Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps?

Context

The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year.

Protein oxidation and ageing

Organisms produce reactive oxygen species (ROS) throughout their lives. The activities of a number of key antioxidant enzymes, such as catalase, superoxide dismutase and glutathione peroxidase, which protect against the damaging effects of ROS, have been reported to decrease with increasing age, though this is not unequivocal. In contrast, sacrificial antioxidants such as ascorbate, thiols and tocopherol do not appear to decrease with increasing age. It is also possible that ROS production increases with age as a result of poorer coupling of electron transport components, and an increased level of redox-active metal ions that could catalyse oxidant formation. As a result of this decrease in antioxidant defences, and increased rate of ROS formation, it is possible that the impact of ROS increases with age. ROS are known to oxidise biological macromolecules, with proteins an important target. If the argument that the impact of ROS increases with age is true, then proteins would be expected to accumulate oxidised materials with age, and the rate of such accumulation should increase with time, reflecting impaired inefficiency of homeostasis. Here we review the evidence for the accumulation of oxidised, or modified, extra- and intra-cellular proteins in vivo.     

Microalbuminuria in a population-based study of diabetes.

The prevalence of microalbuminuria in younger-onset diabetic participants in a large population-based study of diabetic retinopathy was determined, and the relationships of microalbuminuria to blood pressure and other risk factors were investigated. Using an agglutination inhibition test (AlbuScreen), the frequency of microalbuminuria was 21.2%. To evaluate the association of several characteristics with the presence of microalbuminuria, multivariate models based on logistic regression were developed. Microalbuminuria was associated with having higher systolic or diastolic blood pressure and higher glycosylated hemoglobin. These findings give further impetus to efforts to reduce controllable risk factors in younger-onset diabetic persons.     

Randomized Trial of Ivabradine in Patients With Hyperadrenergic Postural Orthostatic Tachycardia Syndrome

BackgroundPostural orthostatic tachycardia syndrome (POTS) is a complex, multifaceted disorder that impairs functional status and quality of life. Current pharmacological treatments are limited.ObjectivesThis study investigated the effect of ivabradine (selective blocker of the I_funny channel in the sinoatrial node) on heart rate, quality of life (QOL), and plasma norepinephrine (NE) levels in patients with hyperadrenergic POTS defined by plasma NE >600 pg/ml and abnormal tilt table test.MethodsIn total, 22 patients with hyperadrenergic POTS as the predominant subtype completed a randomized, double-blinded, placebo-controlled, crossover trial with ivabradine. Patients were randomized to start either ivabradine or placebo for 1 month, and then were crossed over to the other treatment for 1 month. Heart rate, QOL, and plasma NE levels were measured at baseline and at the end of each treatment month.ResultsThe average age was 33.9 ± 11.7 years, 95.5% were women (n = 21), and 86.4% were White (n = 23). There was a significant reduction in heart rate between placebo and ivabradine (p < 0.001). Patients reported significant improvements in QOL with RAND 36-Item Health Survey 1.0 for physical functioning (p = 0.008) and social functioning (p = 0.021). There was a strong trend in reduction of NE levels upon standing with ivabradine (p = 0.056). Patients did not experience any significant side-effects, such as bradycardia or hypotension, with ivabradine.ConclusionIvabradine is safe and effective in significantly improving heart rate and QOL in patients with hyperadrenergic POTS as the predominant subtype.     

Effect of cimetidine and sodium bicarbonate on pancreatic replacement therapy in cystic fibrosis.

Fifteen patients with cystic fibrosis and pancreatic insufficiency were studied during four randomised seven day treatment periods in which they received only pancreatic supplement (Pancrelipase, 27 capsules per day) or supplement plus cimetidine (20 mg/kg body weight/24 h) or sodium bicarbonate (15 g/m2/24 h) alone or in combination. Dietary intake was not fixed but was restricted to foods of known fat and nitrogen content from which daily intakes could be computed. Faecal fat and nitrogen were calculated as g/24 h and percentage of intake. Addition of either cimetidine or bicarbonate resulted in significant improvement in fat and nitrogen excretion, which was not greater with the combination of both drugs. Cimetidine and sodium bicarbonate in these doses are therefore sufficient to produce maximal improvement in digestive activity of pancreatic supplements. Fat excretion per gram of intake fell with cimetidine and bicarbonate from 12 times the normal level, to normal, in patients consuming less than 120 g fat daily. Above this intake the dose of pancreatic supplement appeared to be inadequate. Faecal nitrogen excretion increased with nitrogen intake in all four periods, but, in contrast with fat excretion, the response to cimetidine and bicarbonate was not affected by the level of intake. Dietary intake appears to be a significant factor in determining the faecal output of fat and nitrogen in patients with pancreatic insufficiency and should be considered when determining the optimum amount of pancreatic supplementation.     

Inhibin-activin receptor subunit gene expression in ovarian tumors

Granulosa cell tumors of the ovary (GCT) express the inhibin subunit genes and secrete dimeric inhibin. Transgenic mice null for the alpha-inhibin gene develop GCT. It has been suggested that this apparent contradiction may be reconciled if the human GCT are resistant to the tumor-suppressive effects of inhibin. Inhibin receptors have recently been characterized as consisting of either betaglycan or p120 in association with the type II or type I activin receptor subunits (ActR), respectively. To test the hypothesis that GCT may exhibit loss of inhibin receptor expression we have examined the expression of the receptor subunits in a cohort of GCT and in mucinous and serous cystadenocarcinomas and normal ovary. Expression was determined by RT-PCR using gene-specific primers and probes combined with Southern blot analysis of the PCR products. The ActRI subunits and ActRIIA exhibited widespread albeit variable expression across tissues, with the highest levels in the serous tumors. ActRIIB expression was relatively low in the mucinous tumors and high in the GCT. Betaglycan expression was abundant, widespread, and variable across all tissues; highest mean levels occurred in the GCT and normal ovary. p120 expression was low or absent in all tissues except the GCT. Within the GCT there was parallel expression of the ActR subunits, betaglycan and p120; the levels, however, varied considerably between tumors. Expression of betaglycan and p120 in most GCT argues against the hypothesis, but does not exclude the possibility that low or absent expression of p120 might be significant in a subset of these tumors.     

Integrating the Accreditation Council for Graduate Medical Education Core competencies into the model of the clinical practice of emergency medicine

In response to public pressure for greater accountability from the medical profession, a transformation is occurring in the approach to medical education and assessment of physician competency. Over the past 5 years, the Accreditation Council for Graduate Medical Education (ACGME) has implemented the Outcomes and General Competencies projects to better ensure that physicians are appropriately trained in the knowledge and skills of their specialties. Concurrently, the American Board of Medical Specialties, including the American Board of Emergency Medicine (ABEM), has embraced the competency concept. The core competencies have been integral in ABEM's development of Emergency Medicine Continuous Certification and the development of the Model of Clinical Practice of Emergency Medicine (Model).¹ ABEM has used the Model as a significant part of its blueprint for the written and oral certification examinations in emergency medicine and is fully supportive of the effort to more fully define and integrate the ACGME core competencies into training emergency medicine specialists.To incorporate these competencies into our specialty, an Emergency Medicine Competency Taskforce (Taskforce) was formed by the Residency Review Committee–Emergency Medicine to determine how these general competencies fit in the Model.¹ This article represents a consensus of the Taskforce with the input of multiple organizations in emergency medicine. It provides a framework for organizations such as the Council of Emergency Medicine Residency Directors (CORD) and the Society for Academic Emergency Medicine to develop a curriculum in emergency medicine and program requirement revisions by the Residency Review Committee–Emergency Medicine. In this report, we describe the approach taken by the Taskforce to integrate the ACGME core competencies into the Model. Ultimately, as competency-based assessment is implemented in emergency medicine training, program directors, governing bodies such as the ACGME, and individual patients can be assured that physicians are competent in emergency medicine.