.)

Importance: Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid., Objective: To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees., Design, Setting, and Participants: Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid., Main Outcomes and Measures: Self-reported access to care and annualized emergency department use., Results: Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance., Conclusions and Relevance: We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.

Glutathione redox balance-defined as the ratio GSH/GSSG-is a critical regulator of cellular redox state, and declines in this ratio are closely associated with oxidative stress and disease. However, little is known about the impact of genetic variation on this trait. Previous mouse studies suggest that tissue GSH/GSSG is regulated by genetic background and is therefore heritable. In this study, we measured glutathione concentrations and GSH/GSSG in liver and kidney of 30 genetically diverse inbred mouse strains. Genetic background caused an approximately threefold difference in hepatic and renal GSH/GSSG between the most disparate strains. Haplotype association mapping determined the loci associated with hepatic and renal glutathione phenotypes. We narrowed the number of significant loci by focusing on those located within protein-coding genes, which we now consider to be candidate genes for glutathione homeostasis. No candidate genes were associated with both hepatic and renal GSH/GSSG, suggesting that genetic regulation of GSH/GSSG occurs predominantly in a tissue-specific manner. This is the first quantitative trait locus study to examine the genetic regulation of glutathione concentrations and redox balance in mammals. We identified novel candidate genes that have the potential to redefine our knowledge of redox biochemistry and its regulation and inform future therapeutic applications., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Vitamin D is important for bone, cartilage and muscle function but there are few studies on its association with joint pain., Objective: To investigate whether serum vitamin D predicts change in knee and hip pain in older adults., Methods: Longitudinal population-based cohort study of randomly selected older adults (n=769) aged 50-80 years (mean 62 years); 50% were male. Serum 25-hydroxyvitamin D (25-OHD) was assessed at baseline by radioimmunoassay, and pain at baseline, 2.6 and/or 5 years using the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) questionnaire. We used linear regression with adjustment for age, sex, body mass index and season, then further adjusted for potential structural mechanisms (radiographic osteoarthritis, bone marrow lesions, chondral defects and muscle strength)., Results: Mean total knee WOMAC score was 3.2 (range 0-39). 4.2% of participants had moderate vitamin D deficiency at baseline (25-OHD 12.5-25 nmol/l). 25-OHD <25 nmol/l predicted change in knee pain (using total WOMAC score) over 5 years (β=2.41, p=0.002) with a similar effect size for hip pain over 2.4 years (β=2.20, p=0.083). Results were consistent within pain subscales, and the association was independent of demographic, anthropometric and structural covariates. No association was present when 25-OHD was analysed as a continuous measure., Conclusions: Moderate vitamin D deficiency independently predicts incident, or worsening of, knee pain over 5 years and, possibly, hip pain over 2.4 years. Therefore correcting moderate vitamin deficiency may attenuate worsening of knee or hip pain in elderly people but giving supplements to those with a higher 25-OHD level is unlikely to be effective.

Artificial food colors (AFCs) are widely used to color foods and beverages. The amount of AFCs the Food and Drug Administration has certified over the years has increased more than 5-fold since 1950 (12 mg/capita/day) to 2012 (68 mg/capita/day). In the past 38 years, there have been studies of adverse behavioral reactions such as hyperactivity in children to double-blind challenges with AFCs. Studies that used 50 mg or more of AFCs as the challenge showed a greater negative effect on more children than those which used less. The study reported here is the first to quantify the amounts of AFCs in foods (specifically in beverages) commonly consumed by children in the United States. Consumption data for all foods would be helpful in the design of more challenge studies. The data summarized here should help clinicians advise parents about AFCs and beverage consumption.

Recent studies have shown that 254 nm light can be used to generate organic aerosol from iodoalkane/air mixtures via photodissociation of the C-I bond and subsequent oxidation of the alkyl radical. We examine organic aerosol formed from the 1-iodooctane photolysis at this wavelength using high-performance liquid chromatography (HPLC) with derivatization to selectively probe carbonyl- and hydroxyl-containing molecules. Tandem mass spectrometry reveals that the product distributions are much more complex than a traditional low-NOx peroxy-peroxy oxidation mechanism from a single parent isomer would justify. We propose that this difference is due to peroxy radical photochemistry, leading to two major channels: direct peroxy radical isomerization via internal H-abstraction and reverse dissociation to form alkyl radical and O2. The complexity of the product spectrum is derived from both scrambling of the radical site in the alkyl radical and the additional oxidation of otherwise stable peroxy radicals as a result of the isomerization. A branching ratio for these channels is estimated using a canonical representation of the internal energy distribution. Lifetime estimates using extrapolated ethyl peroxy absorption cross sections and the actinic flux near 310 nm show that peroxy radical photochemistry may play a role in defining the composition of atmospheric secondary organic aerosol formed in pristine (low-NOx) environments.

Patients who have access to different health care systems, such as Medicare-eligible veterans, may obtain services in either or both health systems. We examined whether quality of diabetes care was associated with care continuity or veterans' usual source of primary care in a retrospective cohort study of 1,867 Medicare-eligible veterans with diabetes in 2001 to 2004. Underprovision of quality of diabetes care was more common than overprovision. In adjusted analyses, veterans who relied only on Medicare fee-for-service (FFS) for primary care were more likely to be underprovided HbA1c testing than veterans who relied only on Veteran Affairs (VA) for primary care. Dual users of VA and Medicare FFS primary care were significantly more likely to be overprovided HbA1c and microalbumin testing than VA-only users. VA and Medicare providers may need to coordinate more effectively to ensure appropriate diabetes care to Medicare-eligible veterans, because VA reliance was a stronger predictor than care continuity.

Objectives: To examine population iodine status in Tasmania after mandatory iodine fortification of bread and assess the magnitude of difference compared with results from a period of voluntary iodine fortification., Design and Setting: A cross-sectional urinary iodine survey of schoolchildren from classes that included fourth-grade students was conducted in Tasmania in 2011. Results were compared with surveys conducted before fortification and during a period of voluntary fortification., Participants: Three hundred and twenty students aged 8-13 2013s from 37 participating school classes., Main Outcome Measures: Median urinary iodine concentration (UIC) and proportion of UIC results < 50 µg/L., Results: Median UIC in 2011 was 129 µg/L, and 3.4% of samples had a UIC under 50µg/L. This was significantly higher than during the period of voluntary fortification (129 µg/L v 108 µg/L) (P> < 0.001), which was significantly higher than before fortification (108 µg/L v 73 µg/L) (P < 0.001). There was a reduction in the proportion of samples with UIC under 50 µg/L after mandatory fortification (3.4%) compared with results from the period of voluntary fortification (9.6%) (P = 0.01), which was a further reduction compared with results from the prefortification period (17.7%) (P < 0.001)., Conclusions: Iodine status in Tasmania can now be considered optimal. Mandatory iodine fortification has achieved significantly greater improvements in population iodine status compared with voluntary fortification. However, surveys of schoolchildren cannot be generalised to pregnant and breastfeeding women, who have higher iodine requirements. Measurement of iodine status in population surveys is warranted for ongoing monitoring and to justify the appropriate level of fortification of the food supply into the future.

Context: Severe iodine deficiency (ID) during gestation is associated with neurocognitive sequelae. The long-term impact of mild ID, however, has not been well characterized., Objective: The purpose of this study was to determine whether children born to mothers with urinary iodine concentrations (UICs) <150 μg/L during pregnancy have poorer educational outcomes in primary school than peers whose mothers did not have gestational ID (UIC ≥150 μg/L)., Design: This was a longitudinal follow-up (at 9 years old) of the Gestational Iodine Cohort. Pregnancy occurred during a period of mild ID in the population, with the children subsequently growing up in an iodine-replete environment., Setting and Participants: Participants were children whose mothers attended The Royal Hobart Hospital (Tasmania) antenatal clinics between 1999 and 2001., Main Outcome Measures: Australian national curriculum and Tasmanian state curriculum educational assessment data for children in year 3 were analyzed., Results: Children whose mothers had UIC <150 μg/L had reductions of 10.0% in spelling (-41.1 points, 95% confidence interval [CI], -68.0 to -14.3, P = .003), 7.6% in grammar (-30.9 points, 95% CI, -60.2 to -1.7, P = .038), and 5.7% in English-literacy (-0.33 points, 95% CI, -0.63 to -0.03, P = .034) performance compared with children whose mothers' UICs were ≥150 μg/L. These associations remained significant after adjustment for a range of biological factors (maternal age at birth of child, gestational length at time of birth, gestational age at time of urinary iodine collection, birth weight, and sex). Differences in spelling remained significant after further adjustment for socioeconomic factors (maternal occupation and education)., Conclusions: This study provides preliminary evidence that even mild iodine deficiency during pregnancy can have long-term adverse impacts on fetal neurocognition that are not ameliorated by iodine sufficiency during childhood.

This review examines the research on mechanisms by which artificial food colors (AFCs) and common foods may cause behavioral changes in children with and without attention-deficit/hyperactivity disorder (ADHD). Children with ADHD show excess inattention, impulsivity, and hyperactivity. Studies have shown that a subgroup of children (with or without ADHD) react adversely to challenges with AFCs. Many early studies found few children who reacted to challenges with 20-40 mg of AFCs. However, studies using at least 50 mg of AFCs showed a greater percentage of children who reacted to the challenge. Three types of potential mechanisms are explored: toxicological, antinutritional, and hypersensitivity. Suggestions for future studies in animals and/or children include dose studies as well as studies to determine the effects of AFCs on the immune system, the intestinal mucosa, and nutrient absorption. Given the potential negative behavioral effects of AFCs, it is important to determine why some children may be more sensitive to AFCs than others and to identify the tolerable upper limits of exposure for children in general and for children at high risk., (© 2013 International Life Sciences Institute.)

Objective: To examine variation in culture change to a person-centered care (PCC) model, and the association between culture change and a composite measure of quality in 107 Department of Veterans Affairs nursing homes., Methods: We examined the relationship between a composite quality measure calculated from 24 quality indicators (QIs) from the Minimum Data Set (that measure unfavorable events), and PCC summary scores calculated from the 6 domains of the Artifact of Culture Change Tool, using 3 different methods of calculating the summary scores. We also use a Bayesian hierarchical model to analyze the relationship between a latent construct measuring extent of culture change and the composite quality measure., Results: Using the original Artifacts scores, the highest performing facility has a 2.9 times higher score than the lowest. There is a statistically significant relationship between the composite quality measure and each of the 3 summary Artifacts scores. Depending on whether original scores, standardized scores, or optimal scores are used, a facility at the 10th percentile in terms of culture change compared with one at the 90th percentile has 8.0%, 8.9%, or 10.3% more QI events. When PCC implementation is considered as a latent construct, 18 low performance PCC facilities have, on an average, 16.3% more QI events than 13 high performance facilities., Conclusions: Our results indicate that culture change to a PCC model is associated with higher Minimum Data Set-based quality. Longitudinal data are needed to better assess whether there is a causal relationship between the extent of culture change and quality.

Context: Scrutiny of hospital readmissions has led to the development and implementation of policies targeted at reducing readmission rates., Objective: To assess whether historic hospital readmission rates predict risk-adjusted patient readmission and to measure the costs of readmission, thus informing reimbursement policies under consideration by non-Veterans Health Administration payers., Design, Settings, and Participants: Multivariable hospital-fixed effects regression analyses of patients admitted to 129 Veterans Health Administration hospitals between 2005 and 2009 for 3 common conditions, acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and congestive heart failure (CHF)., Main Outcome Measures: We examined whether previous hospital readmission rates predicted risk-adjusted readmission or 30-day episode cost of care for subsequent patients. We then examined the 30-day inpatient hospitalization episode cost differences between those who had a readmission in the episode and those who did not., Results: Hospital readmission rates in the previous quarter are not predictive of individual patient risk-adjusted readmission or of patients' inpatient hospitalization episode cost in the subsequent quarter. Relative to those who were not readmitted within 30 days of index visit discharge, readmitted patients had 30-day episode costs that were 53.3% (P<0.001), 82.8% (P<0.001), and 79.8% (P<0.001) higher for AMI, CAP, and CHF hospitalization episodes, respectively., Conclusions: Previous hospital readmission rates are poor predictors of readmission for future individual patients, therefore, policies using these measures to guide subsequent reimbursement are problematic for hospitals that are financially constrained. Our findings indicate current diagnosis related group payments would need to be raised by 10.0% for AMI, 11.5% for CAP, and 16.6% for CHF if these are to become 30-day bundled payments.

Beverage consumption has been implicated in weight gain, but questions remain about the veracity of the association, whether the relationship is causal and what property of beverages is responsible. It was hypothesized that food form is the most salient attribute. Thus, a randomized controlled trial of food form was conducted. Energy-matched beverage or solid forms of fruits and vegetables were provided to 34, lean or overweight/obese adults for two 8-week periods with a 3-week washout interspersed. Dietary compensation was incomplete (beverage 53%; solid 78%) and body weight increased after the beverage (1.95 ± 0.33 kg) (77% fat mass) and solid (1.36 ± 0.30 kg) (85% fat mass) treatments (both P < 0.0005). Differences between food forms were not significant. The lean group had the highest dietary compensation (119%) and no significant weight change (0.84 ± 0.53 kg) after consuming the solid fruits and vegetables whereas the overweight/obese group had lower compensation and significant weight gain during the solid arm (46%, 1.77 ± 0.32 kg, P < 0.0001). In contrast, incomplete dietary compensation and weight gain occurred in both the lean (43%, 1.61 ± 0.44 kg, P = 0.003) and overweight/obese (61%, 2.22 ± 0.47 kg, P < 0.0005) groups during the beverage arm. Secondary analyses revealed the obese group gained more weight than the lean and overweight groups during the beverage intervention (P = 0.024). These data demonstrate energy consumed as beverages may be especially problematic for weight gain. They also indicate that advice to increase fruit and vegetable consumption should emphasize total energy intake because the additional energy contributed may promote weight gain, especially among overweight and obese individuals.

Background: Multilevel intervention research holds the promise of more accurately representing real-life situations and, thus, with proper research design and measurement approaches, facilitating effective and efficient resolution of health-care system challenges. However, taking a multilevel approach to cancer care interventions creates both measurement challenges and opportunities., Methods: One-thousand seventy two cancer care articles from 2005 to 2010 were reviewed to examine the state of measurement in the multilevel intervention cancer care literature. Ultimately, 234 multilevel articles, 40 involving cancer care interventions, were identified. Additionally, literature from health services, social psychology, and organizational behavior was reviewed to identify measures that might be useful in multilevel intervention research., Results: The vast majority of measures used in multilevel cancer intervention studies were individual level measures. Group-, organization-, and community-level measures were rarely used. Discussion of the independence, validity, and reliability of measures was scant., Discussion: Measurement issues may be especially complex when conducting multilevel intervention research. Measurement considerations that are associated with multilevel intervention research include those related to independence, reliability, validity, sample size, and power. Furthermore, multilevel intervention research requires identification of key constructs and measures by level and consideration of interactions within and across levels. Thus, multilevel intervention research benefits from thoughtful theory-driven planning and design, an interdisciplinary approach, and mixed methods measurement and analysis.

Advanced glycation end products (AGEs) result from non-enzymatic glycation of proteins and cause cellular oxidative stress in a nicotinamide adenine dinucleotide phosphate (NADPH) oxidase-dependent manner. Due to these effects, AGEs are implicated as a causal factor in diabetic complications. Several antioxidants, including vitamin E, improve cell viability and diminish markers of oxidative damage in cells exposed to AGEs. However, vitamin E has been studied in cell culture systems with primary focus on apoptosis and lipid peroxidation, while its influences on AGE-induced protein and DNA oxidation, intracellular antioxidant status and cell morphology remain largely unknown. Here, we verify the suppression of AGE-induced cell death and lipid peroxidation by 200μM α-tocopherol in SH-SY5Y cells. We report the partial inhibition of DNA oxidation and a decrease in protein carbonyl formation by α-tocopherol with no effects on intracellular GSH concentrations. We observed that 2mM N-acetyl cysteine (NAC) also had a suppressive effect on DNA and protein oxidation, but unlike α-tocopherol, it caused a marked increase in intracellular GSH. Finally, we compared the ability of both antioxidants to maintain neurites in SH-SY5Y cells and found that α-tocopherol had no effect on neurite loss due to AGEs, while NAC fully maintained cell morphology. Thus, while α-tocopherol suppressed AGE-induced macromolecule damage, it was ineffective against neurite degeneration. These results may implicate thiol oxidation and maintenance as a major regulator of neurite degeneration in this model., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The decomposition and intramolecular H-transfer isomerization reactions of the 1-pentyl radical have been studied at temperatures of 880 to 1055 K and pressures of 80 to 680 kPa using the single pulse shock tube technique and additionally investigated with quantum chemical methods. The 1-pentyl radical was generated by shock heating dilute mixtures of 1-iodopentane and the stable products of its decomposition have been observed by postshock gas chromatographic analysis. Ethene and propene are the main olefin products and account for >97% of the carbon balance from 1-pentyl. Also produced are very small amounts of (E)-2-pentene, (Z)-2-pentene, and 1-butene. The ethene/propene product ratio is pressure dependent and varies from about 3 to 5 over the range of temperatures and pressures studied. Formation of ethene and propene can be related to the concentrations of 1-pentyl and 2-pentyl radicals in the system and the relative rates of five-center intramolecular H-transfer reactions and β C-C bond scissions. The 3-pentyl radical, formed via a four-center intramolecular H transfer, leads to 1-butene and plays only a very minor role in the system. The observed (E/Z)-2-pentenes can arise from a small amount of beta C-H bond scission in the 2-pentyl radical. The current experimental and computational results are considered in conjunction with relevant literature data from lower temperatures to develop a consistent kinetics model that reproduces the observed branching ratios and pressure effects. The present experimental results provide the first available data on the pressure dependence of the olefin product branching ratio for alkyl radical decomposition at high temperatures and require a value of <ΔE(down)(1000 K)> = (675 ± 100) cm(-1) for the average energy transferred in deactivating collisions in an argon bath gas when an exponential-down model is employed. High pressure rate expressions for the relevant H-transfer reactions and β bond scissions are derived and a Rice Ramsberger Kassel Marcus/Master Equation (RRKM/ME) analysis has been performed and used to extrapolate the data to temperatures between 700 and 1900 K and pressures of 10 to 1 × 10(5) kPa., (© 2012 American Chemical Society)

Background: More than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time., Objectives: To examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare., Methods: A retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations., Results: Among Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics., Conclusions: Greater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.

Oxidative stress is implicated as a major factor in the development of diabetes complications and is caused in part by advanced glycation end products (AGEs). AGEs ligate to the receptor for AGEs (RAGE), promoting protein kinase C (PKC)-dependent activation of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and superoxide radical generation. While scavenging antioxidants are protective against AGEs, it is unknown if induction of endogenous antioxidant defenses has the same effect. In this study, we confirmed that the compound 3H-1,2-dithiole-3-thione (D3T) increases reduced-state glutathione (GSH) concentrations and NADPH:quinone oxidoreductase 1 (NQO1) activity in SH-SY5Y cells and provides protection against H(2)O(2). Surprisingly, D3T potentiated oxidative damage caused by AGEs. In comparison to vehicle controls, D3T caused greater AGE-induced cytotoxicity and depletion of intracellular GSH levels while offering no protection against neurite degeneration or protein carbonylation. D3T potentiated AGE-induced reactive oxygen species (ROS) formation, an effect abrogated by inhibitors of PKC and NADPH oxidase. This study suggests that chemical induction of endogenous antioxidant defenses requires further examination in models of diabetes.

Objective: To examine longitudinal changes in Medicare-eligible veterans' reliance on the Department of Veterans Affairs (VA) healthcare system for primary and specialty care over 4 years., Methods: We merged VA administrative and Medicare claims data to examine outpatient use during fiscal years (FY) 2001 to 2004 by 15,520 Medicare-eligible veterans who used VA primary care in FY2000. Reliance on VA outpatient care was defined as the proportion of total (VA/Medicare) visits received in VA for primary or specialty care., Results: Of 869,000 primary and specialty care visits in the study period, 39% occurred within VA and 77% were specialty care. Reliance on VA primary care was substantially higher than specialty care (66% vs. 50% in FY2001; P<0.001). Reliance on VA primary and specialty care decreased over time (57% vs. 31% in FY2004; P<0.001). Significant shifts occurred at both extremes of VA reliance. From FY2001 to FY2004, the proportion of patients in the top decile of reliance on VA primary care decreased from 39% to 31%, whereas the proportion in the bottom decile doubled from 8% to 18%. Similarly, the proportion of patients in the top decile of reliance on VA specialty care decreased from 24% to 13%, whereas the proportion in the bottom decile doubled from 22% to 47%., Conclusions: Reliance on VA primary and specialty care among VA primary care patients decreased substantially over time, particularly for specialty care. Increasing use of non-VA services may complicate VA's implementation of patient-centered medical home models and performance measurement.

Ambulatory surgery centers (ASCs), limited-service alternatives for treating surgery patients not requiring an overnight stay, are a health-care service innovation that has proliferated in the U.S. and other countries in recent years. This paper examines the effects of ASC competition on revenues, costs, and profit margins of hospitals that also provided these services as a subset of their general services in Arizona, California, and Texas during the period 1997-2004. We identified all ASCs operating during the period in the 49 Dartmouth Hospital Referral Regions in the three states. The results of fixed effects models suggested that ASCs are meaningful competitors to general hospitals. We found downward pressure on revenues, costs, and profits in general hospitals associated with ASC presence., (Copyright © 2010 John Wiley & Sons, Ltd.)

Artificial food colors (AFCs) have not been established as the main cause of attention-deficit hyperactivity disorder (ADHD), but accumulated evidence suggests that a subgroup shows significant symptom improvement when consuming an AFC-free diet and reacts with ADHD-type symptoms on challenge with AFCs. Of children with suspected sensitivities, 65% to 89% reacted when challenged with at least 100 mg of AFC. Oligoantigenic diet studies suggested that some children in addition to being sensitive to AFCs are also sensitive to common nonsalicylate foods (milk, chocolate, soy, eggs, wheat, corn, legumes) as well as salicylate-containing grapes, tomatoes, and orange. Some studies found "cosensitivity" to be more the rule than the exception. Recently, 2 large studies demonstrated behavioral sensitivity to AFCs and benzoate in children both with and without ADHD. A trial elimination diet is appropriate for children who have not responded satisfactorily to conventional treatment or whose parents wish to pursue a dietary investigation.

Background: Naringenin, a flavonoid present in grapefruit, has recently been shown to exert hypolipidemic and hypocholesterolemic effects, which has a particular importance for protecting against chronic diseases. However, the lipid-lowering potential of naringenin at the concentrations in the dietary range and its underlying mechanisms have yet to be fully elucidated., Aim: The aim of the present study was (1) to investigate the effects of dietary naringenin on plasma and hepatic triglyceride and cholesterol levels and on adipose deposition in rat and (2) to determine the contribution of hepatic peroxisome proliferators-activated receptor α (PPARα) expression to fatty acid oxidation., Methods: Male Long-Evans hooded rats were fed a diet supplemented with naringenin (0.003, 0.006, and 0.012%) for 6 weeks. We analyzed plasma and hepatic lipid contents and determined the protein expression of PPARα, carnitine-palmitoyl transferase 1L (CPT-1), and uncoupling protein 2 (UCP2), all of which are critical genes for fatty acid oxidation., Results: Naringenin supplementation caused a significant reduction in the amount of total triglyceride and cholesterol in plasma and liver. In addition, naringenin supplementation lowered adiposity and triglyceride contents in parametrial adipose tissue. Naringenin-fed animals showed a significant increase in PPARα protein expression in the liver. Furthermore, expression of CPT-1 and UCP2, both of which are known to be regulated by PPARα, was markedly enhanced by naringenin treatment., Conclusions: Our results indicate that the activation of PPARα transcription factor and upregulation of its fatty acid oxidation target genes by dietary naringenin may contribute to the hypolipidemic and anti-adiposity effects in vivo.

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations.

Background: Chronic obstructive pulmonary disease (COPD) is characterized by chronic bronchitis, emphysema and irreversible airflow limitation. These changes are thought to be due to oxidative stress and an imbalance of proteases and antiproteases. Quercetin, a plant flavonoid, is a potent antioxidant and anti-inflammatory agent. We hypothesized that quercetin reduces lung inflammation and improves lung function in elastase/lipopolysaccharide (LPS)-exposed mice which show typical features of COPD, including airways inflammation, goblet cell metaplasia, and emphysema., Methods: Mice treated with elastase and LPS once a week for 4 weeks were subsequently administered 0.5 mg of quercetin dihydrate or 50% propylene glycol (vehicle) by gavage for 10 days. Lungs were examined for elastance, oxidative stress, inflammation, and matrix metalloproteinase (MMP) activity. Effects of quercetin on MMP transcription and activity were examined in LPS-exposed murine macrophages., Results: Quercetin-treated, elastase/LPS-exposed mice showed improved elastic recoil and decreased alveolar chord length compared to vehicle-treated controls. Quercetin-treated mice showed decreased levels of thiobarbituric acid reactive substances, a measure of lipid peroxidation caused by oxidative stress. Quercetin also reduced lung inflammation, goblet cell metaplasia, and mRNA expression of pro-inflammatory cytokines and muc5AC. Quercetin treatment decreased the expression and activity of MMP9 and MMP12 in vivo and in vitro, while increasing expression of the histone deacetylase Sirt-1 and suppressing MMP promoter H4 acetylation. Finally, co-treatment with the Sirt-1 inhibitor sirtinol blocked the effects of quercetin on the lung phenotype., Conclusions: Quercetin prevents progression of emphysema in elastase/LPS-treated mice by reducing oxidative stress, lung inflammation and expression of MMP9 and MMP12.

Context: Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs., Objective: To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease., Design, Setting, and Patients: An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006., Main Outcome Measures: We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome., Results: The average daily total direct hospital costs were $464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p < 0.001)., Comments: Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.

Objective: Optimal diagnostic criteria for the 4-mg intravenous dexamethasone suppression test (IVDST) in patients with Cushing's syndrome (CS), compared with normal subjects, have not been established. We evaluated the performance of the 4-mg IVDST for differentiating CS from normal subjects and to define the responses in CS of various aetiologies. DESIGN, SUBJECTS, MEASUREMENTS: Thirty-two control subjects [normal and overweight/obese participants with or without type 2 diabetes) were prospectively studied, and data from 66 patients with Cushing's disease (CD), three with ectopic ACTH syndrome (EAS), 14 with adrenal Cushing's (AC)] and 15 with low probability of CS (LPC) from three tertiary hospitals were retrospectively evaluated. Dexamethasone was infused at 1 mg/h for 4 h. Plasma cortisol and ACTH were measured at -60 min (baseline), -5 min, +3 h, +4 h, +5 h and at +23 and +23.5 h on Day 2., Results: Control subjects (including those with type 2 diabetes) exhibited a marked suppression of cortisol which was maintained until Day 2. Two of 15 patients with LPC had Day 2 cortisol results that overlapped with CS. Patients with CD demonstrated partial suppression, with rebound hypercortisolism on Day 2. Patients with AC and EAS did not suppress cortisol levels. Day 2 cortisol level of >130 nmol/l (or >20% of the baseline) diagnosed CS with 100% sensitivity and 96% specificity., Conclusion: While the IVDST allowed complete discrimination between control subjects and CS, 13% of LPC overlapped with CS. Given the small number of EAS, no conclusion can be drawn regarding the utility of this test in the differential diagnosis of CS.

Objectives: To assess knowledge and understanding of cost-sharing responsibilities and whether that knowledge and understanding influence actual and perceived use of healthcare services., Study Design: A 3000-person random sample was drawn from a state employee database in Massachusetts., Methods: Survey responses and claims analyses were used to assess knowledge of cost sharing and healthcare utilization over a 3-year study period. Trend models and logistic regression were used., Results: Nearly two-thirds of respondents (62%) accurately recalled the percentage of premium that they paid; 67% recalled the correct copayment for a doctor's visit. Younger, less educated, and lower-income employees recalled their copayment more accurately than older, more educated, higher-income colleagues. Half of the respondents accurately reported the copayment amount for an emergency department visit. Greater knowledge of overall healthcare costs was positively associated with higher utilization of office visits (P <.01). Knowledge of specific office visit and emergency department copayments had no significant relationship with utilization. Self-reported delays and reductions in utilization were much more pronounced than the actual claims data indicated., Conclusions: Employees were reasonably well informed about their cost-sharing responsibilities. Knowledge of costs was associated with higher office visit utilization during the study period. Respondents who were more knowledgeable about their specific copayments for office visits and emergency department visits also were more likely to behave in what appeared to be a more cost-efficient manner, with more office visits and fewer emergency department visits.

Diabetes is a disease characterized by poor glycemic control for which risk of the type 2 form increases with age. A rise in blood glucose concentration causes increased oxidative stress which contributes to the development and progression of diabetes-associated complications. Studies have shown that primary antioxidants or genetic manipulation of antioxidant defenses can at least partially ameliorate this oxidative stress and consequentially, reduce severity of diabetic complications in animal models. Data from humans is less clear and will be summarized in this review. We highlight results from studies performed to investigate the role of vitamin E in preventing diabetes-induced oxidative damage in cell culture, animal models, and human participants, and summarize evidence testing whether this nutrient has an effect on outcomes related to the diabetic complications of nephropathy, retinopathy, and neuropathy. The most compelling evidence for an effect of vitamin E in diabetes is on protection against lipid peroxidation, whereas effects on protein and DNA oxidation are less pronounced. More studies are required to make definitive conclusions about the effect of vitamin E treatment on diabetes complications in human subjects., ((c) 2010. Published by Elsevier Ireland Ltd.)

We report a 46-year-old male with metastatic functioning paraganglioma of the thoracic spine. Thoracic spine functioning paragangliomas are rare and we describe the benefits of embolisation of the lesion prior to surgical decompression., (Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.)

Duplicate gallbladder is a rare congenital anomaly resulting from abnormalities in embryogenesis during the fifth and sixth weeks of gestation. Approximately 210 cases have been described. Variations include duplicate, triplicate, and septated gallbladder. We encountered a 15-year-old girl with both a duplicated gallbladder and a duplicated cystic duct who underwent successful laparoscopic cholecystectomy. This combination is extremely unusual, and based upon our findings in this case and a review of the literature, we propose the Unified Classification of Multiple Gallbladders., (Published by Elsevier Inc.)

Objective: To assess factors associated with enrollment in a Medicare advantage (MA) plan versus Medicare fee-for-service plan in 2000-2004 by Medicare-eligible veterans. We also assessed whether these factors differed between disability-eligible veterans and age-eligible veterans., Methods: Medicare claims data, VA administrative data, and 2000 census data were constructed in a retrospective cohort study of 20,581 age-eligible veterans and 7541 disability-eligible veterans. MA enrollment in 2000-2004 was estimated in a logistic regression in a pooled sample of age-eligible and disability-eligible veterans that controlled for demographic, socioeconomic, and disease risk factors. Separate logistic regressions also were estimated for age-eligible and disability-eligible veterans., Results: Minority veterans and veterans with lower disease risk scores were more likely to be enrolled in an MA plan in 2000-2004 than white veterans or veterans with higher risk scores. Age-eligible veterans were more likely to be enrolled if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid. Disability-eligible veterans were more likely to be enrolled if they were married or elderly., Conclusions: Medicare Advantage plans appeared to benefit from favorable selection of Medicare-eligible veterans.

Calls for screening for HIV infection among individuals with substance use disorders, including alcohol use, are increasing. We investigated HIV screening and its predictors in the Veterans Health Administration (VA) system among such individuals in care. Our primary outcome was retrospective evidence of screening for HIV infection, adjusting for patient demographics and important comorbid disease. Of the 371,749 sample patients with histories of substance use disorders using VA services, 20% had evidence of HIV screening. Screening was lowest among those with alcohol use disorders alone (11%) and highest among those treated in substance use programs (28%) or receiving inpatient care (28%). The findings suggest a low recognition of substance use disorders (especially alcohol use) as risk factors for HIV. Quality improvement initiatives to increase risk factor recognition and screening among patients with substance use disorders will yield benefits in the fight against HIV.

Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004-2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.

Advocates of physician-owned single specialty hospitals (SSHs) maintain that, through healthy competition, SSHs pressure competitor hospitals in local markets to improve performance. This paper investigates data trends on the effects of SSH entry on a potential indicator of quality of care in general hospital competitors: nurse staffing levels. We examined registered nurse (RN) staffing from 1997 to 2004 in ten states in which there was considerable SSH entry during this period. Regression estimates used longitudinal panel data models with hospital fixed effects to compare changes in numbers of RNs in general hospitals located in markets with SSHs with general hospitals located in markets where there were no SSHs. Results indicate that hospitals located in markets with orthopedic/surgical SSH presence raised their RN nurse staffing levels. Whether or not these changes are associated with improved patient outcomes is unknown.

Composite ab initio and density functional theory (DFT) methods were used to explore internal hydrogen-atom transfers in a variety of primary, secondary, and tertiary alkyl and functionalized radicals with implications for combustion environments. The composite ab initio method G3MP2B3 was found to achieve the most reasonable balance between accuracy and economy in modeling the energetics of these reactions. Increased alkyl substitution reduced barriers to isomerization by about 10 and 20 kJ mol(-1) for secondary and tertiary radical formation, respectively, relative to primary radical reactions and was relatively insensitive to the transition-state ring size (extent of H-atom internal shift). Reactions involving alkenyl and alkanoyl radicals were also explored. Hydrogen-atom transfers involving allylic radical formation demonstrated barrier heights that were 15-20 kJ mol(-1) lower than those in corresponding alkyl radicals, whereas those involving oxoallylic species (alpha-site radicals of aldehydes and ketones) were 20-40 kJ mol(-1) lower. In the cases of the alkyl radicals, enthalpies of activation were seen to scale with enthalpies of reaction. This correlation was not seen, however, in the cases of the allylic and oxoallylic radicals; this fact has significant implications in combustion chemistry and mechanism development, considering that such Evans-Polanyi correlations are widely used in estimating barrier heights for rate expressions.

Objective: To investigate longitudinal risk factors of hospitalization for circulatory and pulmonary diseases among veterans with chronic spinal cord injury (SCI). Circulatory and respiratory system illnesses are leading causes of death in patients with chronic SCI, yet risk factors for related hospitalizations have not been characterized., Design: Prospective cohort study., Setting: Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts. PARTICIPANTS/DATA SOURCES: Veterans (N=309) greater than or equal to 1 year post-SCI from the VA Boston Chronic SCI cohort who completed a health questionnaire and underwent spirometry at study entry. Baseline data were linked to 1996 through 2003 hospitalization records from the VA National Patient Care Database., Interventions: Not applicable., Main Outcome Measures: Cardiopulmonary hospital admissions, the predictors of which were assessed by multivariate Cox regression., Results: Of 1478 admissions observed, 143 were a result of cardiopulmonary (77 circulatory and 66 respiratory) illnesses. Independent predictors were greater age (3% increase/y), hypertension, and the lowest body mass index quintile (<22.4 kg/m2). A greater percentage-predicted forced expiratory volume in 1 second was associated with reduced risk. SCI level and completeness of injury were not statistically significant after adjusting for these risk factors., Conclusions: Cardiopulmonary hospitalization risk in persons with chronic SCI is related to greater age and medical factors that, if recognized, may result in strategies for reducing future hospitalizations.

Dried corn distillers grains with solubles (DDGS) fed to swine may adversely affect carcass quality due to the high concentration of unsaturated fat. Feeding CLA enhances pork quality when unsaturated fat is contained in the diet. The effects of CLA on growth and pork quality were evaluated in pigs fed DDGS. Diets containing 0, 20, or 40% DDGS were fed to pigs beginning 30 d before slaughter. At 10 d before slaughter, one-half of each DDGS treatment group was fed 0.6% CLA or 1% choice white grease. Carcass data, liver- and backfat-samples were collected at slaughter. Longissimus muscle area, 10th-rib back-fat depth, last rib midline backfat depth, LM color, marbling, firmness and drip loss, and bacon collagen content were not altered by DDGS or CLA. Outer layer backfat iodine values were increased (P 0.05) for pigs fed DDGS. Feeding CLA decreased (P

Genetic taste sensitivity to the bitterness of 6-n-propylthiouracil (PROP) is a potential marker for food selection. Compared with non-tasters, PROP tasters, especially super-tasters, are less accepting of cruciferous and other green vegetables, bitter citrus, added fats and chili pepper. If super-tasters avoid these foods, it may be hypothesized that they would have lower plasma antioxidant concentrations. Ninety-three healthy, non-smoking college women who did not use vitamins/supplements were classified by PROP-taster status using the paper disk method. Each participant provided a fasting blood sample that was assayed for vitamin C, beta-carotene, alpha-tocopherol, lycopene, uric acid and total peroxyl-trapping antioxidant capacity. Plasma alpha-tocopherol was lower in super-tasters than in non-tasters (P<0.05), but no other indices differed among the groups. These findings suggest that PROP status does not associate with overall antioxidant status, but may be related to alpha-tocopherol intake derived principally from vegetable oils and green vegetables.

High vitamin D intake is associated with reduced insulin resistance. Expression of extra-renal 1alpha,25-dihydroxyvitamin D hydroxylase (1alpha-hydroxylase) has been reported in several tissues and contributes to local synthesis of 1alpha,25-dihydroxyvitamin D(3) (1,25(OH)(2)D) from the substrate 25-hydroxyvitamin D (25OHD). Expression and dietary regulation of 1alpha-hydroxylase in tissues associated with energy metabolism, including adipose tissue, has not been assessed. Male Wistar rats were fed a high calcium (1.5%) and high vitamin D (10,000IU/kg) or a low calcium (0.25%), low vitamin D (400IU/kg) with either a high fat (40% energy) or high sucrose (66% energy) dietary background for 14 weeks. Expression of 1alpha-hydroxylase, assessed by real time PCR, was detected in adipose tissue and did not differ with dietary level of calcium and vitamin D. 1alpha-Hydroxylase mRNA was also detected in 3T3-L1 preadipocytes and 25OHD treatment at 10nM levels induced 1,25(OH)(2)D responsive gene, CYP24, and this response was reduced in the presence of the p450 inhibitor, ketoconazole. In addition, (3)H 25OHD was converted to (3)H 1,25(OH)(2)D in intact 3T3-L1 preadipocytes. Cumulatively, these results demonstrate that 1alpha-hydroxylase is expressed in adipose tissue and is functional in cultured adipocytes. Thus, the capacity for local production may play a role in regulating adipocyte growth and metabolism.

The observations that the peptide hormone gastrin interacts with transferrin in vitro and that circulating gastrin concentrations are increased in the iron-loading disorder hemochromatosis suggest a possible link between gastrin and iron homeostasis. This study tested the hypothesis that gastrin and iron status are interrelated by measurement of iron homeostasis in mice and humans with abnormal circulating gastrin concentrations. Intestinal iron absorption was determined by (59)Fe uptake following oral gavage, and concentrations of duodenal divalent metal transporter-1 (DMT-1) and hepatic hepcidin mRNAs were determined by quantitative real-time PCR in agastrinemic (GasKO), hypergastrinemic cholecystokinin 2 receptor-deficient (CCK2RKO), or wild-type mice. Iron status was measured by standard methods in the same mice and in hypergastrinemic humans with multiple endocrine neoplasia type 1 (MEN-1). Iron absorption was increased sixfold and DMT-1 mRNA concentration fourfold, and transferrin saturation was reduced 0.8-fold and hepcidin mRNA expression 0.5-fold in juvenile GasKO mice compared with age-matched wild-type mice. In mature mice, few differences were observed between the strains. Juvenile CCK2RKO mice were hypergastrinemic and had a 5.4-fold higher DMT-1 mRNA concentration than wild-type mice without any increase in iron absorption. In contrast to juvenile GasKO mice, juvenile CCK2RKO mice had a 1.5-fold greater transferrin saturation, which was reflected in a twofold increase in liver iron deposition at maturity compared with wild-type mice. The correlation between transferrin saturation and circulating gastrin concentration observed in mutant mice was also observed in human patients with MEN, in whom hypergastrinemia correlated positively (P = 0.004) with an increased transferrin saturation. Our data indicate that, in juvenile animals when iron demand is high, circulating gastrin concentrations may alter iron status by a CCK2R-independent mechanism.

Objective: To compare the costs of physician-owned cardiac, orthopedic, and surgical single specialty hospitals with those of full-service hospital competitors., Data Sources: The primary data sources are the Medicare Cost Reports for 1998-2004 and hospital inpatient discharge data for three of the states where single specialty hospitals are most prevalent, Texas, California, and Arizona. The latter were obtained from the Texas Department of State Health Services, the California Office of Statewide Health Planning and Development, and the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Additional data comes from the American Hospital Association Annual Survey Database., Study Design: We identified all physician-owned cardiac, orthopedic, and surgical specialty hospitals in these three states as well as all full-service acute care hospitals serving the same market areas, defined using Dartmouth Hospital Referral Regions. We estimated a hospital cost function using stochastic frontier regression analysis, and generated hospital specific inefficiency measures. Application of t-tests of significance compared the inefficiency measures of specialty hospitals with those of full-service hospitals to make general comparisons between these classes of hospitals., Principal Findings: Results do not provide evidence that specialty hospitals are more efficient than the full-service hospitals with whom they compete. In particular, orthopedic and surgical specialty hospitals appear to have significantly higher levels of cost inefficiency. Cardiac hospitals, however, do not appear to be different from competitors in this respect., Conclusions: Policymakers should not embrace the assumption that physician-owned specialty hospitals produce patient care more efficiently than their full-service hospital competitors.

Managing stressors is essential for optimizing pig growth performance. To determine the effects of temperature and space allocation on growth performance and carcass characteristics, pigs were housed within their thermoneutral zone, at 23.9 degrees C, or above their thermoneutral zone, at 32.2 degrees C, and were provided either 0.66 or 0.93 m(2)/pig for the final 35 d of the grow-finish period. Individual BW were recorded on d 1, 10, 20, and 30. At slaughter, carcass measurements and samples of backfat and belly fat were collected. Final BW was decreased (P < or = 0.05) from 113 to 103 kg for pigs housed at 32.2 degrees C. The ADG was reduced (P < 0.05) for pigs housed at 32.2 degrees C (0.89 vs. 0.54 kg/d), as was G:F (0.28 vs. 0.24). Housing at 0.66 m(2)/pig resulted in pigs that were lighter (P < or = 0.05), at 106 compared with 110 kg, as a result of decreased (P < or = 0.05) ADG (0.78 to 0.65 kg/d) and decreased (P < or = 0.05) G:F (0.275 to 0.255) compared with pigs housed at 0.93 m(2)/pig. Pigs housed at a greater spatial allocation had elevated (P < or = 0.05) ADFI. The interaction of housing at 32.2 degrees C and decreasing spatial allocation increased (P < or = 0.05) the adipose iodine value from 66.8 to 70.4, decreased (P < or = 0.05) the saturated:unsaturated fatty acids ratio from 0.59 to 0.56, and increased (P < or = 0.05) the n-6:n-3 from 23.56 to 25.27. Decreased spatial allocation resulted in decreased (P < or = 0.05) belly weights. Although increased temperature did not affect belly weight, the 32.2 degrees C pigs had decreased (P < or = 0.05) raw and cooked slice weights, increased (P < or = 0.05) percentage lean of bacon, increased (P < or = 0.05) lean:fat ratio of bacon slices, increased (P < or = 0.05) raw slice scores, and increased (P < or = 0.05) quantity of collagen in belly fat. Some of these changes may have resulted from changes in lipid metabolism. Increasing spatial allocation in the 32.2 degrees C pigs decreased fatty acid synthase (P = 0.03) and stearoyl-CoA desaturase- 1 (P = 0.08) mRNA expression in adipose tissue. The results from this study demonstrated decreased growth, carcass lipid quality, and bacon quality in pigs housed at temperatures above the thermoneutral zone; however, increasing the spatial allocation for housing may be a means to ameliorate the negative effects of temperature stress.

Introduction: Median urinary iodine concentration (UIC) is the most commonly used indicator of population iodine nutrition. However, its validity as an indicator of dietary intake relies on a stable relationship between dietary iodine intake and urinary excretion. Physiological alterations in normal pregnancy, such as increased glomerular filtration rate, potentially invalidate UIC as an assessment tool in pregnancy., Objective: The objective of the study was to document the impact of advancing gestation on UIC in normal pregnancy and determine whether the current reference intervals for general population iodine monitoring are appropriate for use in the context of pregnancy., Design: Tasmania has a well-described history of mild iodine deficiency (school-age median UIC of 84 microg/liter). We assessed UIC in 759 urine samples from 431 women attending the Antenatal Clinic at the Royal Hobart Hospital, Tasmania's primary teaching hospital., Main Outcome: The overall median UIC during pregnancy was 75 microg/liter (95% confidence interval 70.03-79.97 microg/liter) at a median gestation of 19.4 wk. Stratification by gestation, however, revealed a dynamic relationship between ioduria and gestation. Median UIC was elevated in early pregnancy and subsequently declined with advancing gestation., Conclusion: In this mildly iodine-deficient population, current reference intervals for UIC overestimated the adequacy of iodine nutrition during the first and early second trimester of pregnancy. Gestation-specific UIC reference intervals are required to classify iodine nutrition during pregnancy. This is particularly important in populations with borderline iodine deficiency.

Employee turnover is a critical concern, particularly for hospitals, because they face a very tight labour market for hiring replacements, and high turnover itself may have substantial negative effects on the continuity and quality of patient care. Hospitals with a stronger teamwork culture may experience lower turnover but this has not been formally studied. Research on determinants of employee turnover has not separated out resignations from the larger, more inclusive definition of turnover that includes retirement. This study investigated the relationship between the teamwork culture of hospitals and physician and nurse resignation rates. The study setting was the Veterans Health Administration (VHA). Each hospital was assessed on teamwork culture based on a survey of current employees. Hospital-level resignation rates were obtained for physicians and nurses. Separate multivariate regression models on physicians and nurses were employed. The models included hospital-level characteristics and labour market variables. Analysis of covariance was also performed to attempt to further reveal effects in high versus low teamwork culture hospitals. Teamwork culture was negatively associated with nurse and physician resignation rates, but was statistically significant in the nurse resignation model only. Additional analyses indicated a 0.47 standard deviation (SD) difference in nurse resignation rates and a 0.40 SD difference in physician resignation rates between hospitals in the top and bottom quartiles of the distribution for teamwork culture. In conclusion, these results suggest that developing and emphasizing a teamwork culture may facilitate greater retention of health-care employees, especially nurses.