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Expanding Time Covered for Medical Nutrition Therapy: A Need for Clear Reporting on the Intensity of Nutrition Interventions
Get PDFMedical Nutrition Therapy (MNT) is an evidence-based health care service that helps people improve their food and nutrition habits to positively influence health outcomes and quality of life, and is part of a suite of complementary interventions that can be implemented for effective disease prevention and management. However, the dose (ie, length and number of sessions) of MNT that is covered by health care payers in outpatient settings is highly variable and may not be adequate to achieve the desired clinical outcomes and cost savings. Interest in improving access to adequate doses of MNT provided by registered dietitian nutritionists (RDNs), through both new and existing coverage, has been growing as nutrition-related chronic diseases continue to take a toll on children and adults, health care costs continue to escalate, and health disparities widen. At the national level, advocacy work has focused on expanding both covered conditions and eligible individuals. For example, the Medical Nutrition Therapy Act of 2023 has support from more than 50 national organizations and the National Strategy for Hunger, Nutrition, and Health recommends expanding Medicare beneficiaries’ access to evidence-based nutrition counseling benefits for additional conditions. However, few advocacy efforts have focused on expanding the covered dose of MNT, which for Medicare-covered conditions remains at 3 hours in the first year and 2 hours in subsequent years, with an underutilized mechanism for additional hours. In this Commentary, evidence is reviewed demonstrating that currently covered doses of MNT may be inadequate to achieve desired nutrition outcomes and payer cost-savings goals, and how research reporting hinders determination of the optimal dose of MNT for nutrition-related chronic diseases is discussed. Specifically, three challenges to determining the optimal dose of MNT for nutrition-related chronic diseases are discussed: inconsistent/incomplete reporting of intervention characteristics, including interventionist and dose; dichotomization of behavior change interventions instead of dose-response treatment; and variety of doses tested. Recommended actions are provided to be taken by researchers and policy makers to fill these knowledge gaps in support of expanded access to adequate outpatient doses of MNT services provided by RDNs, through both new and existing coverage
Nocturnal Paroxysmal Dystonia to Sleep-Related Hypermotor Epilepsy: A Critical Review
Get PDFSleep-related paroxysmal motor episodes (SPMEs) have been described by various names, including nocturnal paroxysmal dystonia, nocturnal frontal lobe epilepsy (NFLE), and sleep-related hypermotor epilepsy. The underlying pathophysiology has been debated over the years, with these episodes assumed to be a form of paroxysmal dystonia or parasomnia versus a form of epilepsy. In most studies published on SPMEs and their variants (paroxysmal arousals, nocturnal paroxysmal dystonia, and episodic nocturnal wanderings) in the early 1990s, the authors speculated on the pathophysiology but did not commit to one idea. It was not until the mid-1990s that epilepsy became the leading prospect. We performed a narrative review of the major articles that have described this syndrome in a chronological fashion. We identified three eras, 1972–1993, 1994–1998, and 1999 to the present, each era marked by a landmark study. Our critical review of these early studies shows that the neurophysiological data supporting epilepsy as the sole basis for all SPME cases is very weak. In 1994–1995, a familial pattern of this syndrome was described and the term autosomal dominant NFLE was coined, with the authors claiming that all their patients had a form of frontal lobe epilepsy. With the exception of a few reference cases, the neurophysiological evidence that all patients had frontal lobe epilepsy was very weak. Compared to articles published on surgical series of frontal lobe epilepsy, the percentage of SPME cases with positive interictal/ictal electroencephalograms remained very low, seriously questioning the epileptic basis of the syndrome. Our critical review and analysis of the published literature shows that the evidence presented in favor of SPMEs being a homogenous focal epilepsy syndrome is very weak. Neurologists must recognize that SPMEs could be a form of movement disorder, parasomnia, or epilepsy. We recommend a pragmatic semiology-based classification of these episodes using the four-dimensional classification system
School Nutrition Stakeholders Find Utility in MealSim: An Agent-Based Model
Get PDFObjective: To obtain feedback from school nutrition stakeholders on an agent-based model simulating school lunch to inform model refinement and future applications. Design: Qualitative study using online discussion groups. Setting: School nutrition professional stakeholders across the US. Participants: Twenty-eight school nutrition stakeholders. Phenomenon of Interest: Perceptions and applicability of MealSim for school nutrition stakeholders to help reduce food waste. Analysis: Deductive approach followed by inductive analysis of discussion group transcripts. Results: Stakeholders appreciated the customizability of the cafeteria characteristics and suggested adding additional characteristics to best represent the school meal system, such as factors relating to school staff supervision of students during meals. The perceived utility of MealSim was high and included using it to train personnel and to advocate for policy and budgetary changes. However, they viewed MealSim as more representative of elementary than high schools. Stakeholders also provided suggestions for training school nutrition administrators on how to use MealSim and requested opportunities for technical assistance. Conclusions and Implications: Although agent-based models were new to the school nutrition stakeholders, MealSim was viewed as a useful tool. Application of these findings will allow the model to meet the intended audience\u27s needs and better estimate the system
Self-reported Determinants of COVID-19 Vaccine Acceptance Among Persons with and without Autoimmune Disease
Get PDFObjective: Patients with autoimmune disease (AD) are at increased risk for complications from COVID-19 infection, so, optimizing vaccine utilization in this population is of particular importance. We compared COVID-19 vaccination perspectives among persons with and without AD. Methods: 471 patients in the MetroHealth System and Cleveland Veteran Affairs Medical Center completed a 38-item questionnaire between August 2021 and February 2022. This survey containing questions regarding COVID-19 vaccine perceptions and demographics was administered both to unvaccinated individuals and individuals who delayed vaccination for at least 2 months. Multivariable ordinary least squares regression models were created to assess factors associated with vaccination likelihood. Results: The number of reasons given for (p \u3c 0.001) and against receiving COVID-19 vaccination (p \u3c 0.001) were highly associated with increased and decreased vaccination likelihood respectively. Factors most closely associated with obtaining vaccine were: protecting family (p = 0.045) personal safety (p \u3c 0.001) and preventing serious infection (p \u3c 0.001). Reasons associated with decreased vaccination likelihood were: lack of concern of COVID-19 infection (p \u3c 0.001), vaccine safety (p \u3c 0.001) and beliefs that the vaccine was made too quickly (p = 0.024). AD patients were more likely to cite having a chronic condition (29.1 % vs 17.1 %, p = 0.003) and physician recommendation(s) (18.4 % vs 9.1 %, p = 0.005) as reasons for vaccination and were more concerned about potential medication interaction than non-AD respondents (22.4 % vs 3.3 %, p \u3c 0.001). Conclusion: The number of benefits of vaccination identified strongly related to vaccination likelihood. Affirmative provider recommendations correlated with increased vaccination likelihood in AD patients. Clinical conversations centered on the benefits of COVID-19 vaccination may help increase vaccine acceptance
Structural Insights into Peptidoglycan Glycosidase EtgA Binding to the Inner Rod Protein EscI of the Type III Secretion System via a Designed EscI-EtgA Fusion Protein
Get PDFBacteria express lytic enzymes such as glycosidases, which have potentially self-destructive peptidoglycan (PG)-degrading activity and, therefore, require careful regulation in bacteria. The PG glycosidase EtgA is regulated by localization to the assembling type III secretion system (T3SS), generating a hole in the PG layer for the T3SS to reach the outer membrane. The EtgA localization was found to be mediated via EtgA interacting with the T3SS inner rod protein EscI. To gain structural insights into the EtgA recognition of EscI, we determined the 2.01 Å resolution structure of an EscI (51–87)-linker-EtgA fusion protein designed based on AlphaFold2 predictions. The structure revealed EscI residues 72–87 forming an α-helix interacting with the backside of EtgA, distant from the active site. EscI residues 56–71 also were found to interact with EtgA, with these residues stretching across the EtgA surface. The ability of the EscI to interact with EtgA was also probed using an EscI peptide. The EscI peptide comprising residues 66–87, slightly larger than the observed EscI α-helix, was shown to bind to EtgA using microscale thermophoresis and thermal shift differential scanning fluorimetry. The EscI peptide also had a two-fold activity-enhancing effect on EtgA, whereas the EscI-EtgA fusion protein enhanced activity over four-fold compared to EtgA. Our studies suggest that EtgA regulation by EscI could be trifold involving protein localization, protein activation, and protein stabilization components. Analysis of the sequence conservation of the EscI EtgA interface residues suggested a possible conservation of such regulation for related proteins from different bacteria
Uncovering the Interhospital Price Variations for Vasectomies in the United States
Get PDFDue to the historic lack of transparency in healthcare pricing in the United States, the degree of price variation for vasectomy is largely unknown. Our study aims to assess characteristics of hospitals reporting prices for vasectomy as well as price variation associated with hospital factors and insurance status. A cross-sectional analysis was performed in October, 2022 using the Turquoise Database which compiles publicly available hospital pricing data. The database was queried for vasectomy prices to identify the cash (paid by patients not using insurance), commercial (negotiated by private insurers) and Medicare and Medicaid prices for vasectomies. Hospital characteristics of those that reported a price for vasectomy and those that did not were compared and pricing differences based on hospital ownership and reimbursement source were determined using multivariable linear regression analysis. Overall, only 24.7% (1657/6700) of hospitals reported a price for vasectomy. Those that reported a price had more beds (median 117 vs 80, p \u3c 0.001), more physicians (median 1745 vs 1275, p \u3c 0.001). They were also more likely to be nonprofit hospitals (77% vs 14%, p \u3c 0.001) and to be in well-resourced areas (ADI 91.7 vs 94.4, p \u3c 0.001). Both commercial prices and cash prices for vasectomy were lower at nonprofit hospitals than at for-profit hospitals (commercial: 2861.56, p \u3c 0.001; cash: 3185.37, p \u3c 0.001). Our study highlights the current state of pricing transparency for vasectomy in the United States. Patients may be counseled to consider seeking vasectomy at a nonprofit hospital to reduce their costs, especially when paying with cash. These findings also suggest a need for new policies to target areas with decreased price transparency to reduce price disparities
Efficacy of Direct Visual Internal Urethrotomy versus Balloon Dilation to Treat Recurrent Urethral Stricture following Failed Urethroplasty
No full textThe Association between Amblyopia and the Risks of Hearing Loss: A Propensity Matched Analysis
No full textIntroduction: Amblyopia occurs due to an imbalance in the visual input between the eyes. This can induce structural changes in the central nervous system and, if left untreated, eventually lead to permanent blindness in the affected eye. As these changes may also impact the auditory system, which closely interacts with the visual system, this study aimed to investigate the risk of hearing loss in patients with amblyopia. Materials and methods: This study was a retrospective review of the electronic medical records contained in a United States national database of medical records. Patients younger than 18 years old with and without amblyopia were matched and compared to evaluate the relative risk (RR) of having a hearing loss. Stratified analyses were further performed to explore whether the disease laterality and the amblyopia subtype influenced the risks. Results: Compared to the controls, patients with amblyopia had a higher overall risk of having hearing loss (RR: 1.09, CI: 1.03–1.14), specifically sensorineural hearing loss (SNHL) (RR: 1.24, CI: 1.08–1.42). The stratified analysis further revealed that SNHL was associated with refractive amblyopia (RR: 1.84, CI: 1.50–2.26), but not strabismic amblyopia (RR: 1.23, CI: 1.10–1.38). The laterality of amblyopia did not influence the risk of hearing loss. Conclusions: Children with amblyopia have a higher rate of SNHL than children without amblyopia. As vision and hearing are essential in the proper cognitive development, language acquisition, and social and emotional well-being of children, patients with amblyopia may benefit from more frequent audiologic screening
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