Medicaid and state health care reform: process, programs, and policy options

Health care reform is a continuously evolving process. The States and the Federal Government have struggled with policy issues to combat escalating Medicaid expenditures while ensuring access and quality of care to an ever-expanding population. In the absence of national health care reform, States are increasingly relying on Federal waivers to develop innovative approaches to address a myriad of issues associated with the present health care delivery system. This article provides a summary of State health care reform efforts that have been initiated under Federal waiver authority.     

Influencing medical student choice of primary care worldwide: international application of the four pillars for primary care physician workforce

Primary care is a crucial part of a functional health care system, though in many parts of the world there are current or projected gaps in the primary care physician workforce. The academic family medicine organizations in the United States (US) developed the “Four Pillars for Primary Care Physician Workforce,” a model built on decades of research, highlighting four main areas of emphasis for increasing primary care physician output: 1) pipeline; 2) process of medical education; 3) practice transformation; and 4) payment reform. This commentary proposes that this model, although developed in the US context, is applicable in other medical education settings, including Israel, based on the recently reported findings of Weissman and colleagues in this journal.     

Emergence of West Nile virus lineage 2 in Europe: Characteristics of the first seven cases of West Nile neuroinvasive disease in horses in Austria

We report details of the first seven equine cases of confirmed West Nile neuroinvasive disease in Austria. The cases presented during summer and autumn of 2016 (n = 2), 2017 (n = 3) and 2018 (n = 2). All horses showed gait abnormalities and 6 of 7 horses exhibited fasciculations and/or tremors, and we provide video recordings of these. Three horses also showed cranial nerve involvement. Following rapid improvement, three horses were discharged. Four horses were euthanized due to the severity of clinical signs and subjected to neuropathological examination. West Nile virus (WNV) lineage 2 nucleic acid was detected in 5 of 7 horses, and WNV‐specific neutralizing antibodies in all 7 horses. In addition, serologic evidence of WNV infection was found in two out of fourteen in‐contact horses. Horses may be considered a sentinel species for human WNV infections, integrating human and veterinary medicine and thus contributing to the one health concept.     

High volume hemofiltration improves right ventricular function in endotoxin-induced shock in the pig

This study assessed the influence of continuous high volume hemofiltration on right ventricular function of pigs with endotoxin induced shock. Eighteen anesthetized and ventilated pigs were studied for 240 min after the start of infusion of 0.5 mg/kg endotoxin over 30 min. Right ventricular ejection fraction (RVEF) was measured by rapid response thermodilution technique. After endotoxin infusion, the pigs were randomly divided into 3 groups: group 1 as a control group, receiving endotoxin only, group 2 to observe the effects of zero balance high volume veno-venous hemofiltration with removal of ultrafiltrate at a rate of 6000 ml/h, and group 3 to evaluate the effect of the extracorporeal circuit itself on RVEF. The decline of RVEF in group 2 was less than in group 1 (0.04±0.02 vs 0.21±0.03 (mean±SEM);p<0.001). The decline of RVEF in group 3 (0.24±0.02) was more pronounced than that in group 1 (p<0.05). The differences in the course of RVEF between group 1 and group 2 could not be explained by differences in heart rate, preload or afterload. Cardiac output and mean arterial pressure were significantly higher in group 2 than in group 1 (p<0.01). It is concluded that in this model, high volume hemofiltration improves RVEF and cardiac performance by removal of vasoactive mediators, responsible for myocardial depression.     

An assessment of polymorphonuclear leukocyte rigidity in HIV-infected individuals after immune recovery

PURPOSE: To determine whether polymorphonuclear leukocytes (PMNs) remain rigid after immune reconstitution in human immunodeficiency virus (HIV)-infected individuals with a history of severe immunosuppression. METHODS: PMN rigidity was measured in vitro in three groups: (1) HIV-infected individuals with a history of CD4+ T-lymphocyte counts of less than 50/microL, but with current counts of more than 200/microL attributable to potent antiretroviral therapy (group 1); (2) HIV-infected individuals whose CD4+ T-lymphocyte counts had always been more than 200/microL (group 2); and (3) HIV-negative control subjects. Rigidity was determined with a cell transit analyzer (containing a micropore filter with 30 identical, 8-microm diameter pores), representing a simple in vitro model of a capillary bed. A longer PMN pore transit time reflects increased PMN rigidity. RESULTS: PMN transit time (median) in group 1 (n = 11) was 3.34 ms, in group 2 (n = 9) was 3.19 ms, and in control subjects (n = 15) was 2.66 ms. PMN rigidity was significantly greater in groups 1 (P = 0.014) and 2 (P = 0.046) than in control subjects (Wilcoxon rank-sum test). A significant difference was not identified between groups 1 and 2 (P = 0.518). CONCLUSIONS: The increased PMN rigidity known to occur in severely immunosuppressed HIV-infected individuals persists after immune reconstitution. Furthermore, PMN rigidity is increased in those HIV-infected individuals who do not have a history of severe immunosuppression. Because PMN rigidity can alter microvascular blood flow, HIV-infected individuals may remain at risk for retinal vascular damage in the era of potent antiretroviral therapy.     

Correlation between midazolam and lignocaine pharmacokinetics and MEGX formation in healthy volunteers

AIMS: The objectives of the present investigation were: (a) to determine the correlation between lignocaine and midazolam pharmacokinetics following intravenous administration in healthy volunteers, (b) to determine the effects of treatment with an inhibitor of CYP3A4 (erythromycin) on this correlation and (c) to assess the precision of the MEGX-test as a sole predictor of lignocaine and midazolam pharmacokinetics. METHODS: The study was conducted in four male and four female healthy volunteers, aged between 21 and 26 years, who received 1 mg kg-1 lignocaine HCl i.v. on days 1, 3, 5, 9 and 10 of the investigation. On days 5 and 10 they also received midazolam, 0.075 mg kg-1 i.v. and from days 6-10 they took erythromycin 500 mg orally, four times daily. Following administration of lignocaine and midazolam, frequent venous blood samples were obtained for determination of the concentrations of lignocaine, MEGX and midazolam. RESULTS: In the absence of erythromycin a statistically significant linear correlation was observed between the clearance of lignocaine and midazolam (CL(midazolam)= 0.41 x CL(lignocaine)+ 1.2; r(2) = 0.857; P < 0.001). Erythromycin cotreatment resulted in a loss of the correlation between the two clearances (r(2) = 0.39; P = 0.1). Erythromycin caused a statistically significant reduction in midazolam clearance from the original value of 3.8 to 2.5 (95% CI for the difference -2.27, -0.35) ml kg-1 min-1. Interestingly there was no significant change in the clearance of lignocaine (6.4 vs 5.8 (95% CI for the difference -2.74, -1.51) ml kg-1 min-1). Furthermore no correlation at all was observed between the MEGX-test and lignocaine or midazolam clearances. Considering the data on day 1, 3 and 5 the intra-individual coefficient of variation in the MEGX-test was 45.3% at 15 min and 23.5% at 30 min, respectively. CONCLUSIONS: It is concluded that there is a significant correlation between lignocaine and midazolam clearances but this correlation is lost after CYP3A4 inhibition by erythromycin. The MEGX-test is of no value in assessing intra- and inter-individual variability in midazolam clearance.     

Child mental health in Latin America: present and future epidemiologic research

OBJECTIVE: This report reviews population studies of child and adolescent mental health carried out in Latin America over the past 15 years. Also considered is the issue of how to meet the needs of children and adolescents who may present mental health problems in Latin America, given that most of them live in poverty in economies that are underdeveloped, providing limited resources. METHOD: Ten studies from six different countries were identified that employed some form of randomized sampling method and used standardized instruments for assessment. The authors present a summary of the main characteristics of these studies, highlighting methodological features that may account for differences in the rates obtained. RESULTS: Overall, a similar pattern of prevalence and risk factors for mental health problems in children and adolescents in Latin American countries emerged. Moreover, rates of disorders in these children are similar to the 15 to 20% found in other countries. These findings are similar to those observed when adult mental health problems are considered. Prevention and treatment strategies are discussed and the peculiarities of the delivery of mental health services for children and adolescents are explored. CONCLUSIONS: Future research needs to focus on understanding of resilience and formal and informal mental health delivery systems of care available in different Latin American countries. Such research has high potential for ameliorating the prevention and treatment of child and adolescent mental health problems in this region of the world.