Strategic Provider Behavior Under Global Budget Payment with Price Adjustment in Taiwan

Global budget payment is one of the most effective strategies for cost containment, but its impacts on provider behavior have not been explored in detail. This study examines the theoretical and empirical role of global budget payment on provider behavior. The study proposes that global budget payment with price adjustment is a form of common‐pool resources. A two‐product game theoretic model is derived, and simulations demonstrate that hospitals are expected to expand service volumes, with an emphasis on products with higher price–marginal cost ratios. Next, the study examines the early effects of Taiwan's global budget payment system using a difference‐in‐difference strategy and finds that Taiwanese hospitals exhibited such behavior, where the pursuit of individual interests led to an increase in treatment intensities. Furthermore, hospitals significantly increased inpatient service volume for regional hospitals and medical centers. In contrast, local hospitals, particularly for those without teaching status designation, faced a negative impact on service volume, as larger hospitals were better positioned to induce demand and pulled volume away from their smaller counterparts through more profitable services and products such as radiology and pharmaceuticals. Copyright © 2014 John Wiley & Sons, Ltd.     

Novel Reassortant Influenza A(H5N8) Viruses among Inoculated Domestic and Wild Ducks,South Korea, 2014

An outbreak of highly pathogenic avian influenza, caused by a novel reassortant influenza A (H5N8) virus, occurred among poultry and wild birds in South Korea in 2014. The aim of this study was to evaluate the pathogenesis in and mode of transmission of this virus among domestic and wild ducks. Three of the viruses had similar pathogenicity among infected domestic ducks: the H5N8 viruses were moderately pathogenic (0%–20% mortality rate); in wild mallard ducks, the H5N8 and H5N1 viruses did not cause severe illness or death; viral replication and shedding were greater in H5N8-infected mallards than in H5N1-infected mallards. Identification of H5N8 viruses in birds exposed to infected domestic ducks and mallards indicated that the viruses could spread by contact. We propose active surveillance to support prevention of the spread of this virus among wild birds and poultry, especially domestic ducks.     

Implementing Adolescent Screening,Brief Intervention,and Referral to Treatment (SBIRT) Education in a Pediatric Residency Curriculum

Background: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care for adolescents as well as adults. In an effort to promote universal SBIRT, the Substance Abuse and Mental Health Services Administration awarded funding to residency programs to develop and implement SBIRT education and training. Our project focused on creating scientifically based, developmentally appropriate strategies and teaching materials for the adolescent age range. This paper describes curriculum development and implementation and presents evaluation data. Methods: Pediatric and child psychiatry residents were trained. The training consisted of 4 activities: (1) case-based teaching modules, (2) role-play of motivational interviewing and brief interventions, (3) mock interviews with trained adolescents, and (4) supervised “hands-on” screening and brief interventions. Main outcome measures included trainee satisfaction, and SBIRT knowledge, perceived self-efficacy, and self- and observer report of use of the SBIRT algorithm. Results: Among 150 total participants completing the SBIRT training modules, nearly all (92.3%) were satisfied/very satisfied with the training modules. Knowledge accuracy immediately post training was high, but declined significantly by the end of the first residency year, with little change across subsequent years of residency. Confidence ratings also declined over time. Use of the SBIRT algorithm during the Adolescent Medicine rotation was high according to trainee self- and faculty observer report. Conclusions: We found evidence of training satisfaction, increased confidence in talking to adolescents about substance use, and widespread use of recommended practices immediately following training. Use of a highly structured algorithm to guide practice, and simple, highly structured brief interventions was a successful training approach, as residents self-reported accurate use of the SBIRT algorithm immediately after training. Knowledge and self-confidence declined over time. It is possible that “booster” sessions and ongoing opportunities to review materials could help residents retain knowledge and skills.     

Vida PURA: A Cultural Adaptation of Screening and Brief Intervention to Reduce Unhealthy Drinking Among Latino Day Laborers

Background: Brief intervention is known to reduce drinking in primary care; however, because health care access is limited for Latino immigrants, traditional brief interventions are unlikely to reach this population. Methods: Using Barrera and Castro's framework, our study aims to culturally adapt a screening and brief intervention program to reduce unhealthy alcohol use among Latino day laborers, a particularly vulnerable group of Latino immigrant men. We conducted 18 interviews with Latino day laborers and 13 interviews with mental health and substance use providers that serve Latino immigrant men. Interviews were conducted until saturation of themes was reached. Themes from interviews were used to identify sources of mismatch between traditional screening and brief intervention in our target population. Results: Unhealthy alcohol use was common, culturally accepted, and helped relieve immigration-related stressors. Men had limited knowledge about how to change their behavior. Men preferred to receive information from trusted providers in Spanish. Men faced significant barriers to accessing health and social services but were open to receiving brief interventions in community settings. Findings were used to design Vida PURA, a preliminary adaptation design of brief intervention for Latino day laborers. Key adaptations include brief intervention at a day labor worker center provided by promotores trained to incorporate the social and cultural context of drinking for Latino immigrant men. Conclusions: Culturally adapted brief intervention may help reduce unhealthy drinking in this underserved population.     

超声内镜对胆总管小结石的诊断价值

为评估超声内镜检查术（endoscopic ultrasonography,EUS）对胆总管小结石的诊断价值,纳入2018年1月—2021年7月在东南大学附属中大医院住院并诊断为可疑胆总管结石的患者60例。所有患者于同一次住院期间行EUS及磁共振胰胆管成像（magnetic resonance cholangiopancreatography,MRCP）。以经内镜逆行胰胆管造影、开腹探查或腹腔镜胆总管探查结果为金标准,比较EUS及MRCP对胆总管结石的诊断结果,计算2种检查方法的灵敏度、特异度、阳性预测值、阴性预测值。结果显示,60例患者中46例确诊胆总管结石,EUS诊断准确43例,MRCP诊断准确35例;14例患者证实胆总管结石阴性,EUS诊断准确12例,MRCP诊断准确13例。EUS诊断灵敏度明显高于MRCP［93.48%（43/46）比76.09%（35/46）,χ2=4.128,P=0.042］。结石直径≤1.0 cm者45例,其中EUS确诊42例,MRCP确诊34例（诊断准确率93.33%比75.56%,χ2=4.145,P=0.042）;直径≤0.8 cm者39例,其中EUS确诊36例,MRCP确诊28例（诊断准确率92.31%比71.79%,χ2=4.266,P=0.039）;直径≤0.5 cm者26例,其中EUS确诊24例,MRCP确诊16例（诊断准确率92.31%比61.54%,χ2=5.038,P=0.021）。在胆总管结石的诊断方面,EUS有明显的诊断优势,且诊断准确性不受结石大小的影响,因此对于临床高度怀疑胆总管结石但MRCP结果阴性的患者,需进一步行EUS。     

Cholangiocyte endothelin 1 and transforming growth factor beta1 production in rat experimental hepatopulmonary syndrome

BACKGROUND & AIMS: Hepatic production and release of endothelin 1 plays a central role in experimental hepatopulmonary syndrome after common bile duct ligation by stimulating pulmonary endothelial nitric oxide production. In thioacetamide-induced nonbiliary cirrhosis, hepatic endothelin 1 production and release do not occur, and hepatopulmonary syndrome does not develop. However, the source and regulation of hepatic endothelin 1 after common bile duct ligation are not fully characterized. We evaluated the sources of hepatic endothelin 1 production after common bile duct ligation in relation to thioacetamide cirrhosis and assessed whether transforming growth factor beta1 regulates endothelin 1 production. METHODS: Hepatopulmonary syndrome and hepatic and plasma endothelin 1 levels were evaluated after common bile duct ligation or thioacetamide administration. Cellular sources of endothelin 1 were assessed by immunohistochemistry and laser capture microdissection of cholangiocytes. Transforming growth factor beta1 expression and signaling were assessed by using immunohistochemistry and Western blotting and by evaluating normal rat cholangiocytes. RESULTS: Hepatic and plasma endothelin 1 levels increased and hepatopulmonary syndrome developed only after common bile duct ligation. Hepatic endothelin 1 and transforming growth factor beta1 levels increased over a similar time frame, and cholangiocytes were a major source of each peptide. Transforming growth factor beta1 signaling in cholangiocytes in vivo was evident by increased phosphorylation and nuclear localization of Smad2, and hepatic endothelin 1 levels correlated directly with liver transforming growth factor beta1 and phosphorylated Smad2 levels. Transforming growth factor beta1 also stimulated endothelin 1 promoter activity, expression, and production in normal rat cholangiocytes. CONCLUSIONS: Cholangiocytes are a major source of hepatic endothelin 1 production during the development of hepatopulmonary syndrome after common bile duct ligation, but not in thioacetamide-induced cirrhosis. Transforming growth factor beta1 stimulates cholangiocyte endothelin 1 expression and production. Cholangiocyte-derived endothelin 1 may be an important endocrine mediator of experimental hepatopulmonary syndrome.     

Determinants of Intima-Media Thickness in the Young: The ALSPAC Study

ObjectivesThis study characterized the determinants of carotid intima-media thickness (cIMT) in a large (n > 4,000) longitudinal cohort of healthy young people age 9 to 21 years.BackgroundGreater cIMT is commonly used in the young as a marker of subclinical atherosclerosis, but its evolution at this age is still poorly understood.MethodsAssociations between cardiovascular risk factors and cIMT were investigated in both longitudinal (ages 9 to 17 years) and cross-sectional (ages 17 and 21 years) analyses, with the latter also related to other measures of carotid structure and stress. Additional use of ultra-high frequency ultrasound in the radial artery at age 21 years allowed investigation of the distinct layers (i.e., intima or media) that may underlie observed differences.ResultsFat-free mass (FFM) and systolic blood pressure were the only modifiable risk factors positively associated with cIMT (e.g., mean difference in cIMT per 1-SD increase in FFM at age 17: 0.007 mm: 95% confidence interval [CI]: 0.004 to 0.010; p < 0.001), whereas fat mass was negatively associated with cIMT (difference: ?0.0032; 95% CI: 0.004 to ?0.001; p = 0.001). Similar results were obtained when investigating cumulative exposure to these factors throughout adolescence. An increase in cIMT maintained circumferential wall stress in the face of increased mean arterial pressure when increases in body mass were attributable to increased FFM, but not fat mass. Risk factor?associated differences in the radial artery occurred in the media alone, and there was little evidence of a relationship between intimal thickness and any risk factor.ConclusionsSubtle changes in cIMT in the young may predominantly involve the media and represent physiological adaptations as opposed to subclinical atherosclerosis. Other vascular measures may be more appropriate for the identification of arterial disease before adulthood.     

Prevalence and potential predictors of gambling disorder among people living with HIV

Specific subsets of the adult population are at an increased risk of problem gambling behaviors. Previous research among these subsets has found increased rates of disordered gambling among those with drug use, alcohol use, mood, anxiety, and personality disorders. To what extent this may apply to the HIV population, known to have a high burden of co-occurring substance use and mental disorders, is not known The current study also examined the effectiveness of The Brief Biosocial Gambling Screen (BBGS) for the diagnosis of gambling disorder.

This study examined the prevalence of gambling behaviors and disordered gambling in patients enrolled in an urban HIV clinic. 100 people living with HIV (PLWH) were assessed on gambling behaviors, impulsivity, and criterion on disordered gambling. Screening for gambling disorder using the BBGS was compared to the American Psychiatric Association DSM-5 criterion.

The mean age was 53, 44% were female, 60% completed high school or above, and 80% self-identified as unemployed/disabled. 13% met four or more criteria for gambling disorder according to DSM-5 criteria. Participants that met criteria were more likely to report marijuana (p?=?.044) and heroin (p?=?.002) use, and greater impulsivity (p?<?0.00001) when compared to participants who did not meet criteria. The BBGS was able to effectively screen individuals for disordered gambling with a sensitivity of 100%, specificity of 90.8%, positive predictive value of 56.2%, and a negative predictive value of 100%.

These results suggest that urban HIV clinics may need to consider actively screening for gambling disorders, and referring to appropriate counseling and treatment for those who screen positive.     

Working memory capacity and addiction treatment outcomes in adolescents

Background: Brief addiction treatments including motivational interviewing (MI) have shown promise with adolescents, but the factors that influence treatment efficacy in this population remain unknown. One candidate is working memory, the ability to hold a fact or thought in mind. This is relevant, as in therapy, a client must maintain and manipulate ideas while working with a clinician. Working memory depends upon brain structures and functions that change markedly during neurodevelopment and that can be negatively impacted by substance use.

Objectives: In a secondary analysis of data from a clinical trial for adolescent substance use comparing alcohol/marijuana education and MI, we evaluated the relationship between working memory and three-month treatment-outcomes with the hypothesis that the relationship between intervention conditions and outcome would be moderated by working memory.

Methods: With a diverse sample of adolescents currently using alcohol and/or marijuana (N = 153, 64.7% male, 70.6% Hispanic), we examined the relationship between baseline measures of working memory and alcohol and cannabis-related problem scores measured at the three-month follow-up.

Results: The results showed that lower working memory scores were associated with poorer treatment response only for alcohol use, and only within the education group. No relationship was found between working memory and treatment outcomes in the MI group.

Conclusion: The results suggest that issues with working memory capacity may interfere with adolescents’ ability to process and implement didactic alcohol and marijuana content in standard education interventions. These results also suggest that MI can be implemented equally effectively across the range of working memory functioning in youth.