Michigan Dentists' Attitudes toward Medicaid and an Alternative Public Dental Insurance System for Children.

PURPOSE: Healthy Kids Dental (HKD) was created as a pilot program of the Michigan State Medicaid program to increase access to care for Medicaid-eligible children. The purpose of this study was to evaluate dentists' attitudes toward Healthy Kids Dental and Medicaid in Michigan. METHODS: An online survey was sent to practitioners with an email address registered with the Michigan Dental Association (n=4,285). RESULTS: Surveys were returned from 965 practitioners (~23 percent). Although practitioners were not fully satisfied with HKD, their satisfaction with the program was significantly higher than their satisfaction with the traditional Medicaid program (P<.001). Sixty-four percent of providers that accept Medicaid limit the number of children seen in some manner, while 28 percent of providers that accept HKD limit the number of children seen. Families with traditional Medicaid who contact an office are significantly less likely to receive treatment for their child than families with HKD insurance who contact the same office (P<.001). CONCLUSIONS: Practitioners were more satisfied with programmatic and patient-related factors of the Healthy Kids Dental program than they were with Medicaid. Dentists were more likely to treat children with HKD than children with Medicaid when the parent contacts a dentist in Michigan.

Michigan dentists' attitudes toward Medicaid and an alternative public dental insurance system for children.

PURPOSE: Healthy Kids Dental (HKD) was created as a pilot program of the Michigan State Medicaid program to increase access to care for Medicaid-eligible children. The purpose of this study was to evaluate dentist's attitudes toward Healthy Kids Dental and Medicaid in Michigan. METHODS: An online survey was sent to practitioners with an e-mail address registered with the Michigan Dental Association (N=4,285). RESULTS: Surveys were returned from 965 practitioners (~23 percent). Although practitioners were not fully satisfied with the HKD, their satisfaction with the program was significantly higher than their satisfaction with the traditional Medicaid program (P<.001). Sixty-four percent of providers that accept Medicaid limit the number of children seen in some manner, while 28 percent of providers that accept HKD limit the number of children seen. Families with traditional Medicaid who contact an office are significantly less likely to receive treatment for their child than families with HKD insurance who contact the same office (P<.001). CONCLUSIONS: Practitioners were more satisfied with programmatic and patient-related factors of the Healthy Kids Dental program than they were with Medicaid. Dentists were more likely to treat children with HKD than children with Medicaid when the parent contacts a dentist in Michigan.

A brief history of phosphorus: from the philosopher's stone to nutrient recovery and reuse.

The element phosphorus has no substitute in sustaining all life and food production on our planet. Yet today's phosphorus use patterns have resulted in both a global environmental epidemic of eutrophication and led to a situation where the future availability of the world's main sources of phosphorus is uncertain. This paper examines the important history of human interference with the phosphorus cycle from initial discovery to present, highlighting key interrelated events and consequences of the Industrial Revolution, Sanitation Revolution and Green Revolution. Whilst these events led to profound advances in technology, public health and food production, they have fundamentally broken the global phosphorus cycle. It is clear a 'Fourth Revolution' is required to resolve this dilemma and ensure humanity can continue to feed itself into the future while protecting environmental and human health.

Towards global phosphorus security: a systems framework for phosphorus recovery and reuse options.

Human intervention in the global phosphorus cycle has mobilised nearly half a billion tonnes of the element from phosphate rock into the hydrosphere over the past half century. The resultant water pollution concerns have been the main driver for sustainable phosphorus use (including phosphorus recovery). However the emerging global challenge of phosphorus scarcity with serious implications for future food security, means phosphorus will also need to be recovered for productive reuse as a fertilizer in food production to replace increasingly scarce and more expensive phosphate rock. Through an integrated and systems framework, this paper examines the full spectrum of sustainable phosphorus recovery and reuse options (from small-scale low-cost to large-scale high-tech), facilitates integrated decision-making and identifies future opportunities and challenges for achieving global phosphorus security. Case studies are provided rather than focusing on a specific technology or process. There is no single solution to achieving a phosphorus-secure future: in addition to increasing phosphorus use efficiency, phosphorus will need to be recovered and reused from all current waste streams throughout the food production and consumption system (from human and animal excreta to food and crop wastes). There is a need for new sustainable policies, partnerships and strategic frameworks to develop renewable phosphorus fertilizer systems for farmers. Further research is also required to determine the most sustainable means in a given context for recovering phosphorus from waste streams and converting the final products into effective fertilizers, accounting for life cycle costs, resource and energy consumption, availability, farmer accessibility and pollution.

Improved phosphorus use efficiency in agriculture: a key requirement for its sustainable use.

Mineral phosphorus (P) fertilizers processed from fossil reserves have enhanced food production over the past 50 years and, hence, the welfare of billions of people. Fertilizer P has, however, not only been used to lift the fertility level of formerly poor soils, but also allowed people to neglect the reuse of P that humans ingest in the form of food and excrete again as faeces and urine and also in other organic wastes. Consequently, P mainly moves in a linear direction from mines to distant locations for crop production, processing and consumption, where a large fraction eventually may become either agronomically inactive due to over-application, unsuitable for recycling due to fixation, contamination or dilution, and harmful as a polluting agent of surface water. This type of P use is not sustainable because fossil phosphate rock reserves are finite. Once the high quality phosphate rock reserves become depleted, too little P will be available for the soils of food-producing regions that still require P supplements to facilitate efficient utilization of resources other than P, including other nutrients. The paper shows that the amounts of P applied in agriculture could be considerably smaller by optimizing land use, improvement of fertilizer recommendations and application techniques, modified livestock diets, and adjustment of livestock densities to available land. Such a concerted set of measures is expected to reduce the use of P in agriculture whilst maintaining crop yields and minimizing the environmental impact of P losses. The paper also argues that compensation of the P exported from farms should eventually be fully based on P recovered from 'wastes', the recycling of which should be stimulated by policy measures.

Right ventricular volume characteristics in ventricular septal defect.

Right and left ventricular volume characteristics were determined from biplane cineangiocardiography in 37 patients with isolated ventricular septal defects. Patients were divided into three categories as determined by the degree of left-to-right shunt: small shunt-less than 35% of pulmonary blood flow (N=9); moderate shunt-35-49% (N=8), and large shunt-greater than 50% (N=20). Right ventricular (RV) end-diastolic volume was increased above normal in 15 of 20 studies performed in patients with large left-to-right shunts and averaged 159 +/- 10% of normal (P less than 0.001). In contrast, only one of the patients in the small shunt group and only half of the patients in the moderate shunt group showed increases in RV end-diastolic volume. The increase in RV volume was proportional to the corresponding increase in left ventricular end-diastolic volume, with the right ventricle ranging from 48 to 116% of LV end-diastolic volume (average 83%). Right ventricular ejection fraction was normal in all patient groups. Right ventricular outpur was increased commensurate with the increases in the RV end-diastolic volume. These data indicate that substantial augmentation in RV end-diastolic volume does occur in patients with isolated ventricular septal defects and large left-to-right shunts. These data can be explained by the significant diastolic and "isovolumic" shunting from left ventricle to right ventricle which occurs in these patients.

Right ventricular volume characteristics before and after palliative and reparative operation in tetralogy of Fallot.

Right heart volume data were obtained in 63 patients with tetralogy of Fallot. The patients were divided into three groups: 1) preoperative tetralogy (N=34); 2) post shunt procedure (N=14); 3A) post repair without outflow patch (N=10); 3B) post repair with an outflow patch (N=8). In Group 1 right ventricular end-diastolic volume (RVEDV), RV ejection fraction (EF), and RV systolic output (SO) were all mildly depressed. In post shunt patients, RVEDV was normal but RVEF remained depressed. RVEDV and RVSO increased following a shunt procedure, and these variables were larger in patients with a large versus a small shunt. In Group 3A RVEDV, RVEF, and RVSO were normal. In contrast in patients in Group 3B, RVEDV was increased averaging 177 +/- 15% of normal RVEF was depressed averaging 0.45 +/- 0.04, and RVSO was normal. RV size and pump function are abnormal in patients whose operation requires an outflow tract patch and the factors which may contribute to these abnormalities include a higher RV peak pressure, pulmonary incompetence, and a larger noncontractile outflow tract. Longitudinal studies relating these variables to clinical performance and exercise testing will be important in assessment of the importance of these abnormalities.

Left heart volume characteristics following ventricular septal defect closure in infancy.

Left ventricular and left atrial volume, left ventricular ejection fraction, and left ventricular muscle mass were determined preoperatively and postoperatively in 13 patients who underwent surgical closure of ventricular septal defects in the first two years of life. Left ventricular end-diastolic volume and systolic output averaged 255 +/- 19% (+/- SEM) and 240 +/- 19% of normal, respectively, before operation but fell to within normal limits postoperatively. Left ventricular ejection fraction was normal preoperatively (100 +/- 4% of normal) and remained so after correction (106 +/- 3%, NS). Left ventricular mass was mildly elevated at the preoperative catheterization (271 +/- 21%) and decreased significantly following repair (P less than 0.001). However, the postoperative left atrial volume (147 +/- 14%) remained abnormal (P greater than 0.05). These data suggest that when early surgical closure of a ventricular septal defect is necessary because of failure of medical management, good results with regard to postoperative left ventricular size and function can be expected.