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Profit over professionalism: the case of the Medicare Physician Fee Schedule
Get PDFTuesday, April 9, 2024 ; noon to 1 p.m. (Central Time); Room NB2,199A or via Zoom. "Profit Over Professionalism: The Case of the Medicare Physician Fee Schedule". Robert A. Berenson, M.D., Institute Fellow in the Health Policy Center at the Urban Institute.The Centers for Medicare & Medicaid Services (CMS) sets fees for 8000+ service codes that comprise the Medicare Physician Fee Schedule based largely on recommendations by the American Medical Association's Relative Value Update Committee (RUC) through notice-and-comment rulemaking. Under RUC supervision, medical specialty societies and other professional organizations ask members to estimate clinical time and "work" for codes. The RUC process eschews reliance on empirical data but rather relies almost entirely on the estimates from the surveys. Various ethical concerns about this process have arisen: physicians completing the survey may have biased judgments because they and their specialty colleagues directly benefit financially from their judgments and therefore inflate time and work estimates; some physicians describing the actual clinical activities comprising work to inform RUC members from other specialties exaggerate or invent work that they do not actually perform; and the AMA/RUC routinely misrepresents the performance of the RUC in determining accurate RVUs, while keeping much of their work protected from public scrutiny. This presentation describes the fee-setting process and elaborates on the ethical concerns that result in distorted fees, which in turn negatively affects access, quality, and spending for Medicare beneficiaries and the public at large.UT Southwestern--Program in Ethic
Prevention of Alzheimer's Disease Through NHE6 Depletion
No full textCurrently, 1 in 9 people over the age of 65 are living with Alzheimer's disease (AD). The highest genetic risk factor for AD is Apolipoprotein E isoform E4 (ApoE4), which accounts for 40-65% of AD patients. AD is characterized by brain atrophy, synaptic dysfunction, and the accumulation of amyloid and tau proteins. These AD phenotypes are exacerbated in the presence of ApoE4, yet the molecular mechanism remains unknown. To develop therapies for AD, it is of the utmost importance to understand the basic molecular and cellular mechanism by which ApoE4 accelerates AD onset and progression. We have previously identified that ApoE4 halts early endosomal recycling, which subsequently causes synaptic dysfunction and impaired learning and memory. We propose a novel approach for rescuing the ApoE4-mediated impairment in endosomal recycling and synaptic dysfunction by lowering the pH of the early endosomes through inhibition or depletion of the early endosomal proton leak channel Na+/H+ Exchanger 6 (NHE6). The long-term goal of our research is to develop a treatment strategy for ApoE4 carriers during the 10- to 15-year period preceding the onset of clinical symptoms. During this period, patients with preclinical AD start accumulating Abeta plaques in the neocortex. The first aim of my thesis project was to investigate how NHE6 depletion affects Abeta pathology. The second aim was to evaluate any untoward side effects such as neuroinflammation or neuronal loss caused by the complete genetic removal of NHE6. For the last portion of my thesis project, I investigated a translational approach to target NHE6 as a therapeutic strategy by using anti-sense oligonucleotides against NHE6. Overall, the goal of my thesis is to determine if NHE6 is a rational target for delaying and/or preventing AD. The findings from my thesis have provided some underlying mechanisms of how NHE6 reduces Abeta plaque load but also have opened new doors on other avenues we need to explore before moving from preclinical to clinical trials
Mental Health Screening and Promoting Positive Identity Development Among Youth Who Are Refugees: Program Development
Get PDFAppendix C is a copy of a published manuscript, which is cited below. The manuscript presents data from Phase One of the current project.By the summer of 2022, more than 100 million individuals had been forcibly displaced by war, persecution, and unrest across the world (United Nations High Commissioner for Refugees, 2022). the prevalence of mental health and psychosocial needs are well-documented among refugee youth and families, however, there exist many barriers to accessing appropriate services. Universal screening, low-intensity, and strengths-based programs are recommended as initial steps in overcoming some of these barriers.
This study was conducted in partnership with the International Rescue Committee (IRC), a community organization that resettles individuals who are displaced by war or crisis. This partnership was established in 2018, when Phase One of the current project began with qualitative interviews that examined challenges refugee youth and families, from sub-Saharan Africa, face upon resettlement. Interviews expanded our understanding of the psychosocial needs of youth, and highlighted the vulnerability of girls (Woodford et al., in review), and the need to support positive ethnic and cultural identity development (Rial et al., 2021). During the second phase, findings from the interviews informed the development of parallel youth and parent group intervention programs, Culture Connection. These group programs could not be implemented as planned due to COVID.
Alternatively, early discussions with the IRC Youth Program staff revealed the need for mental health screening and strategies to promote positive cultural identity. This offered an opportunity to adapt the original group manual into a briefer intervention, Positive Cultural Identity (PCI), which was delivered one-on-one within the IRC's existing Academic Coaching (AC) Program. Thus, the current study presents the modified Phase Two, which involved two primary aims. The first aim of the current project was to a) develop and implement a mental health screening program in the AC Program, b) determine the feasibility and acceptability of the program, c) examine the reliability of the selected screener, and d) explore differences in reported distress across students, particularly sex differences. The second aim was to adapt the original group manual to be a brief, low-intensity, intervention and integrate it into the existing structure of the AC Program. The feasibility and acceptability of the intervention was evaluated, as well as the reliability of the outcome measures. Analyses were also conducted to evaluate changes in positive ethnic identity between pre and posttest measures.
Results: (Aim 1) Mental health (MH) screening was conducted with 54 participants (65% of those eligible). Although it was generally well-accepted and feasible to deliver, certain factors influenced feasibility and acceptability. Coaches noticed that responses to the screener, by both students and families, reflected a strong stigma around MH. The Refugee Health Screener (RHS-15) was found to be a reliable measure of distress. Lastly, girls endorsed more distress than boys. (Aim 2) Coaches delivered a five-lesson intervention promoting positive ethnic identity during individual meetings with students. Among 38 students (45% of those eligible) who completed a pretest scale, 55% completed at least one lesson and the posttest scale. Notable barriers impacted the feasibility and acceptability of the intervention, with few students completing all lessons, as designed. The measure of ethnic identity used (Multigroup Ethnic Identity Measure-Revised) was found to be reliable. Small, but not significant, changes in the expected direction were detected between pre and post measures of positive ethnic identity (n = 21).
The IRC wishes to continue implementing both programs, with adjustments developed in collaboration with the Youth Program Leadership. Mental health screening offered opportunities to discuss sources of stress and well-being. The Positive Cultural Identity (PCI) intervention opened up valuable discussions around ethnicity and culture. For the intervention program, a hybrid of both group and individual format is being implemented in the summer term
Ode to Athena, Patron Goddess of Girls with Glasses
No full textThe author submitted this entry in the Open Verse Poetry category (Professional division) for the 2024 On My Own Time (OMOT) Art Show.This poem is part of a series that imagines what the Olympic goddesses would rule over in our modern day. One of my college roommates loved Athena for representing wisdom, and I realized that the goddess was a great representative for us nerdy girls
RNA Drives Pathogenicity and Diversity of Tau Strains
Get PDFTau aggregation causes neurodegenerative tauopathies. Trans-cellular propagation of tau assemblies of unique structure, i.e., strains, may underlie the diversity of these disorders. Alzheimer's disease (AD), the most common tauopathy, is primarily sporadic in origin. Conformational shifts in tau initiate aggregation, but the precise trigger to convert tau from an inert to a seed-competent form in disease states is unknown. RNA triggers tau fibril formation in vitro and has been observed in association with neurofibrillary tangles in human brain. I tested whether RNA exerts sequence-specific effects on tau assembly and strain formation. Three RNA homopolymers, polyA, polyU, and polyC all bound tau, as assessed by biolayer interferometry, but only polyA triggered detectable fibril formation and seeding in tau biosensors. PolyA:tau seeds and fibrils were sensitive to RNase and dependent upon RNA for assembly and seeding. Other ssRNA and ssDNA sequences, but not double stranded forms, induced seeding in tau in a sequence specific manner. Single stranded-ness as well as sequence were important to induction of tau seeding. RNA sequence was more influential than structure, as tested through compensatory mutations of a ssDNA sequence predicted to form pseudoknots. The origin of RNA influenced the ability of tau to adopt structures that would form stable strains. Human RNA potently induced tau seed formation and created tau conformations that preferentially formed stable strains in a HEK293T cell model, whereas other inducers produced strains that sectored. Seeds from cellular strains, P301S mouse brain, and soluble, but not insoluble, AD brain were sensitive to RNase and not DNase. Tau seeds from progressive supranuclear palsy and corticobasal degeneration were sensitive to benzonase, a nuclease that indiscriminately digests DNA and RNA. Thus, RNA specifically induces stable tau strains, and may trigger the formation of dominant pathological assemblies that propagate in AD, and possibly other tauopathies. Collectively, the data presented in this thesis are the first to demonstrate specificity of tau-RNA interactions that influence the emergence of pathology and diversity of tau strains
Population health care interventions: outcomes and equity considerations
Get PDFDetailed formal protocol with illustrations and extensive bibliography.A recording of the protocol presentation is available on UT Southwestern's Mediasite. Note: Access to the video is restricted to authorized UT Southwestern users only.UT Southwestern--Internal Medicin
Walking Down the Aisle
Get PDFThe author submitted this entry in the 10-Word Story category (Amateur division) for the 2024 On My Own Time (OMOT) Art Show.A dark twist that came to mind after hearing church bells toll on a gloomy Sunday morning
Architecture and Function of the J-Domain Chaperone DNAJB8
Get PDFThe J-domain protein (JDP; a.k.a Hsp40) chaperone family provides specificity for binding to protein substrates and coordinating refolding processes with the Hsp70 family. The JDP/Hsp70 co-chaperone system has been identified as a model system for understanding early recognition stages of misfolded protein substrates. One of these substrates that is recognized by JDP chaperones includes microtubule associated protein tau, which is implicated in Alzheimer's disease (AD) pathology. A subset of JDPs, DNAJB6 and DNAJB8, have emerged as efficient regulators of amyloid protein aggregation in neurodegenerative diseases such as AD. These JDPs have proven resistant to in-depth structural characterization due to their self-assembly into dynamic and polydisperse oligomers. The biological role of these oligomeric assemblies and the exact binding mechanism to protein substrates are not well-characterized due to these challenges. Here, I used a multidisciplinary approach of biophysics, biochemistry, and cell biology to characterize the functional role of different domains within JDP member DNAJB8 and identify structural motifs that fulfill those roles. I identified an intramolecular interaction between the J-domain (JD) and C-terminal domain (CTD) of DNAJB8 that auto-inhibits JD binding to co-chaperone Hsp70. Using mutants of DNAJB8 that replace phenylalanine residues with serine, I characterized DNAJB8 self-assembly as being driven by hydrophobic interactions that stabilize a class 6 steric zipper in the disordered S/T-rich domain. Finally, I demonstrated that DNAJB8 binds to seed-competent tau monomers, and that greater exposure of the disordered G/F-rich and S/T-rich domains further improves DNAJB8 binding efficiency to tau. These results highlight different regulatory elements within DNAJB8 regulate its ability to interact with itself, substrates, and Hsp70 and detail the structural and biochemical forces that drive these interactions
Weak beats and lost rhythm: current concepts in cardiac sarcoidosis
Get PDFDetailed formal protocol with illustrations and extensive bibliography.A recording of the protocol presentation is available on UT Southwestern's Mediasite. Note: Access to the video is restricted to authorized UT Southwestern users only.UT Southwestern--Internal Medicin
Patient reported outcomes in heart failure: an important pathway into transforming care
Get PDFDetailed formal protocol with illustrations and extensive bibliography.A recording of the protocol presentation is available on UT Southwestern's Mediasite. Note: Access to the video is restricted to authorized UT Southwestern users only.UT Southwestern--Internal Medicin