Government policies on job satisfaction of radiographers in tertiary hospitals, Gauteng.

Background: The National Department of Health has different operational policies to monitor the performance of its employees and to reward them accordingly. These policies could have a direct bearing on job satisfaction and career advancement for radiographers employed by the public sector, as there are previous reports that show that these policies affect the job satisfaction of other healthcare professionals negatively. Aim: The aim of the study was to explore the influence of government policies on the job satisfaction of radiographers employed by public tertiary hospitals in the Gauteng province. Setting: The study was conducted in two public tertiary hospitals in the Gauteng province. Methods: The study used a primary exploratory qualitative research design, with a purposive sampling technique. Data were collected through individual and focus group interviews. The researcher recorded and transcribed the interviews. Thematic analysis was used to analyse the data. Results: Three government policies had a negative impact on job satisfaction for radiographers. These were the Occupational Specific Dispensation (OSD), the Performance Management and Development System (PMDS) and the Employment Equity Act (EEA). The failure to effectively implement these policies also had a negative bearing on career pathing. Conclusion: The implementation and structure of these three government policies have resulted in job dissatisfaction amongst radiographers employed by public tertiary hospitals and reduced the structure of career pathing. Contribution: The study highlighted three government policies that negatively affect job satisfaction in Gauteng.

Imbalance in the vWF - ADAMTS13 axis exists early in acute pancreatitis and predicts persistent organ failure and pancreatic necrosis-a prospective study.

BACKGROUND: The pathophysiology of Acute Pancreatitis (AP) may be complicated by endothelial activation. von Willebrand Factor (vWF)- ADAMTS13 axis is a marker of endothelial activation. The study aimed to investigate the axis in AP, comparing it in patients with and without persistent organ failure (OF), with and without pancreatic necrosis, and correlating it with the standard severity scores (CRP, APACHE II, BISAP, SOFA, and qSOFA) METHODS: vWF-Antigen (vWF:Ag), vWF-Collagen-Binding-Assay (vWF:CBA), and ADAMTS13 activity (ADAMTS13:act) levels were measured within 5 days of symptom onset in consecutive patients (n = 98), who were admitted with a first episode of AP (Dec 2021-May 2023). RESULTS: Of the 98 patients admitted with AP, 78(79.6 %) had no or transient OF; 20(20.4 %) had persistent OF. Age was comparable (43.73 ± 15.36 vs 38.65 ± 13.69) [mean ± SD](years), and males were predominant in both groups (70.5 % vs 80 %). Patientswith persistent OF had higher vWF:CBA(%)[323(279-486.5) vs 199.5(159.1-295.75)] and lower ADAMTS13:act(%)[35.4(23.8-56.85) vs 56.35(44.1-71.9)][median (25th - 75th percentile)](P = 0.001) than those with no or transient OF. Patients with pancreatic necrosis (n = 19) had lower ADAMTS13:act(%)[42.79 ± 18.69] than those without pancreatic necrosis (n = 18) [62.49 ± 22.64] (P < 0.01). ADAMTS13:act had a negative correlation(r = -0.2), whereas vWF:Ag and vWF:CBA had a positive correlation (r = 0.2) with the standard severity scores (P < 0.05). ADAMTS13:act could predict pancreatic necrosis [AUROC-0.737, P < 0.05] and persistent OF [AUROC-0.746, P < 0.001], while vWF:CBA could predict persistent OF [AUROC- 0.73, P < 0.001]. CONCLUSION: vWF-ADAMTS13 axis helps to predict severe disease and is associated with poor outcomes in acute pancreatitis.

Important legal principles of consent and mental capacity.

Consent is an essential part of healthcare practice, allowing patients to make autonomous decisions. However, this changes when a patient has mental incapacity or is unable to make decisions for themselves for a duration of time. This month's Policy column looks at some of the key principles of the Mental Capacity Act 2005, and how this can be applied in community nursing practice.

Tethered IL15-IL15Rα augments antitumor activity of CD19 CAR-T cells but displays long-term toxicity in an immunocompetent lymphoma mouse model.

BACKGROUND: Adoptive cell therapy using genetically modified T cells to express chimeric antigen receptors (CAR-T) has shown encouraging results, particularly in certain blood cancers. Nevertheless, over 40% of B cell malignancy patients experience a relapse after CAR-T therapy, likely due to inadequate persistence of the modified T cells in the body. IL15, known for its pro-survival and proliferative properties, has been suggested for incorporation into the fourth generation of CAR-T cells to enhance their persistence. However, the potential systemic toxicity associated with this cytokine warrants further evaluation. METHODS: We analyzed the persistence, antitumor efficacy and potential toxicity of anti-mouse CD19 CAR-T cells which express a membrane-bound IL15-IL15Rα chimeric protein (CD19/mbIL15q CAR-T), in BALB/c mice challenged with A20 tumor cells as well as in NSG mice. RESULTS: Conventional CD19 CAR-T cells showed low persistence and poor efficacy in BALB/c mice treated with mild lymphodepletion regimens (total body irradiation (TBI) of 1 Gy). CD19/mbIL15q CAR-T exhibits prolonged persistence and enhanced in vivo efficacy, effectively eliminating established A20 B cell lymphoma. However, this CD19/mbIL15q CAR-T displays important long-term toxicities, with marked splenomegaly, weight loss, transaminase elevations, and significant inflammatory findings in some tissues. Mice survival is highly compromised after CD19/mbIL15q CAR-T cell transfer, particularly if a high TBI regimen is applied before CAR-T cell transfer. CONCLUSION: Tethered IL15-IL15Rα augments the antitumor activity of CD19 CAR-T cells but displays long-term toxicity in immunocompetent mice. Inducible systems to regulate IL15-IL15Rα expression could be considered to control this toxicity.

Comparison of Demographics: National Amyotrophic Lateral Sclerosis Registry and Clinical Trials Data.

OBJECTIVE: To characterize the participant demographics in the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database compared with the web-portal National Amyotrophic Lateral Sclerosis (ALS) Registry (the Registry). METHODS: Demographics and ALS symptom information were compared between the self-reported registrant data in the Registry web portal (2010-2021) and the latest available PRO-ACT data (updated August 2022), which is a collection of clinical trials data. RESULTS: Greater percentages of younger (≤ 59 years old) but smaller percentages of older (60 + years old) participants were represented in PRO-ACT compared to Registry. Enrollment for minority race groups was greater in the Registry portal data, but race information was largely missing/unknown in PRO-ACT database. Median age at the time of diagnosis and age at the time of symptom onset were significantly higher for Registry enrollees compared to the participants of PRO-ACT. Symptom onset sites were similarly reported, but duration between self-noted symptom onset and diagnosis was slight, but significantly longer for the Registry enrollees (11 vs. 9 months). Hispanic were as likely as non-Hispanic to participate in research studies, based on the Registry data. CONCLUSION: There was a notable difference in the age distribution and minority representation of enrollees between the PRO-ACT and Registry study populations. Age distribution in the PRO-ACT database skewed to a younger and less diverse cohort. Despite the clinical heterogeneity and complex disease mechanism of ALS, identifying the underrepresented demographic niche in the PRO-ACT and Registry study populations can help improve patient participation and criteria for patient selection to enhance generalizability.

Off-the-shelf CAR-NK cells targeting immunogenic cell death marker ERp57 execute robust antitumor activity and have a synergistic effect with ICD inducer oxaliplatin.

BACKGROUND: Chimeric antigen receptor natural killer (CAR-NK) therapy holds great promise for treating hematologic tumors, but its efficacy in solid tumors is limited owing to the lack of suitable targets and poor infiltration of engineered NK cells. Here, we explore whether immunogenic cell death (ICD) marker ERp57 translocated from endoplasmic reticulum to cell surface after drug treatment could be used as a target for CAR-NK therapy. METHODS: To target ERp57, a VHH phage display library was used for screening ERp57-targeted nanobodies (Nbs). A candidate Nb with high binding affinity to both human and mouse ERp57 was used for constructing CAR-NK cells. Various in vitro and in vivo studies were performed to assess the antitumor efficacy of the constructed CAR-NK cells. RESULTS: We demonstrate that the translocation of ERp57 can not only be induced by low-dose oxaliplatin (OXP) treatment but also is spontaneously expressed on the surface of various types of tumor cell lines. Our results show that G6-CAR-NK92 cells can effectively kill various tumor cell lines in vitro on which ERp57 is induced or intrinsically expressed, and also exhibit potent antitumor effects in cancer cell-derived xenograft and patient-derived xenograft mouse models. Additionally, the antitumor activity of G6-CAR-NK92 cells is synergistically enhanced by the low-dose ICD-inducible drug OXP. CONCLUSION: Collectively, our findings suggest that ERp57 can be leveraged as a new tumor antigen for CAR-NK targeting, and the resultant CAR-NK cells have the potential to be applied as a broad-spectrum immune cell therapy for various cancers by combining with ICD inducer drugs.

From virtually extinct to superabundant in 35 years: establishment, population growth and shifts in management focus of the Swedish wild boar (Sus scrofa) population.

BACKGROUND: The wild boar (Sus scrofa) was extinct in Sweden when a few animals established in the 1970s. Over the past 35 years, the species has made a substantial comeback. In this paper, we analyse wild boar population growth using three indices of population size. We also map the legislative decisions and research prompted by the expanding population. We discuss to what extent, in the eyes of the state, the view of wild boar and the management focus has shifted over time, from a perceived pest (eradication) to scarce (conservation), overabundant (reduction/control) or somewhere in between (sustainable management). RESULTS: Wild boar harvest started in the early 1990s with a few hundred animals annually and peaked at 161,000 in 2020/2021. The distribution now comprises most of southern Sweden. Analyses of harvest and traffic accidents involving wild boar showed that the population grew exponentially until 2010/2011, after which the increase levelled off. Thus, logistic growth models showed the best fit for the full study period. We recorded 38 legislative decisions or commissions to government agencies regarding wild boar. The first decision in 1981 was to eradicate the free-ranging population. In 1987 however, the parliament decided that wild boar is native to Sweden and should be allowed in restricted extent. Later decisions mainly concerned hunting regulations and hunting methods as direct means to increase harvest and regulate the population. Another topic, increasing in importance over time, was to facilitate the use of wild boar meat to indirectly stimulate harvest. A local outbreak of African swine fever in 2023 necessitated a stamping out strategy in the affected area. We found 44 scientific papers regarding the present free-ranging population. Topics include movements and feeding patterns, hunting, reproduction, and population development. CONCLUSIONS: The state historically regarded wild boar as a pest to be eradicated. This changed with the decision that wild boar should be allowed in restricted extent, suggesting a conservation approach. In response to population growth, the focus shifted to means facilitating sustainable management and, lately, reducing growth. The story of wild boar in Sweden illustrates attempts to mitigate conflicts and balance interests in wildlife management.

Occupational therapy's role in promoting the "Learn the Signs. Act Early." developmental monitoring program to public health employees.

Background: Occupational therapists can play a key role in early identification of delay at the population health level by providing education to public health employees on how to implement developmental monitoring with caregivers of children birth to age 5. Methods: A pretest posttest design was utilized to assess the online education and training that was provided to Department of Public Health employees (N = 339), including Head Start, Special Supplemental Nutrition Program for Women, Infants and Children, Home Visiting, and Early Intervention. Results: Analysis of pretest-posttest survey data showed significant results for all 12 key learning outcomes. Six out of 12 outcomes were found to have a large effect size (d > 0.8), 4 outcomes indicated a medium effect size (d > 0.5), and 2 outcomes had a small effect size (d > 0.2). Participants gained knowledge of the "Learn the Signs. Act Early." (LTSAE) developmental monitoring program, the difference between developmental monitoring and screening, the state's referral system and age-appropriate parental engagement activities through knowledge of child development. Conclusions: Occupational therapists are child development specialists who can provide education on developmental monitoring and activities for parental engagement. The online course proved to be an effective platform to promote LTSAE within state agencies.

The Art of Delegation.

The nurse staffing crisis requires nurses and administrators to think differently about how to get things done. Delegation is key to doing more work with fewer registered nurses (RNs) and retaining current RN staff. Responsibility for effective delegation does not rest solely with the RN but begins with the institution, and includes both the delegator and delegatee. While effective delegation has often been referred to as an art, knowing the science behind delegation can aid in honing a skill necessary for top of license practice.

MEDINA Catalogue of Cloud Security controls and metrics: Towards Continuous Cloud Security compliance.

In order to address current challenges on security certification of European ICT products, processes and services, the European Comission, through ENISA (European Union Agency for Cybersecurity), has developed the European Cybersecurity Certification Scheme for Cloud Services (EUCS). This paper presents the overview of the H2020 MEDINA project approach and tools to support the adoption of EUCS and offers a detailed description of one of the core components of the framework, the MEDINA Catalogue of Controls and Metrics. The main objective of the MEDINA Catalogue is to provide automated functionalities for CSPs' compliance managers and auditors to ease the certification process towards EUCS, through the provision of all information and guidance related to the scheme, namely categories, controls, security requirements, assurance levels, etc. The tool has been enhanced with all the research and implementation works performed in MEDINA, such as definition of compliance metrics, suggestion of related implementation guidelines, alignment of similar controls in other schemes, and a set of self-assessment questionnaires, which are presented and discussed in this paper.

The European Agency for Cybersecurity, ENISA has developed a new cybersecurity scheme (EUCS-European Cybersecurity Certification Scheme for Cloud Services) that will become legislation in the upcoming years, with the objective of homogenize the current market fragmentation across Europe in the cybersecurity certification domain. organisations providing cloud computing services in Europe will need to become compliant with this upcoming and new certification. The software tool presented in this article, the MEDINA Catalogue of Controls and Metrics, provides automated functionalities to ease the certification process towards EUCS, through the provision of all information and guidance related to the scheme, namely categories, controls, security requirements, assurance levels, etc.

Brief acceptance and commitment therapy for children and adolescents with type 1 diabetes.

Introduction: Children and adolescents with diabetes face challenges that can significantly impact their quality of life. Investigating psychological interventions for stress management can equip them with the skills needed to cope with type 1 diabetes. This study investigated the impact of a brief Acceptance and Commitment Therapy (ACT) intervention on stress management, diabetes acceptance, psychological flexibility, and patient-doctor relationships among this population. Methods: A total of 55 children, and adolescents from Romania participated in a four-session ACT intervention for type 1 diabetes. The evaluation instruments used were the Perceived Stress Scale for Children (PSS-C), Acceptance and Action Diabetes Questionnaire (AADQ), Children's Psychological Flexibility Questionnaire (CPFQ), and Patient-Doctor Relationship Questionnaire (PDRQ-9). Results: The participants (mean age = 14.14, SD = 2.26; 67% girls) reported lower stress levels, increased acceptance of diabetes, and greater psychological flexibility after the intervention. Additionally, the patient-doctor relationship was enhanced, potentially improving patient adherence to treatment. Positive qualitative feedback mirrored previous ACT research in the paediatric population, highlighting the beneficial role of experiential activities and metaphors when working with this target group. Discussion: This study adds to the growing body of evidence supporting the effectiveness of ACT in enhancing healthy coping strategies among children and adolescents with chronic illnesses.

The Uniform Determination of Death Act is Not Changing. Will Physicians Continue to Misdiagnose Brain Death?

Efforts to revise the Uniform Determination of Death Act in order to align law with medical practice have failed. Medical practice must now align with the law. People who are not dead under the law that defines death should not be declared dead. There is no compelling reason to continue the practice of declaring legally living persons to be dead.

Impact of the Affordable Care Act on Revascularization Versus Amputation in Patients Presenting With Chronic Limb-Threatening Ischemia in Maryland.

INTRODUCTION: The Affordable Care Act (ACA) aimed to expand Medicaid, enhance health care quality and efficiency, and address health disparities. These goals have potentially influenced medical care, notably revascularization rates in patients presenting with chronic limb-threatening ischemia (CLTI). This study examines the effect of the ACA on revascularization vs amputation rates in patients presenting with CTLI in Maryland. METHODS: This was a retrospective analysis of the Maryland State Inpatient Database comparing the rate of revascularization to rate of major amputation in patients presenting with CLTI over 2 periods: pre-ACA (2007-2009) and post-ACA (2018-2020). In this study, we included patients presenting with CLTI and underwent a major amputation or revascularization during that same admission. Using regression analysis, we estimated the odds of revascularization vs amputation pre- and post-ACA implementation, adjusting for pertinent variables. RESULT: During the study period, 12,131 CLTI patients were treated. Post-ACA, revascularization rate increased from 43.9% to 77.4% among patients presenting with CLTI. This was associated with a concomitant decrease in the proportion of CLTI patients undergoing major amputation from 56.1% to 22.6%. In the multivariate analysis, there was a 4-fold odds of revascularization among patients with CLTI compared to amputation (OR = 4.73, 95% CI 4.34-5.16) post-ACA. This pattern was seen across all insurance groups. CONCLUSION: The post-ACA period in Maryland was associated with an increased revascularization rate for patients presenting with CLTI with overall benefits across all insurance types.

Preliminary evaluation of home-delivered meals for reducing frailty in older adults at risk for mal-nutrition.

OBJECTIVE: To examine the potential benefit of home-delivered meals for reducing frailty levels among community-dwelling older adults at risk for malnutrition. DESIGN: A retrospective, single-group observational approach. SETTING: One large home-delivered meal agency in the Midwest United States. PARTICIPANTS: 1090 community-dwelling older adults who received home-delivered meal services, funded through the Older Americans Act, between June 2020 and December 2021. MEASUREMENT: Frailty status was measured by the Home Care Frailty Scale (HCFS) which was routinely administered by agency staff to home-delivered meal clients as part of a quality improvement project. The HCFS was administered at the start of meal services, 3-months after meals began, and 6-months after meals began. RESULTS: At baseline, 55.4% of clients were found to be at high risk for malnutrition. While there was a significant and consistent decline in HCFS throughout the follow-up period for both high and low nutritional risk groups, the reduction in frailty from baseline to 6-months was greater for the high nutritional risk group (Δ = -1.9; 95% CI: [-2.7, -1.1]; p < 0.001) compared to those with low nutritional risk (Δ = -1.5; 95% CI: [-2.3, -0.7]; p < 0.001). Compared to those who lived alone, clients who lived with other individuals presented with higher levels of frailty at baseline and 3-month follow-up for both low and high malnutrition risk groups. CONCLUSION: Home-delivered meal clients are commonly at risk for both frailty and malnutrition. Home-delivered meal programs, which are intended to reduce malnutrition among older adults, may serve as a promising solution for reducing frailty in the vulnerable aging population.

Eye Adult Changes in Thought (Eye ACT) Study: Design and Report on the Inaugural Cohort.

Background: Conflicting research on retinal biomarkers of Alzheimer's disease and related dementias (AD/ADRD) is likely related to limited sample sizes, study design, and protocol differences. Objective: The prospective Eye Adult Changes in Thought (Eye ACT) seeks to address these gaps. Methods: Eye ACT participants are recruited from ACT, an ongoing cohort of dementia-free, older adults followed biennially until AD/ADRD, and undergo visual function and retinal imaging assessment either in clinic or at home. Results: 330 participants were recruited as of 03/2023. Compared to ACT participants not in Eye ACT (N = 1868), Eye ACT participants (N = 330) are younger (mean age: 70.3 versus 71.2, p = 0.014), newer to ACT (median ACT visits since baseline: 3 versus 4, p < 0.001), have more years of education (17.7 versus 16.2, p < 0.001) and had lower rates of visual impairment (12% versus 22%, p < 0.001). Compared to those seen in clinic (N = 300), Eye ACT participants seen at home (N = 30) are older (77.2 versus 74.9, p = 0.015), more frequently female (60% versus 49%, p = 0.026), and have significantly worse visual acuity (71.1 versus 78.9 Early Treatment Diabetic Retinopathy Study letters, p < 0.001) and contrast sensitivity (-1.9 versus -2.1 mean log units at 3 cycles per degree, p = 0.002). Cognitive scores and retinal imaging measurements are similar between the two groups. Conclusions: Participants assessed at home had significantly worse visual function than those seen in clinic. By including these participants, Eye ACT provides a unique longitudinal cohort for evaluating potential retinal biomarkers of dementia.

Health Information System Strengthening During Antenatal Care in Haiti: Continuous Quality Improvement Study.

BACKGROUND: Journey to 9 Plus (J9) is an integrated reproductive, maternal, neonatal, and child health approach to care that has at its core the goal of decreasing the rate of maternal and neonatal morbidity and mortality in rural Haiti. For the maximum effectiveness of this program, it is necessary that the data system be of the highest quality. OpenMRS, an electronic medical record (EMR) system, has been in place since 2013 throughout a tertiary referral hospital, the Hôpital Universitaire de Mirebalais, in Haiti and has been expanded for J9 data collection and reporting. The J9 program monthly reports showed that staff had limited time and capacity to perform double charting, which contributed to incomplete and inconsistent reports. Initial evaluation of the quality of EMR data entry showed that only 18% (58/325) of the J9 antenatal visits were being documented electronically at the start of this quality improvement project. OBJECTIVE: This study aimed to improve the electronic documentation of outpatient antenatal care from 18% (58/325) to 85% in the EMR by J9 staff from November 2020 to September 2021. The experiences that this quality improvement project team encountered could help others improve electronic data collection as well as the transition from paper to electronic documentation within a burgeoning health care system. METHODS: A continuous quality improvement strategy was undertaken as the best approach to improve the EMR data collection at Hôpital Universitaire de Mirebalais. The team used several continuous quality improvement tools to conduct this project: (1) a root cause analysis using Ishikawa and Pareto diagrams, (2) baseline evaluation measurements, and (3) Plan-Do-Study-Act improvement cycles to document incremental changes and the results of each change. RESULTS: At the beginning of the quality improvement project in November 2020, the baseline data entry for antenatal visits was 18% (58/325). Ten months of improvement strategies resulted in an average of 89% (272/304) of antenatal visits documented in the EMR at point of care every month. CONCLUSIONS: The experiences that this quality improvement project team encountered can contribute to the transition from paper to electronic documentation within burgeoning health care systems. Essential to success was having a strong and dedicated nursing leadership to transition from paper to electronic data and motivated nursing staff to perform data collection to improve the quality of data and thus, the reports on patient outcomes. Engaging the nursing team closely in the design and implementation of EMR and quality improvement processes ensures long-term success while centering nurses as key change agents in patient care systems.

Neuropsychology intervention for managing invisible symptoms of MS (NIMIS-MS) group: A pilot effectiveness and acceptability study.

BACKGROUND: People with MS (pwMS) commonly experience a range of hidden symptoms, including cognitive impairment, anxiety and depression, fatigue, pain, and sensory difficulties. These "invisible" symptoms can significantly impact wellbeing, relationships, employment and life goals. We developed a novel bespoke online group neuropsychological intervention combining psychoeducation and cognitive rehabilitation with an Acceptance and Commitment Therapy (ACT)-informed approach for pwMS in an acute tertiary hospital. This 'Neuropsychological Intervention for Managing Invisible Symptoms' in MS (NIMIS-MS) consisted of 6 sessions, each with a psychoeducation and ACT component. The content included psychoeducation around managing cognitive difficulties, fatigue, pain, sleep and other unpleasant sensations in MS with the general approach of understanding, monitoring, and recognising patterns and potential triggers. Specific cognitive rehabilitation and fatigue management strategies were introduced. The ACT-informed component focussed on three core ACT areas of the 'Triflex' of psychological flexibility (Harris, 2019): Being Present, Opening Up, and Doing What Matters. METHODS: 118 pwMS attended the NIMIS-MS group intervention which was delivered 14 times in six-week blocks over an 18-month period. To evaluate the effectiveness and acceptability, participants completed measures of depression and anxiety (HADS), functional impairment (WSAS), Values- Progress (VQ) and Values- Obstruction (VQ), and Acceptance of MS (MSAS) pre and post NIMIs-MS group intervention. Qualitative feedback was obtained during focus groups after the final session and via online feedback questionnaires RESULTS: Pre-post analysis showed that symptoms of depression and anxiety were significantly lower and acceptance of MS was significantly higher following completion of the NIMIS-MS group. Qualitative feedback showed that participants reported that they felt more equipped to manage the "invisible" symptoms of MS following completion of the group, and benefited from using ACT-based strategies and techniques. Participants highly valued the peer support that evolved during the NIMIS-MS groups. The online format was considered more accessible than in-person groups, due to less concerns of travel time, cost, fatigue, and comfort and infection. CONCLUSION: Evaluation suggests that our novel NIMIS-MS groups is an acceptable, beneficial and feasible approach for providing neuropsychological interventions to individuals with MS.

Inaccuracies in provider directories persist for long periods of time.

A growing literature has identified substantial inaccuracies in consumer-facing provider directories, but it is unclear how long these inaccuracies persist. We re-surveyed inaccurately listed Pennsylvania providers (n = 5170) between 117 to 280 days after a previous secret-shopper survey. Overall, 19.0% (n = 983) of provider directory listings that had been identified as inaccurate were subsequently removed, 44.8% (n = 2316) of provider listings continued to show at least 1 inaccuracy, and 11.6% (n = 600) were accurate at follow-up. We were unable to reach 24.6% (n = 1271) of providers. Longer passage of time was associated with reductions in directory inaccuracies, particularly related to contact information, and to a lesser degree, with removal of inaccurate listings. We found substantial differences in corrective action by carrier. Together, these findings suggest persistent barriers to maintaining and updating provider directories, with implications for how well these tools can help consumers select health plans and access care.

The activation of Chlamydomonas reinhardtii alpha amylase 2 by glutamine requires its N-terminal aspartate kinase-chorismate mutase-tyrA (ACT) domain.

The coordination of assimilation pathways for all the elements that make up cellular components is a vital task for every organism. Integrating the assimilation and use of carbon (C) and nitrogen (N) is of particular importance because of the high cellular abundance of these elements. Starch is one of the most important storage polymers of photosynthetic organisms, and a complex regulatory network ensures that biosynthesis and degradation of starch are coordinated with photosynthetic activity and growth. Here, we analyzed three starch metabolism enzymes of Chlamydomonas reinhardtii that we captured by a cyclic guanosine monophosphate (cGMP) affinity chromatography approach, namely, soluble starch synthase STA3, starch-branching enzyme SBE1, and α-amylase AMA2. While none of the recombinant enzymes was directly affected by the presence of cGMP or other nucleotides, suggesting an indirect binding to cGMP, AMA2 activity was stimulated in the presence of L-glutamine (Gln). This activating effect required the enzyme's N-terminal aspartate kinase-chorismate mutase-tyrA domain. Gln is the first N assimilation product and not only a central compound for the biosynthesis of N-containing molecules but also a recognized signaling molecule for the N status. Our observation suggests that AMA2 might be a means to coordinate N and C metabolism at the enzymatic level, increasing the liberation of C skeletons from starch when high Gln levels signal an abundance of assimilated N.

Health Care Fraud and Abuse: Lessons From One of the Largest Scandals of the 21st Century in the Field of Spine Surgery.

Up to hundreds of billions of dollars are annually lost to fraud and abuse in the US health care, making it a significant burden on the system. This study investigates a specific instance of health care fraud in spine surgery, in which a medical device company ended up paying $75 million to settle violations of the False Claims Act. We review the surgical background regarding the kyphoplasty procedure, as well as its billing and reimbursement details. We also explore the official legal complaint brought by the US Department of Justice to tell the story of how one of the most significant medical innovations in spine surgery in the 21st century turned into a widespread fraudulent marketing scheme. In the sequence, we provide a detailed root cause analysis of this scandal and propose some proactive measures that can be taken to avoid such type of unfortunate events. Ultimately, this historical health care scandal constitutes a valuable lesson to surgeons, health care administrators, medical device companies, and policymakers on how misaligned incentives and subsequent unscrupulous practices can transform a medical innovation into an unfortunate tale of fraud and deceit.