Pennsylvania: Base Line Report - State Level Field Network Study of the Implementation of the Affordable Care Act

This report is part of a series of 21 state and regional studies examining the rollout of the ACA. The national network -- with 36 states and 61 researchers -- is led by the Rockefeller Institute of Government, the public policy research arm of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania.Although the ACA will no doubt have real financial consequences for insurers, hospitals, and health care providers, at this early stage in implementation, it is difficult to calculate precise gains and losses. For example, the Hospital Association of Pennsylvania supported the ACA, believing, in part, that reform was necessary to reduce current levels of uncompensated care and to reduce reliance on emergency care for patients who put off treatment for as long as possible to avoid out-of-pocket costs. The association agreed to significant cuts in Medicare and Medicaid to support the bill's passage. However, because cost savings from universal coverage have not yet been realized, hospitals reported cutting staff in April 2014 to offset the loss of Medicaid and Medicare funding. Safety net hospitals, which are required to serve all populations, seem especially affected, as many of their patients who fall into the Medicaid coverage gap are still showing up in emergency rooms without insurance

Quantifying mixing using magnetic resonance imaging.

Mixing is a unit operation that combines two or more components into a homogeneous mixture. This work involves mixing two viscous liquid streams using an in-line static mixer. The mixer is a split-and-recombine design that employs shear and extensional flow to increase the interfacial contact between the components. A prototype split-and-recombine (SAR) mixer was constructed by aligning a series of thin laser-cut Poly (methyl methacrylate) (PMMA) plates held in place in a PVC pipe. Mixing in this device is illustrated in the photograph in Fig. 1. Red dye was added to a portion of the test fluid and used as the minor component being mixed into the major (undyed) component. At the inlet of the mixer, the injected layer of tracer fluid is split into two layers as it flows through the mixing section. On each subsequent mixing section, the number of horizontal layers is duplicated. Ultimately, the single stream of dye is uniformly dispersed throughout the cross section of the device. Using a non-Newtonian test fluid of 0.2% Carbopol and a doped tracer fluid of similar composition, mixing in the unit is visualized using magnetic resonance imaging (MRI). MRI is a very powerful experimental probe of molecular chemical and physical environment as well as sample structure on the length scales from microns to centimeters. This sensitivity has resulted in broad application of these techniques to characterize physical, chemical and/or biological properties of materials ranging from humans to foods to porous media (1, 2). The equipment and conditions used here are suitable for imaging liquids containing substantial amounts of NMR mobile (1)H such as ordinary water and organic liquids including oils. Traditionally MRI has utilized super conducting magnets which are not suitable for industrial environments and not portable within a laboratory (Fig. 2). Recent advances in magnet technology have permitted the construction of large volume industrially compatible magnets suitable for imaging process flows. Here, MRI provides spatially resolved component concentrations at different axial locations during the mixing process. This work documents real-time mixing of highly viscous fluids via distributive mixing with an application to personal care products

The Prevalence and Outcomes of Colorectal Cancer Surgery in the Very Elderly

Introduction: Sixty percent of all colorectal cancer patients in the UK undergo major surgery. Of these, 22% of patients are aged 80 years or older. Historically there has been a tendency to exclude very old patients from entering clinical trials (not just those within surgery), making evidence based clinical decision making more challenging [3]. It is difficult, therefore, to accurately guide this group of patients who have been assessed as fit for surgery. This is the first study to assess the outcomes for all older patients with colorectal cancer, regardless of whether they underwent surgical intervention or not. Results: Clinical case notes and electronic patients records were retrospectively reviewed for all patients admitted to North Bristol NHS Trust over a five-year period (January 2009 to February 2014). Patients presenting with a new diagnosis of colorectal cancer were identified. All patients aged 85 years and over were included in the study. Patients were stratified by clinical management strategy i.e. operative or non-operative management of their colorectal cancer. Primary outcome measure was overall survival. Methods: There were 199 patients included in the study, 50.8% (101) were male. Median age of all patients was 88 years (range 85-97 years) and 47% of all patients underwent surgery. More than half (57%) underwent right-sided resections (including hepatic flexure). Overall mean survival for non acute presentations of colorectal cancer were longer in both the operative group and non operative groups (p = 0.007 and p = 0.03 respectively). There was no difference between mean survival in patients presenting as acute surgical emergencies irrespective of operative or non-operative management (p = 0.31). Conclusion: A third of patients with colorectal cancer present as an acute surgical emergency. For this group of patients prognosis is poor and there does not appear to be a survival benefit in undergoing surgical resection

Cities, The Sharing Economy and What's Next

This report seeks to provide an analysis of what is currently happening in American cities so that city leaders may better understand, encourage and regulate the growing sharing economy. Interviews were conducted with city officials on the impact of the sharing economy and related topics, and the report centers around five key themes: innovation, economic development, equity, safety and implementation.The sharing economy is also commonly referred to as collaborative consumption, the collaborative economy, or the peer-to-peer economy. This term refers to business models that enable providers and consumers to share resources and services, from housing to vehicles and more. These business models typically take the form of an online and/or application-based platform for business transactions

Feasibility of Transanal Minimally Invasive Surgery (TAMIS) for Rectal Tumours and Its Impact on Quality of Life ? The Bristol Series

Aim: We assessed feasibility of the transanal minimally invasive surgery (TAMIS) procedure and quality of life postoperatively. Patients and Methods: A total of 28 patients with rectal lesions were treated using TAMIS at Southmead Hospital, North Bristol NHS Trust. Outcome measures included feasibility of excision, negative margin (R0) resection rate, length of hospital stay, morbidity and mortality, and postoperative quality of life associated with anal incontinence. Results; TAMIS was feasible in 90% of cases. R0 resection was 82%. The mean length of hospital stay was 1.5 days. Six (21%) patients experienced acute urinary retention postoperatively. One (4%) patient was re-admitted with rectal bleeding. One patient experienced a perforation. Mortality was 0%. Postoperative quality of life indicated low severity of symptoms of anal incontinence. Conclusion: This study demonstrates that TAMIS is a feasible option in the treatment of rectal tumours and does not impair quality of life postoperatively

Quantifying Kinematic Substructure in the Milky Way's Stellar Halo

We present and analyze the positions, distances, and radial velocities for over 4000 blue horizontal-branch (BHB) stars in the Milky Way's halo, drawn from SDSS DR8. We search for position-velocity substructure in these data, a signature of the hierarchical assembly of the stellar halo. Using a cumulative "close pair distribution" (CPD) as a statistic in the 4-dimensional space of sky position, distance, and velocity, we quantify the presence of position-velocity substructure at high statistical significance among the BHB stars: pairs of BHB stars that are close in position on the sky tend to have more similar distances and radial velocities compared to a random sampling of these overall distributions. We make analogous mock-observations of 11 numerical halo formation simulations, in which the stellar halo is entirely composed of disrupted satellite debris, and find a level of substructure comparable to that seen in the actually observed BHB star sample. This result quantitatively confirms the hierarchical build-up of the stellar halo through a signature in phase (position-velocity) space. In detail, the structure present in the BHB stars is somewhat less prominent than that seen in most simulated halos, quite possibly because BHB stars represent an older sub-population. BHB stars located beyond 20 kpc from the Galactic center exhibit stronger substructure than at $\rm r_{gc} < 20$ kpc.Comment: 29 page, 10 figures, 1 table; accepted by APJ; for related article by another group see arXiv:1011.192

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study

Background: Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors. Methods: Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012–2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded. Results: 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20–0.60 95% CI and 0.47; 0.25–0.88, respectively). Conclusion: Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur

Gene expression profiling of breast tumours from New Zealand patients

AIMS: New Zealand has one of the highest rates of breast cancer incidence in the world. We investigated the gene expression profiles of breast tumours from New Zealand patients, compared them to gene expression profiles of international breast cancer cohorts and identified any associations between altered gene expression and the clinicopathological features of the tumours. METHODS: Affymetrix microarrays were used to measure the gene expression profiles of 106 breast tumours from New Zealand patients. Gene expression data from six international breast cancer cohorts were collated, and all the gene expression data were analysed using standard bioinformatic and statistical tools. RESULTS: Gene expression profiles associated with tumour ER and ERBB2 status, molecular subtype and selected gene expression signatures within the New Zealand cohort were consistent with those found in international cohorts. Significant differences in clinicopathological features such as tumour grade, tumour size and lymph node status were also observed between the New Zealand and international cohorts. CONCLUSIONS: Gene expression profiles, which are a sensitive indicator of tumour biology, showed no clear di¬fference between breast tumours from New Zealand patients and those from non-New Zealand patients. This suggests that other factors may contribute to the high and increasing breast cancer incidence in New Zealand compared to international populations