The Health Care Financing Administration is sponsoring the Medicare Physician Preferred Provider Organization (PPO) Demonstration to assess the feasibility and desirability of including a PPO option under Medicare. Two sites are currently operational. At one site, Blue Cross and Blue Shield of Arizona is offering a PPO linked with a medigap insurance plan. This "medigap PPO" and its initial experience are described, and a preliminary assessment of the viability and effectiveness of medigap PPOs nationally is provided. Impediments to the development and effectiveness of medigap PPOs are identified and possible government actions discussed. 相似文献
European Archives of Psychiatry and Clinical Neuroscience - Intermittent theta burst stimulation (iTBS) is a novel treatment approach for post-traumatic stress disorder (PTSD), and recent... 相似文献
Given the paucity of reliable predictors of tumor recurrence, progression, or response to somatostatin receptor ligand (SRL) therapy in acromegaly, we attempted to determine whether preoperative MR image texture was predictive of these clinical outcomes. We also determined whether image texture could differentiate somatotroph adenomas from non-functioning pituitary adenomas (NFPAs).
Methods
We performed a retrospective study of patients with acromegaly due to a macroadenoma who underwent transsphenoidal surgery at our institution between 2007 and 2015. Clinical data were extracted from electronic medical records. MRI texture analysis was performed on preoperative non-enhanced T1-weighted images using ImageJ (NIH). Logistic and Cox models were used to determine if image texture parameters predicted outcomes.
Results
Eighty-nine patients had texture parameters measured, which were compared to that of NFPAs, while 64 of these patients had follow-up and were included in the remainder of analyses. Minimum pixel intensity, skewness, and kurtosis were significantly different in somatotroph adenomas versus NFPAs (area under the receiver operating characteristic curve, 0.7771, for kurtosis). Furthermore, those with a maximum pixel intensity above the median had an increased odds of IGF-I normalization on SRL therapy (OR 5.96, 95% CI 1.33–26.66), which persisted after adjusting for several potential predictors of response. Image texture did not predict tumor recurrence or progression.
Conclusion
Our data suggest that MRI texture analysis can distinguish NFPAs from somatotroph macroadenomas with good diagnostic accuracy and can predict normalization of IGF-I with SRL therapy.
Children with early surgery for congenital heart disease (CHD) are known to have impaired neurodevelopment; their performance on school-age achievement tests and their need for special education remains largely unexplored. The study aimed to determine predictors of academic achievement at school age and placement in special education services among early CHD surgery survivors. Children with CHD surgery at <1 year of age from January 1, 1998 to December 31, 2003, at the Arkansas Children’s Hospital were identified. Out-of-state births and infants with known genetic and/or neurologic conditions were excluded. Infants were matched to an Arkansas Department of Education database containing standardized assessments at early school age and special-education codes. Predictors for achieving proficiency in literacy and mathematics and the receipt of special education were determined. Two hundred fifty-six children who attended Arkansas public schools and who had surgery as infants were included; 77.7 % had either school-age achievement-test scores or special-education codes of mental retardation or multiple disabilities. Scores on achievement tests for these children were 7–13 % lower than those of Arkansas students (p < 0.01). They had an eightfold increase in receipt of special education due to multiple disabilities [odds ratio (OR) 10.66, 95 % confidence interval (CI) 4.23–22.35] or mental retardation (OR 4.96, 95 % CI 2.6–8.64). Surgery after the neonatal period was associated with decreased literacy proficiency, and cardiopulmonary bypass during the first surgery was associated with decreased mathematics proficiency. Children who had early CHD surgery were less proficient on standardized school assessments, and many received special education. This is concerning because achievement-test scores at school age are “real-world” predictors of long-term outcomes. 相似文献
BACKGROUND: There is no universally accepted instrument that can be used to evaluate changes in self-reported physical function for individuals with leg, ankle, and foot musculoskeletal disorders. The objective of this study was to develop an instrument to meet this need: the Foot and Ankle Ability Measure (FAAM). Additionally, this study was designed to provide validity evidence for interpretation of FAAM scores. METHODS: Final item reduction was completed using item response theory with 1027 subjects. Validity evidence was provided by 164 subjects that were expected to change and 79 subjects that were expected to remain stable. These subjects were given the FAAM and SF-36 to complete on two occasions 4 weeks apart. RESULTS: The final version of the FAAM consists of the 21-item activities of daily living (ADL) and 8-item Sports subscales, which together produced information across the spectrum ability. Validity evidence was provided for test content, internal structure, score stability, and responsiveness. Test retest reliability was 0.89 and 0.87 for the ADL and Sports subscales, respectively. The minimal detectable change based on a 95% confidence interval was +/-5.7 and +/--12.3 points for the ADL and Sports subscales, respectively. Two-way repeated measures ANOVA and ROC analysis found both the ADL and Sports subscales were responsive to changes in status (p < 0.05). The minimal clinically important differences were 8 and 9 points for the ADL and Sports subscales, respectively. Guyatt responsive index and ROC analysis found the ADL subscale was more responsive than general measures of physical function while the Sports subscale was not. The ADL and Sport subscales demonstrated strong relationships with the SF-36 physical function subscale (r = 0.84, 0.78) and physical component summary score (r = 0.78, 0.80) and weak relationships with the SF-36 mental function subscale (r = 0.18, 0.11) and mental component summary score (r = 0.05, -0.02). CONCLUSIONS: The FAAM is a reliable, responsive, and valid measure of physical function for individuals with a broad range of musculoskeletal disorders of the lower leg, foot, and ankle. 相似文献